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Background: Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward., Methods: This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study., Results: In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use., Conclusions: The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward., (Copyright © 2021 The American Association for Thoracic Surgery. All rights reserved.)

Background: Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery., Methods: Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival., Results: There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P < .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79)., Conclusions: A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery., (Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.)

Objective: Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection., Methods: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model., Results: Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall., Conclusions: The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection., Prospero Registration Number: CRD42019133702., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Introduction/background: Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty., Purpose: The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium., Methods: A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder., Main Outcomes and Measures: Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview., Results: A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25-0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p =0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p =0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium., Conclusion: This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium., Competing Interests: This paper/was presented at the 2019 Gerontological Society of America Annual Meeting as a poster presentation with interim findings entitled “The Association of a Frailty Index and Incident Delirium in Hospitalized Veterans”. The conference abstract was published in Innovations In Aging with DOI: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6845397/]. Dr Culley reports grants from NIGMS, during the conduct of the study; personal fees from American Society of Anesthesiology, personal fees from American Board of Anesthesiology, outside the submitted work. Dr. Arora reports an unrestricted educational grant from Pfizer Canada Inc. and honoraria from Abbott Nutrition, and honorarium from Edwards Lifesciences, outside the submitted work. Dr Rudolph reports being an unpaid board member of the American Delirium Society - a professional society dedicated to the advancement of delirium science. The authors report no other potential conflicts of interest for this work., (© 2020 Sillner et al.)

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed., Competing Interests: Funding and conflicts of interest The authors have not received any funding for this article. R.C. Arora has received an unrestricted educational grant from Pfizer Canada Inc and has received honoraria from Abbott Nutrition and Edwards Lifesciences that are unrelated to the current article. D.T. Engelman consults for Edwards Lifesciences., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Delirium is common in the ICU, with incidence rates reported to be upwards of 70%. Due to the significant morbidity and mortality associated with delirium, it is hypothesised that a delirium-free sedative agent will improve outcomes in older adults admitted to the ICU., Objectives: To assess if dexmedetomidine sedation is associated with a reduction in ICU delirium among older adults, and to evaluate its risks and benefits compared with propofol sedation., Design: Systematic review of randomised controlled trials and cohort studies with meta-analyses., Data Sources: Articles published from database inception to 8 April 2019 were retrieved from Medline, EMBASE, Evidence-based Medicine Reviews, International Pharmaceutical Abstracts, Scopus, ClinicalTrials.gov and WHO Trials., Eligibility: Studies were included if they compared dexmedetomidine sedation with propofol in the ICU, reported the incidence of delirium as an outcome and had a mean/median sample age of at least 60. Studies that examined dexmedetomidine and propofol use intra-operatively or as part of general anaesthesia were excluded., Results: Dexmedetomidine sedation was associated with a lower incidence of delirium when compared with propofol: seven studies, n=1249; risk ratio 0.70; 95% confidence interval (CI) 0.52 to 0.95; P = 0.02. There was no statistically significant difference in the incidence of bradycardia: three studies, n=278; risk ratio 1.52; 95% CI 0.85 to 2.72; P = 0.16, and hypotension: six studies, n=867 patients; risk ratio 1.12; 95% CI 0.86 to 1.45; P = 0.42. Dexmedetomidine sedation did not reduce hospital length of stay, ICU length of stay or duration of mechanical ventilation compared with propofol., Conclusion: Compared with propofol, dexmedetomidine sedation in the ICU is associated with lower delirium incidence among older adults with no significant increase in adverse events. In older adult ICU patients at risk of developing delirium, sedation with dexmedetomidine should be considered. Further research is warranted to elucidate and explain the mechanisms underlying this process, and to confirm our findings with large, multicentre trials., Trial Registration: The study protocol has been registered in PROSPERO (CRD42018099339).

