The aim of our meta-analysis was to update evidence for the association between frailty and delirium in different types of hospitalized patients, given the large volume of new studies with inconsistent results.
Systematic review and meta-analysis.
Setting and Participants
In this updated meta-analysis, we searched 3 databases (Embase, PubMed, and the Cochrane Library) for observational studies, exploring the association between frailty and delirium from database inception to September 21, 2020, among hospitalized patients. Relevant data were extracted from the studies that were included. A random effects model was conducted to synthesize and pool the effect size of frailty on delirium due to different frailty score instruments, different countries, and various delirium assessments that were used. The participants enrolled in this meta-analysis were hospitalized patients.
Delirium risk due to frailty.
A total of 30 independent studies from 9 countries, consisting of 217,623 patients, was identified, and the prevalence of frailty ranged from 16.20% to 78.00%. Frail patients exhibited an increased risk for delirium compared to those without frailty [odds ratio (OR) 2.96, 95% confidence interval (CI) 2.36–3.71]. In addition, different types of hospitalized patients had various OR values, which were 2.43 for selective surgical patients (95% CI 1.88–3.14), 3.61 for medical patients (95% CI 3.61–7.89), 3.76 for urgent surgical patients (95% CI 2.88–4.92), and 6.66 for emergency or critical illness patients (95% CI 1.41–31.47). Subgroup analysis based on the frailty score instrument showed the association still existed when using the Clinical Frailty Scale (OR 4.07, 95% CI 2.71–6.11), FRAIL Scale (OR 2.83, 95% CI 1.56–5.13), Frailty Index (OR 6.15, 95% CI 3.75–10.07), frailty phenotype (OR 2.30, 95%CI 1.35–5.66), or Erasmus Frailty Score (OR 2.79, 95% CI 1.63–4.77). However, an association between frailty and delirium was not observed when the Edmonton Frail Scale was used (OR 1.45, 95% CI 0.91–2.30).
Conclusions and Implications
A 2.96-fold incremental risk of delirium in frail patients underscores the need for early screening of frailty and comprehensive delirium prevention. Appropriate interventions by clinicians should be performed to manage delirium, potentially reducing adverse clinical outcomes for hospitalized patients.
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- Delirium in the elderly.Psychiatr Clin North Am. 2018; 41: 1-17
- Frailty is associated with postoperative delirium but not with postoperative cognitive decline in older noncardiac surgery patients.Anesth Analg. 2020; 130: 1516-1523
- Delirium in elderly people.Lancet. 2014; 383: 911-922
- New cutoff scores for delirium screening tools to predict patient mortality.J Am Geriatr Soc. 2021; 69: 140-147
- Delirium and adverse outcomes in hospitalized patients with COVID-19.J Am Geriatr Soc. 2020; 68: 2440-2446
- Impact of delirium on distress, health-related quality of life, and cognition 6 months and 1 year after hematopoietic cell transplant.Biol Blood Marrow Transplant. 2010; 16: 824-831
- Risk factors for incident delirium among older people in acute hospital medical units: A systematic review and meta-analysis.Age Ageing. 2014; 43: 326-333
- Surviving and thriving one year after cardiac surgery: Frailty and delirium matter.Ann Thorac Surg. 2020 Sep 17.; ([Epub ahead of print])
- Fall and its association with the frailty syndrome in the elderly: Systematic review with meta-analysis.Rev Esc Enferm USP. 2016; 50: 1005-1013
- Frailty and cognitive impairment—a review of the evidence and causal mechanisms.Ageing Res Rev. 2013; 12: 840-851
- Relationship between depression and frailty in older adults: A systematic review and meta-analysis.Ageing Res Rev. 2017; 36: 78-87
- Frailty as a predictor of all-cause mortality among older nursing home residents: A systematic review and meta-analysis.J Am Med Dir Assoc. 2019; 20: 657-663.e4
- Frailty and delirium in older adults: A systematic review and meta-analysis of the literature.J Am Geriatr Soc. 2018; 66: 2022-2030
- Accuracy and feasibility of clinically applied frailty instruments before surgery: A systematic review and meta-analysis.Anesthesiology. 2020; 133: 78-95
- Modified Frailty Index independently predicts postoperative delirium and delayed neurocognitive recovery after elective total joint arthroplasty.J Arthroplasty. 2020; 36: 449-453
- Preoperative risk assessment for delirium after hepatic resection in the elderly: A prospective multicenter study.J Gastrointest Surg. 2020; ([Epub ahead of print])
- Impact of frailty and mild cognitive impairment on delirium after cardiac surgery in older patients.J Cardiol. 2020; 76: 147-153
- A cohort study investigating the relationship between patient reported outcome measures and pre-operative frailty in patients with operable, non-palliative colorectal cancer.BMC Geriatr. 2021; 25: 134-144
- Brief preoperative screening for frailty and cognitive impairment predicts delirium after spine surgery.Anesthesiology. 2020; 133: 1184-1191
- The occurrence and timing of delirium in acute care hospitalizations in the last year of life: A population-based retrospective cohort study.Palliat Med. 2020; 34: 1067-1077
- Prospective evaluation of delirium in geriatric patients undergoing emergency general surgery.J Am Coll Surg. 2020; 230: 758-765
- Sinai Abbreviated geriatric evaluation: Development and validation of a practical test.Ann Surg. 2019; 269: 177-183
