Systematic Literature Review on early detection of Postoperative Delirium in Patients with Cardiovascular Disease

Systematic Literature Review on early detection of Postoperative Delirium in Patients with Cardiovascular Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Systematic Literature Review on early detection of Postoperative Delirium in Patients with Cardiovascular Disease Saleh Mohammed Alhaj Othman, Mohammed Ali Ali Aziz, Qin XU This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4355605/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Postoperative delirium (POD) is a cognitive decline and attention deficit that can occur in patients after cardiac surgery. Despite extensive research identifying risk factors, POD often goes undiagnosed and untreated in medical settings. Method This systematic literature review (SLR) aims to summarize studies on early POD identification in patients following cardiovascular surgery. Data was obtained from Scopus, PubMed, and the Cochrane International database. Results Seven examined studies highlight high-risk variables (individual characteristics, underlying diseases, treatment methods) and typical symptoms as crucial components for early POD diagnosis. However, diagnostic criteria and evaluation methodologies need to be more consistent, and there is no consensus on the most efficient early detection approaches. Conclusion The findings underscore the need for standardized diagnostic criteria and evaluation methods for early POD detection in cardiovascular surgery patients. Evidence-based recommendations are necessary to enhance early diagnosis and treatment of POD in this population. Cardiothoracic Surgery cardiovascular disease postoperative delirium early identification risk factors systematic literature review Figures Figure 1 1. Introduction The postoperative delirium (POD) is a common mental disorder observed in patients after they have undergone the cardiovascular surgery with an incidence ranged from 4.1 to 54.9%[ 1 ]. However, this entity has also been shown to be dominant more or less in 12–52 percent of the specimens [ 2 ]. Rising delirium is associated with enhanced death rates, with cognitive weakness, longer hospital stay, and the being debilitated in terms of capacity in patients who undergo cardiac operations and in those who are hospitalized to critical care units [ 3 , 4 ]. Several studies discovered the risk factors of POD in cardiovascular patients after their operations and linked these factors to the early analysis of POD in these cardiac patients [ 5 – 7 ]. In real-world scenarios, POD will be lumped with other similar diseases that are being misdiagnosed and therefore do not have proper treatment having identified risk factors for such diseases. Established detection methods of early delirium in the case of cardiovascular disease are being subjected to distortions because of low accuracy in discriminating delirium from the remaining issues which hardly add to credibility of the illness and complexity of delirium symptoms [ 8 , 9 ]. There are some commonly used scales for determination of delirium, one of them being Confusion assessment method (CAM) which is used widely and can be quickly used for evaluation of mental state. The Delirium Observation Screening Scale (DOSS) and Delirium Rating Scale-98 are other frequently used scales. The two mentioned methods of realizing cardiac rehabilitation are limited in the implementation for patients who had cardiac surgery because of certain situations like pharmacological anesthesia and breathing through intubation which also includes the integration of cardiac tools that were implanted. One of the addressing objectives of this SLR is to review and synthesize the recent research investigations that were concerned with POD diagnosis before the patients have been operated for their hearts. Through studies existing, the aim of this study is finding out early indicators of the POD, which are recommended for the purpose of improving diagnosis and treatment of this condition in the pre-acute stage of cardiac disease. 2. Materials and Methods 2.1 study strategy The Prescribed Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria have been followed in the SLR in its evaluation of early detection of POD of individuals who had undergone cardiovascular surgery. A systematic search strategy was created after getting professional advice on medicine. Our objective was to collate full pertinent assemblage from the current pool of literature. For the purpose of gathering evidence, the international electronic databases Scopus, PubMed, and the Cochrane Library were searched. We use a complete set of most relevant keywords and phrases such as "delirium," "postoperative delirium," "risk factor or POD risk factors," "cardiovascular disease OR cardiovascular surgery," "early detection OR early identification," "cognitive OR cognitive disorder," " screening OR delirium screening," "symptom assessment," and relevant synonyms throughout the search. 2.2. Eligibility Criteria Studies published in English, involving adult patients who have had cardiovascular surgery, and focusing on early identification of POD in this patient population will be considered for inclusion in the study. The aforementioned studies have been omitted from consideration as they do not offer insights into the early identification of postoperative delirium in patients undergoing cardiovascular surgery. As a result, these inquiries are deemed irrelevant to the scope of this research. 2.3 Data extraction and statistical inspection Three senior reviewers examined the papers that met the criteria for inclusion. The titles and abstracts were thoroughly examined to see whether the inclusion/exclusion criteria were satisfied. Data was collected by data extraction using a standardized form to obtain details on the primary author, publication year, country, study design, patient characteristics, surgical type, frequency of delirium detection assessment, and outcomes. Two reviewers independently evaluated the chosen research by analyzing the titles and abstracts, and then examined the complete texts of papers that were likely relevant. We did not use quantitative analysis (meta-analysis) in our research due to the diverse nature of the accurate assessments, outcomes, presenting methods, findings, and the limited number of individual evaluations and studies. Instead, we emphasized qualitative assessment as the primary evaluation approach. 2.4 Risk of bias The Newcastle-Ottawa Scale (NOS), which is an instrument to evaluate the status of nonrandomized research, was implemented in order evaluate the potential for bias in the scientific quality of the studies that were presented via the evaluation process[ 10 ]. The results, comparisons, and preferences are the three important elements that constitute up the NOS standards. All of the studies that were qualified for review were taken into account, and a total of five stars was awarded to each and every research study. 3. Results 3.1 Study selection Following the first database search, which made use of a predetermined set of relevant keywords and phrases, a total of 1434 matches were found. The initial dataset was found to have 942 duplicates, which were afterwards eliminated when additional analysis revealed their existence. In order to facilitate additional review and analysis, this approach ensured that the dataset would be more accurate and enhanced. Following this step, a total of 492 items were considered suitable for additional examination and were subjected to the identification processes shown in Fig. 1 . During the screening process, 810 studies were excluded for a variety of justifications: they were not full-text or original studies published in English; they were review letters, editorials, systematic reviews; they were related to brain surgery or pediatric populations and other specific types of surgery; they were conference proceeding papers; or they were non-clinical studies. 132 original studies met the requirements for the eligibility phase after completing the screening procedure. Among the 124 studies, there were four that did not have their entire texts accessible, twenty-four that were post hoc analyses, thirty-six that did not give quantitative data on the early identification of POD, thirty-two that did not employ a validated POD scale, and twenty-eight that did not prioritize the early identification of POD as a priority or secondary aim. The diagnostic approach that used a validated POD scale to detect POD on early identification was only present in eight out of the total number of studies that were retrieved, which represents for 4.9% of the total number of studies done between the years 2000 and 2024. 3.2 Characteristics of selected studies Following a review of seven research that investigated the evaluation of POD, it came to light that one of the studies did not make use of the POD diagnostic scale, which is summarized in Table 1 . Of the studies that were chosen, four studies used the CAM-ICU POD diagnosis scale, and one research used the Nursing Delirium Screening Scale. The remaining two studies used a mixed methodology, combining the Confusion Assessment Method (CAM-ICU) with tools like the Richmond Agitation Sedation Scale (RASS score) Table 1 The characteristics of the studies that were included. Author Study design Patients delirium detection Type of Surgery Delirium assessment [ 11 ] Sweden Prospective 142 NDSC Cardiac surgery 1, 4 [ 12 ] Poland Multivariate logistic regression 113 Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B CABG and CPB Twice a day [ 13 ] Greece Prospective 179 RASS score and CAM-ICU Open-heart surgery 1, 2 [ 14 ] USA Retrospective 161 non Cardiac surgery non [ 15 ] China Prospective 273 CAM-ICU Cardiac surgery 4, 8 [ 16 ] China Prospective 243 CAM-ICU Cardiac surgery 1, 5 [ 17 ] USA Prospective 148 CAM-ICU Cardiac surgery 12hours [ 18 ] Prospective 332 CAM-ICU Cardiac surgery daily Abbreviations: NDSC nursing delirium screening scale, CABG coronary artery bypass graft, CPB cardiopulmonary bypass, RASS richmond agitation sedation scale, CAM-ICU confusion assessment method for the intensive care unit The Montreal Cognitive Assessment and Trail Making Test Part B, and the Mini International Neuropsychiatric Interview. This SLR included seven distinct kinds of research, including five prospective observational studies, one multivariate logistic regression analysis, and one retrospective research (Table 1 ). The assessments were carried out with the purpose of determining the influence that a particular intervention had on the outcomes encountered by the patients. While some studies placed a greater emphasis on surgical procedures, others placed a greater emphasis on pharmacological therapies. The treatments varied depending on the research, with some placing more of an emphasis on surgical procedures. Furthermore, the demographic characteristics of the patient populations varied from one study to the next over the course of the research that was incorporated in the analysis throughout the whole process. Patients who were over the age of 50 made up the bulk of the participants in the study, and the average age ranged anywhere from 45 to 65 years old. Patients were asked to participate in the bulk of the studies. In each of the studies, around fifty percent of the participants were male and fifty percent were female. This indicates that the gender distribution was reasonably balanced. There were a total of 1254 patients that participated in our study, which was based on seven separate experiments. Table 