Incidence and risk factors of postoperative delirium following total joint arthroplasty based on USA Nationwide Inpatient Sample

doi:10.3877/cma.j.issn.1674-134X.2021.01.010

Abstract

Abstract:

Objective

To explore the incidence and risk factors of delirium after total joint arthroplasty (TJA) using a large-scale national database.

Methods

A retrospective analysis was performed based on Nationwide Inpatient Sample (NIS) database of the United States from 2005~2014. The patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) with available hospitalized information registered in NIS database from 2005 to 2014 were included and analyzed separately. The patients who were less than 18 years of age, were non-elective admission, had osteomyelitis, or had pathologic fracture were excluded from this study. Patient demographics, comorbidities, length of stay (LOS), total charges, and in-hospital mortality were evaluated by Wilcoxon rank test for continuous data and chi-square test for categorical data. Logistic regression was performed to identify risk factors of delirium following TJA.

Results

A total of 1 821 924 TJAs were obtained from the NIS database, including 593 045 THAs and 1 228 879 TKAs. The general incidence of delirium after TJA was 0.99%, which peaked in the year 2008. The patients with delirium after TJA presented more comorbidities(Z=127.86、13.84, both P<0.01), increased LOS (Z=127.82, 19.33, both P<0.01), extra hospital charges(Z=128.10, 14.64, both P<0.01), and higher in-hospital mortality(χ²=102.52, 44.58, both P<0.01). Independent risk factors of delirium following TJA included advanced age, neurological disorders, alcohol and drug abuse, depression, psychoses, fluid and electrolyte disorders, diabetes, weight loss, deficiency or chronic blood loss anemia, coagulopathy, metastatic cancer, hypertension, congestive heart failure, pulmonary circulation disorders, valvular disease, peripheral vascular disorders, and renal failure. Female, black and obesity were detected to be protective factors.

Conclusions

A relatively low incidence is identified, but the occurrence of delirium after TJA usually cause a variety of severe effects. It is of benefit to study risk factors of postoperative delirium to ensure the appropriate perioperative management and moderate its consequences.

Key words: Delirium, Arthroplasty, replacement, hip, Arthroplasty, replacement, knee, Database

Qinfeng Yang, Jian Wang, Yang Zhang, Zhanjun Shi, Yichuan Xu, Yuhang Chen, Qiang Lian. Incidence and risk factors of postoperative delirium following total joint arthroplasty based on USA Nationwide Inpatient Sample[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(01): 57-63.

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References 30

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变量分类	具体变量
人口学基线指标	年龄(≤60岁、≥61岁)，性别(男性、女性)，种族(白人、黑人、西班牙人、亚洲人或太平洋岛国人、美国本土人、其他人种)
医院特征	医院病床规模(小、中、大)，医院教学状况(非教学医院、教学医院)，医院位置(乡村、城市)
合并症	艾滋病、酒精滥用(酗酒)、营养性贫血、类风湿关节炎/胶原血管疾病、慢性失血性贫血、充血性心力衰竭、慢性肺疾病、凝血功能障碍、抑郁症、无并发症的糖尿病、伴有慢性并发症的糖尿病、药物滥用、高血压、甲状腺功能减退症、肝脏疾病、淋巴瘤、水电解质紊乱、转移癌、神经系统疾病、肥胖、瘫痪、外周血管疾病、精神病、肺循环功能障碍、肾衰竭、未转移的实体肿瘤、消化性溃疡病、心脏瓣膜病、体重减轻(营养不良)

变量分类	具体变量
人口学基线指标	年龄(≤60岁、≥61岁)，性别(男性、女性)，种族(白人、黑人、西班牙人、亚洲人或太平洋岛国人、美国本土人、其他人种)
医院特征	医院病床规模(小、中、大)，医院教学状况(非教学医院、教学医院)，医院位置(乡村、城市)
合并症	艾滋病、酒精滥用(酗酒)、营养性贫血、类风湿关节炎/胶原血管疾病、慢性失血性贫血、充血性心力衰竭、慢性肺疾病、凝血功能障碍、抑郁症、无并发症的糖尿病、伴有慢性并发症的糖尿病、药物滥用、高血压、甲状腺功能减退症、肝脏疾病、淋巴瘤、水电解质紊乱、转移癌、神经系统疾病、肥胖、瘫痪、外周血管疾病、精神病、肺循环功能障碍、肾衰竭、未转移的实体肿瘤、消化性溃疡病、心脏瓣膜病、体重减轻(营养不良)

