{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T07:31:27Z","timestamp":1774942287789,"version":"3.50.1"},"reference-count":47,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,11,2]],"date-time":"2023-11-02T00:00:00Z","timestamp":1698883200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Anesthesiol."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Pharmacological avoidance guidelines for preventing delirium have been suggested; however, there are limited pragmatic studies of these strategies. Early (&amp;lt;24\u2005h) delirium can be observed in the postoperative care unit and is associated with an increased risk of subsequent delirium. We examined the effectiveness of an avoid delirium protocol (ADP) in older (&amp;gt;65 years) patients undergoing elective surgeries.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The randomized controlled trial assessed an ADP developed using the American Geriatric Society's Clinical Practice Guidelines for Postoperative Delirium in Older Adults, on early (&amp;lt;24\u2005h) incident or subsyndromal delirium. Delirium was assessed using the confusion assessment method before surgery, in the post-anesthesia care unit, and on postoperative day 1. The primary outcome of early delirium was the combined incidence of incident or subsyndromal delirium.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Early delirium was identified in 24\/235 patients (10.2%) with a risk ratio of 1.27 (95% CI 0.59\u20132.73, <jats:italic>P\u2009<\/jats:italic>=\u20090.667) for patients randomized to the ADP. In cases with protocol adherence and no benzodiazepine use, early delirium was present in 10\/73 (13.7%) compared to 14\/148 (9.5%) in non-adherent cases [risk ratio 1.45 (95% CI 0.57\u20133.10, <jats:italic>P\u2009<\/jats:italic>=\u20090.362)]. Lower American Society of Anesthesiologists physical class [odds ratio 3.31 (95% CI 1.35\u20138.92, <jats:italic>P\u2009<\/jats:italic>=\u20090.008)] and an inpatient admission [odds ratio 2.67 (95% CI 1.55\u20134.87, <jats:italic>P\u2009<\/jats:italic>=\u20090.0002)] were associated with early delirium.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Our findings suggest that pharmacological avoidance protocols limiting or avoiding the use of specific classes of medications are not effective in reducing early incident or subsyndromal delirium in older patients undergoing elective surgery.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fanes.2023.1268263","type":"journal-article","created":{"date-parts":[[2023,11,3]],"date-time":"2023-11-03T05:57:56Z","timestamp":1698991076000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Early incident and subsyndromal delirium in older patients undergoing elective surgical procedures: a randomized clinical trial of an avoid delirium protocol"],"prefix":"10.3389","volume":"2","author":[{"given":"Alisha","family":"Sachdev","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yabtsega","family":"Moges","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Micah","family":"Rubin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amanda C.","family":"Sremac","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zoe","family":"Arvanitakis","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert J.","family":"McCarthy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2023,11,2]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"470","DOI":"10.1111\/cns.13763","article-title":"Recent advances and perspectives of postoperative neurological disorders in the elderly surgical patients","volume":"28","author":"Liu","year":"2022","journal-title":"CNS Neurosci Ther"},{"key":"B2","doi-asserted-by":"publisher","first-page":"675","DOI":"10.1007\/s00540-020-02805-8","article-title":"Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study","volume":"34","author":"Zhang","year":"2020","journal-title":"J Anesth"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1215","DOI":"10.1213\/01.ane.0000167383.44984.e5","article-title":"Recovery room delirium predicts postoperative delirium after hip-fracture repair","volume":"101","author":"Sharma","year":"2005","journal-title":"Anesth Analg"},{"key":"B4","doi-asserted-by":"publisher","first-page":"471","DOI":"10.1213\/ANE.0b013e3182973650","article-title":"Outcomes