1 presents the outcomes of the study that was conducted in China, Sweden, Poland, Greece, and the United States of America. As a result of our study, we discovered that China and the United States of America each had two studies, making them the nations that had the most amount of studies. There were seven publications that were examined by the SRL. These studies explored patients who were having various types of surgeries in cardiac surgery. Five of the papers focused largely on cardiac surgery. One research concentrated on open heart surgery, while another studied coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). The studies included data on the results of various cardiac surgeries and the experiences of the patients. Table 2 predictors of postoperative delirium (POD) Category Subcategory Predictors References High-Risk factors Individual characteristics Age (≥ 65), cognitive impairment, multiple medical conditions, history of alcoholism, gender, level of education ESA guidelines, Mu et al. [ 16 ], Kanova et al. [ 18 ] Underlying medical conditions Surgical procedures: type, duration, complexity; conditions such as aortic dissection, coronary artery bypass grafting, heart transplantation, abdominal incision, major vascular surgery, etc. Hughs et al. [ 21 ], Kazmierski et al. [ 12 ] Treatment procedures ICU admission, immobilization, postsurgical pain, sleep disturbances, endotracheal intubation, blood transfusions, hypoxemia, vasoactive drugs Arenson et al. [ 20 ] Typical symptoms Attentional disturbances, cognitive difficulties, fluctuating consciousness, sleeplessness, hallucinations, emotional instability, restlessness, agitation, hypoactivity, hyperactivity, mixed delirium Research findings 3.3 Early identification of POD in patients with cardiovascular disease Table 3 summarizing the early detection of POD in patients following cardiac surgery is related to risk factors, and researchers have made efforts to uncover the risk factors that are associated with POD [ 19 ]. According to the findings of this SLR, the primary elements that contribute to the early identification of POD in patients who have undergone cardiac surgery are high-risk factors that are related to (individual characteristics, underlying disorders, treatment modalities) and typical symptoms that are present in the following order: 3.3.1 High-Risk factors Individual characteristics The prevalence of POD is closely linked to individual characteristics. According to the guidelines set by the European Society of Anesthesiology (ESA)[ 3 ], which are grounded in evidence-based medicine and expert consensus, patients aged 65 and older are more likely to experience POD. The likelihood of developing POD-related variables rises with age. Research by Mu et al.[ 16 ] has found that age, cognitive impairment, and multiple medical conditions are independent risk factors for POD. This suggests that older patients with cognitive impairment and multiple medical conditions are more likely to experience delirium following surgery. As a means of detecting and treating delirium in patients who have cardiovascular disease, it is vital for medical professionals to have a comprehensive grasp of these factors (risk) that are implicated in the condition. Additionally, it is conceivable that medicines that target these risk factors might be of assistance in reducing the number of POD problems that occur in individuals who have had surgical procedures. In the study by Kanova et al. [ 18 ] indicated that 39 percent of people who suffer from post-traumatic stress disorder have a history of alcoholism. The primary reason for this is that ethanol has a depressant effect on the central nervous system. Patients give up drinking while they are in the hospital, which leads to the development of withdrawal syndrome. It also revealed a substantial link between gender and the occurrence of delirium which indicates that males have a higher likelihood of experiencing POD compared to females, and there is a direct correlation between the amount of education and the occurrence of POD. Signs of postoperative delirium might be seen in severe instances[ 17 ]. Underlying medical conditions Within the realm of surgical procedures, the term "underlying medical conditions" is used to describe the elements that have the potential to have an impact on the final result of the operation. The amount of time it takes to finish the surgery and the particular therapies that are carried out are two of these criteria. Other related variables, such as the surgical method and duration, are also involved in this group [ 12 , 20 ]. Those attending to the concerned meticulously must consider these features in the light of the threats associated with the surgery or its aftereffects. Mu et al. [ 16 ] This association became much clearer when the researchers found that the number of surgical operations performed during the one hour service time period was inversely proportional to the POD incidents. The conclusion seems to be the fact that the number of cases of medical emergencies increases correspondingly with the duration of operation An analysis of surgery conducted by Hughs et al. [ 21 ] established surgical revascularization procedures brought down the rate of occurrence of POD a lot than it reduced in cases of other large vascular operations such as thoracotomy. Undergoing surgical operation of aortic dissection, coronary artery bypass grafting, heart transplantation, abdominal incision, and major vascular surgery would be higher in incidence of POD compared to other surgical procedures. Besides, the statisticians broke down the surgical POD rate in function to the kind of conditions they were applied. The study by the research group of Kazmierski, however, pointed out that the proportion of patients who had POD was seen to be as high as 36.3% among those undergoing coronary bypass surgery, 32.5% among those having aortic dissection, 25.7% in case of heart transplant, 16.3% among those receiving thoracotomy [ 12 ]. Treatment procedures Enrolling into the intensive care unit, immobilization (to use protective restraints), postsurgical pain, sleep disturbances, endotracheal intubation, blood transfusions, blood oxygen amount decrease ( hypoxemia), and the application of vasoactive drugs as risk factors for the beginning of POD [ 11 , 22 ]. Less use of vasoactive drugs, better pain management, or other means of decreasing the number of POD patients that have undergone cardiac surgeries may help in achieving the target. Nurses and doctors could improve predicting and dealing with delirium by increasing their understanding into the early factors that could be the starting point for such a disease. Arenson et al. [ 20 ] found that 14.7% of 1010 patients who had had cardiac surgery presented difficulty in breathing after surgery, called as POD. The potential of the development of particular disorders such as receiving large amounts of blood products in the transfusion; the use of intubation exceeding twenty-four hours are factors that may affect the condition [ 13 ], stroke, renal failure, prolonged cross-clamp time[ 15 ], or transient ischemic attack [ 17 ]. While this is not entirely so, the problem may arise from the undertreated patients after the operation, and or wrong time use of certain drugs such as anticholinergics, opioid narcotic analgesics, and benzodiazepine sedatives [ 14 ]. 3.3.2 Typical symptoms Attentional disturbances, cognitive difficulties, fluctuating consciousness, and sleeplessness, wide unusual perception, and hallucinations, are a few of the possible clinical signs of POD. The POW feelings could trigger dysfunctional emotional reactions in victims, manifesting themselves as anxiety, impatience, and fading emotions. POD affects people in different ways, but usually, it doesn't involve motor skills that may include hyperactivity, hypoactivity or even pendulum-like fluctuations between these two types. Acute delirium agitation is being manifested by rebound of the mental activity and body motility. These symptoms may vary and include obvious ones such as trouble calming down, emotional instability, restlessness, and irritation to name a few. Among the possible signs to be exhibited are hallucinations, deluded thoughts, and a violent extremity of behavior [ 12 ]. This kind of delirium presents a higher danger to patients, is clearly recognizable, but may also be susceptible to misdiagnosis. Hyperactive delirium in critical care settings is sometimes misidentified as regular agitation, resulting in incorrect use of sedatives that might worsen the situation. Patients with hypoactive delirium have an elevated death risk and need specific therapy. Mixed delirium is characterized by the fact that it displays symptoms of both hyperactive and hypoactive delirium. This is one of the characteristic features of mixed delirium which is characterized by intervals of thinking and activity levels that are typically functioning, however these periods are intermittent and occur on a regular basis. Mixed delirium is an illness that is famously difficult to identify and adequately treat. Besides, expresses itself in such a varied variety of symptoms. It is of the utmost importance to identify and treat the specific kind of delirium in individuals to improve the results for the patient and reduce the severity of the repercussions. Several studies that have highlighted the necessity of recognizing these typical symptoms of POD in order to facilitate early identification and immediately begin treatment. Postoperative breathing difficulties are reported by research conducted by Arenson et al. [ 20 ] that 14.7% of patients who underwent cardiac surgery, which an indication of POD. It is challenging to identify POD at an early stage, such as pain, pharmacological side effects, or metabolic abnormalities. Therefore, it is critical to identify the typical symptoms and forms of delirium in patients after cardiac surgery in order to diagnose it early and provide the right care. Practitioners in the medical field need to be vigilant when assessing patients for delirium symptoms since prompt intervention may improve patient outcomes and reduce the likelihood of unfavorable events. Table 3. Assessment performed by the NOS to determine the likelihood of bias. 3.3 Risk of bias Table 3 illustrates that there was a comparable risk of bias across all of the different areas that were evaluated, which is clear when looking at the data of all eight-research taken together. Specifically, A certain amount of robustness in the procedures that were employed for participant selection was indicated by the fact that a reasonably low risk of bias was seen within the parameters of the selection domains. However, in our study a higher risk of bias recorded within the comparability elements among the selected studies which is highly recommending potential limitations in the ability to compare study among different studies. Interesting to note that the risk of bias in result confirmation was found to be constant across all eight studies. This suggests that there is a consistent degree of trustworthiness in the measuring and reporting of outcomes throughout the various study investigations. 