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Review| Volume 34, ISSUE 2, P131-134, August 2007

Delirium in Vascular Surgery

  • B. Balasundaram
    Correspondence
    Corresponding author. Dr. Bharathi Balasundaram, Leeds Mental health Teaching NHS Trust, Specialist Registrar Old Age Psychiatry, Leeds Mental Health Trust, 2 Asket Place, Asket Avenue, Seacroft, Leeds LS14 1PP, UK.
    Affiliations
    Specialist Registrar Old Age Psychiatry, Leeds Mental Health Trust, Leeds UK
    Search for articles by this author
  • J. Holmes
    Affiliations
    Senior Lecturer in Liaison Psychiatry of Old Age, University of Leeds, Institute of Health Sciences, Leeds UK
    Search for articles by this author
Open ArchivePublished:May 11, 2007DOI:https://doi.org/10.1016/j.ejvs.2007.02.016
Delirium in Vascular Surgery
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      Delirium is common in many surgical settings. Patients undergoing elective vascular surgery may be at particular risk of developing delirium, and may have modifiable aetiological factors that can be addressed by pre-operative interventions. We decided to review the literature regarding the incidence and aetiology of delirium in elective vascular surgical patients.

      Methods

      We searched medical databases, journals and bibliographies to identify relevant studies. We used predetermined quality criteria for appraisal of the quality of incidence and aetiological studies.

      Results

      Four studies were identified as relevant to the review. The incidence of delirium ranged from 29.1% to 39.2%. The significant aetiological factors identified were age, pre-operative cognitive impairment, depressive symptoms, inter-operative blood transfusion and previous amputation.

      Conclusions

      Delirium is common in people undergoing elective vascular surgery. Further research is required to examine the effect on outcome of delirium, and the effect of psychiatric and geriatric medicine interventions in this setting.

      Keywords

      Introduction

      Delirium is a syndrome characterised by disturbance of consciousness, impaired attention or concentration and associated problems with memory, behaviour and the sleep-wake cycle.
      • International Classification of Mental and Behavioural Disorders: ICD-10
      Clinical descriptions and Diagnostic Guidelines.
      World Health Organisation, Geneva1992
      It is a common and serious problem in hospitalised patients, particularly in older people.
      • Inouye S.K.
      Delirium in hospitalized older patients.
      Clin Geriatr Med. 1998; 14: 745-764
      Studies on delirium reveal prevalences of about 20% in medical settings rising to 83% in those receiving intensive care
      • Ely E.W.
      • Inouye S.K.
      • Bernard G.R.
      • Gordon S.
      • Francis J.
      • May L.
      • et al.
      Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit CAM- ICU.
      JAMA. 2001; 286: 2703-2710
      and to 61% after hip fracture.
      • Gustafson Y.
      • Berggren D.
      • Brännström B.
      • Bucht G.
      Acute confusional states in elderly patients treated for femoral neck fracture.
      J Am Geriatr Soc. 1988; 36: 525-530
      However, there is good evidence that delirium is often not detected by wards staff, with as many as 50% of cases going unrecognised.
      • Gustafson Y.
      • Berggren D.
      • Brännström B.
      • Bucht G.
      Acute confusional states in elderly patients treated for femoral neck fracture.
      J Am Geriatr Soc. 1988; 36: 525-530
      In many inpatient populations delirium has an adverse effect on several important outcomes such as length of stay, mortality and instituitionalisation.
      • Inouye S.K.
      Delirium in hospitalized older patients.
      Clin Geriatr Med. 1998; 14: 745-764
      A better understanding of the aetiology and management of delirium in particular populations may improve these outcomes by improving the prevention of incident delirium and reducing the severity of prevalent delirium.
      The common elective vascular procedures are major operations including abdominal aortic procedures (open aortic aneurysm repair, open bypass for aorto-iliac disease), carotid endarterectomy, lower limb bypass grafts and above or below knee amputation.
      • McGlade D.P.
      • Poon A.B.
      • Davies M.J.
      The use of a questionnaire and simple exercise test in the preoperative assessment of vascular surgery patients.
      Anaesth Intensive Care. 2001; 29: 520-526
      , 
      • Sobolev B.
      • Brown P.
      • Zelt D.
      Variation in time spent on the waiting list for elective vascular surgery: a case study.
      Clin Invest Med. 2000; 23: 227-238
      Patients undergoing elective vascular surgery may be at increased risk of developing delirium since they are old and often have coexistent cerebrovascular disease, both of which are risk factors for delirium in other populations.
      • Inouye S.K.
      Delirium in hospitalized older patients.
      Clin Geriatr Med. 1998; 14: 745-764
      The elective nature of the procedures means that if modifiable risk factors can be detected, or vulnerable groups at significant risk can be identified, interventions can be targetted at them. In this systematic review we critically appraise the literature on the incidence and aetiology of delirium in elective vascular surgical population.

