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Randomized Controlled Trial
. 2022 Feb 1;157(2):e216370.
doi: 10.1001/jamasurg.2021.6370. Epub 2022 Feb 9.

Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial

Friederike Deeken  1 , Alba Sánchez  1 , Michael A Rapp  1   2 , Michael Denkinger  3 , Simone Brefka  3   4 , Juliane Spank  5 , Carola Bruns  5 , Christine A F von Arnim  6   7 , Olivia C Küster  7 , Lars O Conzelmann  8 , Brigitte R Metz  9 , Christoph Maurer  10 , Yoanna Skrobik  11 , Oksana Forkavets  7   12 , Gerhard W Eschweiler  12   13 , Christine Thomas  5   13 ; PAWEL Study Group
Collaborators, Affiliations
Randomized Controlled Trial

Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial

Friederike Deeken et al. JAMA Surg. .

Abstract

Importance: Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored.

Objective: To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures.

Design, setting, and participants: This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021.

Interventions: First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion.

Main outcomes and measures: Postoperative delirium incidence and duration.

Results: Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54).

Conclusions and relevance: This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rapp has received grants from the German Research Foundation and German Ministry for Education and Research as well as personal fees from Arbuma GmbH, Philipps Healthcare GmbH, Deutschlandfunk (National Radio Station), Quakenbrück Hospital; and serves as president of the German Society for Geriatric Psychiatry and Psychotherapy. Dr von Arnim has received personal fees from Roche GmbH, Lilly GmbH, Daiichi Sankyo, Dr Willmar Schwabe GmbH, and Biogen and has received research support from Roche Diagnostics AG. Dr Conzelmann has received an award from the German Society for Thoracic and Cardiovascular Surgery as well as personal fees from Boston Scientific, Medtronic, and Edwards Lifesciences. Dr Thomas has received grants from Robert-Bosch-Stiftung and personal fees from Roche GmbH. No other disclosures were reported.

Figures

Figure.
Figure.. Recruitment CONSORT Flowchart
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