of early delirium diagnosis after general anesthesia in the elderly","volume":"117","author":"Neufeld","year":"2013","journal-title":"Anesth Analg"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1835","DOI":"10.2147\/CIA.S147585","article-title":"Early postoperative delirium after hemiarthroplasty in elderly patients aged over 70 years with displaced femoral neck fracture","volume":"12","author":"Choi","year":"2017","journal-title":"Clin Interv Aging"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1154","DOI":"10.1213\/ANE.0000000000005959","article-title":"Association between perioperative medication use and postoperative delirium and cognition in older adults undergoing elective noncardiac surgery","volume":"134","author":"Duprey","year":"2022","journal-title":"Anesth Analg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.dadm.2016.11.002","article-title":"Subsyndromal delirium compared with delirium, dementia, and subjects without delirium or dementia in elderly general hospital admissions and nursing home residents","volume":"7","author":"Sepulveda","year":"2016","journal-title":"Alzheimers Dement (Amst)"},{"key":"B8","doi-asserted-by":"publisher","first-page":"402","DOI":"10.1097\/NOR.0000000000000401","article-title":"Preoperative risk factors for subsyndromal delirium in older adults who undergo joint replacement surgery","volume":"36","author":"Denny","year":"2017","journal-title":"Orthop Nurs"},{"key":"B9","doi-asserted-by":"publisher","first-page":"644","DOI":"10.1016\/j.psym.2015.05.002","article-title":"Prognostic significance of postoperative subsyndromal delirium","volume":"56","author":"Shim","year":"2015","journal-title":"Psychosomatics"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e0255607","DOI":"10.1371\/journal.pone.0255607","article-title":"Risk factors for postoperative delirium and subsyndromal delirium in older patients in the surgical ward: a prospective observational study","volume":"16","author":"Kanno","year":"2021","journal-title":"PLoS One"},{"key":"B11","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1111\/jgs.13281","article-title":"American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults","volume":"63","year":"2015","journal-title":"J Am Geriatr Soc"},{"key":"B12","doi-asserted-by":"publisher","first-page":"92","DOI":"10.1111\/anae.15607","article-title":"Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review","volume":"77","author":"Swarbrick","year":"2022","journal-title":"Anaesthesia"},{"key":"B13","doi-asserted-by":"publisher","first-page":"756","DOI":"10.1097\/ACO.0000000000000658","article-title":"Perioperative cognitive evaluation","volume":"31","author":"Borozdina","year":"2018","journal-title":"Curr Opin Anaesthesiol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1186\/s12877-017-0695-x","article-title":"Preoperative medication use and postoperative delirium: a systematic review","volume":"17","author":"Kassie","year":"2017","journal-title":"BMC Geriatr"},{"key":"B15","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1186\/s13030-020-00199-3","article-title":"Association between polypharmacy and the persistence of delirium: a retrospective cohort study","volume":"14","author":"Kurisu","year":"2020","journal-title":"Biopsychosoc Med"},{"key":"B16","doi-asserted-by":"publisher","first-page":"850.e11","DOI":"10.1016\/j.jamda.2014.08.012","article-title":"Impact of polypharmacy on occurrence of delirium in elderly emergency patients","volume":"15","author":"Hein","year":"2014","journal-title":"J Am Med Dir Assoc"},{"key":"B17","doi-asserted-by":"publisher","first-page":"189","DOI":"10.1016\/0022-3956(75)90026-6","article-title":"Mini-mental state. A practical method for grading the cognitive state of patients for the clinician","volume":"12","author":"Folstein","year":"1975","journal-title":"J Psychiatr Res"},{"key":"B18","doi-asserted-by":"publisher","first-page":"2386","DOI":"10.1001\/jama.1993.03500180078038","article-title":"Population-based norms for the mini-mental state examination by age and educational level","volume":"269","author":"Crum","year":"1993","journal-title":"JAMA"},{"key":"B19","doi-asserted-by":"publisher","first-page":"1338","DOI":"10.1164\/rccm.2107138","article-title":"The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients","volume":"166","author":"Sessler","year":"2002","journal-title":"Am