Frequency of postoperative delirium and its risk factors in patients with schizophrenia spectrum disorders: a retrospective cohort study

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Postoperative delirium (POD) is a common complication in patients with SSDs, often requiring psychiatric expertise for management. This study aimed to investigate the incidence and risk factors for POD in patients with SSDs undergoing surgery. A retrospective study was conducted at three tertiary hospitals in Japan, including 200 patients with SSDs who underwent surgery between April 2017 and March 2022. Patients admitted due to psychiatric crises were excluded. Data on demographics, psychiatric history, surgical details, and POD development were collected. Statistical analysis included chi-squared tests and logistic regression to identify risk factors. POD occurred in 10.5% of patients with SSDs, with only one requiring psychiatric ward admission. Most patients had schizophrenia (90.5%), and the mean age was 57.4 years. Significant risk factors for POD included age ≥ 65 years (adjusted odds ratio: 3.25) and smoking before admission (adjusted odds ratio: 2.97). Antipsychotic medication use or dose was not associated with POD. Most POD cases were managed with psychotropic drug adjustments, suggesting that patients with SSDs can be treated at general hospitals if psychiatric expertise is available. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Neurology Biological sciences/Psychology Social science/Psychology Health sciences/Risk factors postoperative delirium schizophrenia spectrum disorders risk factors psychiatric care perioperative management Introduction Schizophrenia spectrum disorders (SSDs) constitute a group of psychiatric conditions characterized by disturbances in cognition, perception, affect, and behavior. At the core of this spectrum lies schizophrenia, a severe and chronic mental illness marked by a high rate of relapse and commonly associated with a broad array of symptoms and functional impairments [ 1 – 3 ]. It affects 1 in every 300 people (0.32%), with a total patient population of approximately 24 million worldwide [ 3 ]. Patients with schizophrenia are 2–3 times more likely to die early than the general population because of the high prevalence of various physical illnesses, including cardiovascular, metabolic, and infectious diseases [ 4 ], as well as reduced engagement in health maintenance practices including maintaining healthy eating habits, performing exercise, and avoiding smoking [ 5 , 6 ]. In addition, disparities in access to treatments for physical illnesses have been associated with higher mortality rates [ 7 ]. The life expectancy for patients with SSDs is still short compared to the general population, while the number and percentage of elderly people with SSDs has been increasing as the population ages [ 8 ], resulting in increased frequency of hospitalization for the treatment of physical illnesses in this population. Additionally, patients with SSDs are at an increased risk of various potential illnesses, including heart disease [ 9 ]; stroke [ 10 ]; pancreatic, esophageal, and breast cancer [ 11 ]; perforated appendicitis [ 12 ]; and cataracts [ 13 ], which may require surgery. Postoperative delirium (POD) is a common disorder that may be accompanied by psychomotor agitation. Patients with SSDs have many factors associated with delirium, including a high prevalence of physical comorbidities, long-term exposure to psychotropic medications, reduced cognitive reserve, and indicators of frailty [ 14 ]. Such delirium in patients with SSDs can be difficult to treat outside the psychiatric ward [ 15 ]. Moreover, patients with SSDs are often prescribed antipsychotics and benzodiazepine receptor agonists (BZRAs), including zolpidem, zopiclone and eszopiclone, upon admission and have more complex background factors than the general population; therefore, the treatment of delirium in a general ward often requires the expertise of a psychiatrist. However, there are very few studies that specifically report the incidence of delirium in patients with SSDs, rather than in the general psychiatric population and it remains unclear what proportion of patients with SSDs who develop POD require transfer to a psychiatric ward. A lack of epidemiological data on POD in patients with SSDs may impede the acceptance of such patients in hospitals without a psychiatric ward. With the continued decline in the number of general hospitals with psychiatric beds in Japan [ 16 ], this problem is becoming increasingly serious, especially in regional cities, which means that hospitals without psychiatric wards need to increase their ability to manage POD in patients with SSD. Therefore, this study investigated the frequency of and risk factors for POD in patients with SSDs to improve their access to medical care. Results Among 208 patients with SSDs who underwent surgery at the study sites during the study period, we included 200 patients after excluding eight patients admitted for suicide attempts. Of these patients, 181 (90.5%) had schizophrenia, nine (4.5%) had schizoaffective disorders, and five (2.5%) had delusional disorders. The mean age of the patients was 57.4 ± 14.4 years, with 35.5% (71/200) of the patients aged ≥ 65 years and 61% (122/200) being female. The median chlorpromazine equivalent of the administered antipsychotic was 400 (interquartile range [IQR], 200–714) mg, and approximately half of all patients used BZRAs (98/200). The median operative time was 133 (IQR, 92–208) min. Surgical duration was ≥ 180 min in 76 (38%) patients. A total of 121 (60.5%) patients were hospitalized from their homes (Table 1 ). Table 1 Patient characteristics Factors Number of patients (N = 200) Male sex, n (%) 78 (39.0) Age, mean (SD), years 57.4 (14.4) Age ≥ 65 years, n (%) 71 (35.5) Hospitalization, days, median (IQR) 11 (6–21) Use of two or more antipsychotics, n (%) 79 (39.5) CPE, median (IQR), mg/day 400 (200–714) CPE < 300 mg/day, n (%) 67 (33.5) CPE ≥ 1000 mg/day, n (%) 31 (15.5) Use of BZRAs, n (%) 98 (49.0) Use of trazodone or mianserin 2 (1.0) Use of sodium valproate 29 (14.5) Use of ramelteon 9 (4.5) Use of suvorexant or lemborexant 21 (10.5) Charlson Comorbidity Index, median (IQR) 4 (2–5) Surgery for malignancy, n (%) 62 (31.0) Place of residence prior to hospitalization home 121 (60.5) Facility or hospital 79 (39.5) Creatinine > 1.2 mg/dL, n(%) ＊ 12 (6.0) Hemoglobin < 12 mg/dL, n (%) ＊ 79 (39.5) Albumin < 3.5 mg/dL, n (%) ＊ 53 (26.5) Psychiatric disease, n (%) Schizophrenia, n (%) 181 (90.5) Schizoaffective disorder, n (%) 9 (4.5) Delusional disorder, n (%) 5 (2.5) Smoking ＊ 45 (22.5) Physical restraint required, n (%) 50 (25.0) ICU admission, n (%) 76 (38.0) Changes in surface morphology, n (%) 16 (8.0) General anesthesia, n (%) 186 (93.0) Emergency surgery, n (%) 39 (19.5) Surgical time, median (IQR), min 133 (92–208) Surgical time ≥ 180 min, n (%) 76 (38.0) Abbreviations: CPE, chlorpromazine equivalent; BZRA, benzodiazepine receptor agonist; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation. ＊Missing value: creatinine (n = 1), hemoglobin (n = 1), albumin (n = 15), smoking (n = 4). In this study, 10.5% (21/200) of patients experienced POD; in particular, 16.9% (12/71) of patients aged ≥ 65 years developed POD. Only one patient with POD required admission to the psychiatric ward. Univariate analysis of the factors contributing to delirium development revealed significant differences for hospitalization from outside of the home (crude odds ratio [OR], 3.5; 95% confidence interval [CI], 1.34–9.13; p < 0.01), age ≥ 65 years (crude OR, 2.7; 95% CI, 