Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Figures & data

Figure 1 PRISMA flowchart.

Figure 2 Summary of ‘Risk of bias’: Review authors’ judgements on risk of bias for each study.

Table 1 Complete overview of study characteristics, patient characteristics, interventions, and outcomes

Study	Country	Year	Study type	Single- or multi-centre	Category	Intervention	Timing compared to surgery	Surgical category	Surgical procedure	Number of patients (I/C)	Age	Gender M/F Interven-tion	Gender M/F Control	Comorbidity scoring	Cognitive impairment
Aizawa^Citation69	Japan	2002	RCT	Single	Sleep-wake cycle	Diazepam 1dd 0.1mg/kg, Flunitrazepam 0,04 mg/kg and Pethidine 1 mg/kg injection vs. usual care	Post	Abdominal	Gastric Colorectal cancer laparotomy	20/20	>70	15/5	11/9	No	Not excluded
Avidan^Citation55	USA	2017	RCT	Multi	Post-operative pain manage-ment	Ketamine 0.5 mg injection vs ketamine 1.0 mg injection vs. saline injection	Intra	Combi-nation	All types not differentiated in statistics. thoracic surgery, major vascular surgery, intra-abdominal surgery, open gynaecological surgery, open urological surgery, major orthopaedic or spine surgery, hepatobiliary surgery, and major otolaryngological surgery	227/223/222	>60, Mean = 70	144/83 and 139/84	135/87	CCI^a	Not excluded
Bakker^Citation63	Netherlands	2014	BAS^b	Single	Peri-operative care	CareWell in Hospital program vs. usual care	Peri	Combi-nation	General and surgical patients; differentiation made for statistics. Vascular, trauma, cardiothoracic and oncologic surgery	121/120	>70	Not specified in surgical subgroup	Not specified in surgical subgroup	ASA	Not excluded
Beaussier^Citation61	France	2006	RCT	Single	Post-operative pain manage-ment	Intrathecal morphine 300 mcg vs. subcutaneous saline	Intra	Abdominal	Descending colon or rectal cancer	26/26	>70	15/11	12/14	ASA	Mental dysfunction excluded
Chan^Citation70	China	2013	RCT	Single	Anaes-thesia	BIS-guided anaesthesia vs. usual care	Intra	Combi-nation	Major, non-cardiac, surgery (not further specified)	450/452	>60, Mean = 68	280/170	273/179	ASA	Dementia excluded (MMSE <24)
Chen^Citation64	Taiwan	2011	BAS	Single	Post-operative care	Modified HELP vs. usual care	Peri	Abdominal	Abdominal surgery for gastric cancer, periampullary cancer, distal pancreatic cancer, and other	102/77	>65	55/47	43/44	CCI	Severe dementia excluded
Chen^Citation56	Taiwan	2017	RCT	Single	Post-operative care	Modified HELP vs. usual care	Peri	Abdominal	Abdominal surgery for gastric cancer, periampullary cancer, distal pancreatic cancer, colorectal cancer and other	197/180	>65	111/86	103/77	CCI	Not excluded
Deiner^Citation57	USA	2017	RCT	Multi	Anaes-thesia	Dexmedetomidine infusion 0.5 μg/kg/h vs. saline	Intra	Combi-nation	Major non-cardiac surgery; spine, thoracic, orthopaedic, urologic, or general surgery	189/201	>68	92/97	98/103	ASA	Severe dementia (MMSE< 20) excluded
Fan^Citation47	China	2014	RCT	Single	Trans-fusion manage-ment	Restrictive blood transfusion (Hb < 8 g/dL) vs. liberal blood transfusion (Hb <10 g/dL)	Peri	Ortho-paedic	Unilateral total hip replacement	94/92	>65	30/64	33/59	ASA	Not excluded
Fukata^Citation71	Japan	2014	RCT	Multi	Anti-psychotics	Haloperidol 1dd 2,5 mg intravenously vs. usual care	Post	Combi-nation	Abdominal malignant and benign/Orthopaedic/Vascular and Others	59/60	>75	32/27	32/30	No	Not excluded