J Respir Crit Care Med"},{"key":"B20","doi-asserted-by":"publisher","first-page":"447","DOI":"10.4037\/ajcc2017263","article-title":"Subsyndromal delirium and institutionalization among patients with critical illness","volume":"26","author":"Brummel","year":"2017","journal-title":"Am J Crit Care"},{"key":"B21","doi-asserted-by":"publisher","first-page":"479","DOI":"10.1111\/j.1532-5415.2005.00621.x","article-title":"Delirium and its motoric subtypes: a study of 614 critically ill patients","volume":"54","author":"Peterson","year":"2006","journal-title":"J Am Geriatr Soc"},{"key":"B22","author":"Broglio","year":""},{"key":"B23","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1186\/s12874-017-0313-9","article-title":"Performance of Firth-and logF-type penalized methods in risk prediction for small or sparse binary data","volume":"17","author":"Rahman","year":"2017","journal-title":"BMC Med Res Methodol"},{"key":"B24","doi-asserted-by":"publisher","first-page":"3824","DOI":"10.3390\/math10203824","article-title":"A double-penalized estimator to combat separation and multicollinearity in logistic regression","volume":"10","author":"Guan","year":"2022","journal-title":"Mathematics"},{"key":"B25","doi-asserted-by":"publisher","first-page":"362","DOI":"10.1213\/ANE.0000000000005593","article-title":"Multicollinearity in logistic regression models","volume":"133","author":"Bayman","year":"2021","journal-title":"Anesth Analg"},{"key":"B26","doi-asserted-by":"publisher","first-page":"635","DOI":"10.1016\/0002-9343(85)90407-3","article-title":"The futility index. An approach to the cost-effective termination of randomized clinical trials","volume":"78","author":"Ware","year":"1985","journal-title":"Am J Med"},{"key":"B27","doi-asserted-by":"publisher","first-page":"198","DOI":"10.1007\/s00540-013-1706-5","article-title":"Incidence of postoperative delirium is high even in a population without known risk factors","volume":"28","author":"Saporito","year":"2014","journal-title":"J Anesth"},{"key":"B28","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1001\/jama.2012.6857","article-title":"Postoperative delirium: a 76-year-old woman with delirium following surgery","volume":"308","author":"Marcantonio","year":"2012","journal-title":"JAMA"},{"key":"B29","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1016\/j.jamcollsurg.2011.05.004","article-title":"Modified hospital elder life program: effects on abdominal surgery patients","volume":"213","author":"Chen","year":"2011","journal-title":"J Am Coll Surg"},{"key":"B30","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1046\/j.1532-5415.2001.49109.x","article-title":"A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients","volume":"49","author":"Milisen","year":"2001","journal-title":"J Am Geriatr Soc"},{"key":"B31","doi-asserted-by":"publisher","first-page":"823","DOI":"10.1111\/j.1532-5415.2008.01674.x","article-title":"The Confusion Assessment Method: a systematic review of current usage","volume":"56","author":"Wei","year":"2008","journal-title":"J Am Geriatr Soc"},{"key":"B32","doi-asserted-by":"publisher","first-page":"411","DOI":"10.1097\/EJA.0b013e3283335cee","article-title":"Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium","volume":"27","author":"Radtke","year":"2010","journal-title":"Eur J Anaesthesiol"},{"key":"B33","doi-asserted-by":"publisher","first-page":"338","DOI":"10.1093\/bja\/aen193","article-title":"Comparison of three scores to screen for delirium in the recovery room","volume":"101","author":"Radtke","year":"2008","journal-title":"Br J Anaesth"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1691","DOI":"10.1111\/jocn.16157","article-title":"Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: a systematic review and meta-analysis","volume":"32","author":"Kim","year":"2023","journal-title":"J Clin Nurs"},{"key":"B35","doi-asserted-by":"publisher","first-page":"852","DOI":"10.1001\/jama.1996.03530350034031","article-title":"Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability","volume":"275","author":"Inouye","year":"1996","journal-title":"JAMA"},{"key":"B36","doi-asserted-by":"publisher","first-page":"1018","DOI":"10.1002\/gps.5104","article-title":"Predicting