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This analysis investigates how sleep duration relates to postoperative delirium (POD) and the role of depressive symptoms in this relationship.

May 1, 2026Open Access

Sleep duration, depressive symptoms, and postoperative delirium: a mediation analysis

Key Points

This analysis investigates how sleep duration relates to postoperative delirium (POD) and the role of depressive symptoms in this relationship.
Included 500 patients aged ≥ 65 years undergoing hip or knee arthroplasty under general anesthesia.
Evaluated associations using three-step linear probability models with HC3 robust standard errors and bootstrapping validation.
Assessed depressive symptoms using the PHQ-9 questionnaire.
Postoperative sleep duration had a significant total association with POD (β=-0.174, 95% CI [-0.190, -0.158]).
An indirect pathway linking depressive symptoms to POD was significant (β=-0.129, 95% CI [-0.146, -0.113]).
Both direct (β=-0.045, 95% CI [-0.057, -0.032]) and adjusted path results were statistically significant.

Abstract

Purpose The mechanism linking postoperative sleep duration to postoperative delirium (POD) remains unclear. This study examined the potential indirect pathway involving depressive symptoms (assessed via the PHQ-9) in the association between postoperative sleep duration and POD. Methods We included 500 patients aged ≥ 65 years undergoing unilateral total hip or knee arthroplasty under general anesthesia. The associative pathways among sleep duration, depressive symptoms, and POD were assessed using covariate-adjusted three-step linear probability models with heteroscedasticity-consistent (HC3) robust standard errors, validated via 1000-resample bootstrapping and the Sobel test. Results Postoperative sleep duration had significant total (β=-0.174, 95% CI -0.190, -0.158) and direct (β=-0.045, 95% CI -0.057, -0.032) associations with POD. An indirect pathway involving depressive symptoms was statistically significant (β=-0.129, 95% CI -0.146, -0.113). Adjusted paths for sleep duration→PHQ-9 (β=-2.660, 95% CI -2.913, -2.407) and PHQ-9→POD (β=0.049, 95% CI 0.045, 0.052) were significant. Sensitivity analysis showed E-values of 1.67, 1.26, and 1.53 for total (OR = 0.840), direct (OR = 0.956), and indirect (OR = 0.879) pathways, respectively. Conclusion Depressive symptoms are indirectly associated with the relationship between postoperative sleep duration and POD, alongside a direct independent association of sleep duration. Concurrent assessment and management of sleep and depressive symptoms are essential for optimizing perioperative care.

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