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Preoperative anxiety predicted the incidence of postoperative delirium in patients undergoing total hip arthroplasty: a prospective cohort study

Abstract

Background

Delirium was characterized with a series of symptoms of a sudden onset of disturbances in attention, a loss in memory loss and defects in other cognitive abilities that were also appeared in the syndrome of anxiety. Even though there are overlapped clinical symptoms existed in anxiety and delirium, the relationship between anxiety and delirium was still unclear. The propose of this study was to investigated the effect of preoperative anxiety on postoperative delirium.

Methods

Three hundred and seventy-two adults undergoing total hip arthroplasty were enrolled from October 2019 to May 2020 in the study. The preoperative anxiety was measured with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A). The participants were allocated into anxiety group (HADS-A7) and non-anxiety group (HADS-A < 7). The primary outcome was the incidence of the postoperative delirium assessed with the Confusion Assessment Method (CAM). The secondary outcomes were the duration and the severity of delirium evaluated with the Memorial Delirium assessment Scale (MDAS). The risks of delirium were also evaluated with logistic regression analysis.

Results

There were 325 patients enrolled in the end, 95 of whom met the criteria for anxiety. The incidence of delirium was 17.8% in all participants. The patients with anxiety had a higher incidence of delirium than the non-anxiety patients (25.3% vs. 14.8%, odds ratio (OR) = 0.51, 95% confidence interval (CI) = 0.92–0.29, p = 0.025). However, no significant differences were found in the duration and the severity of the delirium between the above two groups. The age, alcohol abuse, history of stroke, scores of the HADS-A, and education level were considered to be predictors of delirium.

Conclusions

The preoperative anxiety predicted the incidence of the postoperative delirium in total hip arthroplasty patients. The related intervention may be a good point for delirium prophylaxis.

Trial registration

It was registered at Chinese Clinical Trial Registry (www.chictr.org.cn) with the name of “the effect of preoperative anxiety on the postoperative cognitive function” (ChiCTR1900026054) at September 19, 2019.

Peer Review reports

Background

The postoperative delirium (POD), defined as a sudden onset of disturbances in attention, consciousness and other cognitive abilities, was one of the common surgical complications with bad outcomes. It not only had a closed relationship with other postoperative complications, such as the cognitive impairment, the high incidence of the death after surgery [1, 2], but also increased the burden of the community, including high expensive health expense and more medical resources [3,4,5,6]. Although the underling pathogenesis mechanism of delirium is ambiguous, it is of great significance to study the risk factors associated with the POD to moderate its consequences.

Many risk factors for the delirium [7,8,9,10,11,12,13,14,15,16,17,18,19,20] were reported by previous studies, including age, the educational level, anemia, operative time, alcohol abuse, physical function, medications, blood loss, infection, and cognitive function.

All the risks described above had the same character --it is hard for them to be altered by interventions that may be potentially preventive for the POD. It is more meaningful to find some risk factors that are not only specific for high-risk groups but also can be interfered for prevention. For this reason, psychiatric symptoms were a good indicator. As they had a close relation with the metabolism and function of nervous system [17, 18]. It was proved that depression was a risk factor for the POD [11, 12, 15,16,17,18,19, 21]. Anxiety was another psychiatric symptom in the clinical practice, which was quite common before surgery. There were several studies related to anxiety [17,18,19, 22], however, the relationship between the preoperative anxiety (POA) and the POD remained unclear. Thus, this issue needed further clarification.

Orthopedic surgery, especially hip surgery in elderly, has the high incidence of POD [23, 24], most likely due to advanced age, preoperative cognitive impairment and multiple comorbidities among these patients [25]. A total of 5–45% of orthopedic surgery patients experienced delirium [26,27,28]. Therefore, we planned a prospective study to clarify the relationship between the POA and the POD via orthopedic surgery. The aim of the study was to investigate whether the POA would predict the onset of POD in patients undergoing the total hip arthroplasty (THA).