指标		THA		统计值	P值	TKA		统计值	P值
指标		非谵妄组	谵妄组	统计值	P值	非谵妄组	谵妄组	统计值	P值
总例数		587 342	5 703			1 216 540	12 339
总发生率(%)		0.96		-	-	1.00		χ²＝7.35	<0.01
年龄(岁)		65(58，72)	76(70，82)	Z＝128.38	0.215	66(59，73)	75(69，81)	Z＝14.49	<0.01
年龄组(%)
	≤50岁	11.85	2.07	χ²＝3 963.54	<0.01	6.46	1.13	χ²＝6 792.47	<0.01
	51～60岁	23.12	6.10			23.01	6.50
	61～70岁	29.66	16.85			35.43	22.35
	≥1岁	35.37	74.98			35.10	70.02
女性[例(%) ]		56.05	57.67	χ²＝6.05	0.014	62.90	59.35	χ²＝64.43	<0.01
种族(%)
	白人	86.41	90.07	χ²＝54.90	<0.01	83.35	86.62	χ²＝81.72	<0.01
	黑人	7.10	4.90			7.37	5.72
	西班牙人	3.23	2.43			5.32	4.20
	亚洲人或太平洋岛国人	0.91	0.74			1.25	1.05
	美国本土人	0.33	0.27			0.48	0.39
	其他人种	2.01	1.58			2.22	2.02
CCI		4(3，4)	5(4，6)	Z＝127.86	<0.01	4(3，4)	5(4，6)	Z＝13.84	<0.01
LOS(d)		3(2，3)	5(3，6)	Z＝127.82	<0.01	3(3，4)	4(3，6)	Z＝19.33	<0.01
住院总费用(千美元)		51.41(38.47，69.35)	63.84(47.32，88.97)	Z＝128.10	<0.01	41.24(30.55，57.28)	46.39(33.71，66.75)	Z＝14.64	<0.01
住院死亡率(%)		0.15	0.68	χ²＝102.52	<0.01	0.07	0.24	χ²＝44.58	<0.01

指标		THA		统计值	P值	TKA		统计值	P值
指标		非谵妄组	谵妄组	统计值	P值	非谵妄组	谵妄组	统计值	P值
总例数		587 342	5 703			1 216 540	12 339
总发生率(%)		0.96		-	-	1.00		χ²＝7.35	<0.01
年龄(岁)		65(58，72)	76(70，82)	Z＝128.38	0.215	66(59，73)	75(69，81)	Z＝14.49	<0.01
年龄组(%)
	≤50岁	11.85	2.07	χ²＝3 963.54	<0.01	6.46	1.13	χ²＝6 792.47	<0.01
	51～60岁	23.12	6.10			23.01	6.50
	61～70岁	29.66	16.85			35.43	22.35
	≥1岁	35.37	74.98			35.10	70.02
女性[例(%) ]		56.05	57.67	χ²＝6.05	0.014	62.90	59.35	χ²＝64.43	<0.01
种族(%)
	白人	86.41	90.07	χ²＝54.90	<0.01	83.35	86.62	χ²＝81.72	<0.01
	黑人	7.10	4.90			7.37	5.72
	西班牙人	3.23	2.43			5.32	4.20
	亚洲人或太平洋岛国人	0.91	0.74			1.25	1.05
	美国本土人	0.33	0.27			0.48	0.39
	其他人种	2.01	1.58			2.22	2.02
CCI		4(3，4)	5(4，6)	Z＝127.86	<0.01	4(3，4)	5(4，6)	Z＝13.84	<0.01
LOS(d)		3(2，3)	5(3，6)	Z＝127.82	<0.01	3(3，4)	4(3，6)	Z＝19.33	<0.01
住院总费用(千美元)		51.41(38.47，69.35)	63.84(47.32，88.97)	Z＝128.10	<0.01	41.24(30.55，57.28)	46.39(33.71，66.75)	Z＝14.64	<0.01
住院死亡率(%)		0.15	0.68	χ²＝102.52	<0.01	0.07	0.24	χ²＝44.58	<0.01

