Postoperative delirium in patients with cancer: a narrative review of major risk factors
Keywords:
Postoperative delirium, Delirium, Surgical oncology, Cancer, Aged, Malignant neoplasm, Risk factors, Older adultsAbstract
BACKGROUND: Postoperative delirium (POD) is a severe complication and the most frequent adverse event in older patients, particularly those with cancer. With the increase in the older surgical population and cancer diagnoses, the incidence of POD is expected to increase.
OBJECTIVES: To identify and evaluate major risk factors for POD in patients with cancer.
DESIGN AND SETTING: Narrative review conducted at the A.C.Camargo Cancer Center in São Paulo, Brazil.
METHODS: PubMed, LILACS, and Embase database searches were conducted using relevant keywords from June 2023, to September 2024. We identified 279 studies; after screening and applying the eligibility criteria, 49 studies were included in the analysis.
RESULTS AND DISCUSSION: POD risk factors in patients with cancer are associated with inflammation and the cumulative burden of intensive therapeutic modalities. These factors can be categorized into three domains: directly related to cancer, indirectly related to cancer, and preexisting predisposing factors. Among these factors, age is important. Additional relevant contributors include frailty, cognitive impairment, sarcopenia, pain, anxiety, and depression. A complex interaction exists between these factors that renders POD management in patients with cancer challenging; however, the impact of each factor remains unclear.
CONCLUSION: Multiple overlapping risk factors often contribute to POD development in patients with cancer. Age is a significant risk factor, as reported in the literature. Other relevant factors have been described; however, the relative contribution of each factor to the etiology of POD remains unclear. Further research is required to address this knowledge gap.
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References
Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: advances in diagnosis and treatment. JAMA. 2017;318(12):1161–74. PMID: 28973626; https://doi.org/10.1001/jama.2017.12067.
Dilmen OK, Meco BC, Evered LA, Radtke FM. Postoperative neurocognitive disorders: a clinical guide. J Clin Anesth. 2024;92:111320. PMID: 37944401; https://doi.org/10.1016/j.jclinane.2023.111320.
Yan E, Veitch M, Saripella A, et al. Association between postoperative delirium and adverse outcomes in older surgical patients: a systematic review and meta-analysis. J Clin Anesth. 2023;90:111221. PMID: 37515876; https://doi.org/10.1016/j.jclinane.2023.111221.
Gou RY, Hshieh TT, Marcantonio ER, et al. SAGES Study Group. One-year medicare costs associated with delirium in older patients undergoing major elective surgery. JAMA Surg. 2021;156(5):430–42. PMID: 33625501; https://doi.org/10.1001/jamasurg.2020.7260.
Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2017;377(15):1456–66. PMID: 29020579; https://doi.org/10.1056/NEJMcp1605501.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22. PMID: 23992774; https://doi.org/10.1016/S0140-6736(13)60688-1.
Aldecoa C, Bettelli G, Bilotta F, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol. 2024;41(2):81–108. PMID: 37599617; https://doi.org/10.1097/EJA.0000000000001876.
Schenning KJ, Deiner SG. Postoperative delirium in the geriatric patient. Anesthesiol Clin. 2015;33(3):505–16. PMID: 26315635; https://doi.org/10.1016/j.anclin.2015.05.007.
Gleason LJ, Schmitt EM, Kosar CM, et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg. 2015;150(12):1134–40. PMID: 26352694; https://doi.org/10.1001/jamasurg.2015.2606.
Devore EE, Fong TG, Marcantonio ER, et al. Prediction of long-term cognitive decline following postoperative delirium in older adults. J Gerontol A Biol Sci Med Sci. 2017;72(12):1697–702. PMID: 28329149; https://doi.org/10.1093/gerona/glx030.
Dworkin A, Lee DS, An AR, Goodlin SJ. A simple tool to predict development of delirium after elective surgery. J Am Geriatr Soc. 2016;64(11):e149–e153. PMID: 27650453; https://doi.org/10.1111/jgs.14428.
Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. PMID: 38572751; https://doi.org/10.3322/caac.21834.
Del Barrio V. Diagnostic and statistical manual of mental disorders. In: Spielberger CD, editor. Encyclopedia of applied psychology [Internet]. New York: Elsevier; 2004 [cited 2025 Oct 22]. p. 607–14. Available from: https://www.sciencedirect.com/science/article/pii/B0126574103004578.
