Received: 27 August 2019 Revised: 18 October 2019 Accepted: 25 November 2019

DOI: 10.1111/nicc.12492

RESEARCH

Delirium post-cardiac surgery: Incidence and associated factors

Abla Habeeb-Allah RN, MSC, CNS, PhD, Head of Community Health Nursing
Department1 | Jafar Alasad Alshraideh PhD, Professor2

1
Princess Muna College of Nursing, Mutah
University, Amman, Jordan Abstract
2
School of Nursing, University of Jordan, Background: Post-operative delirium among cardiac surgery patients is a prevalent
Amman, Jordan
complication that associated with multiple negative outcomes.
Correspondence Aims and objectives: This study aimed to assess delirium incidence, associated fac-
Jafar Alasad Alshraideh, Professor, School of
tors, and outcomes for adult patients who underwent elective cardiac surgery.
Nursing, University of Jordan, Amman, 11942,
Jordan. Design: An exploratory prospective cohort design was used for this study.
Email: [email protected]
Methods: Delirium was diagnosed by the Confusion Assessment Method for the
Funding information Intensive Care Unit. Incidence, preoperative, intraoperative, and post-operative vari-
Deanship of Academic Research, University of
ables for 245 patients during 3-month period were collected and analysed.
Jordan, Grant/Award Number: 1-2018-2019;
University of Jordan. Results: Delirium developed in 9% (n = 22) of the sample. Patients with delirium were
significantly older (mean age = 65.7, SD = 8.1), t (243) = −3.66, P < .05); had longer
surgery time (mean time = 286.3, SD = 82.2), t (243) = −2.25, P < .05); received more
blood post-surgery (t (243) = −3.86, P < .05); spent more time on mechanical ventila-
tion (t [21.6] = −2.2, P < .05); had longer critical care unit stay (t [21.7] = −4.0,
P < 0.05); and had longer hospitalization than patients without delirium.
Conclusions: The risk factors associated with development of delirium were
advanced age and increased duration of surgery. Negative outcomes associated with
delirium were increased duration of mechanical ventilation, increased volume of
post-operative infused colloids and blood/products, increased critical care unit stay,
and increased hospitalization. A multifactorial model for delirium risk factors should
be considered to detect and work on potentially preventable delirium factors.
Relevance to clinical practice: Post-cardiac surgery delirium leads to longer mechanical
ventilation time, increased ICU stay, and prolonged hospitalization. Delirium post-cardiac
surgery is potentially preventable with appropriate identification of risk factors by nurses.

KEYWORDS

associated factors, cardiac surgery, delirium, incidence, post-operative delirium

1 | I N T RO DU CT I O N of admitted patients could develop delirium.4 Post-operative delirium

(POD) affects about 87% of surgical patients. The incidence of post-
Delirium is an acute multifaceted neuropsychiatric syndrome that is cardiac surgery delirium varied from 3% to 70% in various studies with
characterized by acute onset and fluctuating course, inattention, most estimation of 26% to 52%.5 This wide range is related to a diverse
1
impaired consciousness, and disordered cognition. It has been priori- methodology of assessing delirium among patients. Early identification
tized on hospitals' health care plans and linked to patient safety of patients at risk for delirium post-cardiac surgery is essential to enable
agendas.2 In intensive care units (ICUs), around 32%3 and up to 80% implementation of modifiable risk factors' interventions.6 There is a

Nurs Crit Care. 2019;1–6. wileyonlinelibrary.com/journal/nicc © 2019 British Association of Critical Care Nurses 1
2 HABEEB-ALLAH AND ALSHRAIDEH

wide variation in the estimated incidence of delirium post-cardiac sur-

gery patients and the identified risk factors as studies used different WHAT IS KNOWN ABOUT THIS TOPIC
5,7
tools and protocols for delirium assessment.
Although delirium risk factors and interventions were identified in • Post-cardiac surgery delirium is a common complication.
medical and non-cardiac ICUs population, further investigation is • There is a wide variation in the estimated incidence of
needed to address such issue in the cardiac surgery settings.5,8 post-cardiac surgery delirium and the identified risk fac-
Despite the growing body of research about post-cardiac surgery tors because of the lack of standardized assessment
delirium incidence, associated factors, and outcomes worldwide, simi- protocol.
lar data within the Jordanian context are still lacking. • Early identification of delirium risk factors helps prevent
this complication.

