To the Editor We read the article by Sieber et al1 with great interest. Postoperative delirium (PD) is an increasing problem and one of the least well-understood problems today. Whether general anesthesia leads to PD that in turn leads to or unmasks dementia (Alzheimer disease) is the bigger question, as referred to in the Editorial accompanying this article.2 Sieber et al1 hereby fail to prospectively find an association of PD with depth of anesthesia. Within its limitations, on the one hand, this reassures us of the safety of use of anesthetics in older patients; on the other hand, this once again reinforces our belief that PD has a more complex etiopathology than we understand to date. Despite controlling for most factors (Table 11), what stands out is the mean age in both groups was older than 80 years. Maybe this could have contributed to the lack of a difference in the primary end point, as most patients in similar studies were much younger (aged approximately 60 to 65 years).3 Second, Sieber et al1 studied a sedation protocol for nonelective low-risk surgery; what if the authors had studied an intermediate-risk or high-risk surgery, such as intraperitoneal or vascular surgery? Third, this article raises the same questions around PD: is it the type of anesthetic drug (eg, intravenous vs inhalational) or is it the patient phenotype and their individual anesthetic sensitivity4 that determines the outcome, since even low anesthetic depth has been associated with delirium?5 The results and scope of this study need to be interpreted and applied with extreme caution, as it may not apply to general anesthesia, longer surgical duration, more invasive or major surgical procedures, and even individual patient phenotype.
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Pal N. Postoperative Delirium—Amplifying the Confusion. JAMA Surg. Published online January 16, 2019. doi:10.1001/jamasurg.2018.5244
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