      Methods

      Literature search

      Medline, Embase, Psychinfo and CINAHL were searched for relevant articles published from 1950 to August 2005, 1974 to August 2005, 1806 to August 2005 and 1982 to August 2005 respectively. A combination of MeSH terms and text words with appropriate use of wild cards and synonyms were used to identify potentially relevant studies. Details of the complete search strategy are available from the authors. The bibliographies of original articles were searched for additional references. The journals Annals of Surgery, European Journal of Vascular and Endovascular Surgery and British Journal of Surgery were hand searched from 1995 to August 2005.
      Articles identified as relevant based on examination of the title and abstract were retrieved for further evaluation. All retrieved articles were screened using predefined eligibility criteria listed below. There were no language restrictions applied to the selection of studies.

      Inclusion criteria for incidence

      We included studies in the review if they met the following predefined eligibility criteria: participants who underwent elective vascular surgery; use of an acceptable definition of delirium (either recognised diagnostic criteria such as ICD-10
      • International Classification of Mental and Behavioural Disorders: ICD-10
      Clinical descriptions and Diagnostic Guidelines.
      World Health Organisation, Geneva1992
      or DSM-IV
      Diagnostic and Statistical Manual of Mental disorders: Diagnostic and Statistical Manual of Mental disorders.
      4th ed. American Psychiatric Association, Washington D.C.1994
      or a validated diagnostic tool such as the Delirium Rating Scale
      • Trzepacz P.T.
      The Delirium Rating Scale Its use in consultation-liaison research.
      Psychosomatics. 1999; 40: 193-204
      or the Confusion Assessment Method
      • Inouye S.K.
      • Van Dyck C.H.
      • Alessi C.A.
      • Balkin S.
      • Siegal A.P.
      • Horwitz R.I.
      Clarifying Confusion: Confusion Assessment Method: a new method for detection of delirium.
      Ann Intern Med. 1990; 113: 941-948
      ); reporting of original data on the incidence of delirium.

      Inclusion criteria for aetiology

      As well as meeting the above criteria, aetiological studies had to measure and adjust for appropriate confounding variables by multivariate logistic regression or other appropriate statistical techniques.

      Study quality assessment

      The quality of the studies was assessed by a predetermined check list produced by a critical appraisal skills programme.

      Critical appraisal skills programme (CASP), www.phru.nhs.uk/casp/critical_appraisal_tools.htm

      Abstraction of data

      We extracted the following data from included studies: information on study design; population; sample size; selection criteria; diagnostic method; aetiological factors; and incidence of delirium. Data extraction was carried out independently by the authors, blind to each others findings.

