Association Between Preoperative Activities of Daily Living and Postoperative Delirium in Elderly Patients Undergoing Non-Cardiac Surgery: A Prospective Cohort Study

Yuting Liu,1 Zhuan Zhu,1 Xuzhou Dang,1 Tingwei Qu,2 Wenjie Zhang,2 Xuesen Su3,4 1The College of Anesthesia, Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China; 2Department of Anesthesiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China; 3The Department of Anesthesiology, The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China; 4Shanxi Key Laboratory of Geriatric Precision Anesthesia and Complication Prevention, the Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of ChinaCorrespondence: Xuesen Su, The Department of Anesthesiology, The Fifth Clinical Medical College of Shanxi Medical University, No. 29 Shuangtasi Street, Taiyuan, Shanxi, 030012, People’s Republic of China, Email xuesensu_sxpph@yeah.net Wenjie Zhang, Department of Anesthesiology, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, Shanxi, 030001, People’s Republic of China, Email zhangwenjie0914@yeah.netBackground: Postoperative delirium (POD) is a common complication in elderly surgical patients associated with adverse outcomes. However, the relationship between low preoperative Barthel Index (BI) and POD remains unclear.Purpose: This study investigated the correlation between preoperative BI and POD incidence in elderly patients undergoing non-cardiac surgery.Patients and Methods: This prospective cohort study enrolled 298 patients (≥ 65 years) undergoing elective non-cardiac surgery under general anesthesia. Preoperative BI assessed activities of daily living (ADL) within 24 hours before surgery. POD was screened twice daily until postoperative day 7 or discharge using the 3-Minute Diagnostic Interview for Confusion Assessment Method–defined Delirium (3D-CAM). Univariate and multivariate logistic regression analyzed associations between BI and POD. Restricted cubic spline (RCS) and two-piecewise linear regression explored non-linearity and identified inflection points. Findings were validated using inverse probability of treatment weighting (IPTW), and BI’s incremental predictive value was evaluated by receiver operating characteristic (ROC) curve analysis.Results: POD incidence was 25.8% (77/298). Multivariate analysis showed lower preoperative BI (OR=0.956, 95% CI: 0.940– 0.973, p< 0.001), lower BMI (OR=0.860, 95% CI: 0.757– 0.977, p=0.020), and advanced age (OR=1.174, 95% CI: 1.102– 1.250, p< 0.001) independently associated with POD. RCS revealed a nonlinear relationship with inflection at BI=75. Patients with BI< 75 had significantly higher POD risk than those with BI≥ 75 (OR=4.615, 95% CI: 2.377– 8.963, p< 0.001), robust after IPTW adjustment (42.9% vs 14.5%; adjusted OR=4.445, 95% CI: 2.564– 7.707, p< 0.001). This association was pronounced in patients with fewer comorbidities, shorter anesthesia duration, and shorter preoperative stays. Incorporating the BI score significantly improved the discrimination of the predictive model for POD.Conclusion: Preoperative ADL impairment (BI< 75) independently predicts POD in elderly non-cardiac surgery patients. Preoperative BI assessment is recommended for perioperative risk stratification, identifying low-BI patients as targets for preventive interventions.Keywords: activities of daily living, barthel index, postoperative delirium, elderly, non-cardiac surgery, 3d-cam, neuropsychological tests