1.08–6.80; p = 0.03), and albumin < 3.5 g/dL (crude OR, 2.88; 95% CI, 1.14–2.23; p = 0.03) as risk factors. Intensive care unit (ICU) admission (crude OR, 2.4; 95% CI, 0.96–5.99; p = 0.06), smoking before admission (crude OR, 2.36; 95% CI, 0.91–6.12; p = 0.09), hemoglobin < 12 g/dL (crude OR, 2.23; 95% CI, 0.89–5.57; p = 0.09), and Charlson Comorbidity Index ≥ 4 (crude OR, 2.47; 95% CI, 0.92–6.66; p = 0.10) were not significantly related to the development of POD. We observed no significant differences in surgery for malignancy, surgery duration of ≥ 180 min, changes in surface morphology during surgery, emergency surgery, use of two or more antipsychotic medications, or antipsychotic medication dose (Table 2 ). Table 2 Factors associated with postoperative delirium: Univariate analysis Number of patients without postoperative delirium (n = 179) Number of patients with postoperative delirium (n = 21) Odds ratio 95% CI P Sex Male 72 6 Reference Female 107 15 1.68 0.62–4.5 0.35 Age < 65 years 120 9 Reference ≥ 65 years 59 12 2.71 1.08–6.80 0.03 Use of BZRAs 89 9 0.76 0.30–1.89 0.65 Use of sodium valproate 28 1 0.27 0.03–2.09 0.32 Use of suvorexant or lemborexant 17 4 2.24 0.68–7.43 0.25 Use of two or more antipsychotics 86 8 0.62 0.25–1.52 0.30 CPE < 300 mg/day 63 5 0.58 0.20–1.64 0.34 CPE ≥ 1000 mg/day 29 2 0.54 0.12–2.47 0.54 Smoking before admission 37 8 2.36 0.91–6.12 0.09 Place of residence prior to hospitalization home 114 7 Reference Facility or hospital 65 14 3.50 1.35–9.13 1.2 mg/dL 12 0 0.62 0 0.62 Hemoglobin < 12 mg/dL 67 12 2.23 0.89–5.57 0.09 Albumin < 3.5 mg/dL 43 10 2.88 1.14–2.23 0.03 ICU admission 64 12 2.40 0.96–5.99 0.06 Changes in surface morphology 29 1 2.13 0.55–8.18 0.23 Emergency surgery 34 5 1.34 0.46–3.89 0.57 Surgical time < 180 min 111 13 Reference ≥ 180 min 68 8 1.00 0.40–2.55 1.00 Anesthesia Local 13 1 Reference General 166 20 1.57 0.19–12.61 1.00 Abbreviations: CI, confidence interval; BZRA, benzodiazepine receptor agonist; CPE, chlorpromazine equivalent; ICU, intensive care unit. As there were 21 patients with POD, the number of factors to be included in the multivariate analysis was determined to be three, and logistic regression analysis was performed using the three variables of age, smoking history before hospitalization, and ICU admission. The results of analysis showed that age ≥ 65 years (adjusted OR, 3.25; 95% CI, 1.23–7.88; p = 0.02) and smoking before admission (adjusted OR, 2.97; 95% CI, 1.03–8.43; p = 0.04) significantly increased the risk of developing POD (Table 3 ). Table 3 Logistic analysis of risk factors for postoperative delirium: Multivariate analysis Odds ratio 95% CI p ICU admission 2.00 0.77–5.27 0.15 Smoking before admission 2.97 1.03–8.43 0.04 Age ≥ 65 years 3.25 1.23–7.88 0.02 Logistic regression analysis, p < 0.05. Abbreviation: CI, confidence interval; ICU, intensive care unit. Discussion Comparisons with previous studies In the present study, the incidence of POD in patients with SSDs was approximately 10%, and only 0.5% required transfer to a psychiatric ward. In this study, POD occurred in 16.9% of patients aged ≥ 65 years and 7.0% in those aged 18–65 years. In a previous study of the general population over 18 years of age [ 17 ], the incidence of POD was 6.3% in those aged ≥ 65 years and 2.3% in those aged 18–65 years. In the present study, POD occurred about three times more often than in that previous study. Among problematic behaviors from a medical safety perspective in patients with SSDs who had undergone surgery, Tsuji et al. reported bizarre behavior in 52.4% (11/21) of patients with psychiatric diseases who had surgery (15 of whom had schizophrenia) [ 18 ], and Farasatpour et al. reported that 19.6% (11/56) and 21.4% (12/56) of patients with schizophrenia who underwent surgery for breast cancer verbally and physically attacked their caregivers, respectively [ 19 ]. Cooke et al. observed disruptive behavior in 29% (16/55) of patients with schizophrenia who underwent surgery for acute appendicitis [ 20 ]. However, these previous studies did not clarify whether these behaviors that interfered with physical treatment during the perioperative period were caused by POD, worsening of psychiatric symptoms due to SSDs, or the patients’ own personality traits. In this study, we were able to show the frequency of POD in patients with SSDs by conducting a more detailed evaluation of the psychiatric symptoms these patients exhibited postoperatively, by conducting a study over a longer period at more facilities than in previous studies. In our previous study of patients with SSDs conducted at the same facility as the present study, the frequency of worsening of psychiatric symptoms other than postoperative delirium and insomnia was 11.1% [ 21 ]. When combined with the results of the present study, the frequency of deterioration of the mental status of patients with SSDs due to POD or worsening of psychiatric symptoms due to SSDs is estimated to be approximately 20%, which is similar to the frequency reported in previous studies [ 19 , 20 ]. Compared with previous studies [ 18 – 20 ], the present study focused on patients with SSDs who developed POD and was conducted over a longer period to ensure a larger number of eligible patients. In patients with SSDs, univariate analysis identified older age, low albumin levels, and pre-admission living environment as significant risk factors for POD. Since low albumin levels and pre-admission living environment were closely related to older age, we selected age, ICU admission, and smoking status as variables in the multivariate analysis, considering the limited number of cases. Although the small sample size necessitates cautious interpretation, these findings are consistent with known risk factors in the general population. Meanwhile, there was no association between POD occurrence and the dosage of antipsychotic medication or the use of BZRAs. The use of BZRAs is generally thought to be a risk factor for POD [ 17 ], although there is a report that the incidence of delirium in patients who had used BZRAs continuously during the perioperative period was not higher than in patients who had not used them at all [ 22 ]. Patients with SSDs take antipsychotic medications that may work therapeutically against delirium, which may have offset the risk of POD from the use of BZRAs. Among the patients with SSDs who developed POD, only one patient required transfer to a psychiatric ward, which was 0.5% of the total. In other words, most cases of POD in patients with SSDs could be managed by adjusting psychotropic medications. Thus, we believe that most cases of perioperative management of patients with SSDs can be performed without problems at general hospitals with a psychiatric liaison consultation service, even if they do not have a psychiatric ward. Strengths and limitations Owing to the retrospective study design, unmeasured items could not be evaluated. Specifically, the severity of the psychiatric symptoms at the time of admission could not be evaluated using a unified scale, and the severity of cognitive impairment due to SSDs could not be assessed. Therefore, we collected information on the place of residence prior to hospitalization and antipsychotic medication dosage as indicators of psychiatric symptom severity. Additionally, the diagnosis of POD was based on chart review rather than standardized assessment scales; therefore, there exists a potential for both underdiagnosis and overdiagnosis of POD. Moreover, as all the participants in this study received psychiatric interventions, it was not possible to evaluate the frequency of POD in patients with SSDs who did