The predictive value of nurse-led preoperative frailty assessment for postoperative delirium in liver transplant recipients: a retrospective cohort study

BACKGROUND: Postoperative delirium (POD) is a severe and frequent complication after liver transplantation (LT), associated with increased morbidity and healthcare utilization. Frailty represents a clinically measurable state of diminished physiological reserve and increased vulnerability to stressors. The predictive value of a structured, nurse-led frailty assessment for POD in LT recipients requires rigorous evaluation. METHODS: This retrospective study enrolled adults who underwent first-time liver transplantation from 2020 to 2024 at a single center. Patients with severe pre-existing cognitive impairment or missing data were excluded. Preoperative frailty was assessed by trained transplant nurse coordinators using the Clinical Frailty Scale (CFS) and Liver Frailty Index (LFI), with frailty defined as CFS ≥ 5 or LFI ≥ 4.5. The primary outcome was POD incidence within 7 days post-LT, diagnosed using the Confusion Assessment Method for the ICU (CAM-ICU). RESULTS: Among 156 patients, 46 (29.5%) were frail. The incidence of POD was markedly elevated in frail patients compared to their non-frail counterparts (52.2% vs. 18.2%, P < 0.001). Following multivariable analysis, preoperative frailty was independently associated with POD (aOR = 4.32, 95% CI: 2.15-8.68). A significant positive correlation was observed between frailty severity (CFS score) and delirium severity (CAM-ICU-7 score; ρ = 0.42, P < 0.001). Frail patients also received prolonged mechanical ventilation (median 28 vs. 18 h, P = 0.002), ICU length of stay (6 vs. 4 days, P < 0.001), and hospital length of stay (22 vs. 17 days, P = 0.001). Kaplan-Meier analysis showed significantly lower delirium-free survival in frail patients (Log-rank P < 0.001). CONCLUSIONS: A nurse-led preoperative frailty assessment is associated with POD and resource use in LT recipients in this retrospective cohort. These findings suggest that integrating this feasible screening into routine nursing practice may facilitate early identification of high-risk patients, supporting targeted preventive strategies.