What are the recommendations for managing acute delirium in elderly patients after anesthesia?

Management of Acute Delirium in Elderly Patients After Anesthesia

Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team should be the first-line approach for managing postoperative delirium in elderly patients, while avoiding medications that can worsen delirium such as benzodiazepines and anticholinergics. 1

Prevention and Initial Management

• A thorough medical evaluation must be performed to identify and manage underlying contributors to delirium as the first step in management 1
• Optimize pain control preferably using nonopioid medications to minimize delirium risk while ensuring adequate analgesia 1
• Regional anesthesia techniques may be considered both during surgery and postoperatively to improve pain control and reduce delirium incidence 1, 2
• Avoid medications with high risk for precipitating delirium, including benzodiazepines, anticholinergics (e.g., diphenhydramine, hydroxyzine), meperidine, and sedative-hypnotics 1

Nonpharmacologic Interventions

• Implement multicomponent interventions including:
  • Frequent reorientation to time, place, and person 1
  • Early mobilization to prevent complications of bed rest 1
  • Ensuring adequate hydration and nutrition 1
  • Promoting normal sleep-wake cycles by reducing nighttime disruptions 1
  • Ensuring sensory aids (glasses, hearing aids) are available and functional 1

Pharmacologic Management

• Cholinesterase inhibitors should NOT be newly prescribed to prevent or treat postoperative delirium 1
• Benzodiazepines should NOT be used as first-line treatment for agitation associated with delirium 1
• Both antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium 1
• For severely agitated patients who pose a risk to themselves or others, antipsychotics may be considered at the lowest effective dose for the shortest possible duration 1

Anesthesia Considerations

• Combined epidural-general anesthesia may reduce the incidence of postoperative delirium compared to general anesthesia alone (1.8% vs 5.0%) 2
• Processed EEG monitors of anesthetic depth may be used during intravenous sedation or general anesthesia, though evidence is insufficient to make a strong recommendation 1
• Propofol-based total intravenous anesthesia (TIVA) may reduce postoperative cognitive dysfunction compared to inhalational maintenance agents, though evidence is limited 3
• Volatile anesthetics may increase delirium risk in elderly patients, particularly those aged 75 and older 4

Special Considerations

• Deeper levels of sedation appear to be associated with increased rates of postoperative delirium 1
• The type of anesthesia (general vs. regional) alone may not significantly affect delirium incidence, but combined approaches may be beneficial 5, 2
• Elderly patients are particularly vulnerable to cognitive effects of anesthesia, requiring special attention to depth and type of anesthesia 6, 4

Monitoring and Follow-up

• Regular assessment for delirium using validated tools (e.g., Confusion Assessment Method) should be performed in the postoperative period 1
• Ongoing educational programs regarding delirium should be provided for healthcare professionals to improve recognition and management 1
• Continued monitoring is essential as postoperative delirium typically occurs between 24 and 72 hours after surgery 3