not receive psychiatric intervention. The incidence of POD in patients with SSDs who did not receive psychiatric intervention during the perioperative period may be lower than that in the patients in this study; therefore, the incidence of POD in patients with SSDs in this study might be overestimated. To calculate the incidence more accurately, it is necessary to conduct a survey of all patients with SSDs who underwent surgery with or without psychiatric intervention. Finally, the small sample size did not allow us to include a sufficient number of variables in multivariate analysis. As such, we could only assess the effects of a few variables. However, a strength of this study is that it included a larger sample size than previous studies, allowing us to calculate the incidence of POD in patients with SSDs and demonstrate that the frequency of transfers to psychiatric wards was low. Future research should utilize standardized delirium assessment tools to clarify the risk of POD in patients with SSDs. Studies with larger sample sizes are needed to investigate a broader range of factors associated with the development of POD and to help guide hospital selection for SSD patients requiring physical treatment. Conclusion POD developed in approximately 10% of patients with SSDs; however, most patients could be managed by adjusting psychotropic medications, and only a very small number of patients required transfer to a psychiatric ward. Thus, POD management for patients with SSDs may be possible even in general hospitals without a psychiatric ward, as long as psychiatric liaison consultation services are available. Methods Study setting and data sources This study included patients from three tertiary care hospitals in urban Japan totaling 2395 beds. All three hospitals perform gastrointestinal, cardiovascular, respiratory, endocrine and breast, plastic, neurologic, orthopedic, and pediatric surgeries and include obstetrics and gynecology, ophthalmology, dermatology, urology, and otolaryngology departments. One hospital has a transplant surgery department. All three hospitals also have psychiatric wards and consultation-liaison teams including psychiatrists, nurses, and psychologists who provide psychosocial care to patients with comorbid mental and physical illnesses admitted to the general wards. All three institutions are core hospitals in the region and accept patients with SSDs requiring surgical treatment, regardless of the type of physical illness. Selection criteria and outcomes The study participants were patients with SSDs with psychiatric involvement admitted for surgical treatment at the three study hospitals between April 1, 2017 and March 31, 2022. SSDs included schizophrenia, delusional disorder, short-term psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance-induced or drug-induced psychotic disorder, or psychotic disorder caused by other medical illnesses diagnosed before admission by psychiatrists managing their regular psychiatric treatment based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [ 23 ]. The participants were consultation-liaison patients, who were admitted to the general ward for surgery and referred to the consultation-liaison team. Psychiatrists advised the surgeons regarding the management of the patients’ psychiatric comorbidities. However, this study excluded patients with SSDs admitted because of worsening psychiatric symptoms, including suicide attempts, owing to unstable mental health before admission. The main outcome of this study was the proportion of patients who developed POD. We also investigated the number of patients who required admission to the psychiatric ward after developing POD. Clinical data collection During this study, psychiatrists with sufficient knowledge and experience in consultation-liaison psychiatry conducted chart reviews of all care records as well as records related to prescriptions and laboratories. The reviewers collected the following patient data: sex, age, smoking status, type and dose of psychotropic medication, Charlson Comorbidity Index [ 24 ], and psychiatric diagnosis based on DSM-5 criteria [ 23 ]. Among psychotropic medication, the amount of chlorpromazine equivalent of antipsychotic drugs used was calculated. The living environment before hospitalization was classified as either home or outside home (psychiatric hospital or support facility). The presence or absence of POD was determined based on DSM-5 criteria through chart review and data on the use of physical restraints postoperatively, ICU admission, anesthesia (general or local), emergency or planned surgery, and operative time were also collected. Long-duration surgery was defined as a surgery with a surgical time of ≥ 180 min, as the risk of worsening perioperative psychiatric symptoms increases beyond this cutoff [ 21 , 25 ]. Additionally, as changes in surface morphology during surgery may affect psychological reactions [ 26 , 27 ], we also investigated whether the patients had undergone tracheostomy, amputation, mastectomy without reconstruction, gastrostomy, colostomy, nephrostomy, or eye resection. After identifying patients who met the criteria for developing POD during an independent review, several reviewers made a final decision on existence of delirium. In cases where it was difficult to distinguish between a worsening of SSD symptoms or the reviewers disagreed on the classification, reviewers reached consensus through discussion. The missing values were treated as normal for blood tests and none for smoking history. Statistical analysis Continuous variables are presented as mean with standard deviation or medians with IQRs. Categorical variables are presented as number and percentage. We performed the chi-squared test to compare categorical variables when the expected value of each cell was > 5; otherwise, we applied Fisher’s exact test to assess the relationship between delirium and background factors. In conducting multivariate analysis, we selected variables based on the number of patients who developed POD from those used in the univariate analysis that were considered to be clinically closely related to the development of POD. For all statistical analyses, a two-tailed p-value of 0.05 was considered statistically significant. All analyses were performed using JMP, version 18 (SAS Institute, Cary, NC). Declarations Authors’ contributions : YM, N. Ayani, MF, and T. Funatsuki conceived of the study. YM and N. Ayani developed the methodology, curated the data, conducted formal analysis, and were responsible for project administration. YM, NA, MF, T. Funatsuki, T. Fukao, SU, AT, N. Oya, and RK conducted the investigation. YM wrote the original manuscript draft. YM, N. Ayani, MF, T. Funatsuki, T. Fukao, SU, AT, N. Oya, RK, SI, and JN reviewed and edited the manuscript. N. Ayani gathered the resources for this study. N. Ayani, SI, and JN supervised the study. Acknowledgments : Not applicable. Funding statement : This research was supported by grants from the Mitsubishi Foundation (Grant number 20203003) and JSPS KAKENHI (Grant number 24K20176); however, the funding sources had no further role in the preparation, data collection, or writing of this paper. Conflict of interest statement : The authors declare no conflict of interest. Ethics approval statement: This retrospective cohort was approved by the Ethics Committees of Kyoto Prefectural University of Medicine, Okayama University, and Kansai Medical University. The requirement for informed consent was waived by the committees due to the retrospective nature of the study. All methods were carried out in accordance with relevant guidelines and regulations. Data availability: The datasets analyzed during the current study are available from the corresponding author on reasonable request. References Tandon, R. et al . Definition and description of schizophrenia in the DSM-5. Schizophr. Res . 