Contents

Search

postoperative delirium

Etiology: - myocardial infarction [2] - electrolyte imbalance - untreated pain - urinary tract infection [2] - postoperative pneumonia - risk factors [2] - preoperative cognitive dysfunction is the major risk factor [1,2] - preoperative plasma tau-p217 & plasma tau-p181 are associated with postoperative delirium, with plasma tau-p217 the stronger indicator [21] - history of stroke or transient ischemic attack (TIA) - depression (Geriatric Depression Scale score > 4) - low serum albumin - age >= 70 years [11] - frailty [26] - alcoholism - tobacco use [14] - functional impairment - dehydration - abnormal serum glucose - dementia & intensive care unit admission [9] - visual impairment - severe illness - intrathoracic surgery - aortic aneurysm surgery [2] - duration of surgery [14] - lymph node involvement in head & neck cancer surgery [14] - intraoperative hypotension may play a role [6] - perioperative gabapentin increases risk of delirium (RR=1.3)& new antipsychotic use (RR=1.2) in elderly patients after major surgery [22] - postoperative opiates for pain control do not seem to play a precipitating role [9] - hypertension & anemia* do not seem to play a role [2] - consider drug withdrawal syndrome - alcohol withdrawal - benzodiazepine withdrawal - opiate withdrawal * anemia would seem to be a risk factor in other sources * BUN/creatinine ratio does not predict postoperative delirium in elderly [2] Complications: - longer hospitalization, more days with mechanical ventilation, functional decline - prolonged cognitive impairment after postoperative delirium [1] - postoperative improvements in patients with preoperative cognitive impairment attenuated by postoperative delirium [15] - progressive cognitive decline, dementia, & death [18] - accelerated cognitive decline that continues for at least 72 months [24] Management: - see delirium - preoperative cognitive assessment is the best predictor of risk for postoperative delirium - preoperative cognitive exercises may diminish risk of postoperative delirium [17,18] - medical consultation by orthopedic surgeons with internists/geriatricians reduces 1 year mortality (RR=0.69) [3] - preoperative geriatric assessment reduces postoperative delirium [2] - keep hematocrit >= 30% - adequate hydration & pain control [23] - prevention of postoperative delirium in the elderly - family involvement is effective in preventing postoperative delirium in older adults [16] - personalized stimulation, company, & relaxation reduces postoperative delirium after non-cardiac surgery [19]; no benefit after cardiac surgery - rivastigmine is not useful [4] - statins are not useful [13] - avoid gabapentin [22] - use of atypical antipsychotic no less likely than haloperidol to result in death or non-fatal adverse in-hospital events [25] - perioperative haloperidol - 0.5 mg PO TID from up to 72 hours preoperatively until postoperative day 3 - does not alter the incidence of postoperative delirium (15.1%) vs placebo (16.5%) [5,7] - does reduce delirium severity ratings, delirium duration (mean: 11.8 to 5.4 days), & length of hospital stay (mean: 22.6 to 17.1 days) [5] - may reduce incidence of delirium in postoperative patients admitted to ICU [27] - electroencephalogram (EEG)-guided anesthetic depth controversial [18] - early postoperative ambulation has not been shown to reduce postoperative delirium [2]

Interactions

disease interactions

Related

postoperative cognitive impairment

General

postoperative complication delirium (acute confusional state)

