| Objectives1.Using the method of systematic review,combining the original research data on the incidence of postoperative delirium(POD)in the elderly,analyzing the longterm trend of the incidence of POD in the elderly;and the characteristics of different populations(gender,age,years of education,marriage Status,body mass index,annual family income,ethnicity);the incidence of POD in the elderly under the influence of different regions and other factors(anesthesia methods,operation methods,operation timing,operation types,national income,diagnostic standards).Provide data support for the clinical further identification of high-risk groups of elderly POD,and provide a more comprehensive pre-research basis for the etiology of POD.2.On the basis of systematic evaluation of the incidence of POD in the elderly,comprehensively discuss its risk factors,comprehensively reveal the risk factors of POD in the elderly,provide a basis for clinical development of targeted risk prevention and control strategies,and provide important for the formulation of public health policies reference.MethodsThis study will follow the method of systematic evaluation of observational studies,according to the following steps,the incidence of POD and the risk factors of POD in the elderly were systematically evaluated:① To determine the inclusion exclusion criteria;②Literature search and screening:four Chinese databases(CNKI,CBM,WANFANG,VIP)and four English databases(The Cochrane Library,Pubmed,EMBASE,Web of Science)were searched by computer.The search time limit is from 2021 to January.The search results were imported into ENDNOTE X9 software,and the two researchers screened the literature according to the pre-defined inclusion criteria after the duplicate literature was removed.The results of literature screening were compared with each other.In case of disagreement,the three researchers will decide whether the document is included or not according to the inclusion exclusion criteria after careful reading;③Literature quality assessment:the Cross sectional study,the Case-control study,and the cohort study were evaluated using different literature quality assessment criteria,the cross-sectional study was evaluated using the crosssectional study evaluation criteria recommended by the U.S.Institute of Health Care Research and quality,the Case-control study and cohort studies will use the Cochrane-recommended Newcastle-Ottawa Scale for literature quality evaluation;④Data extraction:the two researchers independently extracted POD incidence data and POD related risk factors data of the elderly according to the data extraction table.The results were then cross-referenced,and differences were resolved by discussion or adjudication by a third researcher.⑤Data analysis:data were analyzed using STATA15.1 software.The Q test will be used to assess the heterogeneity of the studies:if the heterogeneity tests P>0.10 and I2<50%,the studies will be considered homogeneous and the fixed-effect model will be used to calculate the mergers;otherwise,the heterogeneity of the studies will be considered,random effects model and subgroup analysis were used to explore the sources of heterogeneity,chi-square test was used to evaluate the differences among subgroups,funnel diagram and linear regression were used to estimate publication bias,when<10 and>2 items were included in the study,only Egger linear regression method was used for publication bias estimation,and sensitivity analysis was used to assess the stability of the results;⑥Develop a systematic review and explain the results.Results1.Results of Meta-analysis on the incidence of POD in the elderlyA total of 115 studies with cohort type were included,of which 29 were in Chinese and 86 in English.The investigation time was from 1992 to 2019,and the literature publication time span was from 1997 to 2021,and the sample size was 749,801,of which 79,729 patients had POD.The scores of the included literature’s NOS scale ranged from 4 to 8,of which 44 were high-quality literature,and the rest were medium-quality literature.The overall methodological quality is moderate.The results of Meta-analysis showed that the total incidence of POD in the elderly was 18.80%(95%CI:16.03%～21.69%).According to different survey time,different population characteristics(gender,age group,race,marital status,body mass index,education level,family income),different regions and other related factors(operation factors related factors:anesthesia method,operation method,operation timing,Type of surgery;national income and diagnostic criteria)for subgroup analysis:(1)Long-term trend of postoperative delirium in the elderly:the incidence of POD in the elderly in 1992～2001,2002～2011,and 2012～present are:13.86%(95%CI:5.88%～24.56%),18.92%(95%CI:15.89%～22.15%),19.51%(95%CI:17.87%～21.20%).