Current Factors of Fragility and Delirium in Vascular Surgery Jelle W. Raats,1 Chantal C.H.A. van Hoof-de Lepper,1 Maarten Th. Feitsma,2,3 Johannes J. Meij,4,5 Gwan H. Ho,1 Paul G.H. Mulder,1 and Lijckle van der Laan,1 Breda, Drachten, and Leiden, The Netherlands
Background: Vascular surgery patients are frequently deemed to be in a frail clinical condition and at risk for delirium. Therefore, we evaluated the incidence and independent perioperative risk factors for delirium. In addition, we describe factors on frailty in the various vascular disease groups in current practice. Methods: This observational longitudinal study included 206 selected patients who were referred to a vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia (n ¼ 80), diabetic foot ulcers (n ¼ 27), abdominal aortic aneurysm (AAA) (n ¼ 62), and carotid surgery (n ¼ 37) between April 2013 and December 2013. Data on factors that characterize frailty were collected. Delirium was scored using the Delirium Observation Screening Scale. Multivariable logistic regression analysis was performed to find independent risk factors for delirium. Results: Delirium was present in 24% of the critical limb ischemia patients, in 19% of the patients with a diabetic foot ulcer, in 7% of the patients with an AAA, and in 8% of the patients undergoing carotid surgery (P > 0.05). Of the patients with critical limb ischemia and a delirium, 53% were octogenarians. Multivariable stepwise logistic regression analysis revealed that history of delirium and nurse help at patient’s home were independently associated with delirium. Patients with critical limb ischemia scored worse on factors related to frailty compared with the other disease groups in our current clinical practice on vascular surgery. Conclusions: Delirium is a frequent complication in vascular surgery clinical practice, especially in the elderly. Nurse visits at patients’ homes and the Amphia Risk Score for delirium were independent risk factors for delirium in our study population. In this study, we identified patients with critical limb ischemia as the most frail and vulnerable.
INTRODUCTION The authors declare no conflicts of interest. 1
Department of Surgery, Amphia Hospital, Breda, The Netherlands. Department of Geriatric Medicine, Amphia Hospital, Breda, The Netherlands. 2
3 Department of Geriatric Medicine, Nij Smellinghe Hospital, Drachten, The Netherlands. 4 Department of Gerontology and Geriatrics, LUMC, Leiden, The Netherlands. 5 Department of Innovation, Amphia Hospital, Breda, The Netherlands.
Correspondence to: Jelle W. Raats, MD, Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK Breda, The Netherlands; E-mail: [email protected] Ann Vasc Surg 2015; 29: 968–976 http://dx.doi.org/10.1016/j.avsg.2015.01.005 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: September 17, 2014; manuscript accepted: January 5, 2015; published online: March 11, 2015.
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Population aging is accelerating at a tremendous rate. The number of persons aged 80 years and older is expected to double within the next 3 decades. Frailty is a state of increased vulnerability to poor maintenance of homeostasis after a stressor event, increasing the risk of adverse outcome, including falls, delirium, disability, institutionalization, and death. Recognition of frailty therefore becomes of increasing importance, especially when realizing we will face these patients in increasing numbers. Older patients often require complex medical management and have a decreased tolerance for interventions of any kind. Most vascular procedures are major operations, such as abdominal aortic repair, carotid endarterectomy, arterial bypass
Vol. 29, No. 5, July 2015
grafting, and limb amputation. Patients undergoing such extensive vascular surgical procedures are frequently elderly and considered frail.1 They often carry significant comorbidities such as cerebrovascular disease, cardiopulmonary disease, or dementia.2 Early identification of these patients at risk might be important because early interventions could prevent detrimental outcomes. Over the past few decades, several programs for screening and treatment for frailty have been implemented.3e5 A nationwide government-initiated health care project ‘‘The Dutch Hospital Patient Safety Program (DHPSP)’’ has been implemented in the Netherlands since 2009. The aim was to detect preventable detrimental outcomes in hospitalized frail patients. Frail elderly are at risk for delirium when hospitalized, especially when extensive surgery is performed.6e8 Postoperative delirium is associated with poor final outcomes such as functional decline, increased hospital length of stay, higher costs, and increased mortality up to 44%.9e12 It also impedes optimal medical treatment and requires more intensive nursing care. Therefore, delirium has been increasingly used as an indicator for healthcare quality in elderly.13 Unfortunately, delirium is not frequently recognized in approximately 50% of all hospitalized patients and is often undermanaged by clinicians.14 It is estimated that delirium is preventable in one third of all cases.3,15 This is of great importance as well-timed interventions probably result in a better outcome.16 In the current literature, only a few studies focus on predictive factors for the development of delirium after vascular surgery.17,18 B€ ohner et al. analyzed risk factors after carotid, abdominal aortic aneurysm (AAA), and peripheral bypass surgery and created a prediction model for postoperative delirium. However, specific factors for frailty and their relation to the occurrence of delirium per vascular disease group remain scarce. The aim of the study was to analyze the risk factors for delirium among patients undergoing inhospital treatment for critical limb ischemia, diabetic foot ulcers, AAA, and carotid surgery. In addition, we performed a detailed description of factors on frailty and their relation to the mentioned vascular disease groups.
