consequences of delirium after cardiac operations
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CARDIOTHORACIC ANESTHESIOLOGYThe Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org.To take the CME activity related to this article, you must have either an STS member or anindividual non-member subscription to the journal.
Consequences of Delirium After CardiacOperationsSandra Koster, MANP, Ab G. Hensens, MS, Marieke J. Schuurmans, PhD, andJob van der Palen, PhDDepartment of Cardio Thoracic Surgery, Department of Epidemiology, Medisch Spectrum Twente, Enschede; Department ofHealthcare, University of Professional Education Utrecht, Utrecht; Nursing Science, University Medical Center Utrecht, Utrecht;
and Department of Research Methodology, Measurement and Data Analysis, Faculty of Behavioral Sciences, University of Twente,Enschede, The NetherlandsBackground. Delirium is a transient mental syndromecharacterized by disturbances in consciousness, cogni-tion, and perception. The risk that delirium will developis increased in patients who undergo cardiac operations,especially the elderly. Generally, delirium during hospi-tal admission is independently associated with manynegative consequences, such as higher mortality, in-creased length of hospital stay, nursing home placementafter admission, and cognitive and functional decline.
Methods. This prospective follow-up study used theShort Form 36-Item questionnaire, the Cognitive FailureQuestionnaire, and a purpose-designed questionnaire toassess 300 patients who underwent elective cardiac oper-ations at 6 months after the procedure. Postoperativedelirium developed in 52 patients (17%). Mortality and
readmission were also assessed.Surgery, Medisch Spectrum Twente, Haaksbergerstraat 55, 7500KA En-schede, The Netherlands; e-mail: [email protected].
© 2012 by The Society of Thoracic SurgeonsPublished by Elsevier Inc
Results. Delirium after cardiac procedures is associatedwith increased mortality (13.5% vs 2.0% in patients with-out), more hospital readmissions (45.7% vs 26.5%), andreduced quality of life. It is also associated with reducedcognitive functioning, including failures in attention,memory, perception, and motor function, and with func-tional dysfunction such as independency in activities ofdaily living and mobility.
Conclusions. Postoperative delirium after cardiac oper-ations is associated with many important consequences.These findings provide justification for interventionstudies to evaluate whether delirium prevention, earlyrecognition, or treatment strategies might improve post-operative functional and cognitive function.
(Ann Thorac Surg 2012;93:705–11)
© 2012 by The Society of Thoracic SurgeonsDelirium, or acute confusion, is a transient mentalsyndrome characterized by disturbances in con-
sciousness, cognition, and perception [1]. The risk ofpostoperative delirium is increased in patients who un-dergo cardiac operations, especially the elderly. Thereported incidence of delirium in patients after cardiacoperations was 3% [2] to 52% [3]. In our observationalcohort study, the incidence of delirium after electivecardiac operations was 21% [4]. Developments in opera-tive and anesthetic techniques have enabled older pa-tients to undergo cardiac operations [5], which, togetherwith the aging of the population, will lead to an increasein the incidence of delirium in the near future.
Delirium has been related to higher mortality, in-creased hospital length of stay and nursing home place-ment after admission, reduced quality of life, and cogni-tive and functional decline in older general medicalpatients as well as in surgical patients [6–10]. In cardiacsurgery specifically, however, little is known about theconsequences of postoperative delirium.
Gottesman and colleagues [11] recently found that
Accepted for publication July 12, 2011.
Address correspondence to Dr Koster, Department of Cardio Thoracic
delirium after cardiac operations is a strong independentpredictor of death for up to 10 years postoperatively. Inour earlier cohort study of 112 elective cardiac surgicalpatients, postoperative delirium seemed to be associatedwith increased death and hospital readmissions, as wellas poorer cognitive and functional outcomes [12]. Wewere not able to draw firm conclusions because of thelow number of patients; therefore, we repeated the studyin a larger cohort of patients and added new outcomes.The present study examined the consequences of delir-ium after cardiac operations, including the mortality rateafter discharge, readmission rate, cognitive and func-tional outcomes, and quality of life.
Patients and Methods
The Ethics Committee of Medisch Spectrum Twenteruled that approval was not required because this was anobservational study, without invasive procedures. In-formed consent was obtained from participating patientsin accordance with hospital policy.