4. Discussions Early identification of postoperative delirium in patients after heart surgery is imperative for preventing any negative consequences. Researchers have been involved in pinpointing major risk factors identifying POD from an early stage in order to possibly achieve the early diagnosis of this disease. By the results of this SLR, the high-risk indicators will be essential parts of the early alerts on POD for patients after undergoing heart surgery. These factors are essentially anyone else's personal features, psychological conditions, and the treatment approaches they are utilizing. Personal features like age, gender, education level, and medical history influence delirium susceptibility. Elderly individuals are more vulnerable due to age-related brain changes. Gender differences and higher education levels may also play a role. Additionally, pre-existing medical conditions, like cardiovascular disease and alcoholism, can increase the risk. Psychological conditions such as anxiety, depression, and post-traumatic stress disorder (PTSD) contribute to delirium risk by exacerbating stress responses and neuroinflammation. Patients with trauma or PTSD are particularly susceptible. Treatment methods like surgical procedures and anesthesia impact delirium risk. Cardiac surgeries involving bypass and prolonged anesthesia can trigger neuroinflammatory responses. Choice of anesthetics and postoperative care also affect susceptibility. Delirium as a rule is caused by age among different individual factors that predispose to delirium. According to the research, the chance of people having delirium over the age of 65, after the operation was, however higher. Intellectual disability, particularly as an independent risk factor for postoperative delirium, is recognized as an identifying marker for the mental state. Another risk factor that would increase the likelihood of postoperative delirium is the presence of other medical conditions. Gender and educational ranking constitute a crucial factor related to the likelihood as men and affected group of alcoholics are the most vulnerable. The role of POD is accentuated by considering a patient's medical history and other conditions, along with the length of the procedure and the techniques used by the surgeon [ 23 ]. Specific surgical approaches, such as the coronary artery bypass grafting, have been determined to be related to the disproportionate rate of postoperative amnesia incidence. Duration of surgery has been demonstrated to not only be the decisive factor in postoperative complications, but also to significantly contribute to the overall safety of surgical procedures [ 20 , 24 ]. And lastly, the evolvement of POD probably would be under the influence of postoperative interventions that occur after heart surgeries. The services offered by the hospital frequently involve continuous hospitalization to the hospital's intensive care unit, strict immobilization of the affected limb, and pain control throughout postoperative period. Pain medicines which can be considered vasoactive medicines and that include an inadequate pain control are two factors that have been proven to play a significant role in the onset of delirious conditions after surgery. Moreover, Pharmacology Deficits of Actions or Common Signs of POD consist of cognitive dysfunction that involves the patient's awareness, direction and attention and can be in the form of hyperactive, hypoactive or mixed delirium. In the hyperactive type delirium is enriched with an amped cognitive processes and marked agitation, whereas in the hypoactive the mental activity is diminished and delayed responses to speech or body movement are sometimes displayed. So as to illustrate that, one must point out mixed delirium, where the patient goes back and forth from hyperactive and hypoactive phases [ 25 ]. Healthcare personnel have to act fast to identify early-stage postoperative delirium symptoms and risk factors that can be seen in patients after ECS in order to avoid the progression of delirium. If the factors that lead to developing surgery-related delirium and poor results are identified and dealt with by healthcare providers, they are empowered to enhance the quality of care they already offer to such patients. There will be an emphasis on the following in future research: First, examines the possibility that patients with cardiovascular illness may not be reporting POD as much as they might be owing to differences in diagnostic criteria or evaluation techniques across a number of different studies. Second, Investigate the differences in defining and diagnosing delirium, as well as the influence these differences have on the prevalence rates that have been reported. Third, Examine the degree of variation in the outcomes that have been observed after surgical delirium in individuals with cardiovascular conditions. On cognitive function, mortality, functional recovery, and healthcare usage, it is important to investigate both the short-term and long-term impacts and implications. Our study has strengths enhancing credibility and reliability. This systematic review covered databases like Scopus, PubMed, and the Cochrane Library, ensuring thoroughness and replicability. Our inclusion criteria were rigorous, focusing on English language publications on adult cardiovascular surgery patients, enhancing relevance. Our data extraction involved three senior reviewers, ensuring objectivity and consistency. Qualitative assessment enriched our analysis, addressing the diverse literature nature. The use of the Newcastle-Ottawa Scale strengthened bias evaluation. However, limitations include refraining from meta-analysis due to varied assessments and outcomes, potential publication bias from English-only publications, and heterogeneity across studies. 5. Recommendations 5.1 Preventive approaches without medications POD prevention in cardiac surgery patients receives prime importance because of the advances made in varied studies indicating that different strategies reduced POD occurrence. Employing a multifaceted treatment in early mobilization together with proper pain management, reduction in sedative, proper hydration and food intake, and treatment of concurrent disorders such as dementia and depression as well as sleeping problems has proven for the patients who undergo surgery can decrease the chances of having postoperative delirium [ 26 ]. Adopt alternative strategies that are uncorrelated with medications for instance cognitive stimulation methods, patient communication techniques and family participation may prevent postoperative delirium. Research conducted by Oh et al. [ 27 ] found that the use of multi-component treatments including distractions such as picture testimonies, pictures and pictures through table visits could be of high significance in the prevention of postoperative delirium (POD) in elderly surgical patients. Solutions as mentioned, tend to adopt a strategy which is usually a mix of various methods like i.e. universal screening for most possible delirium risk, early mobility, and improved communications among various health professionals that are involved in the process of treatment. One cause of a rise in the POD rate might be the pharmacotherapy of patients in risk groups by such antipsychotics drugs as the dexmedetomidine, melatonin, and antipsychotic medications. [ 28 ]. But on the flip-side, weighing the benefits of these meds or conversely the potential dangers they carry are of prime importance so as to adjust the treatment plan to the patient’s individual risk factors and needs [ 29 ]. According to the findings of research conducted by Young et al.[ 30 ] mentioned that it might be helpful to adopt broad preventive measures operating at the pre-surgical stages that could reduce POD incidence in patients after cardiac surgery. Thus, it is necessary to employ a multifaceted and proactive approach to avoid POD in the surgical cases to obtain desirable outcomes, low healthcare costs, and greater quality of care for these patients. Evidence based treatments and tailored treatment plans taken by medical professionals will decrease the risk of POD, and hence, expected outcomes of POD will be better. 5.2 The medication prevention measures Due to the absence of substantial clinical trial data indicating that pharmaceuticals or combined non-drug preventive strategies may reduce the occurrence and duration of Parkinson's disease in cardiovascular diseases, it is not recommended to make use of medications on a consistent basis in order to prevent the beginning of Parkinson's disease. It is because of the fact that there is a certain amount of disagreement around the subject that this is the case [ 5 , 6 ]. On the other hand, there are circumstances in which you are able to root. The administration of benzodiazepines is necessary due to the severity of the condition. Those patients, for instance, who had an excessive amount of worry or anxiety before to surgery, as well as those who had been using benzodiazepines for a considerable amount of time previous to surgery, should be used with caution[ 11 ]. 6. Conclusions According to the majority of patients who have had cardiovascular surgery, extended sedation and intubation are necessary in order to satisfy the criteria of the condition and the treatment. This characteristic is typically found in persons after they have had cardiovascular surgery. In this systematic literature review, the early and primary factors that contribute to the early identification of postoperative complications (POD) in patients who have undergone cardiac surgery as a high-risk factor were identified. These factors are related to (individual characteristics, underlying disorders, treatment modalities), and they are associated with typical symptoms. Relevant strategies were also proposed. This research additionally demonstrates that the training of medical professionals in delirium understanding should be enhanced as well as the accurate application of delirium evaluation tools, in order to improve the accuracy of POD monitoring in patients. Increase the effectiveness of the therapy for POD in patients and put into practice effective measures for the prevention of POD in patients who have cardiovascular disease. Future research will focus on exploring discrepancies in postoperative delirium reporting among cardiovascular patients, investigating variations in defining and diagnosing delirium, and assessing outcomes after surgical delirium on cognitive function, mortality, functional recovery, and healthcare usage in both short-term and long-term perspectives. References Chen H, Mo L, Hu H, Ou Y, Luo J. Risk factors of postoperative delirium after cardiac surgery: a meta-analysis. J Cardiothorac Surg. 2021 Apr 26;16(1):113. doi: 10.1186/s13019-021-01496-w. PMID: 33902644; PMCID: PMC8072735. Zhu, L.; Shi, H.; Zhu, C.; Liu, H.; Su, Z.; Zhao, Y. Impact of Permissive Hypercapnia on Regional Cerebral Oxygen Saturation and Postoperative Cognitive Function in Patients Undergoing Cardiac Valve Replacement. Ann Palliat Med 2020 , 9 , 4066–4073, doi:10.21037/apm-20-2090. Aldecoa, C.; Bettelli, G.; Bilotta, F.; Sanders, R.D.; Audisio, R.; Borozdina, A.; Cherubini, A.; Jones, C.; Kehlet, H.; MacLullich, A.; et al. European Society of Anaesthesiology Evidence-Based and Consensus-Based Guideline on Postoperative Delirium. European Journal of Anaesthesiology 2017 , 34 , 192–214, doi:10.1097/EJA.0000000000000594. Karageorgos, V.; Mevorach, L.; Silvetti, M.; Bilotta, F. Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies. Geriatrics 2023 , 8 , 24, doi:10.3390/geriatrics8010024. Ansaloni, L.; Catena, F.; Chattat, R.; Fortuna, D.; Franceschi, C.; Mascitti, P.; Melotti, R.M. Risk Factors and Incidence of Postoperative Delirium in Elderly Patients after Elective and Emergency Surgery. Journal of British Surgery 2010 , 97 , 273–280. Marcantonio, E.R. Postoperative Delirium: A 76-Year-Old Woman with Delirium Following Surgery. Jama 2012 , 308 , 73–81. Wang, J.; Wang, L.; Tang, X.; Wang, F.; Liu, S.; Wu, X.; Dong, R.; Lin, X.; Wang, B.; Bi, Y. The Relationship Between Cardiovascular Disease Risk Score and Postoperative Delirium: The PNDABLE Study. Front. Aging Neurosci. 