Documente Academic
Documente Profesional
Documente Cultură
Summary
Background Preoperative pain and depression predispose patients to delirium. We investigated whether pain and Lancet Psychiatry 2014;
depressive symptoms interact to increase the risk of delirium. 1: 43136
Published Online
October 28, 2014
Methods We enrolled 459 people without dementia, who were aged 70 years or older and were scheduled for elective
http://dx.doi.org/10.1016/
orthopaedic surgery between June, 2010, and August, 2013. At baseline, participants reported their current pain and S2215-0366(14)00006-6
the average and worst pain in the previous 7 days, on a scale of 010. Depressive symptoms before surgery were See Comment page 404
assessed with the 15-item geriatric depression scale and chart. Delirium after surgery was assessed with the confusion *CMK, PAT, MCR, and SKI
assessment method and chart. We used multivariable analysis to assess the relation between preoperative pain and contributed equally to the
postoperative delirium stratied by the presence of depressive symptoms. writing of the paper
Aging Brain Center, Institute
Findings Delirium was reported in 106 (23%) of patients, and was signicantly more frequent in those with depressive for Aging Research, Hebrew
SeniorLife, Boston, MA, USA
symptoms at baseline than in those without (relative risk [RR] 16, 95% CI 1223). Preoperative pain was associated (C M Kosar MA, P A Tabloski PhD,
with an increased adjusted risk of delirium across all pain measures (RR 107108 per 1-point increase in pain). In T G Travison PhD, R N Jones ScD,
stratied analyses, patients with depressive symptoms had a 21% increased risk of delirium for each 1-point increase E M Schmitt PhD, M R Puelle BS,
in worst pain score, which indicated a signicant interaction (pinteraction=0049). Similarly, a 13% increased risk of J B Inloes BS, J S Saczynski PhD,
Prof E R Marcantonio MD,
delirium was seen per 1-point increase in average pain score, but the interaction was not signicant. Prof S K Inouye MD); Boston
College, William F Connell
Interpretation Preoperative pain and depressive symptoms are associated with increased risk of delirium, School of Nursing, Chestnut
independently and with substantial interaction, which suggests a cumulative eect. These factors should be assessed Hill, MA, USA (P A Tabloski);
Department of Psychiatry and
before surgery. Human Behavior, Brown
University Warren Alpert
Funding US National Institute on Aging. Medical School, Providence, RI,
USA (R N Jones); Division of
Geriatric Medicine and Meyers
Introduction In view of the associations between pain and Primary Care Institute,
Delirium is characterised by acute decline in attention depression, delirium and depression, and delirium and University of Massachusetts
and cognitive function, and is a common complication of acute pain, an in-depth investigation of the inter- Medical School, Worcester, MA,
surgery in elderly adults (age 65 years and older), among relationship between preoperative pain, depression, and USA (J S Saczynski); Department
of Medicine, Beth Israel
whom incidence is 1151%.1 Adverse outcomes associated delirium seemed warranted. We did a prospective study Deaconess Medical Center,
with postoperative delirium include prolonged length of to assess whether preoperative pain and depression at Boston, MA, USA (T G Travison,
hospital stay, institutionalisation, mortality, functional baseline were risk factors for delirium, and to characterise Prof E R Marcantonio,
Prof S K Inouye); Harvard
decline, and long-term cognitive impairment.1,2 As the their respective contributions.12,13 We tested the hypothesis
Medical School, Boston, MA,
population of older adults undergoing surgical that the combination of severe pain and depression USA (T G Travison,
procedures continues to grow,3 improved understanding symptoms before surgery would be associated with an Prof E R Marcantonio,
of risk factors for delirium becomes increasingly increased risk of postoperative delirium. Prof S K Inouye); Department of
Adult Psychiatry, University
important.