Design and SampleBetween October 2008 and January 2010, our study in-
cluded 300 consecutive patients, aged 45 years and older,0003-4975/$36.00doi:10.1016/j.athoracsur.2011.07.006
RR �
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who underwent elective cardiac operations at the De-partment of Thoracic Surgery (Table 1).
ProcedurePatients were followed up from the time of admissionuntil hospital discharge. All patients were screened dailyduring hospitalization for delirium with the use of theDelirium Observation Screening (DOS) scale. The DOSscale describes typical behavioral patterns related todelirium in 13 statements or questions, which the ob-server has to answer with “never” (score � 0) or “some-times or always” (score � 1), if applicable (Table 2). ADOS score of 3 or higher indicates delirium [13]. TheDOS scale is a reliable and valid instrument to recognizedelirium based on nurses’ observations of patients dur-ing regular care [13]. Nurses rated their observation threetimes a day at the end of every shift, preoperatively, andpostoperatively. Patients with preoperative delirium ac-
Table 1. Baseline Patient Characteristics
Variable
Total No Delirium(N � 300) (n � 248)
Mean (SD) Mean (SD)
Age, years 70.5 (9.3) 66.7 (9.2)
No. (%) No. (%)
Age�70 138 (46) 96 (70)�70 162 (54) 152 (94)
SexFemale 96 (32) 80 (83)Male 204 (68) 168 (82)
Type of operationCABG 106 (35) 98 (92)Valve 118 (39) 98 (83)CABG � valve 52 (17) 21 (40)Other 24 (8) 3 (13)
CABG � coronary artery bypass graft; CI � confidence interval;
Table 2. The Working Method of the DOS Scalea
The patient:1. Dozes off during conversation or activities2. Is easily distracted by stimuli from the environment3. Loses attention to conversation or action4. Does not finish question or answer5. Gives answers that do not fit the question6. Reacts slowly to instructions7. Thinks to be somewhere else8. Does not know which part of the day it is9. Does not remember recent events
10. Is picking, disorderly, restless11. Pulls intravenous tubes, feeding tubes, catheters, etc12. Is easily or suddenly emotional (frightened, angry,
irritated)13. Sees/hears things that are not there
a Never � 0 points; sometimes or always � 1 point. A total score of �3points indicates a delirium.
DOS � Delirium Observation Screening.
cording to the DOS scale were excluded. If delirium hadnot developed in a patient by day 4, the DOS scale was nolonger rated.
At 6 months after discharge, the 288 surviving patientswere sent a purpose-designed questionnaire (www.mst.nl/thoraxcentrum/appendix.pdf), the Short Form 36-item (SF-36) health survey questionnaire [14], and theCognitive Failure Questionnaire (CFQ) [15] to evaluatereadmission rates, quality of life, and cognitive andfunctional outcomes. A patient who did not respond after1 month was contacted by telephone and asked to com-plete the 3 questionnaires.
The purpose-designed questionnaire to assess cogni-tive and functional outcomes contained questions onhospital readmission, memory, concentration, confusion,sleep patterns, emotions, activities of daily living (ADL),mobility, and in patients with postoperative delirium, theexperience of the episode of confusion. We determinedproblems with memory, concentration, and confusionwere present when the patient felt, thought, or believedhe or she had a problem in this area.
The multipurpose SF-36 measures eight domains ofhealth: physical functioning, role limitations due to phys-ical health, bodily pain, general health perceptions, vital-ity, social functioning, role limitations due to emotionalproblems, and mental health. It yields scale scores foreach of these eight health domains.
The CFQ is a measure of self-reported deficits in thecompletion of simple everyday tasks that a person shouldnormally be capable of completing without error andincludes failures in attention, memory, perception, andmotor function. The patient can answer the questionswith “never,” “rarely,” “sometimes,” “frequent,” and“most of the time”; the range of the scores is 0 to 100.
The hospital’s Medical Computer System was used to
Delirium
RR (95% CI) p Value(n � 52)
Mean (SD)
74.3 (7.1) �0.001
No. (%)
42 (30) 1 �0.00110 (6) 4.9 (2.8–9.5)
16 (17) 1 0.8336 (18) 1.1 (0.6–1.8)
8 (8) 1 �0.00120 (17) 2.3 (1.0–4.9)31 (60) 7.9 (3.9–16.0)21 (87) 11.6 (5.9–23.0)
relative risk.
ascertain mortality and readmission rates.
