Association between preoperative anxiety and postoperative delirium in older patients: a systematic review and meta-analysis

Abstract

Background: Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses. Preoperative anxiety has been suggested as a possible precipitating factor for the development of POD. As such, we aimed to explore the association between preoperative anxiety and POD in older surgical patients.

Methods: Electronic databases including MEDLINE (via PubMed), EMBASE (via Embase.com), Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete; via EBSCOhost) and clinical trial registries were systematically searched to identify prospective studies examining preoperative anxiety as a risk factor for POD in older surgical patients. We used Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies to assess the quality of included studies. The association between preoperative anxiety and POD was summarized with odds ratios (ORs) and 95% confidence intervals (CIs) using DerSimonian-Laird random-effects meta-analysis.

Results: Eleven studies were included (1691 participants; mean age ranging between 63.1-82.3 years). Five studies used a theoretical definition for preoperative anxiety, with the Anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) as the instrument being most often used. When using dichotomized measures and within the HADS-A subgroup analysis, preoperative anxiety was significantly associated with POD (OR = 2.17, 95%CI: 1.01-4.68, I² = 54%, Tau² = 0.4, n = 5; OR = 3.23, 95%CI: 1.70-6.13, I² = 0, Tau² = 0, n = 4; respectively). No association was observed when using continuous measurements (OR = 0.99, 95%CI: 0.93-1.05, I² = 0, Tau² = 0, n = 4), nor in the subgroup analysis of STAI-6 (six-item version of state scale of Spielberger State-Trait Anxiety Inventory, OR = 1.07, 95%CI: 0.93-1.24, I² = 0, Tau² = 0, n = 2). We found the overall quality of included studies to be moderate to good.

Conclusions: An unclear association between preoperative anxiety and POD in older surgical patients was found in our study. Given the ambiguity in conceptualization and measurement instruments used for preoperative anxiety, more research is warranted in which a greater emphasis should be placed on how preoperative anxiety is operationalized and measured.

Keywords: Cognitive dysfunction; Meta-analysis; Older patients; Postoperative delirium; Preoperative anxiety.

Fig. 1

Flow diagram of study selection. CINAHL, Cumulative Index to Nursing and Allied Health Literature; WOSCC, Web of Science Core Collection; CENTRAL, Cochrane Central Register of Controlled Trials; ICTRP, the World Health Organization International Clinical Trials Registry Platform

Fig. 2

Meta-analysis for studies using dichotomized measurements of preoperative anxiety in multivariable analysis. HADS-A, Anxiety subscale of Hospital Anxiety and Depression Scale; APAIS-A, Anxiety subscale of Amsterdam Preoperative Anxiety and Information Scale; OR, odds ratio; CI, confidence interval; the recalculation of dichotomized measurements of HADS-A for Detroyer 2008 and APAIS-A for Milisen 2020 were conducted using multivariate logistic regression analysis adjusting for the same confounders as in the original analysis

Fig. 3

Meta-analysis for studies using continuous measurements of preoperative anxiety in multivariable analysis. APAIS-A, Anxiety subscale of Amsterdam Preoperative Anxiety and Information Scale; STAI-S, State scale of Spielberger State-Trait Anxiety Inventory; STAI-6, short form of state scale of STAI; OR, odds ratio; CI, confidence interval; we calculated STAI-6 instead of full version of STAI-S for Detroyer 2008 corresponding with the data from Van Grootven 2016 using multivariate logistic regression analysis adjusting for the same confounders as in the original analysis