150 , 3–10 (2013). Charlson, F. J. et al . Global epidemiology and burden of schizophrenia: findings from the Global Burden of Disease Study 2016. Schizophr. Bull . 44 , 1195–203 (2018). World Health Organization. Schizophrenia. https://www.who.int/news-room/fact-sheets/detail/schizophrenia (2022). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7201256","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":549328614,"identity":"a62fe720-27b0-4313-9525-79f9627575b3","order_by":0,"name":"Yoshihiro Matsumoto","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yoshihiro","middleName":"","lastName":"Matsumoto","suffix":""},{"id":549328615,"identity":"c0577c71-0851-4904-aa8a-b1e386e330cb","order_by":1,"name":"Nobutaka 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Fujiwara","suffix":""},{"id":549328617,"identity":"339308dd-bab8-40cd-ac4c-8b0393e5c271","order_by":3,"name":"Toshiya Funatsuki","email":"","orcid":"","institution":"Kansai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Toshiya","middleName":"","lastName":"Funatsuki","suffix":""},{"id":549328619,"identity":"50e2d7c9-7946-4322-805f-11c7fb851db3","order_by":4,"name":"Takashi Fukao","email":"","orcid":"","institution":"Okayama University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Fukao","suffix":""},{"id":549328620,"identity":"c9c2d661-d9aa-43e3-8d66-8feb12d3d544","order_by":5,"name":"Shinji Ueda","email":"","orcid":"","institution":"Okayama University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shinji","middleName":"","lastName":"Ueda","suffix":""},{"id":549328621,"identity":"dd7c4b1c-0d42-4e91-a151-9b054be419ac","order_by":6,"name":"Ai Takahashi","email":"","orcid":"","institution":"Kansai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"","lastName":"Takahashi","suffix":""},{"id":549328624,"identity":"a9a47f27-a12f-4f0d-9b43-a614686babba","order_by":7,"name":"Nozomu Oya","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nozomu","middleName":"","lastName":"Oya","suffix":""},{"id":549328628,"identity":"ca181eda-3b5c-41bd-95d9-3675c2429c15","order_by":8,"name":"Riki Kitaoka","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Riki","middleName":"","lastName":"Kitaoka","suffix":""},{"id":549328630,"identity":"3d46ad2d-9066-48e3-b8c7-1114a1a26b87","order_by":9,"name":"Shinichiro Inoue","email":"","orcid":"","institution":"Nimi University","correspondingAuthor":false,"prefix":"","firstName":"Shinichiro","middleName":"","lastName":"Inoue","suffix":""},{"id":549328631,"identity":"dc2525f8-5d2e-4db1-b388-161231712dfb","order_by":10,"name":"Jin Narumoto","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Narumoto","suffix":""}],"badges":[],"createdAt":"2025-07-24 04:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7201256/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7201256/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96668923,"identity":"f0124c1f-8287-4d8e-9923-2bcc59a1df1d","added_by":"auto","created_at":"2025-11-24 22:05:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58501,"visible":true,"origin":"","legend":"","description":"","filename":"20250726R1manuscriptna03092.docx","url":"https://assets-eu.researchsquare.com/files/rs-7201256/v1/44ff7123440b89f832c74d82.docx"},{"id":96668924,"identity":"bbf77932-22dd-4c42-b0d1-d8ff63b32df9","added_by":"auto","created_at":"2025-11-24 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22:05:23","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87615,"visible":true,"origin":"","legend":"","description":"","filename":"1d228147f85146b486d626100f3a4ede1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7201256/v1/9e428a58110751f89eff91fa.xml"},{"id":96668927,"identity":"0774d9bd-b679-4518-b288-5cba3f1b2294","added_by":"auto","created_at":"2025-11-24 22:05:23","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96107,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7201256/v1/b39d0754be285bc9f14b1007.html"},{"id":96710362,"identity":"f20b2810-87fe-496b-b0d2-58eefac4b35a","added_by":"auto","created_at":"2025-11-25 10:10:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":851150,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7201256/v1/8705feda-e9f7-42d0-96a4-a1c32161ea8e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frequency of postoperative delirium and its risk factors in patients with schizophrenia spectrum disorders: a retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSchizophrenia spectrum disorders (SSDs) constitute a group of psychiatric conditions characterized by disturbances in cognition, perception, affect, and behavior. At the core of this spectrum lies schizophrenia, a severe and chronic mental illness marked by a high rate of relapse and commonly associated with a broad array of symptoms and functional impairments [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It affects 1 in every 300 people (0.32%), with a total patient population of approximately 24\u0026nbsp;million worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients with schizophrenia are 2\u0026ndash;3 times more likely to die early than the general population because of the high prevalence of various physical illnesses, including cardiovascular, metabolic, and infectious diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], as well as reduced engagement in health maintenance practices including maintaining healthy eating habits, performing exercise, and avoiding smoking [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, disparities in access to treatments for physical illnesses have been associated with higher mortality rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The life expectancy for patients with SSDs is still short compared to the general population, while the number and percentage of elderly people with SSDs has been increasing as the population ages [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], resulting in increased frequency of hospitalization for the treatment of physical illnesses in this population.\u003c/p\u003e\u003cp\u003eAdditionally, patients with SSDs are at an increased risk of various potential illnesses, including heart disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; stroke [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; pancreatic, esophageal, and breast cancer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; perforated appendicitis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; and cataracts [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which may require surgery. Postoperative delirium (POD) is a common disorder that may be accompanied by psychomotor agitation. Patients with SSDs have many factors associated with delirium, including a high prevalence of physical comorbidities, long-term exposure to psychotropic medications, reduced cognitive reserve, and indicators of frailty [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSuch delirium in patients with SSDs can be difficult to treat outside the psychiatric ward [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, patients with SSDs are often prescribed antipsychotics and benzodiazepine receptor agonists (BZRAs), including zolpidem, zopiclone and eszopiclone, upon admission and have more complex background factors than the general population; therefore, the treatment of delirium in a general ward often requires the expertise of a psychiatrist. However, there are very few studies that specifically report the incidence of delirium in patients with SSDs, rather than in the general psychiatric population and it remains unclear what proportion of patients with SSDs who develop POD require transfer to a psychiatric ward. A lack of epidemiological data on POD in patients with SSDs may impede the acceptance of such patients in hospitals without a psychiatric ward.