(2)The incidence of POD in the elderly with different population characteristics:different genders:male 19.47%(95%CI:17.95%～21.08%),female 20.38%(95%CI:18.22%～22.65%);different age groups:Those who are less than 75 years old are 12.20%(95%CI:8.01%～16.30%),and those who are≥ 75 years old are 26.69%(95%CI:22.39%～31.18%);different races:white people are 24.09%(95%CI:18.26%～55.18%),30.72%for other races people(95%CI:21.45%～63.88%);different marital status:21.60%for singles(95%CI:16.40%～32.70%),married Those with a body mass index of 18.50%(95%CI:4.30%～32.70%);different body mass indexes:28.53%for those with a body mass index<20kg/m2(95%CI:20.34%～37.49%)and those with a body mass index≥ 20kg/m2 25.55%(95%CI:21.77%～29.48%);education level:17.30%(95%CI:8.11%～24.82%)for those with less than 9 years of education,16.78%for those with more than 9 years of education(95%CI:10.59%～24.05%);different income levels:35.9%for those with annual household income of less than $20,000(95%CI:27.00%～44.80%),and 26.50%for those with annual household income of more than $20,000(95%CI:16.70%～36.30%).(3)The incidence of POD in the elderly in different regions:Oceania 22.5%(95%CI:19.70%～25.20%),North America 21.47%(95%CI:8.15%～28.57%),South America 18.10%(95%CI:6.50%～71.73%),Asia 17.98%(95%CI:15.20%～20.09%),Europe 17.75%(95%CI:14.20%～21.16%).(4)The incidence of POD in the elderly affected by other factors:① The incidence of POD in the elderly with surgery-related factors:Different anesthesia methods:18.76%for combined anesthesia(95%CI:1.96%～68.56%),18.29 for general anesthesia(95%CI:14.73%～22.11%),15.13%for regional anesthesia(95%CI:14.09%～21.57%);different surgical methods:18.18%for conventional surgery(95%CI:9.16%～54.57%),10.53%for minimally invasive surgery(95%CI:3.99%～44.43%);different surgical timing:15.61%for elective surgery(95%CI:12.08%～19.43%),and 26.40%for emergency surgery(95%CI:19.80%～33.30%);different types of surgery:cardiovascular surgery 21.04%(95%CI:11.62%～32.30%,thoracic surgery 19.90%(95%CI:8.70%～31.10%),Orthopedic surgery 19.19%(95%CI:16.73%～21.77%),general surgery 14.50%(95%CI:10.10%～18.90%),digestive system surgery 14.48%(95%CI:12.05%～41.37%),Urological surgery was 11.15%(95%CI:4.85%～19.67%),neurosurgery was 8.10%(95%CI:6.5%～9.60%),and gynecological surgery was 4.4%(95%CI:3.00%～5.80%).②Income in different countries:19.47%for high-income countries(95%CI:15.20%～20.35%),and 17.68%for middle-income countries(95%CI:15.85%～23.62%);③Different diagnosis methods:CAM The scale diagnosis was 21.90%(95%CI:18.80%～24.90%),and the non-CAM scale diagnosis was 16.90%(95%CI:14.50%～19.30%).2.Results of Meta-analysis on POD risk factors in the elderlyA total of 129 articles were included,including 68 Chinese articles,61 English articles,38 case-control studies,91 cohort studies,and the investigation time was between 1995-2020,published time is between 2000 and 2021.Contains 55120 study subjects,including 9735 delirium patients.The scores of the included literature’s NOS scale ranged from 4 to 8,of which 22 were high-quality literature,and the rest were medium-quality literature.The overall methodological quality is moderate.There are a total of 42 risk factors related to POD in the elderly,which are divided into preoperative,intraoperative and postoperative factors according to their correlation with surgery:(1)Preoperative factors:age(WMD=3.737,95%CI:3.057～4.417,P<0.05),cognitive dysfunction(OR=4.635,95%CI:2.998～7.166,P<0.05),alcoholism(OR=2.897,95%CI:1.393～6.023,P<0.05),smoking history(OR=3.408,95%CI:2.516～4.618,P<0.05),nutritional status(OR=2.345,95%CI:1.475～3.727,P<0.05),body mass index(WMD=0.372,95%CI:0.121～0.623,P<0.05),sleep disturbance(OR=4.038,95%CI:1.056～15.446,P<0.05),emergency surgery(OR=3.145,95%CI:1.620～6.106,P<0.05),MMSE score<23(OR=2.898,95%CI:1.839～4.566,P<0.05),ASA classification≥3(OR=3.416,95%CI:2.625～4.445,P<0.05),underlying diseases(OR=2.892,95%CI:2.380～3.515,P<0.05),combined hypertension(OR=2.424,95%CI:1.891～3.10,P<0.05),combined with diabetes(OR=2.260,95%CI:1.715～2.977,P<0.05),combined with heart disease(OR=3.354,95%CI:2.476～4.542,P<0.05),combined with chronic obstructive lung Disease(OR=1.832,95%CI:0.890～3.772,P<0.05),preoperative weakness(OR=2.359,95%CI:2.040～2.728,P<0.05),preoperative depression(OR=1.540,95%CI:1.176～2.018,P<0.05),preoperative anxiety(OR=1.359,95%CI:1.165～1.585,P<0.05),preoperative electrolyte disturbance(OR=2.547,95%CI:1.806～3.593,P<0.05),history of cerebrovascular disease(OR=3.955,95%CI:3.004～5.207,P<0.05),history of delirium dementia(OR=6.719,95%CI:2.590～17.428,P<0.05),history of mental illness(OR=3.953,95%CI:3.166～4.934,P<0.05),LVEF value<30%(OR=1.873,95%CI:1.238～2.834,P<0.05).(2)Intraoperative factors:anesthesia(OR=2.987,95%CI:1.722～5.181,P<0.05),operation time(WMD=14.046,95%CI:8.466～19.626,P<0.05),intraoperative hyoxemia Symptoms(OR=3.008,95%CI:1.112～8.135,P<0.05),intraoperative blood loss(WMD=38.434,95%CI:19.531～57.336,P<0.05),intraoperative blood transfusion(OR=2.444,95%CI:1.864～3.204,P<0.05).