2 | METHODS WHAT THIS PAPER ADDS

2.1 | Study objective • This is the first prospective study that estimates the inci-
dence of post-cardiac surgery delirium in Jordan.
This study aimed to provide an estimation of delirium incidence and • The estimated incidence of post-cardiac surgery delirium
associated risk factors among post-cardiac surgery patients in Jordan. was 9%.
• Increased patient's age and longer surgery time are signifi-
cant factors associated with post-cardiac surgery delirium.
2.2 | Sample and setting • Post-cardiac surgery delirium leads to longer mechanical
ventilation time, increased ICU stay, and prolonged
An exploratory, prospective cohort design was used. The study was hospitalization.
conducted at the regional cardiac centre in Amman, Jordan, over a
3-month period from March 2018 to June 2018. A sample of adult
patients aged ≥18 years who underwent elective cardiac surgery
spent more than 24 hours in post-cardiac surgery ICU with no history
of dementia or delirium before hospital admission, and admitted to The Brief Confusion Assessment Method (bCAM)10 at the surgical
the study setting during the study period, were recruited. Ethical floors after patients transfer from the ICU. According to the CAM-
approval was obtained from the setting's Institutional Review Board ICU criteria, assessment of delirium should follow a two-step
(IRB). Patient's participation was voluntary and based on informed method.11 The first step is to assess the consciousness and agitation/
consent. sedation level of the patients. Although different sedation/agitation
and level of consciousness scales could be used, the Richmond Agita-
tion Sedation Scale (RASS)12 was used for the purpose of this study.
2.3 | Data collection This is because the CAM-ICU was originally validated using the RASS
according to the revised manual of CAM-ICU.11 A score of RASS
Patients who met the inclusion criteria of the study were contacted ranged from +4 to −3 should be obtained in order to proceed to
the day before the surgery and assessed for the presence of delirium CAM-ICU. Richmond Agitation-Sedation Scale score of − 4 (indicating
for five consecutive post-operative days. A survey developed by the deep sedation) or −5 (indicating unarousable state) means that
researchers includes patients' demographics, and a checklist of delir- patient is unconscious and therefore not eligible for CAM-ICU.11 The
ium predisposing and precipitating factors was filled out from patients second step was to assess eligible patients for delirium by CAM-ICU
and their records. The second step involved the assessment of through it is four features: (a) acute onset of changes or fluctuations
patients for delirium after 24 hours of the admission to the post- in the course of mental status in the last 24 hours, (b) inattention,
cardiac surgery ICU. Delirium was assessed at least once daily for each (c) disorganized thinking, and (d) altered level of consciousness.
eligible patient for five consecutive post-operative days or till delirium Positive diagnosis of delirium was considered when both feature
was detected. Selected intraoperative and post-operative variables 1 and feature 2 were present in addition to the presence of either
were collected and documented. feature 3 or feature 4.11 All assessment methods were conducted by
the principal investigator and by the ICU's head nurse who both
received training on the use of RASS, CAM-ICU, and brief CAM
2.4 | Delirium assessment under supervision of an expert anaesthetist in the setting of the
study.
Delirium was assessed by the use of the Arabic version of the Confu- Delirium was defined as follows: at least one positive CAM-ICU
sion Assessment Method for Intensive Care Unit (CAM-ICU)9 in the during patient stay in ICU in the first 5 days post-operation, or at least
post-cardiac surgery ICU. Delirium was also assessed by the use of one positive brief CAM during patient stay at surgical ward after
HABEEB-ALLAH AND ALSHRAIDEH 3

