A new guideline is available to help healthcare providers prevent and treat one of the most common postop complications in older patients: delirium. The Clinical Practice Guideline for Postoperative Delirium in Older Adults was developed by the American College of Surgeons (ACS) and other participants in the Geriatrics-for-Specialists Initiative.

A companion best practice statement to use 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 this year.1

Studies show that when a patient’s age is over 65 years, it greatly raises his or her risk of delirium after an operation.2 Delirium can prolong the patient’s stay and lead to other postoperative complications, including reduced physical or cognitive function. Furthermore, patients age 70 and older commonly have the hypoactive subtype of delirium,3 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 15-50% of older adults after a major operation,”4,5 said Thomas Robinson, MD, MS, FACS, co-chair of the panel that wrote the practice guideline and a professor of surgery at the University of Colorado School of Medicine, Aurora. “Yet it is preventable in up to 40% of cases.”6-7

Potentially preventable risk factors for postoperative delirium include immobilization, lack of orientation to surroundings, disrupted sleep, dehydration, inadequately controlled pain, and infection.2 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.2

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, healthcare professionals should implement multiple nondrug interventions, for example:

  • Orient the patient to the time and their surroundings several times.

  • 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).

Recommendations regarding treatment of postoperative delirium in older adults include:

• Avoid prescribing cholinesterase inhibitors (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 postop delirium in patients who are not agitated and not threatening harm to themselves or others.

The comprehensive guideline and evidence tables are available from the American Geriatrics Society via GeriatricsCareOnline.org.

References

1. The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society, J Amer Coll Surg 2014; doi: 10.1016/j.jamcollsurg.2014.10.019.
2. Chow W, Rosenthal R, Merkow P, et al. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012; 215(4):453-466.
3. Robinson T, Raeburn C, Tran Z. Motor subtypes of postoperative delirium in older adults. Arch Surg 2011; 146(3):295-300.
4. Sieber F, Barnett S. Preventing postoperative complications in the elderly. Anesthesiol Clin 2011; 29(1):83-97.
5. Mercantonio E. Postoperative delirium: A 76-year-old woman with delirium following surgery. JAMA 2012; 308(1):73-81.
6. Inouye SK, Bogardus S, Charpentier P. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340:669-676.
7. Mercantonio E, Flacker J, Wright R, et al. Reducing delirium after hip fracture: A randomized trial. J Am Geriatr Soc 2001; 49(5):516-522.