- The relationship among frailty, delirium and attentional tests to detect delirium: A cohort study.Eur J Intern Med. 2019; 70: 33-38
- Incidence, risk factors, and sequelae of post-kidney transplant delirium.J Am Soc Nephrol. 2018; 29: 1752-1759
- FRAIL Questionnaire screening tool and short-term outcomes in geriatric fracture patients.J Am Med Dir Assoc. 2017; 18: 1082-1086
- The association between preoperative frailty and postoperative delirium after cardiac surgery.Anesth Analg. 2016; 123: 430-435
- Observational study examining the association of baseline frailty and postcardiac surgery delirium and cognitive change.Anesth Analg. 2019; 129: 507-514
- Preoperative assessment of frailty predicts age-related events after hepatic resection: A prospective multicenter study.J Hepatobiliary Pancreat Sci. 2018; 25: 377-387
- Impact of delirium on postoperative frailty and long term cardiovascular events after cardiac surgery.PLoS One. 2017; 12: e0190359
- Incidence and predictors of postoperative delirium in the older acute care surgery population: A prospective study.Can J Surg. 2019; 62: 33-38
- Frailty assessment to help predict patients at risk of delirium when consulting the emergency department.J Emerg Med. 2018; 55: 157-164
- The impact of frailty on functional survival in patients 1 year after cardiac surgery.J Thorac Cardiovasc Surg. 2017; 154: 1990-1999
- The impact of frailty on postoperative delirium in cardiac surgery patients.J Thorac Cardiovasc Surg. 2015; 149 (e1–2): 869-875
- Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: Results of a prospective multi-centre study on World Delirium Awareness Day.BMC Med. 2019; 17: 229
- Frailty and poor functional status are common in arterial vascular surgical patients and affect postoperative outcomes.Int J Surg. 2015; 18: 57-63
- The impact of frailty and delirium on mortality in older inpatients.Age Ageing. 2012; 41: 412-416
- A prospective cohort study of older surgical inpatients examining the prevalence and implications of frailty.J Clin Gerontol Geriatr. 2017; 8: 71-76
- The impact of frailty on mortality, length of stay and re-hospitalisation in older patients with atrial fibrillation.Heart Lung Circ. 2016; 25: 551-557
- Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation.Age Ageing. 2020; 49: 389-394
- The Erasmus Frailty Score is associated with delirium and 1-year mortality after transcatheter aortic valve implantation in older patients. The TAVI Care & Cure Program.Int J Cardiol. 2019; 276: 48-52
- Frailty is associated with delirium and mortality after transcatheter aortic valve implantation.Open Heart. 2016; 3: e000478
- 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: 28-33
- Comparison of frequency, risk factors, and time course of postoperative delirium in octogenarians after transcatheter aortic valve implantation versus surgical aortic valve replacement.Am J Cardiol. 2015; 115: 802-809
- Association between frailty and delirium in older adult patients discharged from hospital.Clin Interv Aging. 2016; 11: 55-63
- Predisposing and precipitating risk factors for delirium in palliative care patients.Palliat Support Care. 2020; 18: 437-446
- Is delirium the cognitive harbinger of frailty in older adults? A review about the existing evidence.Front Med (Lausanne). 2017; 4: 188
- Identifying older adults at risk of delirium following elective surgery: A systematic review and meta-analysis.J Gen Intern Med. 2018; 33: 500-509
- Family and healthcare staff's perception of delirium.Eur Geriatr Med. 2020; 11: 95-103
- Frailty and risk of adverse outcomes in hospitalized older adults: A comparison of different frailty measures.J Am Med Dir Assoc. 2017; 18 (638.e7–638.e11)
- Frailty is associated with an increased risk of major adverse outcomes in elderly patients following surgical treatment of hip fracture.Sci Reports. 2019; 9: 19135
- Frailty for perioperative clinicians: A narrative review.Anesth Analg. 2020; 130: 1450-1460
- Performance of Edmonton Frail Scale on frailty assessment: Its association with multi-dimensional geriatric conditions assessed with specific screening tools.BMC Geriatr. 2017; 17: 2
- Which frailty scale for patients admitted via emergency department? A cohort study.Arch Gerontol Geriatr. 2019; 80: 104-114
- Cognitive frailty: A systematic review of epidemiological and neurobiological evidence of an age-related clinical condition.Rejuvenation Res. 2015; 18: 389-412
- Frailty and cognitive impairment among community-dwelling elderly.Arq Neuropsiquiatr. 2013; 71: 362-367
- Frailty as a predictor of cognitive disorders: A systematic review and meta-analysis.Front Med (Lausanne). 2019; 6: 26
- Relationship between cognition and frailty in elderly: A systematic review.Dement Neuropsychol. 2015; 9: 110-119
- Association of inflammatory mediators with frailty status in older adults: Results from a systematic review and meta-analysis.GeroScience. 2020; 42: 1451-1473
- Frailty in elderly people.Lancet. 2013; 381: 752-762
- Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National surgical quality Improvement program and the American geriatrics Society.J Am Coll Surg. 2012; 215: 453-466
- Frailty assessment in the cardiovascular care of older adults.J Am Coll Cardiol. 2014; 63: 747-762
Published online: February 04, 2021
This work was supported by the Basic Scientific Research Fund for Central Universities, Peking Union Medical College (grant number 3332020007).
The authors declare no conflicts of interest.
© 2021 Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.