New guideline now available to help prevent, treat delirium in older patients

A new guideline is available to help health care providers prevent and treat one of the most common postoperative complications in older patients, delirium, which is an episode of sudden confusion. The Clinical Practice Guideline for Postoperative Delirium in Older Adults was developed by the American Geriatrics Society, in collaboration with the American College of Surgeons (ACS) and other organizations participating in the AGS Geriatrics-for-Specialists Initiative whose representatives participated in a multidisciplinary panel of experts.

A companion best practice statement to use in tandem with the guideline appears online as an "article in press" on the Journal of the American College of Surgeons website, in advance of its publication in the Journal early next year.

"The goal of these guidelines is to improve the quality of surgical care for older adults, who, as a group, undergo more than one-third of all inpatient operations in the United States annually," said Thomas Robinson, MD, MS, FACS, co-chair of the panel that wrote the practice guidelines and a professor of surgery at the University of Colorado School of Medicine, Aurora.

Studies show that when a patient's age is over 65 years, it greatly raises his or her risk of delirium after an operation. Delirium is serious because it can prolong the hospital stay and lead to other postoperative complications, including reduced physical or cognitive function. Furthermore, patients 70 and older commonly have the hypoactive subtype of delirium, which is characterized by symptoms such as lethargy, confusion, and inattentiveness, and often goes undiagnosed.

"Postoperative delirium is the most common neurologic surgical complication for older adults, occurring in 15 to 50 percent of older adults after a major operation," Dr. Robinson said. "Yet it is preventable in up to 40 percent of cases."

Potentially preventable risk factors for postoperative delirium include immobilization, lack of orientation to surroundings, disrupted sleep, dehydration, inadequately controlled pain, and infection. Other contributors to delirium are chronic cognitive decline or dementia, vision or hearing impairments, severe illness, poor physical function, and presence of a urinary catheter. In addition, certain major operations carry an increased risk for delirium, including noncardiac chest procedures and aortic aneurysm repair.

Dr. Robinson, with panel co-chair Sharon Inouye, MD, MPH, professor of medicine, Harvard Medical School, and other panel members extensively reviewed the medical literature to develop their evidence-based recommendations. Recommendations to prevent postoperative delirium in older adults include:

• All surgical patients aged 65 and older should receive a preoperative assessment of their risk factors for delirium.
• For surgical patients at risk of postoperative delirium, health care professionals should implement multiple nondrug interventions, for instance:
  • Orient the patient to the time and their surroundings several times a day.
  • Have the patient walk as soon as safely possible after the operation and at least twice a day.
  • Allow the patient to wear his or her eyeglasses and hearing aids if applicable.
  • Ensure that the patient gets adequate fluids and nutrition.
  • Promote good sleep hygiene.
• The patient should receive adequate control of pain, preferably with nonopioid medications, such as acetaminophen.
• Patients should not receive medications known to increase the chance of postoperative delirium (unless the benefits outweigh the risks). (These medications are specified in Table 7 of the published guideline.)

Recommendations regarding treatment of postoperative delirium in older adults include:

• Avoid prescribing cholinesterase inhibitors (drugs used to treat dementia) in patients who have not previously taken these medications.
• Do not use benzodiazepines as first-line treatment of agitation resulting from delirium.
• Avoid prescribing antipsychotics or benzodiazepines for treatment of postoperative delirium in patients who are not agitated and not threatening harm to themselves or others.

"The surgical community needs to be judicious in prescribing antipsychotics to patients with postoperative delirium," Dr. Robinson said. "The medical literature is clear that the harms often outweigh the benefits of these medications."

Furthermore, recognition of delirium symptoms is important. Many people equate delirium with agitation, which is just one type of delirium, Dr. Robinson explained.