Postoperative delirium is a common and serious complication that can occur after surgery, particularly in older adults. Characterized by confusion, disorientation, and fluctuating levels of consciousness, delirium can lead to longer hospital stays, increased healthcare costs, and higher mortality rates 1. Fortunately, preventative strategies can significantly reduce the incidence and severity of postoperative delirium. These strategies span preoperative, intraoperative, and postoperative interventions, aiming to create a comprehensive approach to patient care.
Preventative strategies for postoperative delirium in the preoperative period include patient assessment and medication optimization. A thorough preoperative assessment is crucial in identifying patients at high risk for delirium. This assessment includes evaluating medical history, cognitive function, nutritional status, and medication use. Specific cognitive screening tools can help identify baseline cognitive impairment, a significant risk factor for delirium 2. Reviewing and optimizing medications before surgery can mitigate the risk of delirium. Polypharmacy and the use of certain medications, such as benzodiazepines, anticholinergics, and opioids, are associated with an increased risk of delirium. Reducing or substituting these medications with safer alternatives when possible can be beneficial 3,4.
In addition, educating patients and their families about the risk of delirium and its symptoms can facilitate early recognition and prompt intervention. Informed patients and families are more likely to report changes in behavior that may indicate the onset of delirium 5,6.
Intraoperatively, monitoring the depth of anesthesia can help prevent postoperative delirium. Additionally, short-acting anesthetic agents and multimodal analgesia are useful preventative strategies for minimizing the incidence of postoperative delirium 2.
Encouraging early mobilization and physical activity after surgery can significantly reduce the incidence of delirium. Physical activity helps maintain muscle strength, enhances circulation, and promotes overall well-being. Early mobilization protocols should be tailored to the patient’s condition and capabilities 7,8.
Effective pain management is crucial in preventing delirium. Uncontrolled pain can contribute to agitation and confusion, whereas excessive use of opioids can also precipitate delirium. A balanced approach to pain management, utilizing non-opioid analgesics and non-pharmacologic methods such as physical therapy and relaxation techniques, is recommended 9,10.
Providing cognitive stimulation and orientation can also help prevent delirium. Simple interventions, such as ensuring patients have access to clocks, calendars, and familiar objects, can reduce disorientation. Engaging patients in conversation and cognitive activities, such as reading or puzzles, can also be beneficial 11,12.
Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves; data has demonstrated that dexmedetomidine can be implemented as a viable treatment option for postoperative delirium 13.
Overall, multidisciplinary preventative strategies are vital for addressing postoperative delirium. Collaborative care plans that address the specific needs of high-risk patients using multimodal strategies can enhance outcomes and reduce the incidence of delirium 14.
References
1. Postoperative Delirium – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK534831/.
2. Jin, Z., Hu, J. & Ma, D. Postoperative delirium: perioperative assessment, risk reduction, and management. British Journal of Anaesthesia (2020). doi:10.1016/j.bja.2020.06.063
3. Jeong, Y. M. et al. Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment. BMC Geriatr. (2016). doi:10.1186/s12877-016-0311-5
4. Duprey, M. S. et al. Association between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Non-Cardiac Surgery. Anesth. Analg. 134, 1154 (2022). doi: 10.1213/ANE.0000000000005959
5. Wheeler, A. et al. Delirium education for family caregivers of patients in the intensive care unit: A pilot study. PEC Innov. (2023). doi:10.1016/j.pecinn.2023.100156
6. Wong, S. P. et al. Delirium education for geriatric patients and their families: A quality improvement initiative✰. Aging Heal. Res. (2023). doi:10.1016/j.ahr.2023.100123
7. Nydahl, P. et al. Mobilization in the evening to prevent delirium: A pilot randomized trial. Nurs. Crit. Care (2022). doi:10.1111/nicc.12638
8. Anada, S., Iigaya, M., Takahashi, M., Soda, K. & Wada, N. Impact of early mobilization on the duration of delirium in elderly hospitalized patients A retrospective cohort pilot study. Med. (United States) (2022). doi:10.1097/MD.0000000000031641
9. Sampson, E. L., West, E. & Fischer, T. Pain and delirium: mechanisms, assessment, and management. European Geriatric Medicine (2020). doi:10.1007/s41999-019-00281-2
10. Vaurio, L. E., Sands, L. P., Wang, Y., Mullen, E. A. & Leung, J. M. Postoperative delirium: The importance of pain and pain management. Anesth. Analg. (2006). doi:10.1213/01.ane.0000199156.59226.af
11. Tobar, E., Alvarez, E. & Garrido, M. Cognitive stimulation and occupational therapy for delirium prevention. Revista Brasileira de Terapia Intensiva (2017). doi:10.5935/0103-507X.20170034
12. Garrido, M. et al. Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol. BMC Geriatr. (2023). doi:10.1186/s12877-023-04189-2
13. Mossie, A. et al. Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article. International Journal of General Medicine (2022). doi:10.2147/IJGM.S349232
14. Igwe, E. O. et al. Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis. Journal of Clinical Anesthesia (2020). doi:10.1016/j.jclinane.2020.110004