Hospital Limerick and
Depression is a well recognised risk factor for Methods University of Limerick Medical
delirium, with risk in some studies having been Study population School, Limerick, Ireland
increased by two to three times.4,5 Comorbid depression This study is a secondary analysis of data collected for the (Prof D Meagher MD); and
Divisions of Geriatrics and
and delirium are associated with worse outcomes than Successful Aging After Elective Surgery (SAGES) study,14
Gerontology, and Geriatrics
with either syndrome alone.6 Depression also correlates which is a prospective cohort study of 566 patients who and Palliative Medicine, Weill
with increased pain, 7 which is underdiagnosed and underwent elective surgery, and is designed to assess the Cornell Medical College, New
undertreated in elderly people despite being linked to relation between delirium and outcomes. The methods York, NY, USA
(M Carrington Reid MD)
poor outcomes. 8 The relation between pain and have been described previously.14 Briey, eligible
Correspondence to:
delirium has mostly been described in studies of acute participants were aged 70 years or older, had no clinically
Mr Cyrus M Kosar, Aging Brain
pain experienced during hospital stay, with reports of documented evidence of previous delirium or dementia, Center, Institute for Aging
risk of delirium being increased by up to nine times in and were scheduled for major elective surgery at Beth Research, Hebrew SeniorLife,
patients with severe pain.9 Only two studies have Israel Deaconess Medical Center or Brigham and 1200 Centre Street, Boston,
MA 02131, USA
assessed the association between preoperative pain and Womens Hospital, Boston, MA, USA. Enrolment began
cyruskosar@hsl.harvard.edu
delirium.10,11 in June, 2010, and ended in August, 2013. Patients were
ERM, DM, MCR, and SKI interpreted the data. CMK and SKI drafted the 15 Teng EL, Chui HC. The modied mini-mental state (3MS)
report. All authors provided critical revisions to the report for intellectual examination. J Clin Psychiatry 1987; 48: 31418.
content and provided nal approval. Funding was obtained by SKI. 16 Katz S. Assessing self-maintenance: activities of daily living,
mobility, and instrumental activities of daily living. J Am Geriatr Soc
Declaration of interests 1983; 31: 72127.
We declare no competing interests.
17 Lawton MP, Brody EM. Assessment of older people: self-
Acknowledgments maintaining and instrumental activities of daily living. Gerontologist
This study was funded by the US National Institute on Aging (JSS, 1969; 9: 17986.
grants K01AG33643 and U01HL105268; ERM, grants R01AG030618 and 18 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of
K24AG035075; and SKI, grants P01AG031720 and K07AG041835). SKI classifying prognostic comorbidity in longitudinal studies:
holds the Milton and Shirley F Levy Family Chair at Hebrew SeniorLife/ development and validation. J Chronic Dis 1987; 40: 37383.
Harvard Medical School. We thank the patients, family members, 19 Cleeland CS, Ryan KM. Pain assessment: global use of the brief
nurses, and physicians who participated in the study, and the study sta pain inventory. Ann Acad Med Singapore 1994; 23: 12938.
at Beth Israel Deaconess Medical Center, Brigham and Womens 20 WHO. Cancer pain relief, 2nd edn. Geneva: World Health
Hospital and Hebrew SeniorLife. This work is dedicated to the memory Organization, 1996.
of Joshua Bryan Inouye Helfand. 21 Yesavage JA, Sheikh JI. Geriatric depression scale (GDS) recent
evidence and development of a shorter version. Clin Gerontol
References 1986; 5: 16573.
1 Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly 22 Almeida OP, Almeida SA. Short versions of the geriatric depression
people. Lancet 2014; 383: 91122. scale: a study of their validity for the diagnosis of a major depressive
2 Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry
van Gool WA. Delirium in elderly patients and the risk of 1999; 14: 85865.
postdischarge mortality, institutionalization, and dementia: 23 Smith PJ, Attix DK, Weldon BC, Greene NH, Monk TG. Executive
a meta-analysis. JAMA 2010; 304: 44351. function and depression as independent risk factors for
3 Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal postoperative delirium. Anesthesiology 2009; 110: 78187.
preoperative assessment of the geriatric surgical patient: a best 24 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP,
practices guideline from the American College of Surgeons Horwitz RI. Clarifying confusion: the confusion assessment
National Surgical Quality Improvement Program and the American method. A new method for detection of delirium. Ann Intern Med
Geriatrics Society. J Am Coll Surg 2012; 215: 45366. 1990; 113: 94148.