Inouye SK, Marcantonio ER, Kosar CM, et al. The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimers Dement. 2016;12(7):766–75. PMID: 27103261; https://doi.org/10.1016/j.jalz.2016.03.005.
Gong XY, Hou DJ, Yang J, et al. Incidence of delirium after non-cardiac surgery in the Chinese elderly population: a systematic review and meta-analysis. Front Aging Neurosci. 2023;15:1188967. PMID: 37455941; https://doi.org/10.3389/fnagi.2023.1188967.
Patel M, Onwochei DN, Desai N. Influence of perioperative dexmedetomidine on the incidence of postoperative delirium in adult patients undergoing cardiac surgery. Br J Anaesth. 2022;129(1):67–83. PMID: 35279278; https://doi.org/10.1016/j.bja.2021.11.041.
Yang Y, Zhao X, Gao L, Wang Y, Wang J. Incidence and associated factors of delirium after orthopedic surgery in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res. 2021;33(6):1493–506. PMID: 32772312; https://doi.org/10.1007/s40520-020-01674-1.
Griffin SM, Jones R, Kamarajah SK, et al. Evolution of esophagectomy for cancer over 30 years: changes in presentation, management and outcomes. Ann Surg Oncol. 2021;28(6):3011–22. PMID: 33073345; https://doi.org/10.1245/s10434-020-09200-3.
Papaconstantinou D, Frountzas M, Ruurda JP, et al. Risk factors and consequences of post-esophagectomy delirium: a systematic review and meta-analysis. Dis Esophagus. 2023;36(8):doac103. https://doi.org/10.1093/dote/doac103.
Hartog M, Beishuizen SJE, Togo R, et al. Comprehensive geriatric assessment, treatment decisions, and outcomes in older patients eligible for pancreatic surgery. J Surg Oncol. 2024;130(8):1643–53. PMID: 39290062; https://doi.org/10.1002/jso.27862.
Chen J, Ji X, Xing H. Risk factors and a nomogram model for postoperative delirium in elderly gastric cancer patients after laparoscopic gastrectomy. World J Surg Oncol. 2022;20(1):319. PMID: 36171580; https://doi.org/10.1186/s12957-022-02793-x.
Dong B, Yu D, Jiang L, Liu M, Li J. Incidence and risk factors for postoperative delirium after head and neck cancer surgery: an updated meta-analysis. BMC Neurol. 2023;23(1):371. https://doi.org/10.1186/s12883-023-03418-w.
Tan HJ, Saliba D, Kwan L, Moore AA, Litwin MS. Burden of geriatric events among older adults undergoing major cancer surgery. J Clin Oncol. 2016;34(11):1231–8. PMID: 26884578; https://doi.org/10.1200/JCO.2015.63.4592.
Honda S, Furukawa K, Nishiwaki N, et al. Risk factors for postoperative delirium after gastrectomy in gastric cancer patients. World J Surg. 2018;42(11):3669–75. PMID: 29850948; https://doi.org/10.1007/s00268-018-4682-y.
Janssen TL, Steyerberg EW, Faes MC, et al. Risk factors for postoperative delirium after elective major abdominal surgery in elderly patients: a cohort study. Int J Surg. 2019;71:29–35. PMID: 31526896; https://doi.org/10.1016/j.ijsu.2019.09.011.
Wang Y, Yu H, Qiao H, et al. Risk factors and incidence of postoperative delirium in patients undergoing laryngectomy. Otolaryngol Head Neck Surg. 2019;161(5):807–13. PMID: 31331229; https://doi.org/10.1177/0194599819864304.
Wang Y, Chen K, Ye M, Shen X. Intraoperative hypotension and postoperative delirium in elderly male patients undergoing laryngectomy: a single-center retrospective cohort study. Braz J Anesthesiol. 2025;75(1):844560. PMID: 39277101; https://doi.org/10.1016/j.bjane.2024.844560.
Varpaei HA, Robbins LB, Farhadi K, Bender CM. Preoperative cognitive function as a risk factor of postoperative delirium in cancer surgeries: a systematic review and meta-analysis. J Surg Oncol. 2024;130(2):222–40. PMID: 38865298; https://doi.org/10.1002/jso.27730.