transfer from ICU in the first 5 days post-operation, or if the patient 2.5 | Data analysis
was prescribed haloperidol during the first 5 post-operative days.13 In
our study setting, haloperidol is prescribed only for patients diagnosed The Statistical Package for the Social Sciences for Windows, Version
with delirium.14 21.0,15 was used for data analyses. Descriptive analysis in terms of
frequency and percentage was conducted to calculate the incidence
of delirium among post-cardiac surgery patients. Sample characteris-
T A B L E 1 Summary of chi-square test for delirium and the tics in terms of central tendency and variability measurement were
associated risk factors (n = 245)
prescribed. Chi-square test and the independent samples t-test analy-
Negative Positive sis were performed to assess the presence of delirium-associated risk
delirium delirium
Total 223 (91%) 22 (9%) Pearson P
factors.
variables N (%) N (%) chi-square df value
Gender 0.19 1 0.65
Male 181 (73.9) 17 (6.9) 3 | RE SU LT S
Female 42 (17.1) 5 (2.1)
Stroke 0.91 1 0.34 A total of 245 patients who were scheduled for elective open heart sur-
Yes 10 (4.1) 2 (0.8) gery were contacted and invited to participate in the study over a
No 213 (86.9) 20 (8.2) period of 3 months. Variables categorized into three categories: preop-
DM 2.33 1 0.12 erative, intraoperative, and post-operative variables. The mean age
Yes 94 (38.4) 13 (5.3) of the sample was 58 (SD ± 10.5). Descriptive analysis showed that
No 129 (52.7) 9 (3.6)
9% (n = 22) of patients developed delirium. Most of the patients
Hypertension
with delirium were male 77.3% (n = 17) and had a mean age of
Yes 104 (42.4) 11 (4.5) 0.09 1 0.76
65.7 (SD ± 8.1). Results of chi-square test showed no significant
No 119 (48.6) 11 (4.5)
association between delirium and a group of preoperative and
Smoking 2.21 2 0.33
intraoperative factors (Table 1). A point biserial correlation was run
Yes 78 (31.8) 8 (3.3)
to assess association between delirium and other continuous vari-
No 36 (14.7) 1 (0.4)
ables (Table 2). Only age [pbis (243) = 0.22, P < .05] and duration of
Quit 109 (44.5) 13 (5.3)
surgery [pbis (243) = 0.14, P < .05] showed significant association
Statin use 0.18 1 0.66
with delirium. To further assess the nature of the relation of delir-
Yes 71 (29) 8 (3.3)
ium with both age and duration of surgery, an independent-samples
No 152 (62.0) 14 (5.7)
Surgery type 7.46 4 0.13
t test was performed. Results showed that patients with delirium

CABG 172 (70.2) 14 (5.7) were significantly older (mean age = 65.7, SD ± 8.1), t (243) = −3.66,
Valve 42 (17.1) 5 (2.1) P < .05) than the group of patients without delirium (mean age = 57.2,
Both 6 (2.5) 2 (0.8) SD ± 10.4). Likewise, group of patients with delirium significantly
Aortic 1 (0.4) 1 (0.4) spent more time in the surgery (mean time = 286.3, SD ± 82.2),
Others 2 (0.8) 0 (0.0) t (243) = −2.25, P < .05) than the group of patients without delirium
Use of CPB 0.71 1 0.39 (mean time = 254.5, SD ± 61.0).
Yes 216 (88.2) 22 (9) Independent-samples t test results showed no significant differ-
No 7 (2.8) 0 (0.0) ences between patients with delirium (t (243) = 0.61, P > .05) and
IABP 0.26 1 0.61 patients without delirium regarding volume of infused crystalloids in
Yes 14 (5.7) 2 (0.8) the first 24 hours post-surgery. However, patients with delirium had
No 209 (85.3) 20 (8.2) significantly a higher mean (t (243) = −3.86, P < .05) than patients
Abbreviations: CABG, coronary artery bypass graft; CPB, cardio without delirium with regard to volume of infused blood and colloids
pulmonary bypass; DM, diabetes mellitus; IABP, intra-aortic balloon pump. in the first 24 hours post-surgery.

T A B L E 2 Results of point biserial

Continuous variable N pbis Mean (SD) P value
correlation test between delirium and
continuous variables (n = 245) Age (years) 245 0.22 58.0 (10.5) <.05
Aortic cross clamp duration (minutes) 238 0.11 60.8 (27) >.05
Cardiopulmonary bypass pump duration (minutes) 238 0.07 96.7(33.9) >.05
Intraoperative crystalloids (mL) 245 0.02 2042.8 (241.9) >.05
Intraoperative blood/products (mL) 245 0.08 71.8 (305.7) >.05
Duration of surgery (minutes) 245 0.14 257.4 (63.6) <.05
4 HABEEB-ALLAH AND ALSHRAIDEH

