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. 2025 Apr;39(2):282-291.
doi: 10.1007/s00540-025-03460-7. Epub 2025 Feb 25.

The effect of delirium on the association between frailty and postoperative major complications in elderly patients: a mediation analysis

Ya-Fei Liu  1 , Fan Cui  1 , Xian Su  1 , Ya-Wei Li  1 , Yan Zhang  2 , Chun-Jing Li #  3 , Dong-Liang Mu #  4 , Dong-Xin Wang  1   5
Affiliations

The effect of delirium on the association between frailty and postoperative major complications in elderly patients: a mediation analysis

Ya-Fei Liu et al. J Anesth. 2025 Apr.

Abstract

Purpose: Both preoperative frailty and postoperative delirium (POD) are associated with higher risk of postoperative complications. But it is unclear if the effect of preoperative frailty on postoperative complications was mediated by POD.

Methods: This study was a mediation analysis of a pooled database. Patients aged ≥ 60 years who underwent elective non-cardiac surgery were enrolled. Preoperative frailty was defined as the modified frailty index (mFI) ≥ 0.27. POD was assessed twice daily within the first 3 days using the Confusion Assessment Method (CAM) for patients without intubation and the CAM for intensive care unit (CAM-ICU) for intubated patients. Major complications within postoperative 30 days were screened. Mediation analysis was employed to explore the relationships between frailty, POD, and postoperative complications.

Results: A total of 4684 patients were included. The prevalence of frailty was 10.4% (489/4684). In comparison with non-frail patients, frail patients had a higher incidence of POD (12.7% [62/489] vs 6.5% [271/4195], RR = 2.102, 95% CI 1.568-2.819, P < 0.001) and more postoperative complications (21.5% [105/489] vs 16.7% [701/4195], RR = 1.363, 95% CI 1.082-1.716, P = 0.008). The adjusted total and direct associations between frailty and postoperative complications were 5.8% (adjusted β, 95% CI, 1.8-9.5%; P < 0.001) and 5.0% (adjusted β, 95% CI, 1.1-8.7%; P = 0.004), respectively. A significant indirect association via POD was observed (adjusted β = 0.8%; 95% CI, 0.3-1.4%; P < 0.001), accounting for 13.8% of the total effect.

Conclusion: Preoperative frailty is associated with an increased risk of postoperative complications, mediated in part by early POD, in elderly patients following non-cardiac surgery. Given the modest effect size, further research is warranted to confirm these findings.

Keywords: Elder patients; Frailty; Mediation analysis; Postoperative complications; Postoperative delirium.

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Conflict of interest statement

Declarations. Conflicts of interest: Dr. Dong-Liang Mu is supported by National Key R&D Program of China (No. 2023YFC2506900) and National High-Level Hospital Clinical Research Funding of Peking University First Hospital (No. 2022CR74). Dr. Dong-Xin Wang is supported by National Natural Science Foundation of China (No. 82293644). Dr. Chun-Jing Li is supported by National High-Level Hospital Clinical Research Funding (Interdepartmental Clinical Research Project of Peking University First Hospital) (No. 2023IR30). Dr. Ya-Fei Liu is supported by Natural Science Foundation of Beijing (No. 7234391).

References

    1. Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, Woo J, Dong B, de la Vega S, Poi PJH, Kamaruzzaman SBB, Won C, Chen L, Rockwood K, Arai H, Rodriguez-Mañas L, Cao L, Cesari M, Chan P, Leung E, Landi F, Fried LP, Morley JE, Vellas B, Flickeret L. The Asia-pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc. 2017;18(7):564–75. - PubMed
    1. van de Ree CLP, Landers MJF, Kruithof N, de Munter L, Slaets JPJ, Gosens T, et al. Effect of frailty on quality of life in elderly patients after hip fracture: a longitudinal study. BMJ Open. 2019;9(7): e025941. - PubMed - PMC
    1. Osaki T, Tatebe S, Orihara J, Uchinaka E, Ashida K, Hirooka Y, et al. Impact of frailty and sarcopenia on short- and long-term outcomes in elderly patients undergoing radical gastrectomy for gastric cancer. World J Surg. 2023;47(12):3250–61. - PubMed
    1. Gracie TJ, Caufield-Noll C, Wang N-Y, Sieber FE. The association of preoperative frailty and postoperative delirium: a meta-analysis. Anesth Analg. 2021;133(2):314–23. - PubMed - PMC
    1. Chen D, Ding Y, Zhu W, Fang T, Dong N, Yuan F, et al. Frailty is an independent risk factor for postoperative pulmonary complications in elderly patients undergoing video-assisted thoracoscopic pulmonary resections. Aging Clin Exp Res. 2022;34(4):819–26. - PubMed

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