How can postoperative delirium be prevented and managed in at-risk patients?

Prevention and Management of Postoperative Delirium in At-Risk Patients

Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team throughout hospitalization are the most effective strategy for preventing postoperative delirium in at-risk older adults. 1, 2

Risk Identification

• Key risk factors:
  • Advanced age
  • Pre-existing cognitive impairment/dementia
  • Multiple comorbidities
  • Polypharmacy
  • Sensory impairment
  • Complex or emergency procedures
  • History of alcohol abuse

Prevention Strategies

Nonpharmacologic Interventions (First-Line)

1. Orientation protocols:

   • Frequent reorientation to time, place, and person
   • Visible clocks and calendars
   • Familiar objects from home
   • Clear communication

2. Sensory optimization:

   • Return cognitive aids (glasses, hearing aids) immediately after surgery
   • Ensure adequate lighting during daytime
   • Reduce noise
   • Adapt for visual/hearing impairments

3. Sleep enhancement:

   • Implement nonpharmacologic sleep protocols
   • Provide dark, quiet rooms at night
   • Schedule care activities to minimize sleep disruption

4. Early mobility:

   • Encourage early and frequent mobilization
   • Implement physical rehabilitation when appropriate

5. Nutrition and hydration:

   • Ensure adequate intake
   • Provide assistance with meals if needed
   • Consider supplements for malnourished patients

6. Pain management:

   • Optimize pain control using minimally sedating multimodal approaches
   • Titrate opioids to minimal effective dose
   • Consider non-opioid alternatives when possible

Medication Management

1. Avoid high-risk medications: 1, 2

   • Benzodiazepines
   • Anticholinergics (e.g., diphenhydramine, tricyclic antidepressants)
   • Meperidine
   • Sedative-hypnotics
   • H2-receptor antagonists (e.g., cimetidine)
   • Medications with high anticholinergic properties

2. Anesthesia considerations: 3

   • Monitor depth of anesthesia to avoid excessive sedation
   • Consider dexmedetomidine for sedation (RR=0.39; 95% CI=0.16-0.95)
   • Use multimodal analgesia

Management of Established Delirium

Nonpharmacologic Approaches (First-Line)

• Identify and treat underlying causes (pain, infection, electrolyte disturbances)
• Continue all preventive nonpharmacologic interventions
• Ensure patient safety (fall prevention, supervision)
• Avoid physical restraints

Pharmacologic Management (Second-Line)

• Reserve for severe agitation or distressing perceptual disturbances: 1, 2

  • Use lowest effective dose for shortest duration
  • Start with 25-50% of standard adult doses in elderly
  • Monitor closely for adverse effects

• Medication options:

  • Haloperidol: 0.25-0.5 mg PO/SC
  • Quetiapine: 25 mg PO (lower risk of extrapyramidal symptoms)
  • Olanzapine: 2.5 mg PO/SC

• Avoid benzodiazepines except in alcohol/benzodiazepine withdrawal delirium 1, 2

Monitoring and Assessment

• Screen at-risk patients using validated tools:
  • Confusion Assessment Method (CAM)
  • 4 'A's Test (4AT)
• Continue screening twice daily until day 5 or discharge
• Monitor for medication side effects

Implementation Strategies

• Daily interdisciplinary rounds with specific recommendations
• Staff education on delirium prevention, recognition, and management
• Use checklists to promote adherence to interventions
• Involve family members in reorientation and care
• Minimize unnecessary transfers between hospital units

Common Pitfalls to Avoid

1. Failure to identify hypoactive delirium - often misattributed to dementia or overlooked entirely 1
2. Inappropriate use of antipsychotics - should not be used prophylactically or for non-agitated delirium 1
3. Continuing medications after delirium resolution - 47% of patients continued antipsychotics after ICU discharge without clear indications 1, 2
4. Relying solely on pharmacologic interventions - multicomponent nonpharmacologic approaches are more effective 1, 2
5. Inadequate pain management - undertreated pain can precipitate delirium 1
6. Excessive sedation - monitor depth of anesthesia to avoid oversedation 3, 4

By implementing these evidence-based strategies, healthcare providers can significantly reduce the incidence, severity, and duration of postoperative delirium, ultimately improving patient outcomes and reducing hospital length of stay.