      Results

      The literature search yielded 204 potentially relevant studies of aetiology and incidence of delirium of which 198 were excluded after screening their abstracts. No additional studies of potential relevance were found by hand searching or bibliography searching. Six studies were retrieved for detailed evaluation.
      • Sasajima Y.
      • Sasajima T.
      • Uchida H.
      • Kawai S.
      • Haga M.
      • Akasaka N.
      Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
      Eur J Vasc Endovasc Surg. 2000; 20: 132-137
      , 
      • Schneider F.
      • Böhner H.
      • Habel U.
      • Salloum J.B.
      • Stierstorfer A.
      • Hummel T.C.
      • et al.
      Risk factors for postoperative delirium in vascular surgery.
      Gen Hosp Psychiatry. 2002; 24: 28-34
      , 
      • Böhner H.
      • Hummel T.C.
      • Habel U.
      • Miller C.
      • Reinbott S.
      • Yang Q.
      • et al.
      Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
      Ann Surg. 2003; 238: 149-156
      , 
      • Böhner H.
      • Friedrichs R.
      • Habel U.
      • Muller E.E.
      • Sandmann W.
      • Schneider F.
      Delirium increases morbidity and length of stay after vascular surgery operations, Results of a prospective study.
      Chirurg. 2003; 74: 931-936
      , 
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Postoperative delirium following vascular surgery.
      Anaesthesist. 2000; 49: 427-433
      , 
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Delirium after vascular surgery interventions, Intermediate-term results of a prospective study.
      Chirurg. 2000; 71: 215-221
      Two studies were further excluded for the following reasons; one study
      • Böhner H.
      • Friedrichs R.
      • Habel U.
      • Muller E.E.
      • Sandmann W.
      • Schneider F.
      Delirium increases morbidity and length of stay after vascular surgery operations, Results of a prospective study.
      Chirurg. 2003; 74: 931-936
      reported prognostic data from the same cohort reported used by another study of incidence and aetiology and one study
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Postoperative delirium following vascular surgery.
      Anaesthesist. 2000; 49: 427-433
      was a duplicate of a second study leaving four studies to be included in the review.
      All the four included studies described incidence and three of them also described aetiology. They involved a total of 364 participants of whom 130 developed delirium. Three of the studies were from the same research group.
      • Schneider F.
      • Böhner H.
      • Habel U.
      • Salloum J.B.
      • Stierstorfer A.
      • Hummel T.C.
      • et al.
      Risk factors for postoperative delirium in vascular surgery.
      Gen Hosp Psychiatry. 2002; 24: 28-34
      , 
      • Böhner H.
      • Hummel T.C.
      • Habel U.
      • Miller C.
      • Reinbott S.
      • Yang Q.
      • et al.
      Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
      Ann Surg. 2003; 238: 149-156
      , 
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Delirium after vascular surgery interventions, Intermediate-term results of a prospective study.
      Chirurg. 2000; 71: 215-221
      In all the four studies the participants were followed up over the first seven postoperative days. The Diagnostic and Statistical Manual of Mental Disorders IV and Delirium Rating Scale
      • Trzepacz P.T.
      A review of delirium assessment instruments.
      Gen Hosp Psychiatry. 1994; 16: 397-405
      were used as the case detection method in all the three German studies
      • Schneider F.
      • Böhner H.
      • Habel U.
      • Salloum J.B.
      • Stierstorfer A.
      • Hummel T.C.
      • et al.
      Risk factors for postoperative delirium in vascular surgery.
      Gen Hosp Psychiatry. 2002; 24: 28-34
      , 
      • Böhner H.
      • Hummel T.C.
      • Habel U.
      • Miller C.
      • Reinbott S.
      • Yang Q.
      • et al.
      Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
      Ann Surg. 2003; 238: 149-156
      , 