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Statistical AnalysisThe univariate association between postoperative delir-ium and death, readmission, quality of life, and cognitiveor functional outcomes was estimated. The independenttwo-tailed t test was used to compare the means ofvariables in case of continuous normally distributed data.When data were not distributed normally, the Wilcoxonrank sum test was used. The �2 test was used for thecomparison of categoric variables between patients withand without delirium, and relative risks (RR) are pre-sented. A correction for age was done using logisticregression analysis, with the odds ratio (OR), or linearregression analysis, as appropriate.
Results
Study PopulationThe study included 300 patients, and postoperative de-lirium developed in 52 (17%), as diagnosed with the DOSscale. The mean duration of delirium was 1 to 3 days inmost patients, sometimes 4 to 7 days, and in 2 patients, 11and 14 days. The duration of delirium in some patientscould not be estimated because they were transferred toanother hospital for further postoperative recovery. Al-most all patients were treated with a low dose of halo-peridol (1 to 3 mg/d), and some patients received a higherdose (5 to 15 mg/d). Haloperidol did not have any effectIn 2 patients and the psychiatrist prescribed Quetiapine(300 once daily, or 100 to 150 mg/d). Of the 288 survivingpatients, 264 returned the questionnaire, for a 91.7%.response rate.
Long-Term Outcomes of Delirium AfterCardiac OperationDetails of long-term outcomes in patients, includingsurvival, readmission, cognitive and functional out-comes, morality, subjective cognitive function, and qual-ity of life, in patients with postoperative delirium aresummarized in Tables 3, 4, 5, and 6.
MORTALITY. During the 6-month follow-up period, 12 pa-tients (4%) died. Postoperative delirium developed in 7 ofthese patients (13.5%), for a RR of 6.7 (p � 0.001). Aftercorrection for age, the OR was 5.1 (p � 0.011; Table 3).
Table 3. Mortality and Readmission to the Hospital Within6 Months After Cardiac Operations in Patients With andWithout Postoperative Delirium
Died(n � 300), No. (%)
Readmission(n � 276), No. (%)
Yes No Yes No
DeliriumYes 7 (13.5) 45 (86.5) 21 (45.7) 25 (54.3)No 5 (2.0) 243 (98.0) 61 (26.5) 169 (73.5)
RR (95% CI) 6.7 (2.2–20.2) 1.72 (1.2–2.5)p Value 0.001 0.010
CI � confidence interval; RR � relative risk.
READMISSION. Hospital readmission was required in 82patients (29.7%): 21 (45.7%) in the delirium group and 61(26.5%) in the nondelirium group (RR, 1.72; p � 0.010).We did not have information about readmission for 24patients, of whom delirium developed in 6. Therefore,only 47 patients with delirium are listed in Table 3.Hospital readmission was required in 12 patients whodied. The most commonly mentioned reason for read-mission was a cardiac problem (52.2%). Correction forage led to an OR of 2.16 (p � 0.028).
COGNITIVE AND FUNCTIONAL OUTCOMES. According to thequestionnaires, the patients with and without postoper-ative delirium did not differ significantly in memory,concentration, confusion, sleep disturbance, or emotions(Table 4). When results were corrected for age, theincidence of dependency in ADL in the event of deliriumwas not significantly higher. The results of the othercognitive and functional outcomes remained largely un-changed after correction for age.
After hospital discharge, 85 patients (32.2%) had mem-ory problems and 32% still had memory problems after 6months. Of the 79 patients (30.0%) who had concentra-tion problems at discharge, 26.6% had these problems at3 to 6 months after discharge or still had concentrationproblems at the time they completed the questionnaire.After hospital discharge, 36 patients (13.7%) were disori-entated and 13.9% of them still exhibited these problemsat 6 months, 102 (38.8%) experienced sleep disturbances,and 112 (42.4%) had emotional problems. There was asignificant difference in the duration of the emotionalproblems in patients with and without delirium. In thosewith postoperative delirium, 58.8% still had emotionalproblems at 6 months compared with 23.2% of thepatients without postoperative delirium (p � 0.03).