Methods

Setting and subjects

Ethical approval for this study [2019-N(H)-100] was provided by the biomedicine ethics board of the University of Science and Technology of China (USTC), Hefei, China (Chairperson Professor Liu) on 5 March 2019. The study was registered at the Chinese Clinical Trial Registry (ChiCTR) with the number of ChiCTR1900026054. We consecutively recruited people aged 18 years or older, ASA I-III, undergoing the THA at the Anhui Provincial Hospital (AHPH) from October 2019 to May 2020. We excluded individuals who (1) were unable to provide written informed consent, (2) were not fluent in Chinese, (3) had a history of depression or diagnosed with depression (assessed with the Hospital Anxiety and Depression Scale-Depression [15] and diagnosed by psychiatrists), (4) had dementia or scored 24 or lower on the Mini-mental State Examination (MMSE) [15, 29], or (5) had a score of 15 or higher on the Alcohol Use Disorders Identification Test [30, 31], (6) not evaluated the level of anxiety, (7) not completed the follow-up assessment of delirium. The informed consent was written by all participants.

Demographic and clinical characteristics

We collected information about participant demographics (age, sex, BMI, and education), lifestyle (alcohol abuse, cigarette smoking). And the clinical characteristics were obtained from the clinical medical chart, including surgery sites and co-morbidity.

Preoperative anxiety

The anxiety was assessed using the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), as it was described before [32,33,34]. Briefly, it was a self-reported instrument consisting of 7 items and a 4 points Likert-scale with score ranged from 0 to 21. The severity of anxiety increased in participants with high scores in the HADS-A test. The cut-off point of HADS-A was 6/7 according to the previous study [34]. The participants with scores less than 7 were grouped in the non-anxiety group. And those with score at 7 and more were diagnosed as clinical anxiety and allocated into the anxiety group. The participants were blinded to the criteria and the grouping information.

Postoperative delirium

The incidence of delirium was the primary outcomes of the trial. Participants were assessed twice daily (in the morning and afternoon) during the first 7 postoperative days by trained researchers and nurses who administered the Confusion Assessment Method (CAM). The assessment included a review of the patients file and discussion with their allocated ward nurse and a close relative (if available). The participants who screened positive for delirium were assessed by an experienced geriatric psychiatrist to confirm. The researchers and nurses conducted the assessment of delirium after surgery were blinded to the information about grouping. The CAM is a widely used and well-validated screening tool for delirium [35,36,37], with sensitivity of 94% (95% confidence interval [CI] = 91–97%) and specificity of 89% (95% CI = 85–94%) and has been successfully adapted for use in the intensive care unit (ICU) setting (the CAM-ICU was used where appropriate) [38].

Other risk factors of POD

Secondary measures of interest included the difference between groups in the duration and severity of delirium as well as length of stay (LOS) and cognitive function. The Memorial Delirium Assessment Scale (MDAS) was performed to assess the severity of delirium [39] and was administered daily if delirium was present (range = 0–30). The duration of delirium and LOS were measured by the number of days.

Procedure

We consecutively recruited participants who were admitted to the AHPH for the THA. The demographic data, life style, clinical characteristics, MMSE were recorded on admission by the trained research assistant with patients interview and chart review. Then we assessed the level of the anxiety in the afternoon of the day before surgery with the HADS-A [22]. The general anesthesia was performed in all participants. The surgical procedures were provided by one surgical team to avoid the bias from surgical procedures. The surgeons and anesthesiologists were blinded to the information about grouping. The assessment of the delirium was performed on the first 7 days after surgery as well as the duration and the severity. In participants with the development of the delirium, the severity was assessed using the MDAS and the duration was measured by days.

Statistical analysis

On the basis of the previous study [40] report that postoperative delirium occurred in 1.18% in age 50s of patients after orthopedic surgery, and given the prevalence of delirium of 13% which was the highest rate in the study. With significance and power set at 0.05 and 90% respectively, the sample size of 94 patients was required to detect differences in each group. Of 95 patients in the anxiety group and 230 patients in the non-anxiety group were enrolled in the study.

The software of IBM SPSS statistics 25 was used to manage and analyze the data. Descriptive statistics were used to summarize data according to the allocation. Missing data from the cases not assessing anxiety and delirium were deleted from the analysis. We performed Student’s t test for normally distributed data, the Mann-Whitney U test for ordinal data without a normal distribution, and χ2 tests for proportion distributions to compare the anxiety group and non-anxiety group. p value < 0.05 was considered statistically significant.