PATIENTS AND METHODS Setting and Participants This observational longitudinal study included 206 selected patients who were referred to a
Factors of fragility and delirium in vascular surgery
969
vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia, diabetic foot ulcers, AAA, and carotid surgery between April 2013 and December 2013. All patients with a short hospital stay (
Background: Vascular surgery patients are frequently deemed to be in a frail clinical condition and at risk for delirium. Therefore, we evaluated the incidence and independent perioperative risk factors for delirium. In addition, we describe factors on frailty in the various vascular disease groups in current practice. Methods: This observational longitudinal study included 206 selected patients who were referred to a vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia (n ¼ 80), diabetic foot ulcers (n ¼ 27), abdominal aortic aneurysm (AAA) (n ¼ 62), and carotid surgery (n ¼ 37) between April 2013 and December 2013. Data on factors that characterize frailty were collected. Delirium was scored using the Delirium Observation Screening Scale. Multivariable logistic regression analysis was performed to find independent risk factors for delirium. Results: Delirium was present in 24% of the critical limb ischemia patients, in 19% of the patients with a diabetic foot ulcer, in 7% of the patients with an AAA, and in 8% of the patients undergoing carotid surgery (P > 0.05). Of the patients with critical limb ischemia and a delirium, 53% were octogenarians. Multivariable stepwise logistic regression analysis revealed that history of delirium and nurse help at patient’s home were independently associated with delirium. Patients with critical limb ischemia scored worse on factors related to frailty compared with the other disease groups in our current clinical practice on vascular surgery. Conclusions: Delirium is a frequent complication in vascular surgery clinical practice, especially in the elderly. Nurse visits at patients’ homes and the Amphia Risk Score for delirium were independent risk factors for delirium in our study population. In this study, we identified patients with critical limb ischemia as the most frail and vulnerable.
INTRODUCTION The authors declare no conflicts of interest. 1
Department of Surgery, Amphia Hospital, Breda, The Netherlands. Department of Geriatric Medicine, Amphia Hospital, Breda, The Netherlands. 2
3 Department of Geriatric Medicine, Nij Smellinghe Hospital, Drachten, The Netherlands. 4 Department of Gerontology and Geriatrics, LUMC, Leiden, The Netherlands. 5 Department of Innovation, Amphia Hospital, Breda, The Netherlands.
Correspondence to: Jelle W. Raats, MD, Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK Breda, The Netherlands; E-mail: [email protected] Ann Vasc Surg 2015; 29: 968–976 http://dx.doi.org/10.1016/j.avsg.2015.01.005 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: September 17, 2014; manuscript accepted: January 5, 2015; published online: March 11, 2015.
968
Population aging is accelerating at a tremendous rate. The number of persons aged 80 years and older is expected to double within the next 3 decades. Frailty is a state of increased vulnerability to poor maintenance of homeostasis after a stressor event, increasing the risk of adverse outcome, including falls, delirium, disability, institutionalization, and death. Recognition of frailty therefore becomes of increasing importance, especially when realizing we will face these patients in increasing numbers. Older patients often require complex medical management and have a decreased tolerance for interventions of any kind. Most vascular procedures are major operations, such as abdominal aortic repair, carotid endarterectomy, arterial bypass
Vol. 29, No. 5, July 2015
grafting, and limb amputation. Patients undergoing such extensive vascular surgical procedures are frequently elderly and considered frail.1 They often carry significant comorbidities such as cerebrovascular disease, cardiopulmonary disease, or dementia.2 Early identification of these patients at risk might be important because early interventions could prevent detrimental outcomes. Over the past few decades, several programs for screening and treatment for frailty have been implemented.3e5 A nationwide government-initiated health care project ‘‘The Dutch Hospital Patient Safety Program (DHPSP)’’ has been implemented in the Netherlands since 2009. The aim was to detect preventable detrimental outcomes in hospitalized frail patients. Frail elderly are at risk for delirium when hospitalized, especially when extensive surgery is performed.6e8 Postoperative delirium is associated with poor final outcomes such as functional decline, increased hospital length of stay, higher costs, and increased mortality up to 44%.9e12 It also impedes optimal medical treatment and requires more intensive nursing care. Therefore, delirium has been increasingly used as an indicator for healthcare quality in elderly.13 Unfortunately, delirium is not frequently recognized in approximately 50% of all hospitalized patients and is often undermanaged by clinicians.14 It is estimated that delirium is preventable in one third of all cases.3,15 This is of great importance as well-timed interventions probably result in a better outcome.16 In the current literature, only a few studies focus on predictive factors for the development of delirium after vascular surgery.17,18 B€ ohner et al. analyzed risk factors after carotid, abdominal aortic aneurysm (AAA), and peripheral bypass surgery and created a prediction model for postoperative delirium. However, specific factors for frailty and their relation to the occurrence of delirium per vascular disease group remain scarce. The aim of the study was to analyze the risk factors for delirium among patients undergoing inhospital treatment for critical limb ischemia, diabetic foot ulcers, AAA, and carotid surgery. In addition, we performed a detailed description of factors on frailty and their relation to the mentioned vascular disease groups.
PATIENTS AND METHODS Setting and Participants This observational longitudinal study included 206 selected patients who were referred to a
Factors of fragility and delirium in vascular surgery
969
vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia, diabetic foot ulcers, AAA, and carotid surgery between April 2013 and December 2013. All patients with a short hospital stay (
