Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study

T L Janssen,G H Ho,L Van Der Laan,R Van Alphen,T C J Seerden,J H Wijsman,J C M Langenberg,D Wielders,C C H A Van Hoof- De Lepper De Lepper,D C De Lange,E W Steyerberg,P D Gobardhan

doi:10.1371/journal.pone.0218152

Abstract

BackgroundDelirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients.MethodsA single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients’ physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality.ResultA total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes.ConclusionCurrent prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation.Trial registrationDutch Trial Registration, NTR5932.

Highlights

30% of the patients that undergo a colorectal resection develop postoperative complications [6], which leads to adverse outcomes and a decrease in quality of life in elderly patients [7, 8]
Up to forty-three percent of colorectal cancer patients can be considered frail [10], which makes them likely to be unable to withstand physical stress associated with surgery [11]
The incidence of delirium in elderly patients undergoing elective surgery for CRC or AAA can be reduced by implementing a multimodal prehabilitation program

Summary

Introduction

Incidence rates of common age-related diseases, such as colorectal carcinoma and abdominal aortic aneurysms, that require surgery are likely to undergo a similar increase [2, 3]. People undergoing surgery for these conditions have an increased risk of postoperative complications and mortality [4, 5]. 30% of the patients that undergo a colorectal resection develop postoperative complications [6], which leads to adverse outcomes and a decrease in quality of life in elderly patients [7, 8]. A person’s physical resilience decreases while frailty increases [9]. Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients

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