Variables that achieved significance on uni-variate logistic regression analysis were entered into multivariate logistic regression analysis to estimate the risk of postoperative delirium. The multiple logistic regression analysis was used to adjust for multiple risk factors and interactions. Odds ratio (OR) and 95% confidence interval (CI) were presented to evaluate risk factors.

Results

Samples

A total of 372 individuals undergoing the THA enrolled in the study. They were allocated into the anxiety group and non-anxiety group according to the HADS-A test except 21 people (14 declined participation, 5 emergency surgery, 2 significant cognitive impairment). Six people in the anxiety group and 20 in the non-anxiety group withdrew consent or lost to follow-up during the study. Finally, there were 325 participants available at 7 postoperative days, including 95 in the anxiety group and 230 in the non-anxiety group (Fig. 1). The follow-up time was ended at 7 June 2020 due to the cognitive assessment at 7th postoperative day.

Fig. 1
figure1

Flow of participants in the trial

Baseline characteristics

The prevalence of the anxiety in patients undergoing the THA was 29.2% of all 325 participants. The baseline characteristics of the participants, including demographic data, life style, and clinical characteristics were shown in Table 1. No differences were found in all variables in the Table 1.

Table 1 Baseline characteristics of 325 adults allocated to anxiety or non-anxiety groups

Primary outcomes

The incidence of the POD was 19.6% of all 325 participants. It was higher in patients with anxiety than those without clinical anxiety (25.3% vs. 14.8%, OR 0.51, 95% CI 0.92–0.29, p = 0.025), indicating that the factor of preoperative anxiety predicted the incidence of delirium (Table 2).

Table 2 Primary and secondary outcomes: complete case analysis

Secondary outcomes

The duration and severity of the POD had no statistical differences between two groups (p = 0.518 and p = 0.397, respectively). However, the LOS were longer in the POD patients with anxiety than the POD patients without anxiety [7.8(3.0) vs. 6.4(1.6), p = 0.025]. No differences were found in the other variables between two groups (Table 2).

Postoperative outcomes in all participants

Table 3 showed the postoperative variables in all participants of the study. The LOS was significantly longer in the anxiety participants than those without clinical anxiety (p = 0.038), suggesting that the POA might prolong the recovery time from the surgery due to the longer length of stay. There were no statistical differences in the other variables between those two groups, including admitting to ICU, transfusion, surgery time, and other postoperative complications.

Table 3 Postoperative outcomes in two groups

Delirium risk factors

The logistic regression model was performed to find the predictors of the POD. The age, alcohol abuse, history of stroke, scores of the HADS-A, and education level were considered to be the predictors of the POD, identifying by a multivariate logistic regression model. Surgery time, BMI, and VAS scores were not statistically significant in this model (Table 4).

Table 4 Results of the multivariable logistic regression model predicting postoperative delirium

Discussion

All participants undergoing the THA were assessed with the HADS-A test in the trial. The result showed that the POA might predict the incidence of POD. However, the POA seems not to affect the duration and severity of the POD. The participants with POA were fragile after surgery due to the longer length of stay in hospital.

In order to clarify the relationship between POA and POD, the other factors, such as the emergency surgery and the history of cognitive impairment, that might interfere with the results had been strictly controlled in this case-study. Additionally, the alcohol and smoke use, education level, pain and the surgery time, which might affect the incidence of the POD, were recorded and showed no statistical differences.

The factor of POA predicted the incidence of POD in the study. In consistence with Saho’s study [22], they found that POA strongly predicted POD in cancer patients, which was confirmed our conclusion. The main difference between two studies was the time of anxiety. For the cancer patients usually had been threaten by death, they were more likely to be anxiety or even depressed after diagnosis. This situation lasted for a long time. However, the patients undergoing THA in our study had a few threats from death. They usually felt anxiety or stress in the day before surgery, even though they had endured pain when moved. On the other hand, Van Grootven reported the POA was not associated with the POD in a retrospective study of hip fracture patients [19]. Additionally, Detroyer also found no relationship between the two conditions in cardiac surgery patients [15]. However, the limitations were found in the studies, such as a retrospective study design [19] and the fact that the delirium evaluators were not psychiatric experts [15]. In this prospective study, every delirium case was confirmed by the skillful geriatric psychiatrist. Moreover, it was also proved in the multivariable logistic regression model, in which anxiety, age, alcohol abuse, education level and stroke history were detected as predictors that were also reported in some researches [26, 41, 42]. As anxiety was a quite common symptom before surgery. Our findings suggested that the POA may be a new indicator for the POD prophylaxis [22].

