From the Guidelines
Management of postoperative delirium (POD) requires a multimodal approach focusing on identifying and treating underlying causes while implementing supportive measures, with nonpharmacological interventions as the foundation of treatment, as recommended by the most recent and highest quality study 1. The approach should include a thorough assessment for reversible contributors such as pain, hypoxia, electrolyte abnormalities, infection, medication effects, and withdrawal states. Key nonpharmacological interventions include:
- Maintaining orientation with clocks, calendars, and familiar objects
- Ensuring adequate sleep by minimizing nighttime disruptions
- Promoting early mobilization
- Providing appropriate sensory aids (glasses, hearing aids)
- Encouraging family presence Pharmacological management should be reserved for severe agitation that poses safety risks, with low-dose antipsychotics such as haloperidol 0.5-1mg orally or intramuscularly (avoiding IV due to QT prolongation risk), or second-generation options like quetiapine 25-50mg, as suggested by 1. Benzodiazepines should generally be avoided except in alcohol withdrawal. Prevention strategies are equally important and include optimizing preoperative conditions, maintaining hemodynamic stability, using appropriate anesthesia protocols, providing adequate pain control, and early postoperative mobilization, as highlighted by 1 and 1. The pathophysiology of POD involves neuroinflammation, neurotransmitter imbalances, and disrupted cerebral metabolism, which explains why a comprehensive approach addressing multiple contributing factors yields better outcomes than single interventions alone. Recent studies, such as 1 and 1, have identified various perioperative factors associated with POD, including age, BMI, education, smoking, history of delirium, and preoperative cognitive impairment, which can inform patients and caregivers about the expected risk of developing delirium after surgery and guide clinicians in considering perioperative preventive strategies.
From the Research
Management Approach for Postoperative Delirium (POD)
The management of POD is a multiprofessional approach that consists of different parts, including detection of high-risk patients, preventive nonpharmacological concepts, and an intraoperative anesthetic management plan 2.
Key Components of Management
- Detection of high-risk patients using a validated tool
- Preventive nonpharmacological concepts
- Intraoperative anesthetic management plan individualized to the older patient
- Treatment and diagnostic concepts, both pharmaceutical and nonpharmacological
Risk Factors for POD
- Higher age
- Preexisting cognitive deficits
- Multimorbidity
- Associated prodelirious polypharmacy 2
- Age, diabetes mellitus, severity of disease, perioperative use of benzodiazepine, and mechanical ventilation 3
- Moderate and severe preoperative resting pain, and increase in level of pain from baseline to postoperative day one 4
Treatment Options
- Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, compared with placebo 5
- Atypical antipsychotics such as risperidone, olanzapine, or quetiapine may be used as an alternative to haloperidol, with a lower incidence of extrapyramidal adverse effects 5
- Avoiding too deep anesthesia, avoiding additional psychoactive substances, and effective pain management are essential 6