2022 , 14 , 851372, doi:10.3389/fnagi.2022.851372. Fong, T.G.; Tulebaev, S.R.; Inouye, S.K. Delirium in Elderly Adults: Diagnosis, Prevention and Treatment. Nature Reviews Neurology 2009 , 5 , 210–220. Leslie, D.L.; Marcantonio, E.R.; Zhang, Y.; Leo-Summers, L.; Inouye, S.K. One-Year Health Care Costs Associated with Delirium in the Elderly Population. Archives of internal medicine 2008 , 168 , 27–32. Peterson, J.; Welch, V.; Losos, M.; Tugwell, P. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa: Ottawa Hospital Research Institute 2011 , 2 , 1–12. Lingehall, H.C.; Smulter, N.; Engström, K.G.; Gustafson, Y.; Olofsson, B. Validation of the Swedish Version of the Nursing Delirium Screening Scale Used in Patients 70 Years and Older Undergoing Cardiac Surgery. Journal of Clinical Nursing 2013 , 22 , 2858–2866, doi:10.1111/j.1365-2702.2012.04102.x. Kazmierski, J.; Banys, A.; Latek, J.; Bourke, J.; Jaszewski, R. Raised IL-2 and TNF-α Concentrations Are Associated with Postoperative Delirium in Patients Undergoing Coronary-Artery Bypass Graft Surgery. Int. Psychogeriatr. 2014 , 26 , 845–855, doi:10.1017/S1041610213002378. Theologou, S.; Giakoumidakis, K.; Charitos, C. Perioperative Predictors of Delirium and Incidence Factors in Adult Patients Post Cardiac Surgery. POR 2018 , Volume 9 , 11–19, doi:10.2147/POR.S157909. Mangusan, R.F.; Hooper, V.; Denslow, S.A.; Travis, L. Outcomes Associated With Postoperative Delirium After Cardiac Surgery. American Journal of Critical Care 2015 , 24 , 156–163, doi:10.4037/ajcc2015137. Othman, S.M.A.; Xu, Q.; Zhao, K.; Kafi, L.; Aziz, M.A.A. Identification of Early Delirium and Its Outcomes after Cardiopulmonary Bypass among Adult Patients with Cardiovascular Disease: A Prospective Observational Study. Indian J Thorac Cardiovasc Surg 2024 , 40 , 151–158, doi:10.1007/s12055-023-01613-5. Mu, D.-L.; Wang, D.-X.; Li, L.-H.; Shan, G.-J.; Li, J.; Yu, Q.-J.; Shi, C.-X. High Serum Cortisol Level Is Associated with Increased Risk of Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study. Crit Care 2010 , 14 , R238, doi:10.1186/cc9393. Cahill, A.; Pearcy, C.; Agrawal, V.; Sladek, P.; Truitt, M.S. Delirium in the ICU: What About the Floor? Journal of Trauma Nursing 2017 , 24 , 242–244, doi:10.1097/JTN.0000000000000298. Kanova, M.; Sklienka, P.; Kula, R.; Burda, M.; Janoutova, J. Incidence and Risk Factors for Delirium Development in ICU Patients-a Prospective Observational Study. Biomedical Papers of the Medical Faculty of Palacky University in Olomouc 2017 , 161 . Lin, Y.; Chen, J.; Wang, Z. Meta-Analysis of Factors Which Influence Delirium Following Cardiac Surgery. Journal of Cardiac Surgery 2012 , 27 , 481–492, doi:10.1111/j.1540-8191.2012.01472.x. Arenson, B.G.; MacDonald, L.A.; Grocott, H.P.; Hiebert, B.M.; Arora, R.C. Effect of Intensive Care Unit Environment on In-Hospital Delirium after Cardiac Surgery. The Journal of thoracic and cardiovascular surgery 2013 , 146 , 172–178. Hughes, C.G.; Boncyk, C.S.; Culley, D.J.; Fleisher, L.A.; Leung, J.M.; McDonagh, D.L.; Gan, T.J.; McEvoy, M.D.; Miller, T.E.; for the Perioperative Quality Initiative (POQI) 6 Workgroup American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesthesia & Analgesia 2020 , 130 , 1572–1590, doi:10.1213/ANE.0000000000004641. Cropsey, C.; Kennedy, J.; Han, J.; Pandharipande, P. Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 2015 , 19 , 309–317, doi:10.1177/1089253215570062. Crocker, E.; Beggs, T.; Hassan, A.; Denault, A.; Lamarche, Y.; Bagshaw, S.; Elmi-Sarabi, M.; Hiebert, B.; Macdonald, K.; Giles-Smith, L.; et al. Long-Term Effects of Postoperative Delirium in Patients Undergoing Cardiac Operation: A Systematic Review. The Annals of Thoracic Surgery 2016 , 102 , 1391–1399, doi:10.1016/j.athoracsur.2016.04.071. Brown, C.H. Delirium in the Cardiac Surgical ICU. Current Opinion in Anesthesiology 2014 , 27 , 117–122. Smith, P.J.; Attix, D.K.; Weldon, B.C.; Monk, T.G. Depressive Symptoms and Risk of Postoperative Delirium. The American Journal of Geriatric Psychiatry 2016 , 24 , 232–238. Inouye, S.K.; Marcantonio, E.R.; Kosar, C.M.; Tommet, D.; Schmitt, E.M.; Travison, T.G.; Saczynski, J.S.; Ngo, L.H.; Alsop, D.C.; Jones, R.N. The Short-Term and Long-Term Relationship between Delirium and Cognitive Trajectory in Older Surgical Patients. Alzheimer’s & Dementia 2016 , 12 , 766–775. Oh, E.S.; Fong, T.G.; Hshieh, T.T.; Inouye, S.K. Delirium in Older Persons: Advances in Diagnosis and Treatment. Jama 2017 , 318 , 1161–1174. Neufeld, K.J.; Yue, J.; Robinson, T.N.; Inouye, S.K.; Needham, D.M. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta‐analysis. Journal of the American Geriatrics Society 2016 , 64 , 705–714. Igwe, E.O.; Nealon, J.; O’Shaughnessy, P.; Bowden, A.; Chang, H.-C.; Ho, M.-H.; Montayre, J.; Montgomery, A.; Rolls, K.; Chou, K.-R. Incidence of Postoperative Delirium in Older Adults Undergoing Surgical Procedures: A Systematic Literature Review and Meta‐analysis. Worldviews on Evidence‐Based Nursing 2023 , 20 , 220–237. Young, E.; Philpott, H.; Singh, R. Endoscopic Diagnosis and Treatment of Gastric Dysplasia and Early Cancer: Current Evidence and What the Future May Hold. World Journal of Gastroenterology 2021 , 27 , 5126–5151, doi:10.3748/wjg.v27.i31.5126. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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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-4355605","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":297692905,"identity":"539a3d83-d291-4a41-9fd9-0ee00c5ff166","order_by":0,"name":"Saleh Mohammed Alhaj Othman","email":"","orcid":"","institution":"Nanjing medical university","correspondingAuthor":false,"prefix":"","firstName":"Saleh","middleName":"Mohammed Alhaj","lastName":"Othman","suffix":""},{"id":297692906,"identity":"b32d2414-6204-4e0c-96eb-cbd8c748533f","order_by":1,"name":"Mohammed Ali Ali Aziz","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Ali Ali","lastName":"Aziz","suffix":""},{"id":297692907,"identity":"68d5019f-a863-402e-abc9-efcfca27c55c","order_by":2,"name":"Qin XU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYDACZhBRAaEYeIjXcoYkLSDA2AZlEKWF7zjvMWneeXfYdWckMD5428Ygb05Ii+RhvmRj3m3PmM1uJDAbzm1jMNzZQECLwWEew8e82w6DtLBJ87YxJBgcIKzF4DDvHLAW9t/EagHa0gCxhZkoLZKHeYwN5xwDajnzsFlyzjkJww2EtPCdP2Mm8abmcLLZ8eSDH96U2cgTtIUBqiAZGDsNQFqCkHqEFjsilI6CUTAKRsFIBQBkcDwMRWHVBAAAAABJRU5ErkJggg==","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Qin","middleName":"","lastName":"XU","suffix":""}],"badges":[],"createdAt":"2024-05-01 18:26:51","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-4355605/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4355605/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55817990,"identity":"232c7661-b3c9-428b-b944-dc4690f49f5d","added_by":"auto","created_at":"2024-05-03 20:52:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":819210,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart depicting systematic literature review (SLR) using the PRISMA guidelines.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4355605/v1/7b9c47c132d285f480e36a15.png"},{"id":55817991,"identity":"aa56d597-c901-4962-bee9-f761de671eff","added_by":"auto","created_at":"2024-05-03 20:52:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":829645,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4355605/v1/4b51e6d9-0599-495b-9b55-8523b035b491.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSystematic Literature Review on early detection of Postoperative Delirium in Patients with Cardiovascular Disease\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe postoperative delirium (POD) is a common mental disorder observed in patients after they have undergone the cardiovascular surgery with an incidence ranged from 4.1 to 54.9%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, this entity has also been shown to be dominant more or less in 12\u0026ndash;52 percent of the specimens [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Rising delirium is associated with enhanced death rates, with cognitive weakness, longer hospital stay, and the being debilitated in terms of capacity in patients who undergo cardiac operations and in those who are hospitalized to critical care units [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Several studies discovered the risk factors of POD in cardiovascular patients after their operations and linked these factors to the early analysis of POD in these cardiac patients [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In real-world scenarios, POD will be lumped with other similar diseases that are being misdiagnosed and therefore do not have proper treatment having identified risk factors for such diseases. Established detection methods of early delirium in the case of cardiovascular disease are being subjected to distortions because of low accuracy in discriminating delirium from the remaining issues which hardly add to credibility of the illness and complexity of delirium symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. There are some commonly used scales for determination of delirium, one of them being Confusion assessment method (CAM) which is used widely and can be quickly used for evaluation of mental state. The Delirium Observation Screening Scale (DOSS) and Delirium Rating Scale-98 are other frequently used scales. The two mentioned methods of realizing cardiac rehabilitation are limited in the implementation for patients who had cardiac surgery because of certain situations like pharmacological anesthesia and breathing through intubation which also includes the integration of cardiac tools that were implanted. One of the addressing objectives of this SLR is to review and synthesize the recent research investigations that were concerned with POD diagnosis before the patients have been operated for their hearts. Through studies existing, the aim of this study is finding out early indicators of the POD, which are recommended for the purpose of improving diagnosis and treatment of this condition in the pre-acute stage of cardiac disease.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 study strategy\u003c/h2\u003e\n\u003cp\u003eThe Prescribed Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria have been followed in the SLR in its evaluation of early detection of POD of individuals who had undergone cardiovascular surgery. A systematic search strategy was created after getting professional advice on medicine. Our objective was to collate full pertinent assemblage from the current pool of literature. For the purpose of gathering evidence, the international electronic databases Scopus, PubMed, and the Cochrane Library were searched. We use a complete set of most relevant keywords and phrases such as \"delirium,\" \"postoperative delirium,\" \"risk factor or POD risk factors,\" \"cardiovascular disease OR cardiovascular surgery,\" \"early detection OR early identification,\" \"cognitive OR cognitive disorder,\" \" screening OR delirium screening,\" \"symptom assessment,\" and relevant synonyms throughout the search.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2. Eligibility Criteria\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eStudies published in English, involving adult patients who have had cardiovascular surgery, and focusing on early identification of POD in this patient population will be considered for inclusion in the study. The aforementioned studies have been omitted from consideration as they do not offer insights into the early identification of postoperative delirium in patients undergoing cardiovascular surgery. As a result, these inquiries are deemed irrelevant to the scope of this research.