To explore the exact mechanism, we hypothesized that the inflammatory cytokines may be involved. It is reported that peripheral inflammatory cytokines migrate to the central nervous system and interact with microglia, causing neuroinflammation and the subsequent development of delirium [43,44,45]. Similarly, the pathway was also involved in the process of anxiety [46, 47], therefore, resulting from the increased release of inflammatory cytokines in central nervous system, the POA could be a good predictor for the POD.

There were several limitations in this study. First of all, the related mechanism was not explored during the trial. This study was aimed to confirm the relationship between the POA and the POD. The underlying mechanism will be investigated in our next step. Secondly, this is the single center trial with small sample size. A multi-center randomized controlled study was required to confirm the issue. Thirdly, the randomization was hard to performed in the study. As all participants should be categorized according to the HADS results. However, the control and the double blind was performed to reduce the bias in the study.

Conclusions

In conclusion, the POA predicted the incidence of POD in patients undergoing total hip arthroplasty. The related intervention may be a good point for delirium prophylaxis.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author for reasonable request. And the datasets will be available at www.chictr.org.cn in 6 months after publication.

Abbreviations

HADS-A:

The Hospital Anxiety and Depression Scale-Anxiety

CAM:

The Confusion Assessment Method

MDAS:

The Memorial Delirium Assessment Scale

OR:

Odds Ratio

CI:

Confidence Interval

POD:

The Postoperative Delirium

POA:

The Preoperative Anxiety

THA:

The total Hip Arthroplasty

USTC:

The University of Science and Technology of China

ChiCTR:

The Chinese Clinical Trial Registry

AHPH:

The Anhui Provincial Hospital

MMSE:

The Mini-mental State Examination

LOS:

Length Of Stay

BMI:

Body Mass Index

IHD:

Ischemic Heart Disease

ASA:

American Society of Anesthesiologists

VAS:

Visual Analogue Scale

SD:

Standard Deviation

References

  1. 1.

    Marcantonio E, Flacker J, Michaels M, et al. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):618–24.

    CAS  PubMed  Article  Google Scholar 

  2. 2.

    Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–62.

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    van den Boogaard M, Schoonhoven L, Evers AW, et al. Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med. 2012;40(1):112–8.

    PubMed  Article  Google Scholar 

  4. 4.

    Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306–16.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  5. 5.

    Pisani MA, Kong SY, Kasl SV, et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009;180(11):1092–7.

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6.

    Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  7. 7.

    Hempenius L, Slaets JP, van Asselt DZ, et al. Interventions to prevent postoperative delirium in elderly cancer patients should be targeted at those undergoing nonsuperficial surgery with special attention to the cognitive impaired patients. Eur J Surg Oncol. 2015;41(1):28–33.

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Shah S, Weed HG, He X, et al. Alcohol-related predictors of delirium after major head and neck Cancer surgery. Arch Otolaryngol Head Neck Surg. 2012;138(3):266–71.

    PubMed  Article  Google Scholar 

  9. 9.

    van Meenen LC, van Meenen DM, de Rooij SE, et al. Risk prediction models for postoperative delirium: a systematic review and meta-analysis. J Am Geriatr Soc. 2014;62(12):2383–90.

    Article  Google Scholar 

  10. 10.

    Kalisvaart KJ, Vreeswijk R, de Jonghe JF, et al. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model. J Am Geriatr Soc. 2006;54(5):817–22.

    PubMed  Article  Google Scholar 

  11. 11.

    Leung JM, Sands LP, Mullen EA, et al. Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients? J Gerontol A Biol Sci Med Sci. 2005;60(12):1563–8.

    PubMed  Article  Google Scholar 

  12. 12.

    Smith PJ, Attix DK, Weldon BC, et al. Executive function and depression as Independect risk factors for postoperative delirium. Anesthesiology. 2009;110(4):781–7.

    PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Serafim RB, Dutra MF, Saddy F, et al. Delirium in postoperative nonventilated intensive care patients: risk factors and outcomes. Ann Intensive Care. 2012;2(1):51–6.

