• Juan C Pedemonte, Haoqi Sun, Esteban Franco-Garcia, Carmen Zhou, Marilyn Heng, Sadeq A Quraishi, Brandon Westover, and Oluwaseun Akeju.
• Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. Electronic address: jcpedemo@gmail.com.
• Br J Anaesth. 2021 Jul 1; 127 (1): 102109102-109.

BackgroundFrailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients.MethodsThis was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality.ResultsIn the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect.ConclusionsFrailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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