There were statistically significant differences betweenpatients with and without postoperative delirium forexperiencing nightmares or bad dreams, ADL, and de-pendency in mobility. Nightmares or bad dreams werereported by 36 patients (13.6%) after discharge, of which16 (44.4%) still experienced nightmares at 6 months.Before they underwent the cardiac operation, 94% ofpatients were independent in ADL. After hospital dis-charge, 81 patients (30.7%) were in some way dependentin ADL. The most commonly mentioned dependencywas taking a shower (67.5%); but 40.3% of patients wereindependent within 1 month after hospital discharge. Inthe event of delirium, the incidence of dependency inADL was significantly higher (p � 0.008). When correctedfor age, dependency in ADL was no longer significantlyhigher (p � 0.084).
Before the cardiac operation, 95% of patients were mo-bile. After discharge, 58 patients (22.0%) were in some wayless mobile compared with the period before the cardiacoperation. Most commonly mentioned was the use of acane or a walker (57.6%). In the event of delirium, thenumber of patients who were less mobile was signifi-cantly higher (p� 0.001), and the duration of the “lessmobile period” was also significantly longer in the event
of delirium. When corrected for age, the number of
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patients with mobility problems was still significantlyhigher in patients with postoperative delirium (p �0.014).
SUBJECTIVE COGNITIVE FUNCTION. The mean (standard devia-tion) total score on the CFQ was 31.8 (14.6) in patientswith postoperative delirium and 25.3 (12.2) in thosewithout postoperative delirium, for a difference of 6.5(95% confidence interval [CI], 2.2 to 10.8; p � 0.003; Table5). When corrected for age, the difference was 5.7 (95%CI, 1.3 to 10.2; p � 0.012). In 9 questions, there was asignificant difference between patients with and withoutpostoperative delirium in the domains of memory, con-centration, acting, and observation.
QUALITY OF LIFE. Only two domains of the SF-36 werenormally distributed: vitality and general health percep-tions (Table 6). Patients with postoperative delirium hadsignificantly lower scores in seven of the eight domains ofthe SF-36: physical functioning, role limitations due tophysical health, bodily pain, general health perceptions,vitality, social functioning, and role limitations due tomental health. Only in role limitations due to emotionalproblems was there no significant difference. No correc-tion for age was done because only in the domain of
Table 4. Cognitive and Functional Outcomes 6 Months AfterPostoperative Delirium (N � 264)
OutcomeDelirium No deliriumNo. (%) No. (%)
Memory problemsYes 17 (43.6) 68 (30.2)No 22 (56.4) 157 (69.8)
Concentration problemsYes 13 (33.3) 66 (29.5)No 26 (66.7) 158 (70.5)
ConfusionYes 7 (17.9) 29 (12.9)No 32 (82.1) 195 (87.1)
Sleep disturbanceYes 14 (35.9) 88 (39.3)No 25 (64.1) 136 (60.7)
NightmaresYes 10 (25.6) 26 (11.6)No 29 (74.4) 199 (88.4)
Emotional problemsYes 17 (43.6) 95 (42.2)No 22 (56.4) 130 (57.8)
Dependency in ADLYes 19 (48.7) 62 (27.6)No 20 (51.3) 163 (72.4)
Dependency in mobilityYes 18 (46.2) 40 (17.8)No 21 (53.8) 185 (82.2)
a Unadjusted odds ratio. b Unadjusted p value. c Odds ratio adjus
ADL � activities of daily living; OR � odds ratio.
physical functioning was there a very weak correlation
between age and physical functioning (Spearman � �–0.33). All other correlations were smaller than 0.2 andnot significant.
Comment
Delirium occurring after cardiac operations is associatedwith increased mortality and a higher hospital readmis-sion rate, lower quality of life, cognitive failure as mea-sured with the CFQ, functional dysfunction such asdependency in ADL, and reduced mobility. Because weassumed age could be a confounder, we corrected theoutcomes for age, and found that in the event of delirium,only the incidence of dependency in ADL was no longersignificantly higher. In the other outcomes, the correctionfor age did not influence the results. A very weak corre-lation was found between age and the domain physicalfunctioning of the SF-36, but because physical function-ing was not distributed normally, it was not possible todo a correction for age.
These findings correspond well with the literature thatshows that in general, delirium is related to nursinghome placement and reduced cognitive and functionalrecovery [6–10]. In our earlier study, we concluded that
iac Operations in Patients With and Without A
ORa p Valueb ORc p Valued
1.78 0.136 1.92 0.080
1.20 0.627 1.56 0.263
1.47 0.402 1.41 0.472
0.87 0.689 1.02 0.968
2.64 0.018 2.62 0.032
1.06 0.873 1.29 0.490
2.50 0.008 1.90 0.084
3.96 �0.001 2.61 0.014
r age. d p Value adjusted for age.