Delirium was assessed exclusively during the first 5 post- replacement, combination of both CABG and valve procedures, aortic
operative days, and ICU length of stay and mechanical ventilation dissection, and pericardioctomy. Most patients of this study under-
days were assessed till discharge or death. Patients with delirium sig- went CABG procedure. However, there was no significant association
nificantly spent more time on mechanical ventilation (t [21.6] = −2.2, found between the type of surgery performed and development of
P < .05) than patients without delirium. Likewise, patients with delir- delirium. This finding is similar to that found by Andrejaitiene and
ium had significantly longer ICU stay (t [21.7] = −4.0, P < .05) than Sirvinskas,24 Norkienė and colleagues,21 and Rudiger and col-
patients without delirium. Similarly, patients with delirium had signifi- leagues.22 Conversely, Mangusan and colleagues20 explored a signifi-
cantly longer hospitalization (t [22.8] = −2.2, P < .05) in comparison cant association between delirium and CABG procedure alone or a
with patients without delirium. combination of both CABG and valve replacement procedure. They
rationalized that their findings may be related to the longer cardiopul-
monary bypass duration as well as increased surgery duration when
4 | DISCUSSION both CABG and valve replacement procedures were performed, which
in turn increased the risk of delirium. Similar significant association
To the best of the knowledge of the researcher, this is the first study between CABG procedure and delirium development was also
to estimate the incidence and explore associated factors of delirium reported by Sabol and colleagues.29
among adult patients post-cardiac surgery in Jordan. The incidence of In the current study, there is no significant difference in delirium
delirium in this study as established using the CAM-ICU found to be between beating heart and on-pump surgery. This might be due to
9%, which demonstrates a lower incidence than reported results in the fact that a small number of patients with beating heart surgeries
16-23
previous studies. On the other hand, Andrejaitiene and who were included in the study since Shadvar and colleagues23 found
24 25
Sirvinskas and Jodati and colleagues reported an incidence as low that off-pump cardiac surgery contributed significantly to lower post-
as 4.9% and 4.17%, respectively. operative delirium incidence due to decreased potential harm exerted
The lower incidence rate estimated in the current study may be on cerebral tissues.
related to the decreased mean age of the sample 58 (SD ± 10.5) in Although the volume of infused intravenous fluids including crys-
comparison with other studies' sample mean age that reported a higher talloids and colloids, and infused blood and its products intraoperatively
delirium incidence: incidence of 18% and mean age of 71,18 incidence found to be significantly associated with development of delirium,22
of 24.5% and mean age of 66.5 (±10.8),20 and incidence of 28% and this is considered opposing the results of the present study as well as
16
mean age of 69 (10.9). Likewise, the mean age of the samples in stud- of previous study conducted by Kumar and colleagues.19 However,
ies that reported low delirium incidence was lower. In the study by Smulter and colleagues27 found a strong association between delirium
25
Jodati and colleagues, the mean age of patients without delirium was and intraoperative volume load. They estimated an average of (3, 71) L
55.3(±14.1) and was 59.5(±13.4) in patients with delirium. However, of infused fluids inside theatre for each patient. They reported findings
the mean age of the sample of the study conducted by Andrejaitiene that were not previously studied and found that for each one extra
and Sirvinskas24 was 71.5(±8.9) although they reported a low incidence infused litre of fluids inside operation, the risk of delirium development
rate (4.17%). Another contrast finding is a mean age of 53.3(±11.4) with increased by threefold. On the other hand, they reported no significant
a reported incidence of delirium of 23.5%.23 The incidence noticeably association between delirium and intraoperative infused blood and its
increased when delirium assessment focused on elderly. Bakker and products.
colleagues26 reported an incidence rate of 31% among 201 patients Results of the current study are consistent with those of the previ-
who had age of 70 years or older in the Netherlands. Smulter and ous study of Norkienė and colleagues,21 wherein ICU stay and duration
colleagues27 reported an incidence rate as high as 54.9% among 142 of mechanical ventilation were significantly longer with patients who
28
Sweden patients who aged 70 years or more. Kotfis and colleagues developed delirium. They reported another confirming result of the
went to more specific estimation of delirium in elderly patients post- present study, which was significantly associated between delirium
cardiac surgery in Poland. They estimated an incidence of 21.4% among development and increased volume of infused fluids and blood post-
384 patients who had an age of 65 or above, and an incidence of operation. Jodati and colleagues,25 Rudiger and colleagues,22 and
33.5% among 77 patients who aged 80 or more. Shadvar and colleagues,23 similarly reported significant increases in
Age was found to have significant association with the develop- both duration of mechanical ventilation and length of ICU stay for
ment of delirium. Risk of delirium development increased proportionally patients with delirium. Andrejaitiene and colleagues,16 Andrejaitiene
with increased age. Similar results about the significant association and Sirvinskas,24 and Sabol and colleagues29 also found significant
between post-cardiac surgery delirium and age were reported in previ- association with delirium not only with length of ICU stay but, more-
ous studies.16,18,20,23,25 over, with length of hospital stay, which is parallel to the present study
Results of the present study indicated a significant association findings. Increased hospitalization period also reported to be associated
between post-cardiac surgery and time spent in the surgery. This find- significantly with patients with delirium by Mangusan and colleagues.20
20-22,24
ing is consistent with the results reported in recent studies. Kumar and colleagues19 reported a significant increase in ICU
Different cardiac surgeries performed to patients in the current length of stay only for patients with delirium who spent more than
study include Coronary Artery Bypass Graft (CABG), valve repair or 10 days in the ICU. They also had a contradictory finding concerning
HABEEB-ALLAH AND ALSHRAIDEH 5