4 Galanakis P, Bickel H, Gradinger R, Von Gumppenberg S, Forstl H. 25 Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient
Acute confusional state in the elderly following hip surgery: have delirium?: value of bedside instruments. JAMA 2010;
incidence, risk factors and complications. Int J Geriatr Psychiatry 2001; 304: 77986.
16: 34955.
26 Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The confusion
5 Leung JM, Sands LP, Mullen EA, Wang Y, Vaurio L. Are assessment method: a systematic review of current usage.
preoperative depressive symptoms associated with postoperative J Am Geriatr Soc 2008; 56: 82330.
delirium in geriatric surgical patients? J Gerontol A Biol Sci Med Sci
27 Albert MS, Levko SE, Reilly C, et al. The delirium symptom
2005; 60: 156368.
interview: an interview for the detection of delirium symptoms in
6 Givens JL, Jones RN, Inouye SK. The overlap syndrome of hospitalized patients. J Geriatr Psychiatry Neurol 1992; 5: 1421.
depression and delirium in older hospitalized
28 Inouye SK, Leo-Summers L, Zhang Y, Bogardus ST Jr, Leslie DL,
patients.J Am Geriatr Soc 2009;57: 134753.
Agostini JV. A chart-based method for identication of delirium:
7 Lamb SE, Guralnik JM, Buchner DM, et al. Factors that modify the validation compared with interviewer ratings using the confusion
association between knee pain and mobility limitation in older assessment method. J Am Geriatr Soc 2005; 53: 31218.
women: the Womens Health and Aging Study.
29 Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development
Ann Rheum Dis2000; 59: 331-37.
and validation of a new scoring system for delirium severity in
8 Institute of Medicine. Relieving pain in America: a blueprint for 2 cohorts. Ann Intern Med 2014; 8: 52633.
transforming prevention, care, education and research.
30 Glymour MM, Greenland S. Causal diagrams. In: Rothman KJ,
Washington, DC: National Academies Press, 2011.
Greenland S, Lash TL, eds. Modern epidemiology, 3rd edn. New
9 Morrison RS, Magaziner J, Gilbert M, et al. Relationship between York, NY: Wolters Kluwer, Lippincott Williams & Wilkins; 2008:
pain and opioid analgesics on the development of delirium 183209.
following hip fracture.J Gerontol A Biol Sci Med Sci 2003;58: 7681.
31 Schisterman EF, Cole SR, Platt RW. Overadjustment bias and
10 Leung JM, Sands LP, Lim E, Tsai TL, Kinjo S. Does preoperative unnecessary adjustment in epidemiologic studies. Epidemiology
risk for delirium moderate the eects of postoperative pain and 2009; 20: 488495
opiate use on postoperative delirium?Am J Geriatr Psychiatry 2013;
32 National Institute for Health and Care Excellence. Delirium:
21: 94656.
diagnosis, prevention and management: NICE clinical guideline
11 Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative 103. July, 2010. http://www.nice.org.uk/guidance/cg103/resources/
delirium: the importance of pain and pain management. guidance-delirium-pdf (accessed Jan 6, 2014).
Anesth Analg 2006; 102: 126773.
33 Karp KF, Rudy T, Weiner DK. Persistent pain biases item responses
12 Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. on the geriatric depression scale (GDS): preliminary evidence for
A predictive model for delirium in hospitalized elderly medical validity of the GDS-Pain. Pain Med 2008; 9: 3343.
persons based on admission characteristics. Ann Intern Med 1993;
34 Maclullich AM, Ferguson KJ, Miller T, de Rooij SE, Cunningham C.
119: 474481.
Unravelling the pathophysiology of delirium: a focus on the role of
13 Inouye SK. Prevention of delirium in hospitalized older patients: aberrant stress responses. J Psychosom Res 2008; 65: 22938.
risk factors and targeted intervention strategies. Ann Med 2000;
32: 257263.
14 Schmitt EM, Marcantonio ER, Alsop DC, et al. Novel risk markers
and long-term outcomes of delirium: the successful aging after
elective surgery (SAGES) study design and methods.
J Am Med Dir Assoc 2012; 13: 818.e110.