References

  1. Saczynski JS et al Cognitive Trajectories after Postoperative Delirium N Engl J Med 2012; 367:30-39 PMID: 22762316 http://www.nejm.org/doi/full/10.1056/NEJMoa1112923
  2. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Adams AL, Schiff MA, Koepsell TD et al Physician consultation, multidisciplinary care, and 1-year mortality in Medicare recipients hospitalized with hip and lower extremity injuries. J Am Geriatr Soc. 2010 Oct;58(10):1835-42. PMID: 20929461
  4. Gamberini M, Bolliger D, Lurati Buse GA et al Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery--a randomized controlled trial. Crit Care Med. 2009 May;37(5):1762-8. PMID: 19325490
  5. Schrader SL, Wellik KE, Demaerschalk BM et al Adjunctive haloperidol prophylaxis reduces postoperative delirium severity and duration in at-risk elderly patients. Neurologist. 2008 Mar;14(2):134-7 PMID: 18332845
  6. Tognoni P, Simonato A, Robutti N Preoperative risk factors for postoperative delirium (POD) after urological surgery in the elderly. Arch Gerontol Geriatr. 2011 May-Jun;52(3):e166-9 PMID: 21084123
  7. Vochteloo AJ, Moerman S, van der Burg BL et al Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium. BMC Geriatr. 2011 Aug 11;11:39. doi: 10.1186/1471-2318-11-39. PMID: 21834991
  8. Lee HB, Mears SC, Rosenberg PB et al Predisposing factors for postoperative delirium after hip fracture repair in individuals with and without dementia. J Am Geriatr Soc. 2011 Dec;59(12):2306-13. PMID: 22188077
  9. Sieber FE, Mears S, Lee H, Gottschalk A. Postoperative opioid consumption and its relationship to cognitive function in older adults with hip fracture. J Am Geriatr Soc. 2011 Dec;59(12):2256-62. PMID: 22092232
  10. Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc. 2006 Oct;54(10):1578-89. Review. PMID: 17038078
  11. Kalisvaart KJ, Vreeswijk R, de Jonghe JF et al Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model. J Am Geriatr Soc. 2006 May;54(5):817-22. PMID: 16696749
  12. Rudolph JL, Jones RN, Levkoff SE et al Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009 Jan 20;119(2):229-36. PMID: 19118253
  13. Mariscalco G, Cottini M, Zanobini M et al Preoperative statin therapy is not associated with a decrease in the incidence of delirium after cardiac operations. Ann Thorac Surg. 2012 May;93(5):1439-47. PMID: 22541176
  14. Densky J, Eskander A, Kang S et al Risk Factors Associated With Postoperative Delirium in Patients Undergoing Head and Neck Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg. Published online January 3, 2019. PMID: 30605208 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2718937
  15. Austin CA, O'Gorman T, Stern E et al Association Between Postoperative Delirium and Long-term Cognitive Function After Major Nonemergent Surgery. JAMA Surg. 2019 Jan 16. PMID: 30649138 https://jamanetwork.com/journals/jamasurgery/fullarticle/2720416 - Chandrasekhar R, Ely EW, Patel MB. Challenges With Postoperative Cognitive Impairment Research. JAMA Surg. 2019 Jan 16. PMID: 30649134 https://jamanetwork.com/journals/jamasurgery/fullarticle/2720412
  16. Wang YY, Yue JR, Xie DM et al. Effect of the tailored, family-involved hospital elder life program on postoperative delirium and function in older adults: A randomized clinical trial. JAMA Intern Med 2019 Jan; 180:17. PMID: 31633738 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2753259 - Tang V, Finlayson E, Covinsky K et al. Including the family in the perioperative care of older adults - a call for help. JAMA Intern Med 2019 Jan; 180:25 PMID: 31633747 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2753256
  17. Humeidan ML,Reyes JPC, Martinez AM et al Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery. The Neurobics Randomized Clinical Trial. JAMA Surg. Published online November 11, 2020 PMID: 33175114 PMCID: PMC7658803 https://jamanetwork.com/journals/jamasurgery/fullarticle/2772853
  18. Vacas S, Cole DJ, Cannesson M Cognitive Decline Associated With Anesthesia and Surgery in Older Patients. JAMA. Published online August 2, 2021 PMID: 34338712 https://jamanetwork.com/journals/jama/fullarticle/2782851
  19. Deeken F, Sanchez A, Rapp MA et al Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery. A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg. 2022;157(2):e216370. PMID: 34910080 PMCID: PMC8674802 Free PMC article https://jamanetwork.com/journals/jamasurgery/fullarticle/2787212
  20. Iamaroon A, Wongviriyawong T, Sura-Arunsumrit P et al. Incidence of and risk factors for postoperative delirium in older adult patients undergoing noncardiac surgery: a prospective study. BMC Geriatr. 2020;20(1):40 PMID: 32013872 PMCID: PMC6998823 Free PMC article https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-1449-8
  21. Liang F, Baldyga K, Quan Q et al Preoperative Plasma Tau-PT217 and Tau-PT181 Are Associated With Postoperative Delirium Annals of Surgery. 2022 July 6 PMID: 35794069 https://journals.lww.com/annalsofsurgery/Abstract/9900/Preoperative_Plasma_Tau_PT217_and_Tau_PT181_Are.70.aspx
  22. George J Gabapentin After Surgery Ups Risks in Older Adults. Delirium, new antipsychotic use, and pneumonia more common. MedPage Today September 20, 2022 https://www.medpagetoday.com/neurology/painmanagement/100827 - Park CM, Inouye SK, Marcantonio ER et al Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med. Published online September 19, 2022. PMID: 36121671 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796501
  23. Zang H, Lu Y, Liu M et al Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized studies. Crit Care. 2013 Mar 18;17(2):R47. PMID: 23506796 PMCID: PMC3672487 Free PMC article. Review.
  24. Kunicki ZJ, Ngo LH, Marcantonio ER et al Six-Year Cognitive Trajectory in Older Adults Following Major Surgery and Delirium. JAMA Intern Med. Published online March 20, 2023. PMID: 36939716 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2802538
  25. Kim DH et al. Comparative safety analysis of oral antipsychotics for in-hospital adverse clinical events in older adults after major surgery: A nationwide cohort study. Ann Intern Med 2023 Sep 5; PMID: 37665998 https://www.acpjournals.org/doi/10.7326/M22-3021
  26. Deiner SG, Marcantonio ER, Trivedi S Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity. J Am Geriatr Soc. 2024 Jun;72(6):1781-1792. PMID: 37964474 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18677
  27. Lin P, Zhang J, Shi F, Liang ZA. Can haloperidol prophylaxis reduce the incidence of delirium in critically ill patients in intensive care units? A systematic review and meta-analysis. Heart Lung. 2020 May-Jun;49(3):265-272. PMID: 32033776