no significant association between mechanical ventilation duration OR CID

and delirium development as Sabol and colleagues29 also reported in a Jafar Alasad Alshraideh https://orcid.org/0000-0002-2118-5257
19
different study. Kumar and colleagues also found patients with delir-
ium had to use intra-aortic balloon pump machine (IABP) in ICU more RE FE RE NCE S
frequently than patients without delirium, and they received more red 1. American Psychiatric Association. Diagnostic and statistical manual of
blood cells' transfusion in ICU than patients without delirium. Around mental disorders. 5th ed. Washington DC: American Psychiatric Associ-
ation, Office of Communications and Public Affairs; 2013. https://doi.
half the patients in the current study received blood transfusion post-
org/10.1176/appi.books.9780890425596
surgery; however, patients with delirium received significantly more 2. Teodorczuk A, Reynish E, Milisen K. Improving recognition of delirium
transfusions in comparison with patients without delirium. in clinical practice: a call for action. BMC Geriatr. 2012 Dec;12(1):55.
Post-cardiac surgery delirium is associated with several in- 3. Salluh JI, Wang H, Schneider EB, et al. Outcome of delirium in criti-
cally ill patients: systematic review and meta-analysis. Bio Med J.
hospital and post-discharge adverse outcomes. Standardized protocol
2015;350:h2538.
for delirium assessment and follow-up should be introduced as a rou- 4. Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk fac-
tine care for all patients undergoing cardiac surgery. Although some tors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol.
factors are non-modifiable, fortunately some are modifiable and 2012;26(3):277-287.
5. Brown CH IV. Delirium in the cardiac surgical intensive care unit. Curr
potentially could be manipulated such as sleep deprivation, immobil-
Opin Anaesthesiol. 2014;27(2):117.
ity, dehydration, anaemia, and post-operative pain. Recognition of
6. Huai J, Ye X. A meta-analysis of critically ill patients reveals several poten-
highly associated factors either modifiable or not can help in detection tial risk factors for delirium. Gen Hosp Psychiatry. 2014;36(5):488-496.
of patients who are at risk for developing delirium. 7. Lin Y, Chen J, Wang Z. Meta-analysis of factors which influence delir-
Health care facilities should have continuing education programmes ium following cardiac surgery. J Card Surg. 2012;27(4):481-492.
8. Evans AS, Weiner MM, Arora RC, et al. Current approach to diagnosis
to empower nurses and improve their abilities in recognition, assessment,
and treatment of delirium after cardiac surgery. Ann Card Anaesth.
and management of post-cardiac surgery delirium. Further research on 2016;19(2):328-337.
the effect of specific nursing interventions to reduce the incidence of 9. Ely E, Inouye S, Bernard G, et al. Delirium in mechanically ventilated
delirium and improve patients' outcomes after cardiac surgery is needed. patients: validity and reliability of the confusion assessment method
for the intensive care unit (CAM-ICU). J Am Med Assoc. 2001;286(21):
2703-2746. http://www.promedmail.org Accessed April 29, 2004.
10. Han JH. Brief Confusion Assessment Method (bCAM) Instruction
4.1 | Limitation Manual. Vanderbilt University Medical Center. http://eddelirium.org/
delirium-assessment/bcam. Accessed September 23, 2018.
The study was conducted in one centre that warrants caution about 11. Ely W. The Confusion Assessment Method for the Intensive Care
Unit: The revised complete training manual. Vanderbilt University
generalizability. The frequency of delirium assessment was limited to
Medical Center. http://www.icudelirium.org/delirium/monitoring.
once or twice per day, and there are other delirium risk factors that html. Accessed September 3, 2018.
were not assessed in the current study. 12. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond agitation–
sedation scale: validity and reliability in adult intensive care unit
patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344.
13. Wolters AE, van Dijk D, Pasma W, et al. Long-term outcome of delir-
5 | C O N CL U S I O N ium during intensive care unit stay in survivors of critical illness: a
prospective cohort study. Crit Care. 2014;18(3):125.
The incidence of post-cardiac surgery delirium was 9%. Delirium was 14. Zaal IJ, Spruyt CF, Peelen LM, et al. Intensive care unit environment
may affect the course of delirium. Intensive Care Med. 2013;39(3):
associated with several adverse outcomes including longer mechanical
481-488.
ventilation, longer ICU stay, and prolonged hospitalization. A multifac- 15. Statistical Package for the Social Sciences. IBM SPSS Statistics Version
torial model for delirium risk factors should be considered to detect 21. Boston, Mass: International Business Machines; 2012:126.
and manage potentially preventable delirium risk factors. Staff should 16. Andrejaitiene J, Sirvinskas E, Dvylys D, Legotaite G, Simeliunaite I,
Venclovas Z. Postoperative delirium in patients after cardiac surgery:
be adequately educated for continuous monitoring, prevention, and
incidence, risk factors and outcomes. Biol Psychiat Psychopharmacol.
early detection of post-cardiac surgery delirium using standardized
2015;17(1):22-29.
delirium assessment protocol. 17. Cereghetti C, Siegemund M, Schaedelin S, et al. Independent predic-
tors of the duration and overall burden of postoperative delirium after
ACKNOWLEDGEMEN T cardiac surgery in adults: an observational cohort study. J Cardiothorac
Vasc Anesth. 2017;31(6):1966-1973.
This study was partially funded by the University of Jordan.
18. Jung P, Pereira MA, Hiebert B, et al. The impact of frailty on postop-
erative delirium in cardiac surgery patients. J Thorac Cardiovasc Surg.
E TH I CAL AP PR O V AL 2015;149(3):869-875.
Ethical approval was obtained from the setting's Institutional Review 19. Kumar AK, Jayant A, Arya VK, Magoon R, Sharma R. Delirium after
cardiac surgery: a pilot study from a single tertiary referral center.
Board (IRB). Patient's participation was voluntary and based on
Ann Card Anaesth. 2017;20(1):76-82.
informed consent. The research has been conducted in full accor- 20. Mangusan RF, Hooper V, Denslow SA, Travis L. Outcomes associated
dance with ethical principles, including the World Medical Association with postoperative delirium after cardiac surgery. Am J Crit Care.
Declaration of Helsinki (version, 2002). 2015;24(2):156-163.
6 HABEEB-ALLAH AND ALSHRAIDEH