Card
ted fo
delirium after a cardiac operation seems to be associated
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with increased death and readmissions to the hospital, aswell as poorer cognitive and functional outcomes. Be-cause of the low number of patients, it was not possible todraw far-reaching conclusions; we only saw a consistentnegative tendency in patients with delirium. The fol-low-up in our current study was at 6 months comparedwith after 1 year in the earlier study.
No significant difference was noted in the level ofemotional problems between patients with or withoutpostoperative delirium as measured with the SF-36 andthe purpose-designed questionnaire. Emotional prob-lems might be more a result of the cardiac operation ormay preexist in patients with cardiac diseases and maynot be dependent on having postoperative delirium.Emotional problems, such as anxiety and depression, arecommon in patients with coronary heart disease. Re-cently, Spezzaferri and colleagues [16] observed a highprevalence of depression and a state anxiety at 8 to 12days after coronary artery bypass grafting. The authors ofanother recent study found that cardiac surgical patientswho undergo long procedures commonly have postoper-
Table 5. Cognitive Failure Scores as Measured With the Cogn
Variablea
Ye(n �
Cognitive failure total scoreb 31.8 (1Reading 1.75 (1Forgetting things at home 1.40 (0Missing signposts 1.15 (1Confuse left and right 0.80 (0Hitting someone accidentally 0.53 (0Not remembering to turn off the gas, etc. 1.20 (0Not listening at people’s names 1.58 (1Blurting 1.00 (0Not noticing someone during an activity 1.60 (0Being anxious and later regrets it 1.13 (0Important letters unanswered for several days 1.15 (1Not remembering usual streets 0.95 (0Not finding things in the supermarket 1.35 (0Not knowing how to use words 1.18 (0Difficulties making a decision 1.60 (0Forgetting appointments 1.28 (1Not remembering where things were put 1.58 (0Throwing things away unintended 0.90 (0Daydreaming 1.13 (0Forgetting names 2.05 (0Not finishing jobs 1.23 (1Not finding the right words 2.03 (0Forgetting what to buy 1.00 (0Dropping things 0.95 (0Having no topics to talk about 1.30 (0
a Scores are presented as mean (standard deviation). b The scale for
CI � confidence interval.
ative anxiety and tension [17].
In cardiac operations, little is known about the cogni-tive and functional outcomes after postoperative delir-ium. It may exert a negative influence on health-relatedquality of life during the first 6 months after coronaryartery bypass grafting [18]. Rudolph and colleagues [19]found that functional decline occurred in 36.3% at 1month and in 14.6% at 12 months. In our earlier study,patients with postoperative delirium showed a consistentnegative tendency concerning cognitive and functionaloutcomes [12], but we could not draw firm conclusions.
We used two instruments to examine the cognitivefunction: our own purpose-designed questionnaire andthe CFQ. Concentration was addressed by 1 question inthe questionnaire and by 5 questions in the CFQ. In thequestionnaire, there was no significant difference inconcentration between patients with and without delir-ium, whereas in 3 of the 6 CFQ questions there was asignificant relationship between concentration and post-operative delirium. The results of our questionnaireconcerning the cognitive function and CFQ are difficult tocompare because the CFQ is a more specific and com-
Failure Questionnaire 6 Months After Cardiac Operations
elirium
Difference (95% CI) p ValueNo
(n � 223)
25.3 (12.2) 6.5 (2.2 to 10.8) 0.0031.39 (0.87) 0.36 (0.06 to 0.66) 0.0201.13 (0.81) 0.27 (–0.01 to 0.55) 0.0570.85 (0.76) 0.30 (–0.05 to 0.65) 0.0880.55 (0.79) 0.25 (–0.02 to 0.53) 0.0690.29 (0.54) 0.23 (–0.02 to 0.48) 0.0660.96 (0.81) 0.25 (–0.03 to 0.52) 0.0801.30 (1.02) 0.28 (–0.07 to 0.62) 0.1190.94 (0.76) 0.06 (–0.19 to 0.31) 0.6481.26 (0.86) 0.34 (0.06 to 0.63) 0.0181.16 (0.76) –0.03 (–0.30 to 0.23) 0.8110.70 (0.88) 0.46 (0.15 to 0.76) 0.0040.55 (0.71) 0.40 (0.15 to 0.65) 0.0021.02 (0.87) 0.33 (0.03 to 0.63) 0.0290.92 (0.82) 0.25 (–0.03 to 0.53) 0.0761.14 (0.84) 0.46 (0.17 to 0.75) 0.0020.89 (0.78) 0.39 (0.03 to 0.74) 0.0331.37 (0.86) 0.20 (–0.09 to 0.49) 0.1670.67 (0.68) 0.23 (–0.02 to 0.49) 0.0720.93 (0.82) 0.19 (–0.08 to 0.47) 0.1721.90 (0.98) 0.15 (–0.19 to 0.49) 0.3690.92 (0.75) 0.31 (–0.03 to 0.64) 0.0721.88 (0.86) 0.14 (–0.14 to 0.42) 0.3220.73 (0.78) 0.27 (–0.01 to 0.54) 0.0550.77 (0.79) 0.18 (–0.09 to 0.45) 0.1951.08 (0.89) 0.22 (–0.07 to 0.52) 0.140
estionnaire is 0 to 100.