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Delirium after vascular surgery interventions, Intermediate-term results of a prospective study.
      Chirurg. 2000; 71: 215-221
      whilst the Japanese study
      • Sasajima Y.
      • Sasajima T.
      • Uchida H.
      • Kawai S.
      • Haga M.
      • Akasaka N.
      Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
      Eur J Vasc Endovasc Surg. 2000; 20: 132-137
      used the Confusion Assessment Method
      • Sasajima Y.
      • Sasajima T.
      • Uchida H.
      • Kawai S.
      • Haga M.
      • Akasaka N.
      Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
      Eur J Vasc Endovasc Surg. 2000; 20: 132-137
      as the case detection method. The Japanese study measured preoperative cognitive status using the revised version of Hasewaga's dementia scale
      • Kim K.W.
      • Lee D.Y.
      • Jhoo J.H.
      • Youn J.C.
      • Suh Y.J.
      • Jun Y.H.
      • et al.
      Diagnostic accuracy of mini-mental status examination and revised hasegawa dementia scale for Alzheimer's disease.
      Dement Geriatr Cogn Disord. 2005; 19: 324-330
      whilst the German studies used the Mini-Mental State Examination.
      • Folstein M.F.
      • Folstein S.E.
      • McHugh P.R.
      Mini-mental state. A practical method for grading the cognitive state of patients for the clinician.
      J Psychiatr Res. 1975; 12: 189-198
      Preoperative depressive symptoms were measured with the Hamilton Depression Scale
      • Hamilton M.
      A rating scale for depression.
      J Neurol Neurosurg and Psychiatry. 1960; 23: 56-62
      in the German studies.
      A summary of the studies on incidence and aetiology is shown in Table 1, Table 2. This review yielded a pooled incidence of delirium of 35.85%. Eleven significant aetiological factors were identified by multivariate analysis.
      Table 1Studies on incidence of delirium in elective vascular patients
      StudyCountryDesignCase-finding instrumentType of surgerySample size% of potential sampleMean age (yrs)CasesIncidence
      Bohner et al. 2000GermanyProspective CohortDSM-IV, DRS ≥12aortic, carotid, peripheral bypass542138.9%
      Sasajima et al. 2000JapanProspective CohortHDS-R-<20
      Hasegawa's Dementia Scale.
      , CAM
      Confusion Assessment Method.
      		Limb bypass1103229.1%
      Schneider et al. 2002GermanyProspective CohortDSM-IV, DRS ≥12aortic, carotid, peripheral bypass4778.366.81736.2%
      Bohner et al. 2003GermanyProspective CohortDSM-IV,
      Diagnostic and Statistical Manual of Mental disorders.
      DRS ≥12
      Delirium Rating Scale.
      		aortic, carotid, peripheral bypass1536039.2%
      ∗∗ Confusion Assessment Method.
      aa Delirium Rating Scale.
      ∗ Hasegawa's Dementia Scale.
      a Diagnostic and Statistical Manual of Mental disorders.
      Table 2Findings on aetiology of delirium from multivariate analysis
      StudyAetiological factorsOdds ratioßConfidence interval of odds ratiop value
      Bohner et al. 2003Absence of supra aortic occlusive disease6.73–0.001
      Absence of hypercholesterolemia5.51–0.001
      History of major amputation24.4–0.001
      Age over 64 years3.03–0.018
      Height <170 cm3.95–0.004
      HAMD >8
      Hasegawa's Dementia Scale.
      		2.43–0.066
      MMSE <2528–0.001
      Intra operative need for colloid infusion >800 ml2.62–0.035
      Intra operative minimal potassium <3.5 mmol/l3.18–0.021
      Schneider et al. 2002Preoperative depressive symptoms HAMD
      Hamilton Depression Scale.
      		0.050.0023
      MMSE
      Mini Mental State Examination.
      		−0.080.0007
      Perioperative infusion0.00010.0094
      Perioperative transfusion0.00050.0069
      Sasajima et al. 2000Age >70 years14.12.7–72.00.002
      Critical limb ischemia and ankle pressure mm40 Hg3.81.3–10.90.013
      HDS-R
      Hasegawa's Dementia Scale.
      Score <20      		3.30.8–13.50.093
      Operation time >7 hr1.80.6–4.90.281
      Albumin <3.8 g/dl1.90.5–7.00.330
      a Hamilton Depression Scale.
      aa Mini Mental State Examination.
      ∗ Hasegawa's Dementia Scale.

