Abstract
Introduction
Delirium is a recognised complication of emergency surgery and is associated with unfavourable clinical outcomes. Previous work has suggested that delirium is under-diagnosed. Here we describe risk factors for, and the clinical impact of delirium in an older-adult emergency laparotomy cohort.
Methods
Routinely collected data on emergency laparotomy patients ≥ 65 years admitted to The Grange University Hospital from November 2021 to April 2025 were included. Delirium was scored prospectively using the 4-AT score. Frailty was defined as Clinical Frailty Score (CFS) ≥ 5. Analysis was completed using regression analysis. Outcomes after delirium included length of stay (LOS), adverse events, discharge destination and mortality.
Results
519 patients were included (51.8% female). 153 were frail (29.4%). 150 patients were living with ‘very mild’ frailty (CFS = 4, 28.9%). Post-operative delirium was diagnosed in 125 patients (24.1%).
Frail or mildly frail patients were at higher risk of delirium (CFS 4: OR 1.31 (95% confidence interval (CI) 1.15-3.30), CFS ≥ 5: OR 3.22 (95% CI 1.95-5.32)). In multivariate analysis being male, frailty, intensive care (ITU) admission and having multiple operative procedures were associated with delirium.
Patients with delirium had longer acute LOS (median 13±15.6 days vs 9±10.5 days, P < 0.001), were more likely to need inpatient rehabilitation (OR 4.41 95% CI 2.85-6.82) and to suffer adverse events (acute kidney injury OR 3.60 95% CI 2.24-5.79, cardiac events OR 2.44 95% CI 1.43-4.17, pneumonia OR 2.28 95% CI 1.47-5.49). There was no significant difference in in-hospital mortality.
Conclusions
Nearly 1 in 4 patients in this cohort developed post-operative delirium. Increasing frailty was a significant risk factor for delirium. Patients who had delirium had longer acute LOS and increased risk of adverse events. Although in-hospital mortality was not associated with delirium in this study, more work is needed to understand this fully.
Comments
Risk of delirium
Consent and risk of delirium
Would be interesting to know if practice has changed as a result? Do you think we will see 'Delirium' as part of risks in consent for emergency laparotomy, or is it already in your trust? Did you review any of the consent forms? Given the high risk of delirium with associated LOS/adverse events one could argue that it should be.
Absolutely agree that we…
Absolutely agree that we should be including it in our consent process, I don't think it's routinely mentioned. Am planning on invading our surgical audit day to talk about 4AT scoring pre and post-operatively, so will bring this along with me!
Thanks for the question. I…
Thanks for the question. I suspect the answer might be related to rates of risk factors for brain vulnerability and whether these are more prevalent in the male population, however we haven’t looked at the data from that perspective (yet!). It will be interesting to see if the findings in our population are reflected in the NELA data set following the addition of 4-AT scores.
This study highlights an…
This study highlights an important and often under-recognised issue — it’s striking to see how strongly frailty is linked with post-operative delirium and adverse outcomes. The clear visual presentation really helps communicate the clinical impact.
Did your analysis identify whether any peri-operative interventions, such as delirium screening or medication reviews, were associated with reduced risk of developing delirium in this cohort?