Harari^Citation65	UK	2007	BAS	Single	Pre-operative assess-ment and peri-operative care	Comprehensive geriatric assessment (POPS) vs. usual care	Peri	Ortho-paedic	Orthopaedic surgery	54/54	>65	18/36	25/29	No	Not excluded
Hempenius^Citation72	Netherlands	2013	RCT	Multi	Peri-operative care	Geriatric Liaison Intervention vs. usual care	Peri	Combi-nation	Surgery for solid tumours in breast, skin, vulva, cervix, endometrium, uterus, head/neck, retroperitoneum, gastrointestinal, liver, pancreas, lung, ovary, oropharynx, larynx and intra-abdominal sarcoma	148/149	>65	56/92	51/98	No	Not excluded
Jia^Citation73	China	2014	RCT	Single	Peri-operative care	Fast-track vs. usual care	Peri	Abdominal	Colorectal carcinoma	117/116	>70	76/41	70/46	No	Dementia excluded
Kalisvaart^Citation61	Netherlands	2005	RCT	Single	Anti-psychotics	Haloperidol 3dd 0,5 mg orally vs. placebo	Peri	Ortho-paedic	Hip surgery (elective only)	159/157	>70	Not specified in surgical subgroup	Not specified in surgical subgroup	APACHE-II	Dementia excluded (MMSE <25)
Kaneko^Citation77	Japan	1999	RCT	Single	Anti-psychotics	Haloperidol 1dd 5 mg intravenously vs. saline	Post	Abdominal	Gastrectomy/Colectomy	38/40	Mean = 73	24/14	26/14	No	Not excluded
Kratz^Citation68	Germany	2015	RCT	Single	Peri-operative care	Psychogeriatric liaison intervention vs. usual care	Peri	Combi-nation	General, abdominal and trauma surgery; not further specified	61/53	>70	22/39	28/25	No	Advanced dementia excluded
Kudoh^Citation48	Japan	2004	RCT	Single	Anaes-thesia	Bupivacaine spinal and propofol general anaesthesia + LMA vs. propofol and fentanyl anaesthesia + Tracheal intubation	Intra	Ortho-paedic	Total Knee Arthroplasty	75/75	>70	6/69	9/66	No	Dementia excluded
Larsen^Citation58	USA	2010	RCT	Single	Anti-psychotics	Olanzapine 5 mg orally vs. placebo	Peri	Ortho-paedic	Knee- or hip-replacement	196/204	>65	102/94	81/123	ASA	Dementia excluded
Lee^Citation74	South Korea	2018	RCT	Single	Anaes-thesia	Dexmedetomidine 1 mcg/kg bolus followed by 0.2 to 0.7 mcg/kg/h infusion vs. dexmede-tomidine 1 mcg/kg diluted to a total volume of 10 mL in saline vs. 10 ml saline	Intra	Abdominal	Radical cystectomy, partial or total nephrectomy or colorectal surgery	95/114/109	>65	44/51 and 50/64	47/62	ASA	Cognitive impaired excluded
Leung^Citation49	USA	2006	RCT	Single	Anaes-thesia	N2O with O2 vs. O2	Intra	Combi-nation	Spine/orthopaedic surgery, gynaecological surgery and 'others'	105/105	>65	52/62	63/51	CCI + ASA	Not excluded
Leung^Citation59	USA	2017	RCT	Single	Post-operative pain manage-ment	Gabapentin 3dd 300 mg vs. placebo	Peri	Ortho-paedic	Spinal surgery, hip and knee arthroplasty	350/347	>65	157/193	189/158	CCI + ASA	Not excluded
Liu^Citation78	China	2016	RCT	Single	Anaes-thesia	Dexmedetomidine 0.2–0.4 mcg/kg/h continuous infusion vs saline	Intra	Ortho-paedic	Hip, knee or shoulder joint replacement	39/40/60/58	>65	18/21 and 26/34	23/17 and 29/29	No	Not excluded
Mann^Citation50	France	2000	RCT	Single	Post-operative pain manage-ment	PCA vs. PCEA	Peri	Abdominal	Major abdominal surgery	33/31	>70	17/18	15/20	No	Abnormal mental status excluded (AMT <8)