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3 Data extraction and statistical inspection\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThree senior reviewers examined the papers that met the criteria for inclusion. The titles and abstracts were thoroughly examined to see whether the inclusion/exclusion criteria were satisfied. Data was collected by data extraction using a standardized form to obtain details on the primary author, publication year, country, study design, patient characteristics, surgical type, frequency of delirium detection assessment, and outcomes. Two reviewers independently evaluated the chosen research by analyzing the titles and abstracts, and then examined the complete texts of papers that were likely relevant.\u003c/p\u003e\n\u003cp\u003eWe did not use quantitative analysis (meta-analysis) in our research due to the diverse nature of the accurate assessments, outcomes, presenting methods, findings, and the limited number of individual evaluations and studies. Instead, we emphasized qualitative assessment as the primary evaluation approach.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.4 Risk of bias\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThe Newcastle-Ottawa Scale (NOS), which is an instrument to evaluate the status of nonrandomized research, was implemented in order evaluate the potential for bias in the scientific quality of the studies that were presented via the evaluation process[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. The results, comparisons, and preferences are the three important elements that constitute up the NOS standards. All of the studies that were qualified for review were taken into account, and a total of five stars was awarded to each and every research study.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Study selection\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eFollowing the first database search, which made use of a predetermined set of relevant keywords and phrases, a total of 1434 matches were found. The initial dataset was found to have 942 duplicates, which were afterwards eliminated when additional analysis revealed their existence. In order to facilitate additional review and analysis, this approach ensured that the dataset would be more accurate and enhanced. Following this step, a total of 492 items were considered suitable for additional examination and were subjected to the identification processes shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. During the screening process, 810 studies were excluded for a variety of justifications: they were not full-text or original studies published in English; they were review letters, editorials, systematic reviews; they were related to brain surgery or pediatric populations and other specific types of surgery; they were conference proceeding papers; or they were non-clinical studies. 132 original studies met the requirements for the eligibility phase after completing the screening procedure. Among the 124 studies, there were four that did not have their entire texts accessible, twenty-four that were post hoc analyses, thirty-six that did not give quantitative data on the early identification of POD, thirty-two that did not employ a validated POD scale, and twenty-eight that did not prioritize the early identification of POD as a priority or secondary aim. The diagnostic approach that used a validated POD scale to detect POD on early identification was only present in eight out of the total number of studies that were retrieved, which represents for 4.9% of the total number of studies done between the years 2000 and 2024.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Characteristics of selected studies\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eFollowing a review of seven research that investigated the evaluation of POD, it came to light that one of the studies did not make use of the POD diagnostic scale, which is summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the studies that were chosen, four studies used the CAM-ICU POD diagnosis scale, and one research used the Nursing Delirium Screening Scale. The remaining two studies used a mixed methodology, combining the Confusion Assessment Method (CAM-ICU) with tools like the Richmond Agitation Sedation Scale (RASS score)\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe characteristics of the studies that were included.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAuthor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edelirium detection\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of Surgery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelirium assessment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e] Sweden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNDSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1, 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003ePoland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultivariate logistic regression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCABG and CPB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwice a day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRASS score and CAM-ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen-heart surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1, 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetrospective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enon\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCAM-ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4, 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCAM-ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1, 5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCAM-ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCAM-ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edaily\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eAbbreviations: NDSC nursing delirium screening scale, CABG coronary artery bypass graft, CPB cardiopulmonary bypass, RASS richmond agitation sedation scale, CAM-ICU confusion assessment method for the intensive care unit\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe Montreal Cognitive Assessment and Trail Making Test Part B, and the Mini International Neuropsychiatric Interview. This SLR included seven distinct kinds of research, including five prospective observational studies, one multivariate logistic regression analysis, and one retrospective research (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The assessments were carried out with the purpose of determining the influence that a particular intervention had on the outcomes encountered by the patients. While some studies placed a greater emphasis on surgical procedures, others placed a greater emphasis on pharmacological therapies. The treatments varied depending on the research, with some placing more of an emphasis on surgical procedures. Furthermore, the demographic characteristics of the patient populations varied from one study to the next over the course of the research that was incorporated in the analysis throughout the whole process. Patients who were over the age of 50 made up the bulk of the participants in the study, and the average age ranged anywhere from 45 to 65 years old. Patients were asked to participate in the bulk of the studies. In each of the studies, around fifty percent of the participants were male and fifty percent were female. This indicates that the gender distribution was reasonably balanced.\u003c/p\u003e\n \u003cp\u003eThere were a total of 1254 patients that participated in our study, which was based on seven separate experiments. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the outcomes of the study that was conducted in China, Sweden, Poland, Greece, and the United States of America. As a result of our study, we discovered that China and the United States of America each had two studies, making them the nations that had the most amount of studies.\u003c/p\u003e\n \u003cp\u003eThere were seven publications that were examined by the SRL. These studies explored patients who were having various types of surgeries in cardiac surgery. Five of the papers focused largely on cardiac surgery. One research concentrated on open heart surgery, while another studied coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). The studies included data on the results of various cardiac surgeries and the experiences of the patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003epredictors of postoperative delirium (POD)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubcategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePredictors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh-Risk factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividual characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (\u0026ge;\u0026thinsp;65), cognitive impairment, multiple medical conditions, history of alcoholism, gender, level of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eESA guidelines, Mu et al. [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e], Kanova et al. [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderlying medical conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical procedures: type, duration, complexity; conditions such as aortic dissection, coronary artery bypass grafting, heart transplantation, abdominal incision, major vascular surgery, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHughs et al. [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e], Kazmierski et al. [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTreatment procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eICU admission, immobilization, postsurgical pain, sleep disturbances, endotracheal intubation, blood transfusions, hypoxemia, vasoactive drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArenson et al. [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypical symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAttentional disturbances, cognitive difficulties, fluctuating consciousness, sleeplessness, hallucinations, emotional instability, restlessness, agitation, hypoactivity, hyperactivity, mixed delirium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResearch findings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Early identification of POD in patients with cardiovascular disease\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e summarizing the early detection of POD in patients following cardiac surgery is related to risk factors, and researchers have made efforts to uncover the risk factors that are associated with POD [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. According to the findings of this SLR, the primary elements that contribute to the early identification of POD in patients who have undergone cardiac surgery are high-risk factors that are related to (individual characteristics, underlying disorders, treatment modalities) and typical symptoms that are present in the following order:\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.1 High-Risk factors\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eIndividual characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe prevalence of POD is closely linked to individual characteristics. According to the guidelines set by the European Society of Anesthesiology (ESA)[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e], which are grounded in evidence-based medicine and expert consensus, patients aged 65 and older are more likely to experience POD. The likelihood of developing POD-related variables rises with age. Research by Mu et al.