    PubMed  PubMed Central  Article  Google Scholar 

  14. 14.

    Cohen M. Depression, anxiety, and somatic symptoms in older cancer patients: a comparison across age groups. Psychooncology. 2014;23(2):151–7.

    PubMed  Article  Google Scholar 

  15. 15.

    Detroyer E, Dobbels F, Verfaillie E, et al. Is preoperative anxiety and depression associated with onset of delirium after cardiac surgery in older patients? A prospective cohort study. J Am Geriatr Soc. 2008;56(12):2278–84.

    PubMed  Article  Google Scholar 

  16. 16.

    Smith PJ, Attix DK, Weldon BC, et al. Depressive symptoms and risk of postoperative delirium. Am J Geriatr Psychiatry. 2016;24(3):232–8.

    PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Bowman AM. The relationship of anxiety to development of postoperative delirium. J Gerontol Nurs. 1992;18(1):24–30.

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Simpson CJ, Kellett JM. The relationship between pre-operative anxiety and post-operative delirium. J Psychosom Res. 1987;31(4):491–7.

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Van Grootven B, Detroyer E, Devriendt E, et al. Is preoperative state anxiety a risk factor for postoperative delirium among elderly hip fracture patients? Geriatr Gerontol Int. 2016;16(8):948–55.

    PubMed  Article  Google Scholar 

  20. 20.

    van der Zanden V, Beishuizen SJ, Scholtens RM, et al. The effects of blood transfusion on delirium incidence. J Am Med Dir Assoc. 2016;17(8):748–53.

    PubMed  Article  Google Scholar 

  21. 21.

    Ghoneim MM, O'Hara MW. Depression and postoperative complications: an overview. BMC Surg. 2016;16:5.

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Wada S, Inoguchi H, Sadahiro R, et al. Preoperative anxiety as a predictor of delirium in Cancer patients: a prospective observational cohort study. World J Surg. 2019;43(1):134–42.

    PubMed  Article  Google Scholar 

  23. 23.

    Poeran J, Cozowicz C, Zubizarreta N, et al. Modifiable factors associated with postoperative delirium after hip fracture repair: an age-stratified retrospective cohort study. Eur J Anaesthesiol. 2020;37:649–58.

    PubMed  Google Scholar 

  24. 24.

    Halaas NB, Blennow K, Idland A-V, et al. Neurofilament light in the serum and cerebrospinal fluid of hip fracture patients with delirium. Dement Geriatr Cogn Disord. 2018;46:346–57.

    PubMed  Article  Google Scholar 

  25. 25.

    Yang Y, Zhao X, Dong T, et al. Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res. 2017;29(2):115–26.

    PubMed  Article  Google Scholar 

  26. 26.

    Yang Y, Zhao X, Gao L, et al. Incidence and associated factors of delirium after orthopedic surgery in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res. 2020. https://doi.org/10.1007/s40520-020-01674-1.

  27. 27.

    Berggren D, Gustafson Y, Eriksson B, et al. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesth Analg. 1987;66(6):497–504.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Williams-Russo P, Urquhart BL, Sharrock NE, et al. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc. 1992;40(8):759–67.

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Molloy DW, Alemayehu E, Roberts R. Reliability of a standardized mini-mental state examination compared with the traditional mini-mental state examination. Am J Psychiatry. 1991;148:102–5.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Moreta-Herrera R, Rodas JA, Lara-Salazar M. Factor validity of alcohol use disorders identification test (AUDIT) using robust estimations in ecuadorian adolescents. Alcohol Alcohol. 2020:1–9. https://doi.org/10.1093/alcalc/agaa126.

  31. 31.

    Sauders JB, Aasland OG, Babor TF, et al. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88:891–04. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x.

    Article  Google Scholar 

  32. 32.

    Akira K, Tatsuo A, Toru O, et al. Screening for psychological distress in Japanese cancer patients. Jpn J Clin Oncol. 1998;28(5):333–8.

    Article  Google Scholar 

  33. 33.

    Snaith R, Zigmond A. The hospital anxiety and depression scale. Br Med J (Clin Res Ed). 1986;292(6516):344.

    CAS  Article  Google Scholar 

  34. 34.

