Sex Differences in Postoperative Delirium Severity and Burden in Older Adults

Postoperative delirium is a common complication in older adults. Binary delirium outcomes may obscure clinically meaningful, sex-specific differences in delirium severity and burden. We sought to characterize these patterns in a surgical cohort.

We prospectively studied older patients with repeated postoperative delirium assessments, obtaining daily Delirium Rating Scale (DRS) scores to measure severity, calculating area under the curve (AUC) across postoperative assessments as a measure of cumulative delirium burden (total symptom load over time). We used sex-stratified models and pooled models with sex interaction terms, adjusting for age, American Society of Anesthesiology (ASA) physical status, opioid exposure, and other physiologic covariates.

Risk factors for delirium severity and burden differed significantly by sex. Among women, higher ASA class was the primary predictor of increased delirium burden (AUC: β = 2.79 per class; peak DRS: β = 1.71). Among men, increasing age (AUC: β = 0.427 per year) and intraoperative opioid exposure were strongly associated with higher burden. The age-by-sex interaction was significant across all outcomes (p < 0.05), with age being a much stronger predictor of delirium severity in men than in women. At matched baseline risk, predicted delirium severity was consistently higher in men.

Delirium risk factors are sex-differentiated. For men, age was the dominant predictor of delirium severity and burden, whereas for women, baseline physiologic status was more strongly associated with these outcomes. These findings highlight the importance of using severity-based outcomes to reveal sex-specific vulnerability patterns that are otherwise obscured by simple binary endpoints.