[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] has found that age, cognitive impairment, and multiple medical conditions are independent risk factors for POD. This suggests that older patients with cognitive impairment and multiple medical conditions are more likely to experience delirium following surgery. As a means of detecting and treating delirium in patients who have cardiovascular disease, it is vital for medical professionals to have a comprehensive grasp of these factors (risk) that are implicated in the condition. Additionally, it is conceivable that medicines that target these risk factors might be of assistance in reducing the number of POD problems that occur in individuals who have had surgical procedures. In the study by Kanova et al. [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] indicated that 39 percent of people who suffer from post-traumatic stress disorder have a history of alcoholism. The primary reason for this is that ethanol has a depressant effect on the central nervous system. Patients give up drinking while they are in the hospital, which leads to the development of withdrawal syndrome. It also revealed a substantial link between gender and the occurrence of delirium which indicates that males have a higher likelihood of experiencing POD compared to females, and there is a direct correlation between the amount of education and the occurrence of POD. Signs of postoperative delirium might be seen in severe instances[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnderlying medical conditions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWithin the realm of surgical procedures, the term \u0026quot;underlying medical conditions\u0026quot; is used to describe the elements that have the potential to have an impact on the final result of the operation. The amount of time it takes to finish the surgery and the particular therapies that are carried out are two of these criteria. Other related variables, such as the surgical method and duration, are also involved in this group [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Those attending to the concerned meticulously must consider these features in the light of the threats associated with the surgery or its aftereffects. Mu et al. [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] This association became much clearer when the researchers found that the number of surgical operations performed during the one hour service time period was inversely proportional to the POD incidents. The conclusion seems to be the fact that the number of cases of medical emergencies increases correspondingly with the duration of operation\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAn analysis of surgery conducted by Hughs et al. [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] established surgical revascularization procedures brought down the rate of occurrence of POD a lot than it reduced in cases of other large vascular operations such as thoracotomy. Undergoing surgical operation of aortic dissection, coronary artery bypass grafting, heart transplantation, abdominal incision, and major vascular surgery would be higher in incidence of POD compared to other surgical procedures. Besides, the statisticians broke down the surgical POD rate in function to the kind of conditions they were applied. The study by the research group of Kazmierski, however, pointed out that the proportion of patients who had POD was seen to be as high as 36.3% among those undergoing coronary bypass surgery, 32.5% among those having aortic dissection, 25.7% in case of heart transplant, 16.3% among those receiving thoracotomy [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment procedures\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEnrolling into the intensive care unit, immobilization (to use protective restraints), postsurgical pain, sleep disturbances, endotracheal intubation, blood transfusions, blood oxygen amount decrease ( hypoxemia), and the application of vasoactive drugs as risk factors for the beginning of POD [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Less use of vasoactive drugs, better pain management, or other means of decreasing the number of POD patients that have undergone cardiac surgeries may help in achieving the target. Nurses and doctors could improve predicting and dealing with delirium by increasing their understanding into the early factors that could be the starting point for such a disease. Arenson et al. [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] found that 14.7% of 1010 patients who had had cardiac surgery presented difficulty in breathing after surgery, called as POD. The potential of the development of particular disorders such as receiving large amounts of blood products in the transfusion; the use of intubation exceeding twenty-four hours are factors that may affect the condition [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e], stroke, renal failure, prolonged cross-clamp time[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], or transient ischemic attack [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. While this is not entirely so, the problem may arise from the undertreated patients after the operation, and or wrong time use of certain drugs such as anticholinergics, opioid narcotic analgesics, and benzodiazepine sedatives [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.2 Typical symptoms\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAttentional disturbances, cognitive difficulties, fluctuating consciousness, and sleeplessness, wide unusual perception, and hallucinations, are a few of the possible clinical signs of POD. The POW feelings could trigger dysfunctional emotional reactions in victims, manifesting themselves as anxiety, impatience, and fading emotions. POD affects people in different ways, but usually, it doesn\u0026apos;t involve motor skills that may include hyperactivity, hypoactivity or even pendulum-like fluctuations between these two types. Acute delirium agitation is being manifested by rebound of the mental activity and body motility. These symptoms may vary and include obvious ones such as trouble calming down, emotional instability, restlessness, and irritation to name a few. Among the possible signs to be exhibited are hallucinations, deluded thoughts, and a violent extremity of behavior [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. This kind of delirium presents a higher danger to patients, is clearly recognizable, but may also be susceptible to misdiagnosis. Hyperactive delirium in critical care settings is sometimes misidentified as regular agitation, resulting in incorrect use of sedatives that might worsen the situation. Patients with hypoactive delirium have an elevated death risk and need specific therapy.\u003c/p\u003e\n \u003cp\u003eMixed delirium is characterized by the fact that it displays symptoms of both hyperactive and hypoactive delirium. This is one of the characteristic features of mixed delirium which is characterized by intervals of thinking and activity levels that are typically functioning, however these periods are intermittent and occur on a regular basis. Mixed delirium is an illness that is famously difficult to identify and adequately treat. Besides, expresses itself in such a varied variety of symptoms. It is of the utmost importance to identify and treat the specific kind of delirium in individuals to improve the results for the patient and reduce the severity of the repercussions.\u003c/p\u003e\n \u003cp\u003eSeveral studies that have highlighted the necessity of recognizing these typical symptoms of POD in order to facilitate early identification and immediately begin treatment. Postoperative breathing difficulties are reported by research conducted by Arenson et al. [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] that 14.7% of patients who underwent cardiac surgery, which an indication of POD. It is challenging to identify POD at an early stage, such as pain, pharmacological side effects, or metabolic abnormalities. Therefore, it is critical to identify the typical symptoms and forms of delirium in patients after cardiac surgery in order to diagnose it early and provide the right care. Practitioners in the medical field need to be vigilant when assessing patients for delirium symptoms since prompt intervention may improve patient outcomes and reduce the likelihood of unfavorable events.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eAssessment performed by the NOS to determine the likelihood of bias.\u003c/p\u003e\n \u003cp\u003e\u003cimg 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\" width=\"642\" height=\"361\"\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Risk of bias\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates that there was a comparable risk of bias across all of the different areas that were evaluated, which is clear when looking at the data of all eight-research taken together. Specifically, A certain amount of robustness in the procedures that were employed for participant selection was indicated by the fact that a reasonably low risk of bias was seen within the parameters of the selection domains. However, in our study a higher risk of bias recorded within the comparability elements among the selected studies which is highly recommending potential limitations in the ability to compare study among different studies. Interesting to note that the risk of bias in result confirmation was found to be constant across all eight studies. This suggests that there is a consistent degree of trustworthiness in the measuring and reporting of outcomes throughout the various study investigations.