Langenbecks Arch Surg DOI 10.1007/s00423-014-1190-x
LETTER TO THE EDITOR
Delirium, frailty and IL-6 in the elderly surgical patient Nigel Bagnall & Omar D. Faiz
Received: 20 January 2014 / Accepted: 30 March 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor, We commend Jia and colleagues for their important contribution [1], as there is a paucity of research into the safety and efficacy of enhanced recovery after surgery in elderly patients. This is the first evidence to suggest that enhanced recovery care may reduce the incidence of delirium in patients undergoing colorectal resection. Postoperative delirium has been found to be associated with increased risk of hospitalization and premature death [2]. The virtue of their study lies with the objective assessment of the primary outcome of delirium using a validated scoring system with high sensitivity and specificity, administered by a psychiatrist and a nurse [3]. This enhances the strength of the methodology and the credibility of the study findings. I have two points for the authors’ consideration. Firstly, did the incidence of postoperative delirium correlate either with failure to adhere to the enhanced recovery protocol or with the development of postoperative complications? Intuitively, acutely confused patients are less likely to report pain, perform deep breathing exercises and comply with enforced mobilization predisposing pulmonary infections and leading to delays with removal of catheter which leads to urinary infections. Also in the study, there was a lower incidence of postoperative heart failure in the group receiving enhanced recovery compared with that receiving traditional care which may reflect that patients given early liquid intake orally are less likely to be administered excessive intravenous fluid administration leading to cardiac decompensation. As such, were there recorded differences in the volume of intravenous fluid given after surgery? N. Bagnall (*) : O. D. Faiz Imperial College London, London, UK e-mail: [email protected] O. D. Faiz St Mark’s Academic Institute, London, UK
Second, there is evidence that frail elderly patients with colorectal cancer have higher preoperative serum interleukin6 levels than non-frail patients [4]. Patients with frailty characteristics (slow walking pace, weight loss, exhaustion, weakness, low levels of physical activity) are known to be at an increased risk of postoperative complications. Frail patients have been known to be more likely to develop delirium than non-frail patients undergoing surgery [5]. Did the authors look for features of frailty in their study population? Could frailty, elevated interleukin-6 and delirium be interrelated? Interestingly, a recent multicenter prospective randomized study by Hempenius and colleagues [6] found that a preoperative geriatric consultation, individualized treatment plan and daily inpatient geriatric nurse visits did not reduce the incidence or severity of postoperative delirium in elderly cancer patients. Perhaps, Jia and colleagues’ focus on perioperative enhanced recovery care represents a means of improving the outcome for elderly patients with cancer facing surgery. Conflicts of interest None.
References 1. Jia Y, Jin G, Guo S, Gu B, Jin Z, Goa X, Li Z (2013) Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 399(1):77–84. doi:10.1007/s00423-013-1151-9 2. Sieber FE (2009) Postoperative delirium in the elderly surgical patient. Anesthesiol Clin 27(3):451–464 3. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001) Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 13(2):229–242 4. Rønning B, Wyller TB, Seljeflot I, Jordhøy MS, Skovlund E, Nesbakken A, Kristjansson SR (2010) Frailty measures, inflammatory
Langenbecks Arch Surg biomarkers and post-operative complications in older surgical patients. Age Ageing 39(6):758–761 5. Leung J, Tsai TL, Sands LP (2011) Preoperative frailty in older surgical patients is associated with early postoperative delirium. Anesth Analg 112(5):1199–1201
6. Hempenius L, Slaets JP, van Asselt D, de Bock GH, Wiggers T, van Leeuwen BL (2013) Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly cancer patients: report on a multicentre, randomized, controlled trial. PLoS One 8(6):e64834
LETTER TO THE EDITOR
Delirium, frailty and IL-6 in the elderly surgical patient Nigel Bagnall & Omar D. Faiz
Received: 20 January 2014 / Accepted: 30 March 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor, We commend Jia and colleagues for their important contribution [1], as there is a paucity of research into the safety and efficacy of enhanced recovery after surgery in elderly patients. This is the first evidence to suggest that enhanced recovery care may reduce the incidence of delirium in patients undergoing colorectal resection. Postoperative delirium has been found to be associated with increased risk of hospitalization and premature death [2]. The virtue of their study lies with the objective assessment of the primary outcome of delirium using a validated scoring system with high sensitivity and specificity, administered by a psychiatrist and a nurse [3]. This enhances the strength of the methodology and the credibility of the study findings. I have two points for the authors’ consideration. Firstly, did the incidence of postoperative delirium correlate either with failure to adhere to the enhanced recovery protocol or with the development of postoperative complications? Intuitively, acutely confused patients are less likely to report pain, perform deep breathing exercises and comply with enforced mobilization predisposing pulmonary infections and leading to delays with removal of catheter which leads to urinary infections. Also in the study, there was a lower incidence of postoperative heart failure in the group receiving enhanced recovery compared with that receiving traditional care which may reflect that patients given early liquid intake orally are less likely to be administered excessive intravenous fluid administration leading to cardiac decompensation. As such, were there recorded differences in the volume of intravenous fluid given after surgery? N. Bagnall (*) : O. D. Faiz Imperial College London, London, UK e-mail: [email protected] O. D. Faiz St Mark’s Academic Institute, London, UK
Second, there is evidence that frail elderly patients with colorectal cancer have higher preoperative serum interleukin6 levels than non-frail patients [4]. Patients with frailty characteristics (slow walking pace, weight loss, exhaustion, weakness, low levels of physical activity) are known to be at an increased risk of postoperative complications. Frail patients have been known to be more likely to develop delirium than non-frail patients undergoing surgery [5]. Did the authors look for features of frailty in their study population? Could frailty, elevated interleukin-6 and delirium be interrelated? Interestingly, a recent multicenter prospective randomized study by Hempenius and colleagues [6] found that a preoperative geriatric consultation, individualized treatment plan and daily inpatient geriatric nurse visits did not reduce the incidence or severity of postoperative delirium in elderly cancer patients. Perhaps, Jia and colleagues’ focus on perioperative enhanced recovery care represents a means of improving the outcome for elderly patients with cancer facing surgery. Conflicts of interest None.
References 1. Jia Y, Jin G, Guo S, Gu B, Jin Z, Goa X, Li Z (2013) Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 399(1):77–84. doi:10.1007/s00423-013-1151-9 2. Sieber FE (2009) Postoperative delirium in the elderly surgical patient. Anesthesiol Clin 27(3):451–464 3. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001) Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 13(2):229–242 4. Rønning B, Wyller TB, Seljeflot I, Jordhøy MS, Skovlund E, Nesbakken A, Kristjansson SR (2010) Frailty measures, inflammatory
Langenbecks Arch Surg biomarkers and post-operative complications in older surgical patients. Age Ageing 39(6):758–761 5. Leung J, Tsai TL, Sands LP (2011) Preoperative frailty in older surgical patients is associated with early postoperative delirium. Anesth Analg 112(5):1199–1201
6. Hempenius L, Slaets JP, van Asselt D, de Bock GH, Wiggers T, van Leeuwen BL (2013) Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly cancer patients: report on a multicentre, randomized, controlled trial. PLoS One 8(6):e64834