Objective: Delirium is a common neurologic complication after cardiac surgery. Our primary objective was to determine the impact of delirium on self-reported problems with midterm cognitive functioning and mood postcardiac surgery., Methods: A single-center, prospective cohort study was conducted, enrolling 197 patients undergoing coronary artery bypass grafting or valve replacement. Baseline cognition and mood were assessed preoperatively in elective patients as a part of routine care using the Montreal Cognitive Assessment and Patient Health Questionnaire 9, respectively. During hospitalization, delirium was diagnosed using the Confusion Assessment Method (Confusion Assessment Method/Confusion Assessment Method Intensive Care Unit). Follow-up assessments were carried out via telephone interview at 6 to 9 months after cardiac surgery using the EuroQoL-5D, Patient Health Questionnaire 9, Alcohol Use Disorders Identification Test Consumption, Memory Impairment Screen, and Category Fluency Test assessments. We examined resultant scores in the domains of cognition and mood among delirious and nondelirious cohorts, controlling for confounders deemed clinically relevant., Results: A total of 197 patients were enrolled in the study, of whom 44 (22%) developed postoperative delirium. After adjustment, no differences were observed in cognitive functioning between the delirious and nondelirious subjects after 6 to 9 months. However, delirious patients were more likely to experience self-reported problems in affective (depression and anxiety) functioning as measured by the EuroQoL-5D (odds ratio, 4.41; 95% confidence interval, 1.51-12.92; P < .01)., Conclusions: Postoperative delirium is associated with increased anxiety and depression at 6 to 9 months postcardiac surgery. Future investigation should seek to evaluate the utility of screening programs for affective disorders in those individuals who develop delirium in the postoperative period., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Delirium is an acute change in cognitive functioning, characterized by inattention and associated with alterations in awareness and fluctuation in arousal, disorganized thinking, or altered level that preferentially affects older adult patients. In the acutely ill cardiac patient, the incidence of delirium has been reported as high as 73%, depending on the type and sensitivity of delirium assessment. Cardiac patients with delirium experience higher rates of in-hospital and longer-term mortality and are at risk for progressive cognitive impairment, loss of functional independence, and increased hospitalization costs. As such, delirium represents an undesirable outcome in cardiac patients. Care improvements such as identifying risk of delirium at time of admission or in the preoperative setting; training cardiologist, surgeons, anaesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols might reduce the incidence of delirium and its associated morbidity., (Copyright © 2016 Canadian Cardiovascular Society. All rights reserved.)

Delirium is an acute syndrome that involves fluctuating changes in attention and cognition. Although delirium is the most common neurologic complication after cardiac operation, data about its impact on long-term outcomes are lacking. The purpose of this systematic review was to examine the effect of postoperative delirium (PoD) on long-term outcomes, including morbidity, probability of death, cognitive decline, institutionalization, and health-related quality of life (HRQoL) in patients undergoing cardiac operation. After performing this systematic review we determined that PoD after cardiac operation is associated with an increased risk of probability of death and readmission to the hospital and a decrease in cognitive function, overall function, and HRQoL., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.

