By Chiara Ghetti, MD, Associate Professor of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
Source: The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Coll Surg 2014 Nov 14; doi: 10.1016/j.jamcollsurg.2014.10.019.
As an urogynecologist, I have become increasingly interested in the unique needs of the elderly woman. The elderly operative patient has very different and specific needs compared to a younger woman. In addition to a higher risk of medical comorbidities, elderly women are affected by cognitive impairment, depression, gait, and balance disturbances. As discussed in a prior OB/GYN Clinical Alert, the prevalence of incontinence increases with age. Prolapse is the most common indication for gynecological surgery for women older than 50 years in the United States.1 Previous studies have shown that approximately 40% of women undergoing prolapse surgery are 60 years of age or older.2 The U.S. Department of Health and Human Services reports that the number of Americans aged 65 or older increased by 3.4 million, or 10%, from 1996 to 2006, with current estimates placing 1 in 8 Americans in this age category.3 This older cohort of women is expected to continue to increase in number, with estimates suggesting that by 2030 in the United States 1 in 5 adults will be 65 years of age or older.3 As the U.S. population ages, the proportion of elderly female patients undergoing gynecologic surgery will increase. This shifting demographic lends increasing importance of the effects of surgery on the elderly patient.
Delirium is a common complication of the older patient undergoing surgery and is the most common surgical complication affecting older adults. Delirium diagnosis and treatment is an essential component of optimal surgical care of the older adult, but teaching regarding delirium may be underemphasized in surgical training.4 The American Geriatrics Society, in collaboration with an interdisciplinary, multi-specialty panel from the American Geriatrics Society’s Geriatrics-for-Specialists Initiative, recently published a best practice statement regarding postoperative delirium in older adults to provide evidence-based recommendations to aid practitioners in the care of older women.
Delirium is a sudden change in cognitive function and is a form of brain dysfunction, in essence it represents acute brain failure. Delirium can precipitate a series of major postoperative complications, prolonged hospitalization, loss of functional independence, reduced cognitive function, and death.5,6 The annual cost of delirium in the United States is estimated to be $150 billion.7 However, delirium is preventable in up to 40% of patients,8,9 and its prevention can significantly improve the perioperative outcomes of older adults. These guidelines were developed to aid clinical decision-making for provider caring for elderly patients in the operative setting; however, the authors emphasize they are not intended to replace clinical judgment or individual patient choices or values. The original wording of recommendations of the Best Practice Statement regarding Postoperative Delirium in Older Adults are presented below in italics.
I. POSTOPERATIVE DELIRIUM RISK FACTORS
- Health care professionals caring for surgical patients should perform a preoperative assessment of delirium risk factors, including age > 65 years, chronic cognitive decline or dementia, poor vision or hearing, severe illness, and presence of infection.
II. DELIRIUM DIAGNOSIS
- Health care professionals caring for postsurgical patients should be trained in the recognition and documentation of signs and symptoms associated with delirium, including hypoactive presentations.
- Health care professionals should assess and clearly document preoperative cognitive function in older adults at risk of postoperative delirium.
- Health care professionals competent in diagnosing delirium should perform a full clinical assessment in any patient suspected of having symptoms of delirium, found positive on a delirium screening test, or having an acute cognitive change on repeated cognitive testing.
The diagnosis of delirium is made primarily from history and physical examination and informed by witness reports, medical records, laboratory, and radiologic findings. While screening tools are recommended (see III below), the hallmark symptoms of delirium are changes in level of arousal, consciousness, and cognition that occur over a short time, over hours or days. In more detail, symptoms can comprise: 1) a change in level of arousal (this can include drowsiness or decreased arousal or increased arousal with hyper vigilance); 2) an abrupt change in cognitive function, including problems with attention, difficulty concentrating, new memory problems, new disorientation, or difficulty tracking conversations and following instructions; 3) thinking and speech that is more disorganized, difficult to follow, slow, or rapid; 4) quick-changing emotions, easy irritability, tearfulness; and 5) fluctuating symptoms and/or level of arousal. Additionally, delirium can be characterized by: 1) delayed awakening from anesthesia; 2) uncharacteristic refusals to engage with postoperative care; 3) expression of new paranoid thoughts or delusions (i.e., fixed false beliefs); 4) new perceptual disturbances (e.g., illusions, hallucinations); 5) motor changes such as slowed or decreased movements; 6) purposeless fidgeting or restlessness; 7) new difficulties in maintaining posture such as sitting or standing; 8) changes in sleep/wake cycle;
9) decreased appetite; and/or 10) new incontinence of
urine or stool.
III. DELIRIUM SCREENING
- When screening a patient for delirium, a health care professional trained in the assessment of delirium should use a validated delirium screening instrument for optimal delirium detection.
- The health care team may consider instituting daily postoperative screening of older patients for the development of delirium in order to initiate delirium treatment as early as possible.
Studies have demonstrated that providers do not accurately diagnose delirium based on a bedside evaluation alone. A variety of screening measures exist that are specific to different patient populations. The use of screening measures may allow for earlier delirium diagnosis and activation of applicable treatment. One such screening tool, Confusion Assessment Method (CAM), is used by many as a screening (short form) and diagnostic instrument (long form). An extensive list of other measures is listed in Appendix 2D of the source manuscript.
IV. INTRAOPERATIVE MEASURES TO PREVENT DELIRIUM
- The anesthesia practitioner may use processed electroencephalographic monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium.
There are few studies pertaining to electroencephalographic monitoring of adequate quality. The premise of this recommendation is that lighter anesthesia will reduce the risk of postoperative delirium. Several trials have shown lower rates of delirium with use of lighter anesthesia. Light anesthesia, however, is not without risk.