Sun Y, Peng HP, Wu TT. Postoperative C-Reactive protein predicts postoperative delirium in colorectal cancer following surgery. Clin Interv Aging. 2023;18:559–70. PMID: 37038607; https://doi.org/10.2147/CIA.S387117.
Mahanna-Gabrielli E, Schenning KJ, Eriksson LI, et al. State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth. 2019;123(4):464–78. https://doi.org/10.1016/j.bja.2019.07.004. Erratum in: Br J Anaesth. 2019;123(6):917. PMID: 31439308; https://doi.org/10.1016/j.bja.2019.09.014.
Bush SH, Lawlor PG, Ryan K, et al; ESMO Guidelines Committee. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(Suppl 4):iv143–iv165. PMID: 29992308; https://doi.org/10.1093/annonc/mdy147.
Sadeghirad B, Dodsworth BT, Schmutz Gelsomino N, et al. Perioperative factors associated with postoperative delirium in patients undergoing noncardiac surgery: an individual patient data meta-analysis. JAMA Netw Open. 2023;6(10):e2337239. PMID: 37819663; https://doi.org/10.1001/jamanetworkopen.2023.37239.
Lu Y, Liu X. Postoperative delirium and its influencing factors in elderly patients with lung cancer in the intensive care unit. J Thorac Dis. 2023;15(2):701–10. PMID: 36910101; https://doi.org/10.21037/jtd-23-259.
Hayashi K, Motoishi M, Sawai S, Horimoto K, Hanaoka J. Postoperative delirium after lung resection for primary lung cancer: risk factors, risk scoring system, and prognosis. PLoS One. 2019;14(11):e0223917. PMID: 31738751; https://doi.org/10.1371/journal.pone.0223917.
Heo SC, Ahn HS, Shin R, Lim CS, Han DS. Risk factors of elderly patients with postoperative delirium following major abdominal surgery for cancer. Korean J Clin Oncol. 2020;16(2):104–9. PMID: 36945720; https://doi.org/10.14216/kjco.20016.
Shaw JF, Budiansky D, Sharif F, McIsaac DI. The association of frailty with outcomes after cancer surgery: a systematic review and metaanalysis. Ann Surg Oncol. 2022;29(8):4690–704. PMID: 35072860; https://doi.org/10.1245/s10434-021-11321-2.
Tsai CY, Liu KH, Lai CC, et al. Association of preoperative frailty and postoperative delirium in older cancer patients undergoing elective abdominal surgery: a prospective observational study in Taiwan. Biomed J. 2023;46(4):100557. PMID: 35985478; https://doi.org/10.1016/j.bj.2022.08.003.
Fu D, Tan X, Zhang M, Chen L, Yang J. Association between frailty and postoperative delirium: a meta-analysis of cohort study. Aging Clin Exp Res. 2022;34(1):25–37. PMID: 33834367; https://doi.org/10.1007/s40520-021-01828-9.
Handforth C, Clegg A, Young C, et al. The prevalence and outcomes of frailty in older cancer patients: a systematic review. Ann Oncol. 2015;26(6):1091–101. PMID: 25403592; https://doi.org/10.1093/annonc/mdu540.
Zhou Y, Zhang XL, Ni HX, Shao TJ, Wang P. Impact of frailty on short-term postoperative outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. World J Gastrointest Surg. 2024;16(3):893–906. PMID: 38577090; https://doi.org/10.4240/wjgs.v16.i3.893.
Tian JY, Hao XY, Cao FY, et al. Preoperative frailty assessment predicts postoperative mortality, delirium and pneumonia in elderly lung cancer patients: a retrospective cohort study. Ann Surg Oncol. 2023;30(12):7442–51. https://doi.org/10.1245/s10434-023-13696-w.
Evered L, Silbert B, Knopman DS, et al. Nomenclature Consensus Working Group. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery, 2018. Anesthesiology. 2018;129(5):872–9. PMID: 30325806; https://doi.org/10.1097/ALN.0000000000002334.