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussions","content":" \u003cp\u003eEarly identification of postoperative delirium in patients after heart surgery is imperative for preventing any negative consequences. Researchers have been involved in pinpointing major risk factors identifying POD from an early stage in order to possibly achieve the early diagnosis of this disease. By the results of this SLR, the high-risk indicators will be essential parts of the early alerts on POD for patients after undergoing heart surgery. These factors are essentially anyone else's personal features, psychological conditions, and the treatment approaches they are utilizing. Personal features like age, gender, education level, and medical history influence delirium susceptibility. Elderly individuals are more vulnerable due to age-related brain changes. Gender differences and higher education levels may also play a role. Additionally, pre-existing medical conditions, like cardiovascular disease and alcoholism, can increase the risk. Psychological conditions such as anxiety, depression, and post-traumatic stress disorder (PTSD) contribute to delirium risk by exacerbating stress responses and neuroinflammation. Patients with trauma or PTSD are particularly susceptible. Treatment methods like surgical procedures and anesthesia impact delirium risk. Cardiac surgeries involving bypass and prolonged anesthesia can trigger neuroinflammatory responses. Choice of anesthetics and postoperative care also affect susceptibility. Delirium as a rule is caused by age among different individual factors that predispose to delirium. According to the research, the chance of people having delirium over the age of 65, after the operation was, however higher. Intellectual disability, particularly as an independent risk factor for postoperative delirium, is recognized as an identifying marker for the mental state. Another risk factor that would increase the likelihood of postoperative delirium is the presence of other medical conditions. Gender and educational ranking constitute a crucial factor related to the likelihood as men and affected group of alcoholics are the most vulnerable. The role of POD is accentuated by considering a patient's medical history and other conditions, along with the length of the procedure and the techniques used by the surgeon [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Specific surgical approaches, such as the coronary artery bypass grafting, have been determined to be related to the disproportionate rate of postoperative amnesia incidence. Duration of surgery has been demonstrated to not only be the decisive factor in postoperative complications, but also to significantly contribute to the overall safety of surgical procedures [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. And lastly, the evolvement of POD probably would be under the influence of postoperative interventions that occur after heart surgeries. The services offered by the hospital frequently involve continuous hospitalization to the hospital's intensive care unit, strict immobilization of the affected limb, and pain control throughout postoperative period. Pain medicines which can be considered vasoactive medicines and that include an inadequate pain control are two factors that have been proven to play a significant role in the onset of delirious conditions after surgery. Moreover, Pharmacology Deficits of Actions or Common Signs of POD consist of cognitive dysfunction that involves the patient's awareness, direction and attention and can be in the form of hyperactive, hypoactive or mixed delirium. In the hyperactive type delirium is enriched with an amped cognitive processes and marked agitation, whereas in the hypoactive the mental activity is diminished and delayed responses to speech or body movement are sometimes displayed. So as to illustrate that, one must point out mixed delirium, where the patient goes back and forth from hyperactive and hypoactive phases [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHealthcare personnel have to act fast to identify early-stage postoperative delirium symptoms and risk factors that can be seen in patients after ECS in order to avoid the progression of delirium. If the factors that lead to developing surgery-related delirium and poor results are identified and dealt with by healthcare providers, they are empowered to enhance the quality of care they already offer to such patients.\u003c/p\u003e\u003cp\u003eThere will be an emphasis on the following in future research: First, examines the possibility that patients with cardiovascular illness may not be reporting POD as much as they might be owing to differences in diagnostic criteria or evaluation techniques across a number of different studies. Second, Investigate the differences in defining and diagnosing delirium, as well as the influence these differences have on the prevalence rates that have been reported. Third, Examine the degree of variation in the outcomes that have been observed after surgical delirium in individuals with cardiovascular conditions. On cognitive function, mortality, functional recovery, and healthcare usage, it is important to investigate both the short-term and long-term impacts and implications.\u003c/p\u003e\u003cp\u003eOur study has strengths enhancing credibility and reliability. This systematic review covered databases like Scopus, PubMed, and the Cochrane Library, ensuring thoroughness and replicability. Our inclusion criteria were rigorous, focusing on English language publications on adult cardiovascular surgery patients, enhancing relevance. Our data extraction involved three senior reviewers, ensuring objectivity and consistency. Qualitative assessment enriched our analysis, addressing the diverse literature nature. The use of the Newcastle-Ottawa Scale strengthened bias evaluation. However, limitations include refraining from meta-analysis due to varied assessments and outcomes, potential publication bias from English-only publications, and heterogeneity across studies.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"5. Recommendations","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Preventive approaches without medications\u003c/h2\u003e \u003cp\u003ePOD prevention in cardiac surgery patients receives prime importance because of the advances made in varied studies indicating that different strategies reduced POD occurrence. Employing a multifaceted treatment in early mobilization together with proper pain management, reduction in sedative, proper hydration and food intake, and treatment of concurrent disorders such as dementia and depression as well as sleeping problems has proven for the patients who undergo surgery can decrease the chances of having postoperative delirium [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Adopt alternative strategies that are uncorrelated with medications for instance cognitive stimulation methods, patient communication techniques and family participation may prevent postoperative delirium. Research conducted by Oh et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] found that the use of multi-component treatments including distractions such as picture testimonies, pictures and pictures through table visits could be of high significance in the prevention of postoperative delirium (POD) in elderly surgical patients. Solutions as mentioned, tend to adopt a strategy which is usually a mix of various methods like i.e. universal screening for most possible delirium risk, early mobility, and improved communications among various health professionals that are involved in the process of treatment. One cause of a rise in the POD rate might be the pharmacotherapy of patients in risk groups by such antipsychotics drugs as the dexmedetomidine, melatonin, and antipsychotic medications. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. But on the flip-side, weighing the benefits of these meds or conversely the potential dangers they carry are of prime importance so as to adjust the treatment plan to the patient\u0026rsquo;s individual risk factors and needs [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. According to the findings of research conducted by Young et al.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] mentioned that it might be helpful to adopt broad preventive measures operating at the pre-surgical stages that could reduce POD incidence in patients after cardiac surgery. Thus, it is necessary to employ a multifaceted and proactive approach to avoid POD in the surgical cases to obtain desirable outcomes, low healthcare costs, and greater quality of care for these patients. Evidence based treatments and tailored treatment plans taken by medical professionals will decrease the risk of POD, and hence, expected outcomes of POD will be better.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e5.2 The medication prevention measures\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eDue to the absence of substantial clinical trial data indicating that pharmaceuticals or combined non-drug preventive strategies may reduce the occurrence and duration of Parkinson's disease in cardiovascular diseases, it is not recommended to make use of medications on a consistent basis in order to prevent the beginning of Parkinson's disease. It is because of the fact that there is a certain amount of disagreement around the subject that this is the case [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. On the other hand, there are circumstances in which you are able to root. The administration of benzodiazepines is necessary due to the severity of the condition. Those patients, for instance, who had an excessive amount of worry or anxiety before to surgery, as well as those who had been using benzodiazepines for a considerable amount of time previous to surgery, should be used with caution[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusions","content":"\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAccording to the majority of patients who have had cardiovascular surgery, extended sedation and intubation are necessary in order to satisfy the criteria of the condition and the treatment. This characteristic is typically found in persons after they have had cardiovascular surgery.\u003c/p\u003e\n \u003cp\u003eIn this systematic literature review, the early and primary factors that contribute to the early identification of postoperative complications (POD) in patients who have undergone cardiac surgery as a high-risk factor were identified. These factors are related to (individual characteristics, underlying disorders, treatment modalities), and they are associated with typical symptoms. Relevant strategies were also proposed. This research additionally demonstrates that the training of medical professionals in delirium understanding should be enhanced as well as the accurate application of delirium evaluation tools, in order to improve the accuracy of POD monitoring in patients. Increase the effectiveness of the therapy for POD in patients and put into practice effective measures for the prevention of POD in patients who have cardiovascular disease.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eFuture research will focus on exploring discrepancies in postoperative delirium reporting among cardiovascular patients, investigating variations in defining and diagnosing delirium, and assessing outcomes after surgical delirium on cognitive function, mortality, functional recovery, and healthcare usage in both short-term and long-term perspectives.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen H, Mo L, Hu H, Ou Y, Luo J. Risk factors of postoperative delirium after cardiac surgery: a meta-analysis. J Cardiothorac Surg. 2021 Apr 26;16(1):113. doi: 10.1186/s13019-021-01496-w. PMID: 33902644; PMCID: PMC8072735.\u003c/li\u003e\n\u003cli\u003eZhu, L.; Shi, H.; Zhu, C.; Liu, H.; Su, Z.; Zhao, Y. Impact of Permissive Hypercapnia on Regional Cerebral Oxygen Saturation and Postoperative Cognitive Function in Patients Undergoing Cardiac Valve Replacement. \u003cem\u003eAnn Palliat Med\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e9\u003c/em\u003e, 4066\u0026ndash;4073, doi:10.21037/apm-20-2090.\u003c/li\u003e\n\u003cli\u003eAldecoa, C.; Bettelli, G.; Bilotta, F.; Sanders, R.D.; Audisio, R.; Borozdina, A.; Cherubini, A.; Jones, C.; Kehlet, H.; MacLullich, A.; et al. European Society of Anaesthesiology Evidence-Based and Consensus-Based Guideline on Postoperative Delirium. \u003cem\u003eEuropean Journal of Anaesthesiology\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e34\u003c/em\u003e, 192\u0026ndash;214, doi:10.1097/EJA.0000000000000594.\u003c/li\u003e\n\u003cli\u003eKarageorgos, V.; Mevorach, L.; Silvetti, M.; Bilotta, F. Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies. \u003cem\u003eGeriatrics\u003c/em\u003e \u003cstrong\u003e2023\u003c/strong\u003e, \u003cem\u003e8\u003c/em\u003e, 24, doi:10.3390/geriatrics8010024.\u003c/li\u003e\n\u003cli\u003eAnsaloni, L.; Catena, F.; Chattat, R.; Fortuna, D.; Franceschi, C.; Mascitti, P.; Melotti, R.M. Risk Factors and Incidence of Postoperative Delirium in Elderly Patients after Elective and Emergency Surgery. \u003cem\u003eJournal of British Surgery\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e97\u003c/em\u003e, 273\u0026ndash;280.