\u003c/p\u003e\u003cp\u003eWith the continued decline in the number of general hospitals with psychiatric beds in Japan [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], this problem is becoming increasingly serious, especially in regional cities, which means that hospitals without psychiatric wards need to increase their ability to manage POD in patients with SSD. Therefore, this study investigated the frequency of and risk factors for POD in patients with SSDs to improve their access to medical care.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong 208 patients with SSDs who underwent surgery at the study sites during the study period, we included 200 patients after excluding eight patients admitted for suicide attempts. Of these patients, 181 (90.5%) had schizophrenia, nine (4.5%) had schizoaffective disorders, and five (2.5%) had delusional disorders. The mean age of the patients was 57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 years, with 35.5% (71/200) of the patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years and 61% (122/200) being female. The median chlorpromazine equivalent of the administered antipsychotic was 400 (interquartile range [IQR], 200\u0026ndash;714) mg, and approximately half of all patients used BZRAs (98/200). The median operative time was 133 (IQR, 92\u0026ndash;208) min. Surgical duration was \u0026ge;\u0026thinsp;180 min in 76 (38%) patients. A total of 121 (60.5%) patients were hospitalized from their homes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78 (39.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, mean (SD), years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.4 (14.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;65 years, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (35.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospitalization, days, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (6\u0026ndash;21)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of two or more antipsychotics, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (39.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPE, median (IQR), mg/day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e400 (200\u0026ndash;714)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPE\u0026thinsp;\u0026lt;\u0026thinsp;300 mg/day, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (33.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPE\u0026thinsp;\u0026ge;\u0026thinsp;1000 mg/day, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (15.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of BZRAs, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (49.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of trazodone or mianserin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of sodium valproate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (14.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of ramelteon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (4.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of suvorexant or lemborexant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharlson Comorbidity Index, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery for malignancy, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (31.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace of residence prior to hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121 (60.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility or hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (39.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine\u0026thinsp;\u0026gt;\u0026thinsp;1.2 mg/dL, n(%)\u003csup\u003e＊\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;12 mg/dL, n (%)\u003csup\u003e＊\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (39.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\u0026thinsp;\u0026lt;\u0026thinsp;3.5 mg/dL, n (%)\u003csup\u003e＊\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (26.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric disease, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchizophrenia, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e181 (90.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchizoaffective disorder, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (4.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelusional disorder, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003csup\u003e＊\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (22.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical restraint required, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (25.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU admission, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76 (38.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChanges in surface morphology, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (8.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral anesthesia, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e186 (93.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (19.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical time, median (IQR), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133 (92\u0026ndash;208)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical time\u0026thinsp;\u0026ge;\u0026thinsp;180 min, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76 (38.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: CPE, chlorpromazine equivalent; BZRA, benzodiazepine receptor agonist; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e＊Missing value: creatinine (n\u0026thinsp;=\u0026thinsp;1), hemoglobin (n\u0026thinsp;=\u0026thinsp;1), albumin (n\u0026thinsp;=\u0026thinsp;15), smoking (n\u0026thinsp;=\u0026thinsp;4).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn this study, 10.5% (21/200) of patients experienced POD; in particular, 16.9% (12/71) of patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years developed POD. Only one patient with POD required admission to the psychiatric ward.\u003c/p\u003e\u003cp\u003eUnivariate analysis of the factors contributing to delirium development revealed significant differences for hospitalization from outside of the home (crude odds ratio [OR], 3.5; 95% confidence interval [CI], 1.34\u0026ndash;9.13; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), age\u0026thinsp;\u0026ge;\u0026thinsp;65 years (crude OR, 2.7; 95% CI, 1.08\u0026ndash;6.80; p\u0026thinsp;=\u0026thinsp;0.03), and albumin\u0026thinsp;\u0026lt;\u0026thinsp;3.5 g/dL (crude OR, 2.88; 95% CI, 1.14\u0026ndash;2.23; p\u0026thinsp;=\u0026thinsp;0.03) as risk factors. Intensive care unit (ICU) admission (crude OR, 2.4; 95% CI, 0.96\u0026ndash;5.99; p\u0026thinsp;=\u0026thinsp;0.06), smoking before admission (crude OR, 2.36; 95% CI, 0.91\u0026ndash;6.12; p\u0026thinsp;=\u0026thinsp;0.09), hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL (crude OR, 2.23; 95% CI, 0.89\u0026ndash;5.57; p\u0026thinsp;=\u0026thinsp;0.09), and Charlson Comorbidity Index\u0026thinsp;\u0026ge;\u0026thinsp;4 (crude OR, 2.47; 95% CI, 0.92\u0026ndash;6.66; p\u0026thinsp;=\u0026thinsp;0.10) were not significantly related to the development of POD. We observed no significant differences in surgery for malignancy, surgery duration of \u0026ge;\u0026thinsp;180 min, changes in surface morphology during surgery, emergency surgery, use of two or more antipsychotic medications, or antipsychotic medication dose (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with postoperative delirium: Univariate analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients without postoperative delirium\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;179)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of patients with postoperative delirium\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62\u0026ndash;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;65 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;65 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.08\u0026ndash;6.