Crouch A, Champion VL, Unverzagt FW, et al. Cognitive dysfunction prevalence and associated factors in older breast cancer survivors. J Geriatr Oncol. 2022;13(1):33–9. PMID: 34246583; https://doi.org/10.1016/j.jgo.2021.07.001.
Harrison R, Kesler S. Effects of cancer therapy on cognition, in essentials of cancer survivorship. a guide for medical professionals. Boca Raton (FL): CRC Press; 2021. p. 119–40.
Lange M, Joly F, Vardy J, et al. Cancer-related cognitive impairment: an update on state of the art, detection, and management strategies in cancer survivors. Ann Oncol. 2019;30(12):1925–40. PMID: 31617564; https://doi.org/10.1093/annonc/mdz410.
Ahles TA, Schofield E, Li Y, et al. Relationship between cognitive functioning and frailty in older breast cancer survivors. J Geriatr Oncol. 2022;13(1):27–32. PMID: 34366276; https://doi.org/10.1016/j.jgo.2021.07.011.
Mandelblatt JS, Small BJ, Luta G, et al. Cancer-related cognitive outcomes among older breast cancer survivors in the thinking and living with cancer study. J Clin Oncol. 2018;36(32):JCO1800140. PMID: 30281396; https://doi.org/10.1200/JCO.18.00140.
Vardy JL, Dhillon HM, Pond GR, et al. Cognitive function in patients with colorectal cancer who do and do not receive chemotherapy: a prospective, longitudinal, controlled study. J Clin Oncol. 2015;33(34):4085–92. PMID: 26527785; https://doi.org/10.1200/JCO.2015.63.0905.
Graus F, Vogrig A, Muñiz-Castrillo S, et al. Updated diagnostic criteria for paraneoplastic neurologic syndromes. Neurol Neuroimmunol Neuroinflamm. 2021;8(4):e1014. PMID: 34006622; https://doi.org/10.1212/NXI.0000000000001014.
Oliveira V, Videira G, Samões R, et al. Paraneoplastic neurological syndromes with onconeural antibodies: a single center retrospective study. J Neurol Sci. 2020;418:117103. PMID: 32877801; https://doi.org/10.1016/j.jns.2020.117103.
Mohile SG, Dale W, Somerfield MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol. 2018;36(22):2326–47. PMID: 29782209; https://doi.org/10.1200/JCO.2018.78.8687.
Mosk CA, Van Vugt JLA, De Jonge H, et al. Low skeletal muscle mass as a risk factor for postoperative delirium in elderly patients undergoing colorectal cancer surgery. Clin Interv Aging. 2018;13:2097–106. PMID: 30425464; https://doi.org/10.2147/CIA.S175945.
Makiguchi T, Yamaguchi T, Nakamura H, et al. Impact of skeletal muscle mass on postoperative delirium in patients undergoing free flap repair after oral cancer resection. J Plast Surg Hand Surg. 2020;54(3):161–6. PMID: 32031462; https://doi.org/10.1080/2000656X.2020.1724545.
Chen A, An E, Yan E, et al. Prevalence of preoperative depression and adverse outcomes in older patients undergoing elective surgery: A systematic review and meta-analysis. J Clin Anesth. 2024;97:111532. PMID: 38936304; https://doi.org/10.1016/j.jclinane.2024.111532.
Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2021;32(3):371–9. PMID: 33831217; https://doi.org/10.1093/icvts/ivaa277.
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. PMID: 30128769; https://doi.org/10.1007/s00268-018-4761-0.
Holzer KJ, Bartosiak KA, Calfee RP, et al. Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials. BMJ Open. 2024;14(4):e082656. PMID: 38569683; https://doi.org/10.1136/bmjopen-2023-082656.
Kosar CM, Tabloski PA, Travison TG, et al. Effect of preoperative pain and depressive symptoms on the development of postoperative delirium. Lancet Psychiatry. 2014;1(6):431–6. PMID: 25642413; https://doi.org/10.1016/S2215-0366(14)00006-6.
Snijders RAH, Brom L, Theunissen M, Van den Beuken-van Everdingen MHJ. Update on prevalence of pain in patients with cancer 2022: a systematic literature review and meta-analysis. Cancers (Basel). 2023;15(3):591. PMID: 36765547; https://doi.org/10.3390/cancers15030591.
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