(3)Postoperative factors:postoperative complications(OR=2.712,95%CI:1.699～4.328,P<0.05),postoperative hypoproteinemia(OR=3.669,95%CI:2.028～6.638,P<0.05),Postoperative admission to ICU(OR=2.753,95%CI:1.768～4.287,P<0.05),postoperative hypoxemia(OR=4.242,95%CI:2.088～8.616,P<0.05),postoperative pain(OR=2.254,95%CI:1.585～3.207,P<0.05),postoperative analgesia(OR=4.246,95%CI:1.103～16.338,P<0.05),postoperative anemia(OR=4.208,95%CI:1.031～17.168,P<0.05),the length of hospital stay(WMD=3.110,95%CI:1.587～4.632,P<0.05).All are related to the occurrence of POD in the elderly.Among the preoperative factors:years of education≤9 years(OR=1.599,95%CI:0.876～2.919,P>0.05),Charles Comorbidity Index(WMD=0.240,95%CI:0.012～0.493,P>0.05),abnormal blood picture before operation(OR=2.317,95%CI:0.827～6.491,P>0.05),time from admission to operation(WMD=0.394,95%CI:0.043～0.831,P>0.05),room Fibrillation history(OR=7.807,95%CI:0.680～89.589,P>0.05)and intraoperative factors:anesthesia time(WMD=1.052,95%CI:0.102～2.205,P>0.05)and elderly POD No significant correlation occurred.Conclusions1.Conclusion of the systematic review on the incidence of postoperative delirium in the elderly(1)The total incidence of elderly POD and its long-term trend:the overall incidence of elderly POD is high,and it shows an upward trend with the growth of time.(2)The incidence of POD in the elderly under different population characteristics:the incidence of POD in female patients is slightly higher than that in men;the incidence of POD in elderly patients≥ 75 years is higher than that in patients under 75 years of age;the incidence of POD in non-white elderly The incidence of POD is higher than that of white elderly;the incidence of POD of single patients is higher than that of married elderly patients;the incidence of POD of people with body mass index<20kg/m2 is higher than that of people with body mass index≥20kg/m2;there is no statistically significant difference in the incidence of POD between those with less than 9 years of education and those with more than 9 years of education;the incidence of POD in elderly surgical patients whose family income is less than$20,000 is higher than that of elderly patients whose family income is more than$20,000.(3)The incidence of elderly POD in different regions:South America has the highest incidence of elderly POD,followed by North America,and Europe has the lowest incidence of elderly POD.(4)The incidence of POD in the elderly under other factors:the incidence of POD in elderly surgical patients who use general anesthesia and combined anesthesia is higher than the incidence of POD in elderly surgical patients who use regional anesthesia;elderly patients undergoing conventional surgery The incidence of POD in patients is higher than that of elderly patients undergoing minimally invasive surgery;the incidence of POD in elderly patients undergoing emergency surgery is higher than the incidence of POD in elderly patients undergoing elective surgery;among all types of surgery,elderly POD occurs Cardiovascular surgery has the highest rate,followed by thoracic surgery and orthopedic surgery.In comparison,elderly patients undergoing gynecological surgery have the lowest incidence of POD;elderly patients in high-income countries have a higher incidence of POD than middle-income countries The incidence of POD in elderly patients diagnosed with the CAM scale is higher than those diagnosed with the non-CAM scale.2.Conclusion of the systematic review on the risk factors for POD in the elderly(1)The preoperative risk factors for POD in the elderly are mainly:advanced age,cognitive dysfunction,alcoholism,long-term smoking,malnutrition,low body mass index,emergency surgery,MMSE score<23,high ASA score,combined basis Disease,combined electrolyte dysfunction,preoperative weakness,preoperative depression,preoperative anxiety,preoperative hypertension,preoperative disease combined with diabetes,combined with heart disease,combined with chronic obstructive pulmonary disease,history of delirium or dementia,History of mental illness and cardiac insufficiency(LVEF value less than 30%).(2)Intraoperative risk factors for elderly POD:general anesthesia,longer operation time,intraoperative hypoxemia,large intraoperative blood loss,and intraoperative blood transfusion are the intraoperative risk factors for elderly POD.(3)Postoperative risk factors for elderly POD:long hospital stay,multiple postoperative complications,postoperative hypoproteinemia,postoperative admission to ICU,postoperative hypoxemia,high postoperative pain,Postoperative analgesic analgesia and postoperative anemia are postoperative risk factors for POD in the elderly.Among the preoperative factors,the Charles comorbidity index,education years≤9 years,preoperative hematologic abnormalities,atrial fibrillation history,long time from hospital admission to operation and intraoperative anesthesia factors are not related to the occurrence of elderly POD. |
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