择期非心脏手术老年患者围术期药物的使用与术后谵妄认知的关系

择期非心脏手术老年患者围术期药物的使用与术后谵妄认知的关系

贵州医科大学  麻醉与心脏电生理课题组

翻译：胡廷菊   编辑：张中伟   审校：曹莹

  01   背景

老年人术后谵妄频发，且与术后认知障碍（PND）相关。评估围术期用药与谵妄关系的研究普遍为总体研究，且对比性欠佳。围术期用药与谵妄关系仍不清楚。我们试图评估药物使用与接受重大择期手术的老年人术后谵妄和PND之间的关系。

  02   方法

这是一个前瞻性队列研究的二次分析，研究对象为接受重大择期手术≥70岁的非痴呆老人。术前访视了解患者居家用药的情况。收集术后医院日常使用且指南中列出的谵妄危险因素的7种不同类别的药物。这些药物是确诊谵妄发生前给予的。住院期间，每日使用谵妄评估和经验证的图表回顾法评估患者的谵妄。用神经认知成套测验评估患者术前和术后一个月的认知情况。在控制年龄、性别、手术类型、查尔森共病指数和基线认知能力因素后，使用具有对数链接函数的广义线性模型评估住院前药物的使用和术后谵妄的关系。在调整了年龄、性别、手术类型、查尔森共病指数、急性生理学、慢性健康评估(apache)-II评分和基线认知能力后，使用时变Cox模型评估日常术后药物的使用和谵妄发生的时间的关系。利用中介分析评估从基线到1个月药物使用、谵妄和认知变化之间的关系。

  03   结果

在纳入的560个病人中，134例（24%）住院期间发生了谵妄。多变量分析显示院前使用苯二氮卓类药物(相对风险[RR]，1.44;95%置信区间[CI] 0.85-2.44)β受体阻滞剂(RR, 1.38;95% CI, 0.94-2.05)、非甾体抗炎药 (RR, 1.12;95% CI, 0.77 ~ 1.62)、阿片类药物(RR, 1.22;95％CI, 0.82-1.82)或他汀类药物(RR, 1.34;95% CI, 0.92-1.95)的暴露和谵妄之间无显著相关性。术后医院使用苯二氮卓类药物(校正风险比[aHR]， 3.23;95% CI, 2.10-4.99)与严重谵妄相关。术后院内服用抗精神药物(aHR, 1.48; 95% CI, 0.74–2.94)、阿片类药物（aHR，0.82；95%CI，0.62–1.11）与谵妄无关。抗精神病药的使用(术前或术后)通过对谵妄的影响在1个月一般认知表现方面有0.34分下降(标准差，0.16)，(P = 0.03)，尽管没有观察到总的影响。

  0 4 结论

接受大手术老年人住院病人苯二氮卓类药物使用与术后谵妄增加相关。未发现住院、术后用药与1个月认知能力(独立于谵妄)之间的相关性。

  0 5 原始文献来源

Duprey MS, Devlin JW, Griffith JL, et al. Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery. Anesth Analg. 2022 Feb 24. 

英文原文    

Association Between Perioperative Medication Use

and Postoperative Delirium and Cognition in Older

Adults Undergoing Elective Noncardiac Surgery

Abstract

Background: Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery.

Methods: This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month.

Results: Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85–2.44), beta-blocker (RR, 1.38; 95% CI, 0.94–2.05), NSAID (RR, 1.12; 95% CI, 0.77–1.62), opioid (RR, 1.22; 95% CI, 0.82–1.82), or statin (RR, 1.34; 95% CI, 0.92–1.95) exposure and delirium. Postoperative

hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10–4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74–2.94) nor opioid (aHR, 0.82; 95% CI, 0.62–1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed.

Conclusions: Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.

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