postoperative delirium severity in older adults: the role of surgical risk and executive function","volume":"34","author":"Lindroth","year":"2019","journal-title":"Int J Geriatr Psychiatry"},{"key":"B37","doi-asserted-by":"publisher","first-page":"1039","DOI":"10.12740\/PP\/45368","article-title":"Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis","volume":"50","author":"Ciesielska","year":"2016","journal-title":"Psychiatr Pol"},{"key":"B38","doi-asserted-by":"publisher","first-page":"351","DOI":"10.2147\/cia.s2759","article-title":"Postoperative delirium in the elderly: diagnosis and management","volume":"3","author":"Robinson","year":"2008","journal-title":"Clin Interv Aging"},{"key":"B39","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1016\/j.ygyno.2008.02.016","article-title":"The incidence and risk factors associated with postoperative delirium in geriatric patients undergoing surgery for suspected gynecologic malignancies","volume":"109","author":"McAlpine","year":"2008","journal-title":"Gynecol Oncol"},{"key":"B40","doi-asserted-by":"publisher","first-page":"e2094","DOI":"10.1002\/rcs.2094","article-title":"Postanesthesia care unit delirium following robot-assisted vs open retropubic radical prostatectomy: a prospective observational study","volume":"16","author":"Beck","year":"2020","journal-title":"Int J Med Robot"},{"key":"B41","doi-asserted-by":"publisher","first-page":"e101815","DOI":"10.5812\/aapm.101815","article-title":"Effect of general versus spinal anesthesia on postoperative delirium and early cognitive dysfunction in elderly patients","volume":"10","author":"Ehsani","year":"2020","journal-title":"Anesth Pain Med"},{"key":"B42","doi-asserted-by":"publisher","first-page":"704","DOI":"10.1016\/j.bja.2021.07.021","article-title":"Anaesthetic depth and delirium after major surgery: a randomised clinical trial","volume":"127","author":"Evered","year":"2021","journal-title":"Br J Anaesth"},{"key":"B43","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1016\/j.knee.2021.08.009","article-title":"Postoperative delirium following total joint arthroplasties in a multi-ethnic population\u2014a prospective observational study","volume":"32","author":"Chew","year":"2021","journal-title":"Knee"},{"key":"B44","doi-asserted-by":"publisher","first-page":"636","DOI":"10.1213\/ANE.0000000000004517","article-title":"Association between perioperative hypotension and delirium in postoperative critically ill patients: a retrospective cohort analysis","volume":"130","author":"Maheshwari","year":"2020","journal-title":"Anesth Analg"},{"key":"B45","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1093\/bja\/aeu458","article-title":"Impact of intraoperative hypotension and blood pressure fluctuations on early postoperative delirium after non-cardiac surgery","volume":"115","author":"Hirsch","year":"2015","journal-title":"Br J Anaesth"},{"key":"B46","doi-asserted-by":"publisher","first-page":"2002","DOI":"10.1053\/j.jvca.2021.09.046","article-title":"The use of cerebral oximetry in surgery: a systematic review and meta-analysis of randomized controlled trials","volume":"36","author":"Wong","year":"2022","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"B47","doi-asserted-by":"publisher","first-page":"297","DOI":"10.1007\/s11606-015-3514-0","article-title":"Detection of delirium in hospitalized older general medicine patients: a comparison of the 3D-CAM and CAM-ICU","volume":"31","author":"Kuczmarska","year":"2016","journal-title":"J Gen Intern Med"}],"container-title":["Frontiers in Anesthesiology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fanes.2023.1268263\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,3]],"date-time":"2023-11-03T05:58:12Z","timestamp":1698991092000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fanes.2023.1268263\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11,2]]},"references-count":47,"alternative-id":["10.3389\/fanes.2023.1268263"],"URL":"https:\/\/doi.org\/10.3389\/fanes.2023.1268263","relation":{},"ISSN":["2813-480X"],"issn-type":[{"value":"2813-480X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,11,2]]},"article-number":"1268263"}}