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of BZRAs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.30\u0026ndash;1.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of sodium valproate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u0026ndash;2.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of suvorexant or lemborexant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.68\u0026ndash;7.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of two or more antipsychotics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.25\u0026ndash;1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPE\u0026thinsp;\u0026lt;\u0026thinsp;300 mg/day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u0026ndash;1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPE\u0026thinsp;\u0026ge;\u0026thinsp;1000 mg/day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.12\u0026ndash;2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking before admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.91\u0026ndash;6.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace of residence prior to hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility or hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.35\u0026ndash;9.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharlson Comorbidity Index\u0026thinsp;\u0026ge;\u0026thinsp;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.92\u0026ndash;6.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery for malignancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u0026ndash;1.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine\u0026thinsp;\u0026gt;\u0026thinsp;1.2 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;12 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.89\u0026ndash;5.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\u0026thinsp;\u0026lt;\u0026thinsp;3.5 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.14\u0026ndash;2.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.96\u0026ndash;5.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChanges in surface morphology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.55\u0026ndash;8.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46\u0026ndash;3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;180 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;180 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.40\u0026ndash;2.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19\u0026ndash;12.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: CI, confidence interval; BZRA, benzodiazepine receptor agonist; CPE, chlorpromazine equivalent; ICU, intensive care unit.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs there were 21 patients with POD, the number of factors to be included in the multivariate analysis was determined to be three, and logistic regression analysis was performed using the three variables of age, smoking history before hospitalization, and ICU admission. The results of analysis showed that age\u0026thinsp;\u0026ge;\u0026thinsp;65 years (adjusted OR, 3.25; 95% CI, 1.23\u0026ndash;7.88; p\u0026thinsp;=\u0026thinsp;0.02) and smoking before admission (adjusted OR, 2.97; 95% CI, 1.03\u0026ndash;8.43; p\u0026thinsp;=\u0026thinsp;0.04) significantly increased the risk of developing POD (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLogistic analysis of risk factors for postoperative delirium: Multivariate analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.77\u0026ndash;5.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking before admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.03\u0026ndash;8.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;65 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.23\u0026ndash;7.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eLogistic regression analysis, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviation: CI, confidence interval; ICU, intensive care unit.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eComparisons with previous studies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn the present study, the incidence of POD in patients with SSDs was approximately 10%, and only 0.5% required transfer to a psychiatric ward. In this study, POD occurred in 16.9% of patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years and 7.0% in those aged 18\u0026ndash;65 years. In a previous study of the general population over 18 years of age [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], the incidence of POD was 6.3% in those aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years and 2.3% in those aged 18\u0026ndash;65 years. In the present study, POD occurred about three times more often than in that previous study. Among problematic behaviors from a medical safety perspective in patients with SSDs who had undergone surgery, Tsuji et al. reported bizarre behavior in 52.4% (11/21) of patients with psychiatric diseases who had surgery (15 of whom had schizophrenia) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and Farasatpour et al. reported that 19.6% (11/56) and 21.4% (12/56) of patients with schizophrenia who underwent surgery for breast cancer verbally and physically attacked their caregivers, respectively [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Cooke et al. observed disruptive behavior in 29% (16/55) of patients with schizophrenia who underwent surgery for acute appendicitis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, these previous studies did not clarify whether these behaviors that interfered with physical treatment during the perioperative period were caused by POD, worsening of psychiatric symptoms due to SSDs, or the patients\u0026rsquo; own personality traits. In this study, we were able to show the frequency of POD in patients with SSDs by conducting a more detailed evaluation of the psychiatric symptoms these patients exhibited postoperatively, by conducting a study over a longer period at more facilities than in previous studies.