Objective: To determine if adding frailty measures to the EuroSCORE II improves model performance in predicting postoperative delirium., Methods: In a prospective observational study in elective cardiac surgery patients, frailty was defined using the Modified Fried Criteria (MFC), the Short Physical Performance Battery (SPPB) and a 35-item Frailty Index (FI). The primary outcome was postoperative delirium, assessed using the Confusion Assessment Method (CAM)., Results: Seventy-two (54.1%) of the 133 participants met the MFC definition for frailty and 69 (51.9%) met the SPPB definition. Eighty-eight (66.2%) participants had an FI score ≥ 0.2, and 47 (35.3%) had a score ≥ 0.3. After adjusting for the EuroSCORE II, frail patients as identified by the MFC were at increased risk of postoperative delirium (adjusted odds ratio [OR], 5.05, 95% confidence interval [CI], 1.58-16.13). Patients in the "high risk frailty" SPPB category had even greater risk (adjusted OR, 8.26, 95% CI, 2.23-30.64). FI scores ≥ 0.3 were also associated with higher risk of delirium (adjusted OR, 3.72, 95% CI, 1.39-9.92). The inclusion of any of these definitions of frailty improved the discrimination of the EuroSCORE II in predicting postoperative delirium., Conclusions: Frailty results in a 3- to 8-fold increase in risk of postoperative delirium, independent of the EuroSCORE II. "Frail" and "fit" may be considered 2 ends of a continuum, and the risk of postoperative delirium grows as one becomes increasingly frail. The addition of frailty improves the ability of the EuroSCORE II to predict postoperative delirium, pointing to opportunities for improved prevention and management., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The etiology of postcardiac surgery delirium is complex. Our primary objective was to determine the effect of the postoperative environment on the prevalence of delirium by examining the in-hospital delirium rates in 2 postoperative intensive care units with differing physical infrastructure. We further sought to identify other risk factors associated with in-hospital delirium., Methods: The rates of postoperative delirium were retrospectively examined in consecutive cardiac surgery patients during 2 separate 6-month periods. Environment 1 was characterized by a lack of physical barriers between bed spaces and was windowless, and environment 2 consisted of private rooms with physical barriers for each patient and with wall-to-wall exterior windows. Univariate and multivariate analyses to determine the risk factors associated with in-hospital delirium, including the effect of environment, were undertaken., Results: Of the 1010 patients studied, 148 (14.7%) experienced in-hospital delirium after cardiac surgery. The prevalence of delirium was not significantly different between environments 1 and 2 (16.1% vs 13.5%; P = .25). However, in patients younger than 65 years, the proportion of intensive care unit days on which delirium occurred was greater in environment 1 than in environment 2 (5.4% vs 1.7%; P = .006). Postoperative stroke or transient ischemic attack, mechanical ventilation longer than 24 hours, age 65 years or older, concomitant coronary artery bypass grafting and valve surgery, prehospital admission benzodiazepine use, a requirement for any postoperative blood product transfusion, and postoperative renal insufficiency were identified as risk factors., Conclusions: The intensive care unit environment did not have a significant effect on the overall prevalence of delirium. However, that does not preclude the possibility that the intensive care unit environment might interact with other factors, such as age, in a complex manner. Attempts to reduce delirium by adjusting the intensive care unit environment alone will likely not be sufficient, and instead will require a more comprehensive multimodal approach., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Post-operative delirium is a common and dangerous complication of cardiac surgery. Many risk factors for delirium have been identified, but its pathogenesis remains largely elusive. A study by Kazmierski and colleagues investigates a more recently considered risk factor for delirium: perturbations in the hypothalamic pituitary axis and depression. This and further work may help define novel prevention and treatment strategies for delirium.

