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      Geriatric Nutritional Risk Index can predict postoperative delirium and hospital length of stay in elderly patients undergoing non‐cardiac surgery

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          Abstract

          Aim

          Malnutrition is common in older patients and is associated with adverse outcomes. The Geriatric Nutritional Risk Index (GNRI) has been developed as an objective index to assess nutritional risk in these patients. However, there is limited evidence regarding the association between GNRI and postoperative delirium (POD) as well as length of stay (LOS) in surgical older patients. Therefore, our goal was to examine the impact of poor nutrition, evaluated by the GNRI, on POD and length of stay in older patients undergoing non‐cardiac surgery.

          Methods

          In this prospective cohort study, older patients undergoing non‐cardiac surgery from April to June of 2015 were included. Preoperative nutritional status was assessed by the GNRI within the first 48 h after hospital admission. The outcomes were POD and LOS. Multivariable logistic regression and linear regression analyses were used to assess the role of GNRI in predicting these outcomes.

          Results

          In the whole sample ( N = 288), the prevalence of severe/moderate (GNRI <92) and low (GNRI 92–98) nutritional risk was 15.6% and 29.5%, respectively. The median length of hospital stay was 14 days. Delirium was present in 49 patients (17%). A linear regression analysis showed that low (β = 4.56, 95% confidence interval [CI]: 2.18–6.94) and severe/moderate (β = 3.70, 95% CI: 0.74–6.65) nutritional risk were associated with prolonged LOS. Moreover, a multivariate analysis revealed that patients with severe/moderate nutritional risk were more likely to develop POD compared with those without (odds ratio = 2.56, 95% CI: 1.11–5.89).

          Conclusion

          Preoperative malnutrition, as assessed using the GNRI, predicted LOS and the development of POD in elderly non‐cardiac surgical patients. Geriatr Gerontol Int 2020; 20: 759–764.

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          Most cited references24

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          Geriatric Nutritional Risk Index: a new index for evaluating at-risk elderly medical patients.

          Patients at risk of malnutrition and related morbidity and mortality can be identified with the Nutritional Risk Index (NRI). However, this index remains limited for elderly patients because of difficulties in establishing their normal weight. Therefore, we replaced the usual weight in this formula by ideal weight according to the Lorentz formula (WLo), creating a new index called the Geriatric Nutritional Risk Index (GNRI). First, a prospective study enrolled 181 hospitalized elderly patients. Nutritional status [albumin, prealbumin, and body mass index (BMI)] and GNRI were assessed. GNRI correlated with a severity score taking into account complications (bedsores or infections) and 6-mo mortality. Second, the GNRI was measured prospectively in 2474 patients admitted to a geriatric rehabilitation care unit over a 3-y period. The severity score correlated with albumin and GNRI but not with BMI or weight:WLo. Risk of mortality (odds ratio) and risk of complications were, respectively, 29 (95% CI: 5.2, 161.4) and 4.4 (95% CI: 1.3, 14.9) for major nutrition-related risk (GNRI: <82), 6.6 (95% CI: 1.3, 33.0), 4.9 (95% CI: 1.9, 12.5) for moderate nutrition-related risk (GNRI: 82 to <92), and 5.6 (95% CI: 1.2, 26.6) and 3.3 (95% CI: 1.4, 8.0) for a low nutrition-related risk (GNRI: 92 to < or =98). Accordingly, 12.2%, 31.4%, 29.4%, and 27.0% of the 2474 patients had major, moderate, low, and no nutrition-related risk, respectively. GNRI is a simple and accurate tool for predicting the risk of morbidity and mortality in hospitalized elderly patients and should be recorded systematically on admission.
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            Preoperative risk assessment for delirium after noncardiac surgery: a systematic review.

            Delirium is a common postoperative complication in older adults associated with adverse events including functional decline, longer lengths of stay, and risk of institutionalization. The purpose of this article is to systematically review preoperative risk factors associated with delirium following noncardiac surgery. A medical literature search was conducted using several bibliographic databases (PubMed, CINAHL, Cochrane, PsychInfo), supplemented by a manual search of the references of retrieved articles. Studies were retained for review after meeting strict inclusion criteria that included only operative patients with incident postoperative delirium diagnosed prospectively using criteria derived from the Diagnostic and Statistical Manual of Mental Disorders Third or Fourth Edition. Quantitative analyses included significance testing, homogeneity testing, and effect-size pooling. Twenty-five articles were included for review. The incidence of delirium ranged from 5.1% to 52.2%, with greater rates after hip fracture and aortic surgeries. This review found two scales, a clinical prediction rule, and a delirium risk classification system that were validated in other operative settings. Individual risk factor analysis suggested that cognitive impairment, older age, functional impairment, sensory impairment, depression, preoperative psychotropic drug use, psychopathological symptoms, institutional residence, and greater comorbidity were associated with postoperative delirium. Of the risk factors examined, evidence was most robust for an association between delirium and cognitive impairment or psychotropic drug use, with moderate effect sizes for both. Missing data and measurement differences did not allow for inferences to be made about other risk factors. Effect-size pooling supports the concept that delirium is a heterogeneous disorder with multiple risk factors. More research is needed to better identify patients at risk for postoperative delirium and to develop preventive strategies.
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              Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study.

              Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028). Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.
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                Author and article information

                Contributors
                grace7733@163.com
                Journal
                Geriatr Gerontol Int
                Geriatr Gerontol Int
                10.1111/(ISSN)1447-0594
                GGI
                Geriatrics & Gerontology International
                John Wiley & Sons Australia, Ltd (Kyoto, Japan )
                1444-1586
                1447-0594
                22 June 2020
                August 2020
                : 20
                : 8 ( doiID: 10.1111/ggi.v20.8 )
                : 759-764
                Affiliations
                [ 1 ] Department of Geriatrics and National Clinical Research Center for Geriatrics West China Hospital of Sichuan University Chengdu China
                [ 2 ] Department of Respiratory Diseases First Affiliated Hospital of Guangxi Medical University Nanning China
                Author notes
                [*] [* ] Correspondence

                Dr Ning Ge, MD, Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China.

                Email: grace7733@ 123456163.com

                Author information
                https://orcid.org/0000-0002-3730-779X
                Article
                GGI13963
                10.1111/ggi.13963
                7496996
                32570290
                af9fb619-d605-4964-8b79-44bd8102d3cb
                © 2020 The Authors. Geriatrics & Gerontology International published by John Wiley & Sons Australia, Ltd on behalf of Japan Geriatrics Society

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 December 2019
                : 01 May 2020
                : 18 May 2020
                Page count
                Figures: 0, Tables: 3, Pages: 6, Words: 4784
                Funding
                Funded by: Department of Science and Technology of Sichuan Province , open-funder-registry 10.13039/501100004829;
                Award ID: 2018SZ0252
                Funded by: Health Research of Cadres in Sichuan Province
                Award ID: 2017‐111
                Categories
                Original Article: Epidemiology, Clinical Practice and Health
                Original Articles: Epidemiology, Clinical Practice and Health
                Custom metadata
                2.0
                August 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.9.0 mode:remove_FC converted:11.09.2020

                elderly,geriatric nutritional risk index,length of stay,postoperative delirium

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