变量		THA			TKA
变量		OR值	95% CI	P值	OR值	95% CI	P值
年龄≥ 61岁		4.78	(4.30，5.33)	<0.01	4.39	(4.07，4.73)	<0.01
女性		0.83	(0.78，0.89)	<0.01	0.82	(0.78，0.85)	<0.01
种族
	白人	-	-	-	-	-	-
	黑人	0.82	(0.71，0.94)	<0.01	0.88	(0.80，0.96)	<0.01
	西班牙人	0.81	(0.67，0.99)	0.03	0.82	(0.74，0.90)	<0.01
	亚洲人或太平洋岛国人	0.91	(0.65，1.27)	0.56	0.82	(0.68，1.00)	0.05
	美国本土人	0.77	(0.43，1.38)	0.38	0.84	(0.61，1.16)	0.30
	其他人种	0.86	(0.68，1.09)	0.21	0.92	(0.80，1.06)	0.27
医院病床规模
	小	-	-	-	-	-	-
	中	0.95	(0.87，1.04)	0.26	0.94	(0.89，1.00)	0.06
	大	0.92	(0.85，0.99)	0.04	0.93	(0.88，0.98)	<0.01
教学医院		1.08	(1.02，1.15)	0.01	1.11	(1.07，1.16)	<0.01
城市医院		0.89	(0.81，0.98)	0.02	0.85	(0.80，0.91)	<0.01
艾滋病		0.77	(0.25，2.42)	0.65	0.72	(0.10，5.26)	0.75
酒精滥用(酗酒)		1.89	(1.59，2.24)	<0.01	2.64	(2.31，3.01)	<0.01
营养性贫血		1.31	(1.22，1.41)	<0.01	1.41	(1.34，1.48)	<0.01
类风湿关节炎/胶原血管疾病		0.90	(0.78，1.05)	0.20	1.02	(0.93，1.13)	0.65
慢性失血性贫血		1.34	(1.12，1.60)	<0.01	1.59	(1.40，1.79)	<0.01
充血性心力衰竭		1.72	(1.54，1.92)	<0.01	1.77	(1.63，1.92)	<0.01
慢性肺疾病		1.04	(0.96，1.13)	0.30	1.14	(1.08，1.20)	<0.01
凝血功能障碍		1.37	(1.20，1.57)	<0.01	1.64	(1.49，1.80)	<0.01
抑郁症		1.42	(1.31，1.54)	<0.01	1.33	(1.26，1.40)	<0.01
无并发症的糖尿病		1.19	(1.10，1.29)	<0.01	1.15	(1.10，1.21)	<0.01
伴有慢性并发症的糖尿病		1.64	(1.37，1.95)	<0.01	1.77	(1.60，1.96)	<0.01
药物滥用		2.53	(1.97，3.25)	<0.01	2.06	(1.66，2.56)	<0.01
高血压		1.21	(1.13，1.30)	<0.01	1.12	(1.07，1.18)	<0.01
甲状腺功能减退症		1.06	(0.98，1.15)	0.15	1.01	(0.96，1.07)	0.63
肝脏疾病		1.18	(0.92，1.51)	0.18	1.14	(0.94，1.37)	0.18
淋巴瘤		1.67	(1.19，2.33)	<0.01	1.08	(0.77，1.54)	0.65
水电解质紊乱		2.44	(2.28，2.62)	<0.01	2.48	(2.36，2.61)	<0.01
转移癌		1.82	(1.28，2.59)	<0.01	1.95	(1.23，3.11)	<0.01
神经系统疾病		7.57	(7.06，8.12)	<0.01	8.69	(8.29，9.11)	<0.01
肥胖		0.72	(0.65，0.79)	<0.01	0.72	(0.68，0.76)	<0.01
瘫痪		1.23	(0.90，1.67)	0.19	1.19	(0.92，1.55)	0.19
外周血管疾病		1.38	(1.22，1.57)	<0.01	1.46	(1.32，1.61)	<0.01
精神病		1.97	(1.70，2.28)	<0.01	2.28	(2.07，2.50)	<0.01
肺循环功能障碍		1.55	(1.29，1.86)	<0.01	1.53	(1.34，1.74)	<0.01
肾衰竭		1.38	(1.24，1.52)	<0.01	1.50	(1.39，1.61)	<0.01
未转移的实体肿瘤		1.10	(0.82，1.49)	0.53	1.47	(1.17，1.84)	<0.01
消化性溃疡病		2.26	(0.68，7.53)	0.18	1.43	(0.52，3.95)	0.49
心脏瓣膜病		1.36	(1.22，1.52)	<0.01	1.26	(1.16，1.37)	<0.01
体重减轻(营养不良)		1.62	(1.33，1.97)	<0.01	2.18	(1.77，2.68)	<0.01

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