itive
D
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4.6).03).90).05).91).75).82).04).64).78).88).03).88).95).81).98).06).81).74).79).99).00).66).96).88).82)
the qu
prehensive list. Because the questionnaire is not a vali-
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dated instrument to measure the cognitive function andthe CFQ is a validated instrument, the outcome of thequestionnaire concerning the cognitive function can bequestioned.
In contrast to findings of other studies, we did not finda difference in patients with and without delirium inconfusion at 6 months after cardiac operations. Althoughwe have no data to support this, we hypothesize that thepresurgical cognitive status in our patients was relativelygood compared with other studies.
A number of critical considerations pertaining to ourstudy can be made. The diagnosis of delirium was deter-mined by the DOS scale rather than by a psychiatrist. Apsychiatrist was consulted only when the treatment ofdelirium was not successful or the delirium was verysevere. In all these patients, the psychiatrist diagnoseddelirium. With a DOS score of less than 3, we assumedthat there was no delirium. It is very unlikely thatdelirium was present in patients with a DOS score of lessthan 3 because of the similarity between the DOS scaleitems and the diagnostic criteria for delirium. Also, anearlier study showed the validity of the DOS scale wasvery accurate, with a sensitivity of 100% and a specificityof 96.6% [20]. Therefore, using the DOS scale has prob-ably not influenced the results of the study.
Another limitation is that we did not see the patientface-to-face at the 6-month follow-up, but we used aquestionnaire. An interview might have rendered morespecific information. In addition, although we sent thequestionnaire to the patients, we cannot be sure that thepatients completed questionnaires themselves. Spousesor significant others could have completed the question-
Table 6. Quality of Life Assessed by the Short Form 36-ItemWith and Without Postoperative Delirium
Domain Delirium
Physical functioning YesNo
Social functioning YesNo
Role limitationsPhysical health Yes
NoEmotional problems Yes
NoMental health Yes
NoVitality Yes
NoBodily pain Yes
NoGeneral health perceptions Yes
No
a The t test was used for vitality and general health perceptions, and therole limitations due to physical health, role limitations due to emotional
IQR � interquartile range; SD � standard deviation.
naire or influenced the answers. When patients com-
pleted the questionnaire by themselves, there was apossibility of a confounding effect of depression onself-reported cognitive symptoms.
In conclusion, our findings provide justification forintervention studies to evaluate whether delirium pre-vention, early recognition, or treatment strategies mightimprove postoperative functional and cognitive functionand thereby the quality of life. To prevent postoperativedelirium, it is important to identify the risk factors fordelirium in patients when they present themselves to thehospital and observe any changes in these risk factorsduring the admission [21].
The initial management of delirium, according to theNational Institute for Health and Clinical Excellenceguideline, is to identify and manage the possible under-lying cause(s) of delirium. Next, it is important to ensureeffective communication and reorientation, consider in-volving family, friends, and other caregivers to help withthis, and provide a suitable care environment [21]. Fi-nally, it may be possible to design interventions tostimulate cognitive and functional functioning after de-lirium in cardiac surgical patients.
We thank all included patients, nurses, doctors, and medicalsecretarial staff for their help and cooperation with this study.
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