\u003c/p\u003e\u003cp\u003eIn our previous study of patients with SSDs conducted at the same facility as the present study, the frequency of worsening of psychiatric symptoms other than postoperative delirium and insomnia was 11.1% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. When combined with the results of the present study, the frequency of deterioration of the mental status of patients with SSDs due to POD or worsening of psychiatric symptoms due to SSDs is estimated to be approximately 20%, which is similar to the frequency reported in previous studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Compared with previous studies [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], the present study focused on patients with SSDs who developed POD and was conducted over a longer period to ensure a larger number of eligible patients. In patients with SSDs, univariate analysis identified older age, low albumin levels, and pre-admission living environment as significant risk factors for POD. Since low albumin levels and pre-admission living environment were closely related to older age, we selected age, ICU admission, and smoking status as variables in the multivariate analysis, considering the limited number of cases. Although the small sample size necessitates cautious interpretation, these findings are consistent with known risk factors in the general population. Meanwhile, there was no association between POD occurrence and the dosage of antipsychotic medication or the use of BZRAs. The use of BZRAs is generally thought to be a risk factor for POD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], although there is a report that the incidence of delirium in patients who had used BZRAs continuously during the perioperative period was not higher than in patients who had not used them at all [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Patients with SSDs take antipsychotic medications that may work therapeutically against delirium, which may have offset the risk of POD from the use of BZRAs.\u003c/p\u003e\u003cp\u003eAmong the patients with SSDs who developed POD, only one patient required transfer to a psychiatric ward, which was 0.5% of the total. In other words, most cases of POD in patients with SSDs could be managed by adjusting psychotropic medications. Thus, we believe that most cases of perioperative management of patients with SSDs can be performed without problems at general hospitals with a psychiatric liaison consultation service, even if they do not have a psychiatric ward.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOwing to the retrospective study design, unmeasured items could not be evaluated. Specifically, the severity of the psychiatric symptoms at the time of admission could not be evaluated using a unified scale, and the severity of cognitive impairment due to SSDs could not be assessed. Therefore, we collected information on the place of residence prior to hospitalization and antipsychotic medication dosage as indicators of psychiatric symptom severity. Additionally, the diagnosis of POD was based on chart review rather than standardized assessment scales; therefore, there exists a potential for both underdiagnosis and overdiagnosis of POD.\u003c/p\u003e\u003cp\u003eMoreover, as all the participants in this study received psychiatric interventions, it was not possible to evaluate the frequency of POD in patients with SSDs who did not receive psychiatric intervention. The incidence of POD in patients with SSDs who did not receive psychiatric intervention during the perioperative period may be lower than that in the patients in this study; therefore, the incidence of POD in patients with SSDs in this study might be overestimated. To calculate the incidence more accurately, it is necessary to conduct a survey of all patients with SSDs who underwent surgery with or without psychiatric intervention.\u003c/p\u003e\u003cp\u003eFinally, the small sample size did not allow us to include a sufficient number of variables in multivariate analysis. As such, we could only assess the effects of a few variables. However, a strength of this study is that it included a larger sample size than previous studies, allowing us to calculate the incidence of POD in patients with SSDs and demonstrate that the frequency of transfers to psychiatric wards was low. Future research should utilize standardized delirium assessment tools to clarify the risk of POD in patients with SSDs. Studies with larger sample sizes are needed to investigate a broader range of factors associated with the development of POD and to help guide hospital selection for SSD patients requiring physical treatment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePOD developed in approximately 10% of patients with SSDs; however, most patients could be managed by adjusting psychotropic medications, and only a very small number of patients required transfer to a psychiatric ward. Thus, POD management for patients with SSDs may be possible even in general hospitals without a psychiatric ward, as long as psychiatric liaison consultation services are available.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy setting and data sources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study included patients from three tertiary care hospitals in urban Japan totaling 2395 beds. All three hospitals perform gastrointestinal, cardiovascular, respiratory, endocrine and breast, plastic, neurologic, orthopedic, and pediatric surgeries and include obstetrics and gynecology, ophthalmology, dermatology, urology, and otolaryngology departments. One hospital has a transplant surgery department. All three hospitals also have psychiatric wards and consultation-liaison teams including psychiatrists, nurses, and psychologists who provide psychosocial care to patients with comorbid mental and physical illnesses admitted to the general wards. All three institutions are core hospitals in the region and accept patients with SSDs requiring surgical treatment, regardless of the type of physical illness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSelection criteria and outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study participants were patients with SSDs with psychiatric involvement admitted for surgical treatment at the three study hospitals between April 1, 2017 and March 31, 2022. SSDs included schizophrenia, delusional disorder, short-term psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance-induced or drug-induced psychotic disorder, or psychotic disorder caused by other medical illnesses diagnosed before admission by psychiatrists managing their regular psychiatric treatment based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The participants were consultation-liaison patients, who were admitted to the general ward for surgery and referred to the consultation-liaison team. Psychiatrists advised the surgeons regarding the management of the patients’ psychiatric comorbidities. However, this study excluded patients with SSDs admitted because of worsening psychiatric symptoms, including suicide attempts, owing to unstable mental health before admission.\u003c/p\u003e\u003cp\u003eThe main outcome of this study was the proportion of patients who developed POD. We also investigated the number of patients who required admission to the psychiatric ward after developing POD.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical data collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring this study, psychiatrists with sufficient knowledge and experience in consultation-liaison psychiatry conducted chart reviews of all care records as well as records related to prescriptions and laboratories. The reviewers collected the following patient data: sex, age, smoking status, type and dose of psychotropic medication, Charlson Comorbidity Index [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and psychiatric diagnosis based on DSM-5 criteria [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Among psychotropic medication, the amount of chlorpromazine equivalent of antipsychotic drugs used was calculated. The living environment before hospitalization was classified as either home or outside home (psychiatric hospital or support facility).