Abstract
Background and Objectives
Delirium is a common disorder among older adults following hospitalization or major surgery. Whereas many studies examine the risk of proximate exposures and ...comorbidities, little is known about pathways linking childhood exposures to later-life delirium. In this study, we explored the association between paternal occupation and delirium risk.
Research Design and Methods
A prospective observational cohort study of 528 older adults undergoing elective surgery at two academic medical centers. Paternal occupation group (white collar vs. blue collar) served as our independent variable. Delirium incidence was assessed using the Confusion Assessment Method (CAM) supplemented by medical chart review. Delirium severity was measured using the peak CAM-Severity score (CAM-S Peak), the highest value of CAM-S observed throughout the hospital stay.
Results
Blue-collar paternal occupation was significantly associated with a higher rate of incident delirium (91/234, 39%) compared with white-collar paternal occupation (84/294, 29%), adjusted odds ratio OR (95% confidence interval CI) = 1.6 (1.1, 2.3). All analyses were adjusted for participant age, race, gender, and Charlson Comorbidity Index. Blue-collar paternal occupation was also associated with greater delirium severity, with a mean score (SD) of 4.4 (3.3), compared with white-collar paternal occupation with a mean score (SD) of 3.5 (2.8). Among participants reporting blue-collar paternal occupation, we observed an adjusted mean difference of 0.86 (95% CI = 0.4, 1.4) additional severity units.
Discussion and Implications
Blue-collar paternal occupation is associated with greater delirium incidence and severity, after adjustment for covariates. These findings support the application of a life-course framework to evaluate the risk of later-life delirium and delirium severity. Our results also demonstrate the importance of considering childhood exposures, which may be consequential even decades later.
BACKGROUND/OBJECTIVES
Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between ...neighborhood‐level characteristics and delirium incidence and severity, and compared neighborhood‐ with individual‐level indicators of socioeconomic status in predicting delirium incidence.
DESIGN
A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status.
SETTING
Two academic medical centers in Boston, MA.
PARTICIPANTS
A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery.
INTERVENTION
The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage.
MEASUREMENTS
Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM‐S) occurring during daily hospital assessments (CAM‐S Peak).
RESULTS
Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3–3.1). The CAM‐S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P = .009). Mean CAM‐S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual‐level markers of socioeconomic status and cultural background were: 1.2 (0.9–1.7) for education of 12 years or less; 1.3 (0.8–2.1) for non‐White race; and 1.7 (1.1–2.6) for annual household income of less than $20,000. None of these individual‐level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk.
CONCLUSIONS
Neighborhood‐level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure‐response relationship. Future studies should consider contextual‐level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention.
Background
Delirium is common in older adults and is a risk factor for long‐term cognitive decline. Efforts to conceptualize risk factors for delirium have focused on the time period proximate to the ...episode, and the role of early‐life exposures on delirium risk is poorly understood. Social and historical factors interact with psychological and biological predispositions, particularly during critical and sensitive periods in childhood, to influence health across the lifespan. Understanding the association between early life exposures and acute conditions occurring after surgeries provides an innovative first step in applying cumulative lifecourse models to examine perioperative risks and outcomes.
Method
Patients in the Successful Aging after Elective Surgery study, a cohort of adults 70+ scheduled for major non‐cardiac surgery, were interviewed prior to surgery to assess reading abilities. Cognitive functioning, neighborhood‐level characteristics, and medical co‐morbidities. Delirium incidence and severity were measured daily after surgery using the Confusion Assessment Method (CAM) and CAM‐severity (CAM‐S), respectively. Parental education and participation in cognitive stimulating activities were also assessed.
Result
In our sample of 547 patients, higher paternal education was associated with significantly lower incidence of delirium (odds ratio OR = 0.93, 95% CI 0.87, 0.98) and inversely associated with delirium severity (Spearman’s rho = ‐.13, p < .001). Higher maternal education was associated with lower delirium incidence, but this association did not reach statistical significance. A multivariate model revealed that the effect of paternal education on delirium incidence was independent of the patient’s education, the patient’s verbal intelligence assessed pre‐operatively, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities throughout the lifespan. Paternal education and general cognitive functioning at baseline explained about 10% of the variance in incidence of delirium (R2=.10, X2(7) =39.35, p<.001).
Conclusion
Paternal education is associated with delirium severity and predicts delirium incidence independent of other delirium risk factors. A life course perspective examining early‐life exposures may yield unique insights into the risks and pathogenesis of delirium. More broadly, this study represents a novel exploration in the field of delirium, and our results contribute to the growing body of literature on the early‐life exposures associated with health in adulthood and will into older age.
Efforts to conceptualize risk factors for postoperative delirium in older adults have focused on the time proximate to the episode, but how early-life exposures influence delirium risk is poorly ...understood.
An observational cohort of 547 patients aged 70+undergoing major non-cardiac surgery at two academic medical centers in Boston. Demographic characteristics, cognition, parental education, health, and participation in cognitively stimulating activities were assessed prior to surgery. Delirium incidence and severity were measured daily during hospitalization.
Higher paternal education was associated with significantly lower incidence of delirium (X
2
(1, N =547)=8.35, p <.001; odds ratio OR=.93, 95% CI, .87 to .98) and inversely associated with delirium severity (r(545)=−.13, p <.001). Higher maternal education was associated with lower delirium incidence but did not reach statistical significance. The effect of paternal education on delirium incidence was independent of the patient's education, estimated premorbid intelligence, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities (X
2
(2, N =547)=31.22, p <.001).
Examining early-life exposures may yield unique insights into the risks and pathogenesis of delirium.
Evaluating long-term factors that increase vulnerability to delirium may improve our ability to calculate risk. It may guide clinical decision-making and inform pre- and post-operative recommendations.
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