      Discussion

      This review has the following limitations. Due to a small number of studies being identified, publication bias and heterogeneity were not formally assessed.
      We employed a systematic search strategy to detect relevant studies, meaning that we are unlikely to have missed important studies from this review. We employed recognised critical appraisal tools to determine the quality of studies and excluded those studies which did not meet out criteria. We therefore believe our findings to be a reflection of the literature in this area. It is worth noting that three of the four studies were from the same research group, which may limit further the generalisability of our findings. Also, only one study
      • Sasajima Y.
      • Sasajima T.
      • Uchida H.
      • Kawai S.
      • Haga M.
      • Akasaka N.
      Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
      Eur J Vasc Endovasc Surg. 2000; 20: 132-137
      employed a consecutive sampling method, and the other three studies
      • Schneider F.
      • Böhner H.
      • Habel U.
      • Salloum J.B.
      • Stierstorfer A.
      • Hummel T.C.
      • et al.
      Risk factors for postoperative delirium in vascular surgery.
      Gen Hosp Psychiatry. 2002; 24: 28-34
      , 
      • Böhner H.
      • Hummel T.C.
      • Habel U.
      • Miller C.
      • Reinbott S.
      • Yang Q.
      • et al.
      Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
      Ann Surg. 2003; 238: 149-156
      , 
      • Böhner H.
      • Schneider F.
      • Stierstorfer A.
      • Weiss U.
      • Gabriel A.
      • Friedrichs R.
      • et al.
      Delirium after vascular surgery interventions, Intermediate-term results of a prospective study.
      Chirurg. 2000; 71: 215-221
      used neither consecutive nor random sampling method to identify participants, meaning that selection bias is a potential limitation in all the studies.
      Despite these concerns, the rates of delirium we report in this review are in keeping with the overall rates of delirium in the postoperative period in other surgical populations.
      Eleven significant aetiological factors were identified by multivariate analysis. Age and intraoperative excess blood transfusion have been identified as aetiological factors in studies on post-cardiotomy delirium
      • Gokgoz L.
      • Gunaydin S.
      • Sinci V.
      • Unlu M.
      • Boratav C.
      • Babacan A.
      • et al.
      Psychiatric complications of cardiac surgery postoperative delirium syndrome.
      Scand Cardiovasc J. 1997; 31: 217-222
      , 
      • Santana S.F.
      • Tadeu V.I.
      • Fráguas J.R.
      Risk factors for delirium in the elderly after coronary artery bypass graft surgery.
      Int Psychogeriatr. 2004; 16: 175-193
      and this has been replicated in this review. Increased age, preoperative parameters such as cognitive impairment and depressive symptoms identified in orthopaedic studies
      • Galanakis P.
      • Bickel H.
      • Gradinger R.
      • Von G.S.
      • Forstl H.
      Acute confusional state in the elderly following hip surgery: Incidence, risk factors and complications.
      Int J Geriatr Psychiatry. 2001; 16: 349-355
      have been further replicated in this review. Stratification of the sample on basis of age was not employed in any of the four studies included in the review.
      The study by Schneider et al.
      • Schneider F.
      • Böhner H.
      • Habel U.
      • Salloum J.B.
      • Stierstorfer A.
      • Hummel T.C.
      • et al.
      Risk factors for postoperative delirium in vascular surgery.
      Gen Hosp Psychiatry. 2002; 24: 28-34
      included subjects of younger age (53–84 years old). The younger subjects are likely to have reduced comorbid factors when compared with the older subjects (>60 years old) who were included in the remainder of studies. Only the study by Sasajima et al.
      • Sasajima Y.
      • Sasajima T.
      • Uchida H.
      • Kawai S.
      • Haga M.
      • Akasaka N.
      Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
      Eur J Vasc Endovasc Surg. 2000; 20: 132-137
      generated odds ratios with confidence interval in its findings on aetiological risk factors for delirium. The wide confidence intervals reported are likely to be due to the small sample size. The study by Bohner et al.
      • Böhner H.
      • Hummel T.C.
      • Habel U.
      • Miller C.
      • Reinbott S.
      • Yang Q.
      • et al.
      Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
      Ann Surg. 2003; 238: 149-156
      on the findings on aetiology of delirium has unusually high odds ratio for some factors (e.g 28 for cognitive impairment and 24.4 for previous amputation) which would alert us to interpret the results with caution.
      The results of this review could not be combined in a formal metaanalysis due to variation between studies in participants age, type of surgery case-finding method, and difference in confounding variables measured.
      Our findings have important implications for care of the older vascular surgical patient. The incidence of delirium is high after vascular surgery and at-risk populations can be identified pre-operatively. However, the overall quality of the studies that we found was not as high as we would have liked, and in particular no studies employed survival analysis to examine the effect of multiple confounding variables on the development of delirium.
      There seems to be a need for further research in this area, we need to know more about the prognosis of delirium if we are to understand the personal and organisational costs of a delirious episode after vascular surgery. We also need to clarify the aetiology of delirium in this population in order to develop protective interventions for those at risk, as has been carried out in other delirious populations.
      • Cole M.G.
      • Primeau F.J.
      • Bailey R.F.
      • Bonnycastle M.J.
      • Masciarelli F.
      • Engelsmann F.
      • et al.
      Systematic intervention for elderly inpatients with delirium: a randomised trial.
      CMAJ. 1994; 151: 965-970
      , 
      • Inouye S.K.
      • Bogardus Jr., S.T.
      • Charpentier P.A.
      • Leo S.L.
      • Acampora D.
      • Holford T.R.
      • et al.
      A multicomponent intervention to prevent delirium in hospitalized older patients.
      N Engl J Med. 1999; 340: 669-676
      , 
      • Marcantonio E.R.
      • Flacker J.M.
      • Wright R.J.
      • Resnick N.M.
      Reducing delirium after hip fracture: a randomised trial.
      J Am Geriatr Soc. 2001; 49: 516-522
      Likely interventions may mirror those proposed in the hip fracture population,
      • Strain J.J.
      • Lyons J.S.
      • Hammer J.S.
      • Fahs M.
      • Lebovits A.
      • Paddison P.L.
      Cost offset from a psychiatric consultation - liaison intervention with elderly hip fracture patients.
      Am J Psychiatry. 1991; 148: 1044-1049
      , 
      • Huusko T.M.
      • Karppi P.
      • Avikainen V.
      • Kautiainen H.
      • Sulkava R.
      Randomised clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia.
      BMJ. 2000; 321: 1107-1111
      where involvement of geriatricians and old age psychiatrists, using protocol-driven screening and management, may improve outcomes for all.

      Acknowledgements

      Sources of funding: none.
      Statistical help: none.
      There are no conflicts of interest in this study.

      References

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        Clinical descriptions and Diagnostic Guidelines.
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        • Brown P.
        • Zelt D.
        Variation in time spent on the waiting list for elective vascular surgery: a case study.
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        Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?.
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        Risk factors for postoperative delirium in vascular surgery.
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        Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.
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      Article info

      Publication history

      Published online: May 11, 2007
      Accepted: February 26, 2007

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      DOI: https://doi.org/10.1016/j.ejvs.2007.02.016

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      © 2007 Elsevier Ltd. Published by Elsevier Inc.

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