\u003c/p\u003e\u003cp\u003eThe presence or absence of POD was determined based on DSM-5 criteria through chart review and data on the use of physical restraints postoperatively, ICU admission, anesthesia (general or local), emergency or planned surgery, and operative time were also collected. Long-duration surgery was defined as a surgery with a surgical time of ≥ 180 min, as the risk of worsening perioperative psychiatric symptoms increases beyond this cutoff [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, as changes in surface morphology during surgery may affect psychological reactions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], we also investigated whether the patients had undergone tracheostomy, amputation, mastectomy without reconstruction, gastrostomy, colostomy, nephrostomy, or eye resection. After identifying patients who met the criteria for developing POD during an independent review, several reviewers made a final decision on existence of delirium. In cases where it was difficult to distinguish between a worsening of SSD symptoms or the reviewers disagreed on the classification, reviewers reached consensus through discussion. The missing values were treated as normal for blood tests and none for smoking history.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eContinuous variables are presented as mean with standard deviation or medians with IQRs. Categorical variables are presented as number and percentage. We performed the chi-squared test to compare categorical variables when the expected value of each cell was \u0026gt; 5; otherwise, we applied Fisher’s exact test to assess the relationship between delirium and background factors. In conducting multivariate analysis, we selected variables based on the number of patients who developed POD from those used in the univariate analysis that were considered to be clinically closely related to the development of POD. For all statistical analyses, a two-tailed p-value of 0.05 was considered statistically significant. All analyses were performed using JMP, version 18 (SAS Institute, Cary, NC).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e: YM, N. Ayani, MF, and T. Funatsuki conceived of the study. YM and N. Ayani developed the methodology, curated the data, conducted formal analysis, and were responsible for project administration. YM, NA, MF, T. Funatsuki, T. Fukao, SU, AT, N. Oya, and RK conducted the investigation. YM wrote the original manuscript draft. YM, N. Ayani, MF, T. Funatsuki, T. Fukao, SU, AT, N. Oya, RK, SI, and JN reviewed and edited the manuscript. N. Ayani gathered the resources for this study. N. Ayani, SI, and JN supervised the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e: This research was supported by grants from the Mitsubishi Foundation (Grant number 20203003) and JSPS KAKENHI (Grant number 24K20176); however, the funding sources had no further role in the preparation, data collection, or writing of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e: The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval statement:\u003c/strong\u003e This retrospective cohort was approved by the Ethics Committees of Kyoto Prefectural University of Medicine, Okayama University, and Kansai Medical University. The requirement for informed consent was waived by the committees due to the retrospective nature of the study. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003eData availability: The datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTandon, R. \u003cem\u003eet al\u003c/em\u003e. Definition and description of schizophrenia in the DSM-5. \u003cem\u003eSchizophr. Res\u003c/em\u003e. \u003cstrong\u003e150\u003c/strong\u003e, 3\u0026ndash;10 (2013).\u003c/li\u003e\n\u003cli\u003eCharlson, F. J. \u003cem\u003eet al\u003c/em\u003e. Global epidemiology and burden of schizophrenia: findings from the Global Burden of Disease Study 2016. \u003cem\u003eSchizophr. Bull\u003c/em\u003e. \u003cstrong\u003e44\u003c/strong\u003e, 1195\u0026ndash;203 (2018). \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. 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Experiences and coping with the altered body image in digestive stoma patients. \u003cem\u003eRev. Lat. Am. Enfermagem\u003c/em\u003e. \u003cstrong\u003e24\u003c/strong\u003e, e2840 (2016).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"postoperative delirium, schizophrenia spectrum disorders, risk factors, psychiatric care, perioperative management","lastPublishedDoi":"10.21203/rs.3.rs-7201256/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7201256/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePatients with schizophrenia spectrum disorders (SSDs) have a high risk of physical illnesses that require surgery. Postoperative delirium (POD) is a common complication in patients with SSDs, often requiring psychiatric expertise for management. This study aimed to investigate the incidence and risk factors for POD in patients with SSDs undergoing surgery. A retrospective study was conducted at three tertiary hospitals in Japan, including 200 patients with SSDs who underwent surgery between April 2017 and March 2022. Patients admitted due to psychiatric crises were excluded. Data on demographics, psychiatric history, surgical details, and POD development were collected. Statistical analysis included chi-squared tests and logistic regression to identify risk factors. POD occurred in 10.5% of patients with SSDs, with only one requiring psychiatric ward admission. Most patients had schizophrenia (90.5%), and the mean age was 57.4 years. Significant risk factors for POD included age\u0026thinsp;\u0026ge;\u0026thinsp;65 years (adjusted odds ratio: 3.25) and smoking before admission (adjusted odds ratio: 2.97). Antipsychotic medication use or dose was not associated with POD. Most POD cases were managed with psychotropic drug adjustments, suggesting that patients with SSDs can be treated at general hospitals if psychiatric expertise is available.\u003c/p\u003e","manuscriptTitle":"Frequency of postoperative delirium and its risk factors in patients with schizophrenia spectrum disorders: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 22:05:19","doi":"10.21203/rs.3.rs-7201256/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T20:30:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T18:08:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T15:29:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68950156804100166862178717160678273722","date":"2025-11-18T08:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43506242590885735310967790200654193898","date":"2025-11-18T07:16:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-17T03:03:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281747321245591393325253986150703735466","date":"2025-11-13T08:09:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-13T07:59:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-12T06:00:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-29T10:43:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-26T10:26:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-07-26T09:13:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0f2a06a-f316-40e7-a284-5ca232fb62d7","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":58450821,"name":"Health sciences/Diseases"},{"id":58450822,"name":"Health sciences/Health care"},{"id":58450823,"name":"Health sciences/Medical research"},{"id":58450824,"name":"Health sciences/Neurology"},{"id":58450825,"name":"Biological sciences/Psychology"},{"id":58450826,"name":"Social science/Psychology"},{"id":58450827,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-19T06:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 22:05:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7201256","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7201256","identity":"rs-7201256","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}