21. Norkienė I, Ringaitienė D, Kuzminskaitė V, Šipylaitė J. Incidence and 27. Smulter N, Lingehall HC, Gustafson Y, Olofsson B, Engström KG.
risk factors of early delirium after cardiac surgery. Biomed Res Int. Delirium after cardiac surgery: incidence and risk factors. Interact
2013;2013:1-5. Cardiovasc Thorac Surg. 2013;17(5):790-796.
22. Rudiger A, Begdeda H, Babic D, et al. Intra-operative events during ska A, Listewnik M, et al. Early delirium after cardiac sur-
28. Kotfis K, Szylin
cardiac surgery are risk factors for the development of delirium in the gery: an analysis of incidence and risk factors in elderly (≥ 65 years) and
ICU. Crit Care. 2016;20(1):264. very elderly (≥ 80 years) patients. Clin Interv Aging. 2018;13:1061-1070.
23. Shadvar K, Baastani F, Mahmoodpoor A, Bilehjani E. Evaluation of the 29. Sabol F, Bily B, Artemiou P, et al. Incidence and risk factors of delir-
prevalence and risk factors of delirium in cardiac surgery ICU. ium in patients after cardiac surgery: modifiable and non-modifiable
J Cardiovascular Thoracic Res. 2013;5(4):157-161. factors. Coret Vasa. 2015;57(3):e168-e175.
24. Andrejaitiene J, Sirvinskas E. Early post-cardiac surgery delirium risk
factors. Perfusion. 2012;27(2):105-112.
25. Jodati A, Safaie N, Raoofi M, et al. Prevalence and risk factors of
postoperative delirium in patients undergoing open heart surgery How to cite this article: Habeeb-Allah A, Alshraideh JA.
in northwest of Iran. J Cardiovascular Thoracic Res. 2013;5(3): Delirium post-cardiac surgery: Incidence and associated
97-99.
factors. Nurs Crit Care. 2019;1–6. https://doi.org/10.1111/
26. Bakker RC, Osse RJ, Tulen JH, Kappetein AP, Bogers AJ. Preoperative
and operative predictors of delirium after cardiac surgery in elderly
nicc.12492
patients. Eur J Cardiothorac Surg. 2011;41(3):544-549.