Lionel Lim, MD, MPH, FACP, FACPM
Postoperative delirium is an under-diagnosed yet common
geriatric syndrome that manifests as an acute confusional state, typically
within 48 to 72 hours after surgery.
Occurrence of postoperative delirium is variable (15-25% in elective
surgery) and its incidence is highest in hip and coronary artery bypass surgeries
(>50%).1 Delirium in elderly patients is associated
with increased mortality, hospital length of stay, institutionalization, and
dementia.2, 3 Furthermore, functional and cognitive
impairment from delirium may persist for months after discharge from hospital.1 Risk factors for delirium are older age, neurocognitive
impairment, multiple comorbidities, functional and sensory impairments, male
gender and alcoholism.1 Patients should be screened for risk factors
or cognitive impairment at baseline so that appropriate delirium-preventing
interventions can be implemented.
It is also important to educate the patient and family
regarding the etiology, treatment and prognosis of delirium. Informing family that delirium is not
permanent and may take weeks to months to eventually resolve may help to reduce
anxiety or frustration. Having the
support and continued presence of family members or caregivers can also help
patients during their recovery by providing frequent orientation, reassurance,
and avoiding the need to institute unfamiliar “sitters” or physical restraint
use during episodes of confusion. Providers
should pay close attention for delirium occurrence in previously affected or
high-risk patients by using a validated screening tool like the Confusion
Assessment Method (CAM).4 Appropriate steps should be taken to avoid the
precipitants mentioned above and to correct and treat any underlying infective
or metabolic derangements.
Patients at high risk of post-operative delirium should be
followed closely by an interdisciplinary team that is knowledgeable in the
prevention, detection and management of delirium. This team should include a geriatrician or
internist working in a setting with established protocols in place to reduce
the risk of postoperative delirium.5 These protocols would include adequate
postoperative pain management, early mobilization, close monitoring of fluid
status to avoid dehydration, adequate cognitive stimulation to maintain
orientation, maintenance of diurnal rhythm through nonpharmacologic sleep
protocols, bowel regimens to avoid constipation, minimizing the use of bladder
or vascular catheters, and avoiding deliriogenic medications (benzodiazepines
or sedatives and highly anticholinergic medications, e.g. diphenhydramine). Implementation of the Hospital Elder Life
Program (HELP) which targets some of the above risk factors and includes a
nonpharmacologic sleep protocol in hospitalized older adults has been shown to
reduce the risk of delirium by over a third.6 Although haloperidol for postoperative
delirium prophylaxis may be a promising agent for use in high risk patients, larger
trials are needed before their routine use can be justified in higher-risk patients.7-9
References
1. Marcantonio ER. In the clinic.
Delirium. Ann Intern Med. Jun 7
2011;154(11):ITC6-1 to 6-16.
2. Inouye
SK. Delirium in older persons. N Engl J
Med. Mar 16 2006;354(11):1157-1165.
3. Witlox
J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA.
Delirium in elderly patients and the risk of postdischarge mortality,
institutionalization, and dementia: a meta-analysis. Jama. Jul 28 2010;304(4):443-451.
4. Inouye
SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying
confusion: the confusion assessment method. A new method for detection of
delirium. Ann Intern Med. Dec 15
1990;113(12):941-948.
5. Marcantonio
ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a
randomized trial. J Am Geriatr Soc. May
2001;49(5):516-522.
6. Inouye
SK, Bogardus ST, Jr., Charpentier PA, et al. A multicomponent intervention to
prevent delirium in hospitalized older patients. N Engl J Med. Mar 4 1999;340(9):669-676.
7. Girard
TD, Pandharipande PP, Carson SS, et al. Feasibility, efficacy, and safety of
antipsychotics for intensive care unit delirium: the MIND randomized,
placebo-controlled trial. Crit Care Med. Feb
2010;38(2):428-437.
8. Kalisvaart
KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly
hip-surgery patients at risk for delirium: a randomized placebo-controlled
study. J Am Geriatr Soc. Oct
2005;53(10):1658-1666.
9. Wang
W, Li HL, Wang DX, et al. Haloperidol prophylaxis decreases delirium incidence
in elderly patients after noncardiac surgery: a randomized controlled trial*. Crit Care Med. Mar 2012;40(3):731-739.