\u003c/li\u003e\n\u003cli\u003eMarcantonio, E.R. Postoperative Delirium: A 76-Year-Old Woman with Delirium Following Surgery. \u003cem\u003eJama\u003c/em\u003e \u003cstrong\u003e2012\u003c/strong\u003e, \u003cem\u003e308\u003c/em\u003e, 73\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eWang, J.; Wang, L.; Tang, X.; Wang, F.; Liu, S.; Wu, X.; Dong, R.; Lin, X.; Wang, B.; Bi, Y. The Relationship Between Cardiovascular Disease Risk Score and Postoperative Delirium: The PNDABLE Study. \u003cem\u003eFront. Aging Neurosci.\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e14\u003c/em\u003e, 851372, doi:10.3389/fnagi.2022.851372.\u003c/li\u003e\n\u003cli\u003eFong, T.G.; Tulebaev, S.R.; Inouye, S.K. Delirium in Elderly Adults: Diagnosis, Prevention and Treatment. \u003cem\u003eNature Reviews Neurology\u003c/em\u003e \u003cstrong\u003e2009\u003c/strong\u003e, \u003cem\u003e5\u003c/em\u003e, 210\u0026ndash;220.\u003c/li\u003e\n\u003cli\u003eLeslie, D.L.; Marcantonio, E.R.; Zhang, Y.; Leo-Summers, L.; Inouye, S.K. One-Year Health Care Costs Associated with Delirium in the Elderly Population. \u003cem\u003eArchives of internal medicine\u003c/em\u003e \u003cstrong\u003e2008\u003c/strong\u003e, \u003cem\u003e168\u003c/em\u003e, 27\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003ePeterson, J.; Welch, V.; Losos, M.; Tugwell, P. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. \u003cem\u003eOttawa: Ottawa Hospital Research Institute\u003c/em\u003e \u003cstrong\u003e2011\u003c/strong\u003e, \u003cem\u003e2\u003c/em\u003e, 1\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eLingehall, H.C.; Smulter, N.; Engstr\u0026ouml;m, K.G.; Gustafson, Y.; Olofsson, B. Validation of the Swedish Version of the Nursing Delirium Screening Scale Used in Patients 70 Years and Older Undergoing Cardiac Surgery. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e \u003cstrong\u003e2013\u003c/strong\u003e, \u003cem\u003e22\u003c/em\u003e, 2858\u0026ndash;2866, doi:10.1111/j.1365-2702.2012.04102.x.\u003c/li\u003e\n\u003cli\u003eKazmierski, J.; Banys, A.; Latek, J.; Bourke, J.; Jaszewski, R. Raised IL-2 and TNF-\u0026alpha; Concentrations Are Associated with Postoperative Delirium in Patients Undergoing Coronary-Artery Bypass Graft Surgery. \u003cem\u003eInt. Psychogeriatr.\u003c/em\u003e \u003cstrong\u003e2014\u003c/strong\u003e, \u003cem\u003e26\u003c/em\u003e, 845\u0026ndash;855, doi:10.1017/S1041610213002378.\u003c/li\u003e\n\u003cli\u003eTheologou, S.; Giakoumidakis, K.; Charitos, C. Perioperative Predictors of Delirium and Incidence Factors in Adult Patients Post Cardiac Surgery. \u003cem\u003ePOR\u003c/em\u003e \u003cstrong\u003e2018\u003c/strong\u003e, \u003cem\u003eVolume 9\u003c/em\u003e, 11\u0026ndash;19, doi:10.2147/POR.S157909.\u003c/li\u003e\n\u003cli\u003eMangusan, R.F.; Hooper, V.; Denslow, S.A.; Travis, L. Outcomes Associated With Postoperative Delirium After Cardiac Surgery. \u003cem\u003eAmerican Journal of Critical Care\u003c/em\u003e \u003cstrong\u003e2015\u003c/strong\u003e, \u003cem\u003e24\u003c/em\u003e, 156\u0026ndash;163, doi:10.4037/ajcc2015137.\u003c/li\u003e\n\u003cli\u003eOthman, S.M.A.; Xu, Q.; Zhao, K.; Kafi, L.; Aziz, M.A.A. Identification of Early Delirium and Its Outcomes after Cardiopulmonary Bypass among Adult Patients with Cardiovascular Disease: A Prospective Observational Study. \u003cem\u003eIndian J Thorac Cardiovasc Surg\u003c/em\u003e \u003cstrong\u003e2024\u003c/strong\u003e, \u003cem\u003e40\u003c/em\u003e, 151\u0026ndash;158, doi:10.1007/s12055-023-01613-5.\u003c/li\u003e\n\u003cli\u003eMu, D.-L.; Wang, D.-X.; Li, L.-H.; Shan, G.-J.; Li, J.; Yu, Q.-J.; Shi, C.-X. High Serum Cortisol Level Is Associated with Increased Risk of Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study. \u003cem\u003eCrit Care\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e14\u003c/em\u003e, R238, doi:10.1186/cc9393.\u003c/li\u003e\n\u003cli\u003eCahill, A.; Pearcy, C.; Agrawal, V.; Sladek, P.; Truitt, M.S. Delirium in the ICU: What About the Floor? \u003cem\u003eJournal of Trauma Nursing\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e24\u003c/em\u003e, 242\u0026ndash;244, doi:10.1097/JTN.0000000000000298.\u003c/li\u003e\n\u003cli\u003eKanova, M.; Sklienka, P.; Kula, R.; Burda, M.; Janoutova, J. Incidence and Risk Factors for Delirium Development in ICU Patients-a Prospective Observational Study. \u003cem\u003eBiomedical Papers of the Medical Faculty of Palacky University in Olomouc\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e161\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eLin, Y.; Chen, J.; Wang, Z. Meta-Analysis of Factors Which Influence Delirium Following Cardiac Surgery. \u003cem\u003eJournal of Cardiac Surgery\u003c/em\u003e \u003cstrong\u003e2012\u003c/strong\u003e, \u003cem\u003e27\u003c/em\u003e, 481\u0026ndash;492, doi:10.1111/j.1540-8191.2012.01472.x.\u003c/li\u003e\n\u003cli\u003eArenson, B.G.; MacDonald, L.A.; Grocott, H.P.; Hiebert, B.M.; Arora, R.C. Effect of Intensive Care Unit Environment on In-Hospital Delirium after Cardiac Surgery. \u003cem\u003eThe Journal of thoracic and cardiovascular surgery\u003c/em\u003e \u003cstrong\u003e2013\u003c/strong\u003e, \u003cem\u003e146\u003c/em\u003e, 172\u0026ndash;178.\u003c/li\u003e\n\u003cli\u003eHughes, C.G.; Boncyk, C.S.; Culley, D.J.; Fleisher, L.A.; Leung, J.M.; McDonagh, D.L.; Gan, T.J.; McEvoy, M.D.; Miller, T.E.; for the Perioperative Quality Initiative (POQI) 6 Workgroup American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. \u003cem\u003eAnesthesia \u0026amp; Analgesia\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e130\u003c/em\u003e, 1572\u0026ndash;1590, doi:10.1213/ANE.0000000000004641.\u003c/li\u003e\n\u003cli\u003eCropsey, C.; Kennedy, J.; Han, J.; Pandharipande, P. Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients. \u003cem\u003eSemin Cardiothorac Vasc Anesth\u003c/em\u003e \u003cstrong\u003e2015\u003c/strong\u003e, \u003cem\u003e19\u003c/em\u003e, 309\u0026ndash;317, doi:10.1177/1089253215570062.\u003c/li\u003e\n\u003cli\u003eCrocker, E.; Beggs, T.; Hassan, A.; Denault, A.; Lamarche, Y.; Bagshaw, S.; Elmi-Sarabi, M.; Hiebert, B.; Macdonald, K.; Giles-Smith, L.; et al. Long-Term Effects of Postoperative Delirium in Patients Undergoing Cardiac Operation: A Systematic Review. \u003cem\u003eThe Annals of Thoracic Surgery\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e102\u003c/em\u003e, 1391\u0026ndash;1399, doi:10.1016/j.athoracsur.2016.04.071.\u003c/li\u003e\n\u003cli\u003eBrown, C.H. Delirium in the Cardiac Surgical ICU. \u003cem\u003eCurrent Opinion in Anesthesiology\u003c/em\u003e \u003cstrong\u003e2014\u003c/strong\u003e, \u003cem\u003e27\u003c/em\u003e, 117\u0026ndash;122.\u003c/li\u003e\n\u003cli\u003eSmith, P.J.; Attix, D.K.; Weldon, B.C.; Monk, T.G. Depressive Symptoms and Risk of Postoperative Delirium. \u003cem\u003eThe American Journal of Geriatric Psychiatry\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e24\u003c/em\u003e, 232\u0026ndash;238.\u003c/li\u003e\n\u003cli\u003eInouye, S.K.; Marcantonio, E.R.; Kosar, C.M.; Tommet, D.; Schmitt, E.M.; Travison, T.G.; Saczynski, J.S.; Ngo, L.H.; Alsop, D.C.; Jones, R.N. The Short-Term and Long-Term Relationship between Delirium and Cognitive Trajectory in Older Surgical Patients. \u003cem\u003eAlzheimer\u0026rsquo;s \u0026amp; Dementia\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e12\u003c/em\u003e, 766\u0026ndash;775.\u003c/li\u003e\n\u003cli\u003eOh, E.S.; Fong, T.G.; Hshieh, T.T.; Inouye, S.K. Delirium in Older Persons: Advances in Diagnosis and Treatment. \u003cem\u003eJama\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e318\u003c/em\u003e, 1161\u0026ndash;1174.\u003c/li\u003e\n\u003cli\u003eNeufeld, K.J.; Yue, J.; Robinson, T.N.; Inouye, S.K.; Needham, D.M. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta‐analysis. \u003cem\u003eJournal of the American Geriatrics Society\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e64\u003c/em\u003e, 705\u0026ndash;714.\u003c/li\u003e\n\u003cli\u003eIgwe, E.O.; Nealon, J.; O\u0026rsquo;Shaughnessy, P.; Bowden, A.; Chang, H.-C.; Ho, M.-H.; Montayre, J.; Montgomery, A.; Rolls, K.; Chou, K.-R. Incidence of Postoperative Delirium in Older Adults Undergoing Surgical Procedures: A Systematic Literature Review and Meta‐analysis. \u003cem\u003eWorldviews on Evidence‐Based Nursing\u003c/em\u003e \u003cstrong\u003e2023\u003c/strong\u003e, \u003cem\u003e20\u003c/em\u003e, 220\u0026ndash;237.\u003c/li\u003e\n\u003cli\u003eYoung, E.; Philpott, H.; Singh, R. Endoscopic Diagnosis and Treatment of Gastric Dysplasia and Early Cancer: Current Evidence and What the Future May Hold. \u003cem\u003eWorld Journal of Gastroenterology\u003c/em\u003e \u003cstrong\u003e2021\u003c/strong\u003e, \u003cem\u003e27\u003c/em\u003e, 5126\u0026ndash;5151, doi:10.3748/wjg.v27.i31.5126.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"a15651f8-5c2f-46db-bb4a-06c6e8f61c36","identifier":"10.13039/501100012246","name":"Priority Academic Program Development of Jiangsu Higher Education Institutions","awardNumber":"(2018) No.87)","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Nanjing Medical University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cardiovascular disease, postoperative delirium, early identification, risk factors systematic literature review","lastPublishedDoi":"10.21203/rs.3.rs-4355605/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4355605/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative delirium (POD) is a cognitive decline and attention deficit that can occur in patients after cardiac surgery. Despite extensive research identifying risk factors, POD often goes undiagnosed and untreated in medical settings.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis systematic literature review (SLR) aims to summarize studies on early POD identification in patients following cardiovascular surgery. Data was obtained from Scopus, PubMed, and the Cochrane International database.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeven examined studies highlight high-risk variables (individual characteristics, underlying diseases, treatment methods) and typical symptoms as crucial components for early POD diagnosis. However, diagnostic criteria and evaluation methodologies need to be more consistent, and there is no consensus on the most efficient early detection approaches.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings underscore the need for standardized diagnostic criteria and evaluation methods for early POD detection in cardiovascular surgery patients. Evidence-based recommendations are necessary to enhance early diagnosis and treatment of POD in this population.\u003c/p\u003e","manuscriptTitle":"Systematic Literature Review on early detection of Postoperative Delirium in Patients with Cardiovascular Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-03 20:52:06","doi":"10.21203/rs.3.rs-4355605/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"164420f5-97d7-4ef9-ae3e-bcf3ccf8175c","owner":[],"postedDate":"May 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31401878,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2024-05-03T20:52:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-03 20:52:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4355605","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4355605","identity":"rs-4355605","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}