title: EFFECT OF PREOPERATIVE PAIN AND DEPRESSIVE SYMPTOMS ON THE DEVELOPMENT OF POSTOPERATIVE DELIRIUM.
abstract: BACKGROUND
  Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk.
  
  
  METHODS
  We enrolled 459 persons without dementia aged ≥70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0-10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms.
  
  
  RESULTS
  Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1·6, 95% confidence interval, CI, 1·2-2·3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1·07-1·08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0·049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance.
  
  
  CONCLUSIONS
  Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery.
  
  
  BACKGROUND
  U.S. National Institute on Aging.
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
authors: Cyrus M
authors: CM
authors: Kosar
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Boston College, William F. Connell School of Nursing, Chestnut Hill, MA.
authors: Patricia A
authors: PA
authors: Tabloski
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA ; Harvard Medical School, Boston, MA.
authors: Thomas G
authors: TG
authors: Travison
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI.
authors: Richard N
authors: RN
authors: Jones
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
authors: Eva M
authors: EM
authors: Schmitt
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
authors: Margaret R
authors: MR
authors: Puelle
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
authors: Jennifer B
authors: JB
authors: Inloes
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA.
authors: Jane S
authors: JS
authors: Saczynski
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA ; Harvard Medical School, Boston, MA.
authors: Edward R
authors: ER
authors: Marcantonio
authors: Department of Adult Psychiatry, University Hospital Limerick and University of Limerick Medical School, Limerick Ireland.
authors: David
authors: D
authors: Meagher
authors: Divisions of Geriatrics and Gerontology, and Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY.
authors: M Carrington
authors: MC
authors: Reid
authors: Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA ; Harvard Medical School, Boston, MA.
authors: Sharon K
authors: SK
authors: Inouye
keywords: Delirium; depression; effect modification; elderly; pain; surgery
references: Am J Geriatr Psychiatry. 2013 Oct;21(10):946-56
references: 23659900
references: Epidemiology. 2009 Jul;20(4):488-95
references: 19525685
references: Anesthesiology. 2009 Apr;110(4):781-7
references: 19326492
references: J Geriatr Psychiatry Neurol. 1992 Jan-Mar;5(1):14-21
references: 1571069
references: J Am Geriatr Soc. 2008 May;56(5):823-30
references: 18384586
references: JAMA. 2010 Jul 28;304(4):443-51
references: 20664045
references: Lancet. 2014 Mar 8;383(9920):911-22
references: 23992774
references: Ann Acad Med Singapore. 1994 Mar;23(2):129-38
references: 8080219
references: J Chronic Dis. 1987;40(5):373-83
references: 3558716
references: J Am Geriatr Soc. 2009 Aug;57(8):1347-53
references: 19558475
references: J Am Med Dir Assoc. 2012 Nov;13(9):818.e1-10
references: 22999782
references: JAMA. 2010 Aug 18;304(7):779-86
references: 20716741
references: Int J Geriatr Psychiatry. 2001 Apr;16(4):349-55
references: 11333420
references: Pain Med. 2008 Jan-Feb;9(1):33-43
references: 18254765
references: J Am Geriatr Soc. 2005 Feb;53(2):312-8
references: 15673358
references: Int J Geriatr Psychiatry. 1999 Oct;14(10):858-65
references: 10521885
references: J Am Geriatr Soc. 1983 Dec;31(12):721-7
references: 6418786
references: J Clin Psychiatry. 1987 Aug;48(8):314-8
references: 3611032
references: J Gerontol A Biol Sci Med Sci. 2005 Dec;60(12):1563-8
references: 16424289
references: J Pain Symptom Manage. 2000 Apr;19(4):240-8
references: 10799790
references: Ann Intern Med. 1990 Dec 15;113(12):941-8
references: 2240918
references: Anesth Analg. 2006 Apr;102(4):1267-73
references: 16551935
references: Gerontologist. 1969 Autumn;9(3):179-86
references: 5349366
references: Ann Med. 2000 May;32(4):257-63
references: 10852142
references: Ann Rheum Dis. 2000 May;59(5):331-7
references: 10784513
references: Ann Intern Med. 1993 Sep 15;119(6):474-81
references: 8357112
references: J Am Coll Surg. 2012 Oct;215(4):453-66
references: 22917646
references: J Psychosom Res. 2008 Sep;65(3):229-38
references: 18707945
references: Ann Intern Med. 2014 Apr 15;160(8):526-33
references: 24733193