Date Published: June 13, 2019
Publisher: Public Library of Science
Author(s): T. L. Janssen, E. W. Steyerberg, J. C. M. Langenberg, C. C. H. A. van Hoof- de Lepper, D. Wielders, T. C. J. Seerden, D. C. de Lange, J. H. Wijsman, G. H. Ho, P. D. Gobardhan, R. van Alphen, L. van der Laan, Terence J. Quinn.
Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients.
A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients’ physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality.
A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes.
Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation.
Dutch Trial Registration, NTR5932.
Our society is ageing progressively. The number of people above 60 years old in the world is expected to more than double in the next 35 years . Incidence rates of common age-related diseases, such as colorectal carcinoma and abdominal aortic aneurysms, that require surgery are likely to undergo a similar increase [2, 3]. Elderly people undergoing surgery for these conditions have an increased risk of postoperative complications and mortality [4, 5]. Roughly 30% of the patients that undergo a colorectal resection develop postoperative complications , which leads to adverse outcomes and a decrease in quality of life in elderly patients [7, 8].
For the control group, 360 patients were considered eligible. In our prehabilitation group, 395 prospective patients were assessed for eligibility. A total of seventy-seven patients were excluded, mostly due to not being interested or early planning of surgery. Of the 318 eligible patients that entered the prehabilitation program and were seen in the outpatient clinic, 45 patients discontinued intervention and 6 were excluded from further analysis, leaving a total of 267 patients who were included in the final analysis. Two patients died before surgery, one due to respiratory failure and one due to a cerebral infarction. Fig 1 shows a diagram with a complete overview of eligibility, patient allocation and attrition .
The incidence of delirium in elderly patients undergoing elective surgery for CRC or AAA can be reduced by implementing a multimodal prehabilitation program. Although prehabilitation has previously been investigated in other surgical areas (i.e. in orthopedic surgery), this study is the first to specifically investigate the role of prehabilitation in reducing the incidence of delirium after major abdominal surgery. Patients were preoperatively assessed for frailty, physical dependence, malnourishment, cognitive impairment and other factors that increase the chance of developing a postoperative delirium and were given home-based training exercises, dietary advice and nutritional support, and intravenous iron injections in case of anaemia.
In elderly patients undergoing elective major abdominal surgery, the incidence of postoperative delirium can be reduced by implementing a prehabilitation program, during the pre-admission period, which focuses on optimizing patients’ fitness and nutritional status, and tackling factors of frailty and anaemia. Reducing delirium in these patients is feasible and safe with an easy-to-perform program. This program did not reduce LOS, the number and length of unplanned ICU admissions, and rates of other postoperative complications, readmissions, institutionalization and short-term mortality.