BERKELEY, CA (UroToday Inc.) - The development of postoperative delirium can be distressing to all those involved and may compromise the patient's outcome. Because few investigators have studied this problem and then only in selected urologic populations, Johannes Hamann and colleagues from Munich, Germany performed a prospective study to determine the incidence and predictors of ACS in patients undergoing typical urologic procedures. Their findings were published in the March 2005 edition of Urology.

They examined a total of 100 patients (≥ 60 years old) undergoing elective urologic procedures at the Technical University of Munich. All those consenting to the study underwent a preoperative assessment which included a review of medications and past medical history. They were screened for delirium using the Confusion Assessment Method (Ann Intern Med 1990; 113: 941-948) and a checklist based on the criteria for delirium from the World Health Organization's International Classification of Diseases. A Mini Mental State Examination (MMSE) was performed to assess dementia, and the Depression Status Inventory (DSI) was used to detect depression. The Charlson Comorbidity Index (CCI) was used to estimate the overall severity of the patients' illnesses, and all patients were screened for alcohol abuse with the CAGE questionnaire. Postoperatively, all patients were evaluated daily for ACS using the Confusion Assessment Method and delirium checklist until the seventh postoperative day or the day of discharge. The lowest postoperative hematocrit and any use of benzodiazepines were recorded.

The mean age of patients was 71.9 years (range, 60-92 years). A total of 77 men and 23 women were studied. The most common diagnoses were: bladder tumor (n=28), benign prostatic hyperplasia (n=27), and prostate cancer (n=20). The most commonly performed procedures were: transurethral resection of the bladder (n=26), transurethral resection of the prostate (n=26), and radical retropubic prostatectomy (n=17). The median operative time was 188 minutes (range, 15-510 minutes).

Overall, preoperative evaluation revealed 29 patients who were considered severely ill by the CCI, 7 patients had cognitive impairment by MMSE, 7 patients were depressed by DSI (5 moderate and 2 severe), and none were diagnosed with delirium. Four patients were considered possible alcoholics by the CAGE questionnaire. Older patients were more likely to have severe illness and more cognitive deficits than younger patients.

Seven patients developed postoperative ACS. Six of these became delirious between postoperative days 1-4, and one on postoperative day 6. The mean duration of the ACS was 2 days (range, 1-3 days).

An analysis was performed to determine the correlation between preoperative factors and the development of postoperative ACS. This revealed pre-existing cognitive dysfunction and longer operative times as being significant risk factors. Depression and visual impairment were also associated with an increased risk; however, these were not statistically significant.

The authors concluded that although the incidence of postoperative ACS is low, there are factors which may identify patients who are at risk. The postoperative treatment plan for these patients should include environmental strategies and prophylactic delirium care that is instituted early to prevent the potential adverse consequences of postoperative ACS.

Urology 2005; 65:449-453