V. MEDICATIONS AS RISK FACTORS FOR POSTOPERATIVE DELIRIUM
- Prescribing health care providers should avoid medications that induce delirium postoperatively in older adults to prevent delirium.
Medications that contribute to the increased risk of postoperative delirium in older adult include: 1) anticholinergic medications, 2) sedative-hypnotics, and 3) meperidine. Diphenhydramine, meperidine and benzodiazepines increase the odds ratio of developing delirium of 2.3, 2.7, and 3.0, respectively.10 These medications should be avoided. In addition, the use of multiple medications (five or greater) has been associated with an increased risk of delirium.11
VI. PHARMACOLOGIC PREVENTION OF POSTOPERATIVE DELIRIUM
- A health care professional trained in regional anesthetic injection may consider providing regional anesthetic at the time of surgery and postoperatively to improve pain control and prevent delirium in older adults.
- Health care professionals should optimize postoperative pain control, preferably with nonopioid pain medications, to minimize pain in older adults to prevent delirium.
- There is insufficient evidence to recommend for or against the use of antipsychotic medications prophylactically in older surgical patients to prevent delirium.
- In older adults not currently taking cholinesterase inhibitors, the prescribing practitioner should not newly prescribe cholinesterase inhibitors perioperatively to older adults to prevent or treat delirium.
The use of regional anesthesia has been found to reduce delirium in two studies.12,13 Insufficient analgesia postoperatively contributes to delirium, hence maximizing postoperative pain control is important to decrease the occurrence of delirium.14 There is some evidence suggesting that using non-opioid alternatives to manage pain can minimize delirium compared to opioid-only pain regimens.15,16 Evidence regarding prescribing antipsychotic medications to prevent delirium in postoperative patients is limited and inconsistent, and the prophylactic administration of cholinesterase inhibitors has not been shown to be effective in reducing postoperative delirium and may cause increased harm (including death).
VII. NONPHARMACOLOGIC PREVENTION AND TREATMENT OF POSTOPERATIVE DELIRIUM
- Health care systems and hospitals should implement formal educational programs with ongoing (at least quarterly) formal and/or informal refresher sessions for health care professionals on delirium in at-risk older surgical adults to improve understanding of the epidemiology, assessment, prevention, and treatment of delirium.
- Health care systems and hospitals should implement multicomponent nonpharmacologic intervention programs delivered by an interdisciplinary team for the entire hospitalization in at-risk older adults undergoing surgery to prevent delirium.
- Health care professionals should consider multicomponent interventions implemented by an interdisciplinary team in older adults diagnosed with postoperative delirium to improve clinical outcomes.
- There is insufficient evidence to recommend for or against hospitals creating, and health care professionals using, specialized hospital units for the inpatient care of older adults with postoperative delirium to improve clinical outcomes.
At least 10 moderate- to high-quality studies have documented the effectiveness of non-pharmacologic prevention in reducing the incidence of delirium.
VIII. MEDICAL EVALUATION OF POSTOPERATIVE DELIRIUM
- The health care professional should perform a medical evaluation, make medication and/or environmental adjustments, and order appropriate diagnostic tests and clinical consultations after an older adult has been diagnosed with postoperative delirium to identify and manage underlying contributors to delirium.
It is critically important for the surgeon to identify and treat the underlying causes of a patient’s delirium. Additionally, including a geriatric or medical consultant in the peri-operative care of an elderly patient may be helpful.
IX. PHARMACOLOGIC TREATMENT OF POSTOPERATIVE DELIRIUM
- The prescribing practitioner may use antipsychotics at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated or distressed, and are threatening substantial harm to self and/or others. In all cases, treatment with antipsychotics should be employed only if behavioral interventions have failed or are not possible, and ongoing use should be evaluated daily with in-person examination of patients.
- The prescribing practitioner should not prescribe antipsychotic or benzodiazepine medications for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others.
- The prescribing practitioner should not use benzodiazepines as a first-line treatment of the agitated postoperative delirious patient who is threatening substantial harm to self and/or others to treat postoperative delirium, except when benzodiazepines are specifically indicated (including but not limited to treatment of alcohol or benzodiazepine withdrawal). Treatment with benzodiazepines should be at the lowest effective dose for the shortest possible duration, and should be employed only if behavioral measures have failed or are not possible and ongoing use should be evaluated daily with in-person examination of the patient.
Evidence supporting the benefits of pharmacologic therapy in the treatment of postoperative delirium is inconsistent. There is no evidence of benefit from treatment of antipsychotics in patients without agitation; hence, the use of antipsychotics should be reserved for short-term management of acute agitation in cases in which the patient’s safety or the safety of others is at risk.
Delirium confers significant morbidity to postoperative elderly patients. These recommendations are intended to provide a framework to address delirium in perioperative patients. While a comprehensive approach to the prevention and treatment of delirium will require direct involvement of both individual providers and entire hospital and health care systems, an increased understanding of delirium, its risk factors, symptoms, appropriate screening and diagnosis, as well as the non-pharmacologic and pharmacologic interventions to prevent and treat delirium, will allow us to more accurately and successfully diagnose and manage postoperative delirium.
- Administration on Aging. Available at: http://www.aoa.gov/agingstatsdotnet/Main_Site/Data/2010_Documents/About.aspx.
- World Health Organization; 2012. Available at: www.who.int/healthinfo/survey/ageingdefnolder/en/index.html.
- U.S. Department of Commerce, U.S. Census Bureau; 2012. http://www. census.gov/prod/cen2010/briefs/c2010br-03.pdf
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