Incidence and relative risk of delirium after major surgery for patients with pre‐operative depression: a systematic review and meta‐analysis

Summary Background Delirium is a common and potentially serious complication after major surgery. A previous history of depression is a known risk factor for experiencing delirium in patients admitted to the hospital, but the generalised risk has not been estimated in surgical patients. Methods We conducted a systematic review and meta‐analysis of studies reporting the incidence or relative risk (or relative odds) of delirium in the immediate postoperative period for adults with pre‐operative depression. We included studies that defined depression as either a formal pre‐existing diagnosis or having clinically important depressive symptoms measured using a patient‐reported instrument before surgery. Multilevel random effects meta‐analyses were used to estimate the pooled incidences and pooled relative risks. We also conducted subgroup analyses by various study‐level characteristics to identify important moderators of pooled estimates. Results Forty‐two studies (n = 4,664,051) from five continents were included. The pooled incidence of postoperative delirium for patients with pre‐operative depression was 29% (95%CI 17–43%, I 2 = 99.0%), compared with 15% (95%CI 6–28%, I 2 = 99.8%) in patients without pre‐operative depression and 21% (95% CI 11–33%, I 2 = 99.8%) in the cohorts overall. For patients with pre‐operative depression, the risk of delirium was 1.91 times greater (95%CI 1.68–2.17, I 2 = 42.0%) compared with patients without pre‐operative depression. Conclusions Patients with a previous diagnosis of depression or clinically important depressive symptoms before surgery have substantially greater risk of experiencing delirium after surgery. Clinicians and patients should be informed of these increased risks. Robust screening and other risk mitigation strategies for postoperative delirium are warranted, especially for patients with pre‐operative depression.