Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial

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Abstract

Background: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. Methods: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0–2] or lighter (OAA/S 3–5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan–Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. Results: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02–1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60–0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84–0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03–1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24–2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53–0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10–0.97; P=0.04]. Conclusions: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. Clinical trial registration: ClinicalTrials.gov NCT00590707.

Original languageEnglish (US)
JournalBritish Journal of Anaesthesia
DOIs
StatePublished - Jan 1 2019

Fingerprint

Delirium
Randomized Controlled Trials
Walking
Confidence Intervals
Mortality
Incidence
Spinal Anesthesia
Hip Fractures
Odds Ratio
Comorbidity
Propofol
Activities of Daily Living
Proportional Hazards Models
Survivors
Logistic Models
Clinical Trials

Keywords

  • activities of daily living
  • anaesthesia, spinal
  • delirium
  • hip fractures
  • mortality

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

@article{7c8fb197dc5c4238b2443504a21d4a01,
title = "Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial",
abstract = "Background: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. Methods: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0–2] or lighter (OAA/S 3–5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan–Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. Results: One-year mortality was 14{\%} in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95{\%} confidence interval (CI), 1.02–1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95{\%} CI, 0.60–0.91; P=0.005], BMI [HR=0.91, 95{\%} CI 0.84–0.998; P=0.04], and delirium severity [HR=1.20, 95{\%} CI, 1.03–1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64{\%}, 30{\%}, and 6{\%} of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95{\%} CI, 0.24–2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95{\%} CI, 0.53–0.97; P=0.03] and delirium [OR=0.32, 95{\%} CI, 0.10–0.97; P=0.04]. Conclusions: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. Clinical trial registration: ClinicalTrials.gov NCT00590707.",
keywords = "activities of daily living, anaesthesia, spinal, delirium, hip fractures, mortality",
author = "Frederick Sieber and Neufeld, {Karin Jane} and Allan Gottschalk and George Bigelow and Esther Oh and Rosenberg, {Paul B} and Mears, {Simon C.} and Kerry Stewart and Jean-Pierre Ouanes and Mahmood Jaberi and Hasenboehler, {Erik Anton} and Wang, {Nae Yuh}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.bja.2018.12.021",
language = "English (US)",
journal = "British Journal of Anaesthesia",
issn = "0007-0912",
publisher = "Oxford University Press",

}

TY - JOUR

T1 - Depth of sedation as an interventional target to reduce postoperative delirium

T2 - mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial

AU - Sieber, Frederick

AU - Neufeld, Karin Jane

AU - Gottschalk, Allan

AU - Bigelow, George

AU - Oh, Esther

AU - Rosenberg, Paul B

AU - Mears, Simon C.

AU - Stewart, Kerry

AU - Ouanes, Jean-Pierre

AU - Jaberi, Mahmood

AU - Hasenboehler, Erik Anton

AU - Wang, Nae Yuh

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. Methods: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0–2] or lighter (OAA/S 3–5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan–Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. Results: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02–1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60–0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84–0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03–1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24–2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53–0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10–0.97; P=0.04]. Conclusions: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. Clinical trial registration: ClinicalTrials.gov NCT00590707.

AB - Background: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. Methods: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0–2] or lighter (OAA/S 3–5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan–Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. Results: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02–1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60–0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84–0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03–1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24–2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53–0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10–0.97; P=0.04]. Conclusions: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. Clinical trial registration: ClinicalTrials.gov NCT00590707.

KW - activities of daily living

KW - anaesthesia, spinal

KW - delirium

KW - hip fractures

KW - mortality

UR - http://www.scopus.com/inward/record.url?scp=85060954146&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85060954146&partnerID=8YFLogxK

U2 - 10.1016/j.bja.2018.12.021

DO - 10.1016/j.bja.2018.12.021

M3 - Article

C2 - 30857604

AN - SCOPUS:85060954146

JO - British Journal of Anaesthesia

JF - British Journal of Anaesthesia

SN - 0007-0912

ER -