    Yang Y, Ding R, Hu D, et al. Reliability and validity of a Chinese version of the HADS for screening depression and anxiety in psycho-cardiological outpatients. Compr Psychiatry. 2014;55(1):215–20.

    PubMed  Article  Google Scholar 

  35. 35.

    O’Mahony R, Murthy L, Akunne A, et al. Synopsis of the national institute for health and clinical excellence guideline for prevention of delirium. Ann Intern Med. 2011;154(11):746.

    PubMed  Article  Google Scholar 

  36. 36.

    Wong CL, Holroyd-Leduc J, Simel DL, et al. Does this patient have delirium?: value of bedside instruments. JAMA. 2010;304(7):779–86.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Wei LA, Fearing MA, Sternberg EJ, et al. The confusion assessment method: a systematic review of current usage. J Am Geriatr Soc. 2008;56(5):823–30.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med. 2001;29(7):1370–9.

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Breitbart W, Rosenfeld B, Roth A, et al. The memorial delirium assessment scale. J Pain Symptom Manag. 1997;13(3):128–37.

    CAS  Article  Google Scholar 

  40. 40.

    Song K, Ko J, Kwon T, et al. Etiology and related factors of postoperative delirium in orthopedic surgery. Clinics Orthopedic Surgery. 2019;11(3):297–301.

    Article  Google Scholar 

  41. 41.

    Low S, Wee E, Dorevitch M. Impact of place of residence, frailty and other factors on rehabilitation outcomes post hip fracture. Age Ageing. 2020. https://doi.org/10.1093/ageing/afaa131.

  42. 42.

    Yang Q, Wang J, Huang X, et al. Incidence and risk factors associated with postoperative delirium following primary elective total hip arthroplasty: a retrospective nationwide inpatient sample database study. BMC Psychiatry. 2020;20(1):343–52.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22.

    PubMed  Article  Google Scholar 

  44. 44.

    Vasunilashorn SM, Ngo L, Inouye SK, et al. Cytokines and postoperative delirium in older patients undergoing major elective surgery. J Gerontol A Biol Sci Med Sci. 2015;70(10):1289–95.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  45. 45.

    Hoogland IC, Houbolt C, van Westerloo DJ, et al. Systemic inflammation and microglial activation: systematic review of animal experiments. J Neuroinflammation. 2015;12:114.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  46. 46.

    Furtado M, Katzman MA. Neuroinflammatory pathways in anxiety, posttraumatic stress, and obsessive compulsive disorders. Psychiatry Res. 2015;229(1–2):37–48.

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    O'Donovan A, Hughes BM, Slavich GM, et al. Clinical anxiety, cortisol and interleukin-6: evidence for specificity in emotion-biology relationships. Brain Behav Immun. 2010;24(7):1074–7.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

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Acknowledgements

the surgical team of Professor Shang and Professor Zhu finished the surgery procedures of all participants in this study. We appreciated their great help and assistance.

Funding

The Youth Program of National Natural Science Foundation of China (No. 81503080), the Youth Program of Anhui Provincial Natural Science Foundation (No. 1608085QH210) and the Anhui Provincial Key Research and Development Project Foundation (No. 1804 h08020286) funded this work.

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Authors

Contributions

XC was responsible for the design of the study and revised the manuscript. He was responsible for the included and excluded cases. SS and SW carried out the protocol in the study. JM and WZ assessed the level of anxiety before surgery and the delirium after surgery. CL and LZ collected the data and were blinded to the patients’ allocation. JM also performed the statistical analysis and drafted the manuscript with DW. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiaoqing Chai.

Ethics declarations

Ethics approval and consent to participate

Ethical approval for this study [2019-N(H)-100] was provided by the biomedicine ethics board of the University of Science and Technology of China (USTC), Hefei, China (Chairperson Prof. Liu) on 5 March 2019. The informed consent was written by all participants.

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Not Applicable.

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All authors declared no conflict of interest.

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Ma, J., Li, C., Zhang, W. et al. Preoperative anxiety predicted the incidence of postoperative delirium in patients undergoing total hip arthroplasty: a prospective cohort study. BMC Anesthesiol 21, 48 (2021). https://doi.org/10.1186/s12871-021-01271-3

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Keywords

  • Anxiety
  • Delirium
  • Cognitive ability
  • Hip surgery