Background: Delirium is a common neurologic complication after cardiac surgery, and may be associated with increased morbidity and mortality. Research has focused on potential causes of delirium, with little attention to its sequelae., Methods: Perioperative data were collected prospectively on all isolated cases of coronary artery bypass grafting (CABG) performed from 1995 to 2006 at a single center. The definition of delirium used in the study was that of the Society of Thoracic Surgeons. Characteristics of patients who became delirious postoperatively were compared with those of patients who did not. The outcomes of interest were long-term all-cause mortality, hospital admission for stroke, and in-hospital mortality, examined in all three cases through multivariate analysis., Results: Of 8,474 patients who underwent CABG within the defined period, 496 (5.8%) developed postoperative delirium and 229 (2.7%) died while in the hospital. At baseline, patients who developed delirium were more likely to be older and to have a greater burden of comorbid illness. Delirium was an independent predictor of perioperative stroke (odds ratio [OR]; 1.96; 95% confidence interval [CI], 1.22 to 3.16), but was not associated with in-hospital mortality (OR, 0.81; 95%CI, 0.49 to 1.34). Delirious patients had a median postoperative hospital stay of 12 days (interquartile range [IQR], 8 to 21 days) versus 6 days (IQR, 5 to 8 days) for those who were nondelirious. Delirium was identified as an independent predictor of all-cause mortality (hazard ratio [HR], 1.52; 95%CI, 1.29 to 1.78) and hospitalization for stroke (HR, 1.54; 95%CI, 1.10 to 2.17)., Conclusions: There was an association between delirium and adverse outcomes after CABG that persisted beyond the immediate perioperative period. Patients with delirium after CABG appear to have an increased long-term risk of death and stroke. The advancing age and rising rates of delirium in the CABG population make it necessary to address the prevention and management of delirium in this population., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Delirium is the most common neurological complication following cardiac surgery. Much research has focused on potential causes of delirium; however, the sequelae of delirium have not been well investigated. The objective of this study was to investigate the relationship between delirium and sepsis post coronary artery bypass grafting (CABG) and to determine if delirium is a predictor of sepsis., Methods: Peri-operative data were collected prospectively on all patients. Subjects were identified as having agitated delirium if they experienced a short-term mental disturbance marked by confusion, illusions and cerebral excitement. Patient characteristics were compared between those who became delirious and those who did not. The primary outcome of interest was post-operative sepsis. The association of delirium with sepsis was assessed by logistic regression, adjusting for differences in age, acuity, and co-morbidities., Results: Among 14,301 patients, 981 became delirious and 227 developed sepsis post-operatively. Rates of delirium increased over the years of the study from 4.8 to 8.0% (P = 0.0003). A total of 70 patients of the 227 with sepsis, were delirious. In 30.8% of patients delirium preceded the development of overt sepsis by at least 48 hours. Multivariate analysis identified several factors associated with sepsis, (receiver operating characteristic (ROC) 79.3%): delirium (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6 to 3.4), emergent surgery (OR 3.3, CI 2.2 to 5.1), age (OR 1.2, CI 1.0 to 1.3), pre-operative length of stay (LOS) more than seven days (OR 1.6, CI 1.1 to 2.3), pre-operative renal insufficiency (OR 1.9, CI 1.2 to 2.9) and complex coronary disease (OR 3.1, CI 1.8 to 5.3)., Conclusions: These data demonstrate an association between delirium and post-operative sepsis in the CABG population. Delirium emerged as an independent predictor of sepsis, along with traditional risk factors including age, pre-operative renal failure and peripheral vascular disease. Given the advancing age and increasing rates of delirium in the CABG population, the prevention and management of delirium need to be addressed.

In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50 years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including “cardiac surgery, frailty, and aged” in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes. [ABSTRACT FROM AUTHOR]

Earlier extubation after cardiac surgery is reported to have benefits on length of stay and complication rates, but the influence on postoperative delirium remains unclear. We sought to determine the effect of earlier extubation on delirium after coronary artery bypass grafting. A single-center retrospective review of consecutive isolated coronary artery bypass grafting patients from January 1, 2010, to December 31, 2015, was conducted. Baseline demographic characteristics, preoperative comorbidities, intraoperative data, and postoperative data were collected. A multivariable logistic regression was performed with analysis limited to extubation within the first 24 hours postoperatively. We identified 2561 eligible patients. Delirium occurred in 13.9% (n = 357). Duration of postoperative mechanical ventilation was associated with higher delirium rates following adjustment, particularly after 12 to 24 hours (hourly odds ratio, 1.12; 95% confidence interval, 1.05-1.19; P <.001). No association was observed during the time period from 0 to 12 hours (hourly odds ratio, 1.02; 95% confidence interval, 0.99-1.06; P =.218). Major adverse events were associated with duration of ventilation after 0 to 12 hours (hourly odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P <.002) but not after 12 to 24 hours (hourly odds ratio, 1.04; 95% CI, 0.96-1.14; P =.316). The overall rate of reintubation was 2.9% (n = 73). Our findings suggest that delirium rates increase with lengthier postoperative ventilation times. This study provides the basis for consideration of the appropriate selection of earlier extubation to minimize delirium in patients undergoing cardiac surgery. After identifying suitable individuals and adjusting for potential confounders, delirium was associated with the occurrence of postoperative delirium after 12 to 24 hours of postoperative mechanical ventilation. [ABSTRACT FROM AUTHOR]