McCaffrey^Citation67	USA	2006	RCT	Single	Post-operative care	Music therapy 4dd 1 hour vs. usual care	Post	Ortho-paedic	Hip or knee surgery	11/11	>70	4/7	4/7	No	Not excluded
McDonald^Citation66	USA	2018	BAS	Single	Peri-operative care	POSH program vs. usual care	Peri	Abdominal	Colorectal, general and hepatopancreaticobiliary surgery	183/143	>65	82/98	73/70	No	Not excluded
Mu^Citation60	China	2017	RCT	Multi	Post-operative pain manage-ment	Parecoxib 2dd 40 mg dissolved in 5 ml saline vs. 5 ml saline	Post	Ortho-paedic	Total hip and knee replacement	310/310	>60, Mean = 70	81/229	83/227	ASA	Not excluded
Nadler^Citation75	USA	2017	RCT	Single	Airway manage-ment	Perioperative continuous airway pressure vs. usual care	Peri	Ortho-paedic	Knee or hip arthroplasty	58/56	>50, Mean = 65	22/36	24/32	No	Not excluded
Nishikawa^Citation51	Japan	2004	RCT	Single	Anaes-thesia	Propofol vs sevoflurane anaesthesia	Intra	Abdominal	Laparoscopic choledocholithotomy, colectomy and sigmoidectomy	25/25	>65	13/12	12/13	ASA	Cognitive impaired excluded
Papaioannou^Citation52	Greece	2005	RCT	Single	Anaes-thesia	General vs. regional anaesthesia	Intra	Combi-nation	Orthopaedic, urological, vascular and gynaecologic surgery	28/19	>60, Mean = 68	18/10	12/7	ASA	Dementia excluded MMSE <24)
Partridge^Citation53	United Kingdom	2017	RCT	Single	Pre-operative assess-ment	Comprehensive Geriatric Assessment and optimization vs. usual care	Pre	Vascular	Endovascular/open aortic aneurysm repair or lower-limb arterial bypass surgery	85/91	>65	80/24	79/26	No	Not excluded
Radtke^Citation76	Germany	2013	RCT	Single	Anaes-thesia	BIS-guided anaesthesia vs. usual care	Intra	Combi-nation	General, abdominal, thoracic, vascular, orthopaedic, otorhinolaryngological, oral and maxillofacial, gynaecological and urologic surgery.	575/580	>60, Mean = 70	318/257	304/276	ASA	Cognitive impaired excluded (MMSE <24)
Sugano^Citation79	Japan	2017	RCT	Multi	Sleep-wake cycle	Yokukansan 3dd 2.5 mg vs. usual care	Peri	Combi-nation	Gastrointestinal or lung malignancy surgery	93/93	>70	60/33	60/33	No	Not excluded
Sultan^Citation80	Saudi Arabia	2010	RCT	Single	Sleep-wake cycle	Melatonin 5 mg vs. Midazolam 7.5 mg vs. Clonidine 100 mcg vs. usual care	Pre	Ortho-paedic	Hip arthroplasty	53/50/51/49	>65	24/29, 26/24 and 27/24	22/27	No	Dementia excluded
Wang^Citation81	China	2015	RCT	Single	Anaes-thesia	Variable ventilation vs. conventional ventilation	Intra	Abdominal	Open gastrointestinal tumour resection	79/83	>60, Mean = 67	33/46	30/53	ASA	Cognitive impaired patients excluded (MMSE <24)
Williams-Russo^Citation54	USA	1995	RCT	Single	Anaes-thesia	General vs. regional (epidural) anaesthesia	Intra	Ortho-paedic	Total knee replacement	134/128	>40, Mean = 69	63/71	58/70	CCI	Not excluded

Abbreviations: ^aCCI, Charlson Comorbidity Index; ^bBAS, Before-and-After study; ^cN.S., not specified, ^dLOS, length of stay; ^eNS, not significant.

Figure 3 Forest plot 1. Multicomponent interventions.

Figure 4 Forest plot 2. Antipsychotics.

Figure 5 Forest plot 3. Postoperative pain management.

Figure 6 Forest plot 4. Sleep-wake cycle.

Figure 7 Forest plot 5. Dexmedetomidine treatment

Figure 8 Forest plot 6. Regional vs. general anaesthesia

Figure 9 Forest plot 7. BIS-guidance.

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