What strategies can be used to prevent delirium in a geriatric patient with Alzheimer's disease undergoing hip arthroplasty?

Preventing Delirium in Alzheimer's Patients Undergoing Hip Arthroplasty

All older patients with Alzheimer's disease hospitalized for hip arthroplasty must receive a multicomponent nonpharmacologic intervention delivered by an interdisciplinary team throughout the entire perioperative period to prevent delirium. 1

Critical Context for Alzheimer's Patients

• Patients with pre-existing dementia like Alzheimer's disease represent a particularly high-risk subgroup where the effect of multicomponent interventions remains uncertain, but these interventions remain the only evidence-based approach available. 1

• Elderly patients with Alzheimer's disease are highly vulnerable to both hip fracture and delirium, with severely reduced physiologic reserves requiring integrated orthopedic-geriatric collaboration. 2

• The incidence of postoperative delirium after hip surgery in elderly patients ranges between 4% and 53%, with preoperative cognitive impairment being one of the most common risk factors. 3

Core Multicomponent Nonpharmacologic Interventions (Grade A Evidence)

Cognitive and Environmental Modifications

• Provide regular reorientation using visible clocks, calendars, and familiar objects from home. 1, 4

• Ensure adequate lighting throughout the day and minimize room changes to maintain environmental consistency. 4

• Assign consistent nursing staff and caregivers to reduce confusion and maintain continuity of care. 1, 4

• Engage patients in cognitively stimulating activities at least three times daily, including discussing current events or word games. 1

Sensory Optimization

• Ensure hearing aids and eyeglasses are available, functioning properly, and used consistently throughout hospitalization. 1, 4

• Resolve reversible sensory impairments such as impacted ear wax before surgery when possible. 4

Hydration and Nutrition Management

• Implement aggressive hydration and nutrition protocols, as dehydration is a common precipitating factor and malnutrition a common contributing factor to delirium. 1

• Offer oral nutritional supplements postoperatively to improve dietary intake and reduce complications. 1

• Nutrition and hydration interventions have only shown efficacy when part of multidisciplinary interventions (10 of 19 trials on multidisciplinary interventions included nutrition/hydration components). 1

Sleep Hygiene and Day-Night Cycle Maintenance

• Avoid nursing procedures and medication rounds during sleeping hours whenever possible. 4

• Reduce noise to minimum levels during sleep periods and maintain normal day-night cycles. 1, 4

• Never use benzodiazepines as sleep enhancers, as they are associated with causing delirium. 4

Early Mobilization and Physical Rehabilitation

• Initiate early mobilization and physical therapy as soon as medically safe postoperatively. 1, 4

• Promote walking and range-of-motion exercises with assistance to prevent functional decline. 1

Pain Management

• Optimize postoperative pain control, preferably with nonopioid medications when adequate. 1, 4

• Consider regional anesthesia (such as peripheral nerve blocks or epidural analgesia) at the time of surgery and postoperatively to improve pain control and prevent delirium. 1

• Two studies found that regional anesthesia was beneficial in reducing postoperative delirium incidence in lower extremity orthopedic operations. 1

Oxygenation and Medical Optimization

• Address hypoxia promptly and optimize oxygenation throughout the perioperative period. 1, 4

• Treat infections promptly and manage all metabolic derangements aggressively. 1, 4

• Review and minimize medications with high risk for precipitating delirium, particularly anticholinergics. 4

Anesthesia Considerations

• The anesthesia practitioner may use processed EEG monitors (such as Bispectral Index) during general anesthesia to avoid excessive anesthetic depth, as deeper levels of sedation are associated with increased rates of postoperative delirium. 1

• However, the safety of conducting "light anesthesia" has not been fully demonstrated, and lighter anesthesia may lead to intraoperative recall, movement, or adverse hemodynamic changes. 1

Preoperative Anxiety Management

• Screen for and address preoperative anxiety, as it predicts increased incidence of postoperative delirium (25.3% vs. 14.8% in non-anxious patients). 5

• Preoperative anxiety intervention may be an important point for delirium prophylaxis. 5

Pharmacologic Management: What NOT to Do

• Avoid antipsychotics and benzodiazepines for routine delirium prevention or treatment, particularly for hypoactive delirium. 6, 4

• Consider low-dose antipsychotics ONLY for severely agitated patients with distressing psychotic symptoms, patients threatening substantial harm to themselves or others, or symptoms refractory to nonpharmacologic interventions. 6, 4

• If antipsychotics are necessary, use the lowest effective dose for the shortest possible duration and discontinue immediately following resolution of distressing symptoms. 4

• Medical prophylaxis with medications has been demonstrated to have limited utility. 3

Implementation and Monitoring

• Implement daily interdisciplinary team rounds with physicians, nurses, physical therapists, and other healthcare professionals providing both general and specific recommendations. 1

• Use the Confusion Assessment Method (CAM) to screen for delirium daily, which takes only 2-5 minutes and has the highest psychometric properties for detection. 6, 4

• Look for cardinal features: acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness. 6, 4

• Adherence to the multicomponent protocol is critical for effectiveness, with dose-response evidence showing better outcomes with higher adherence. 1

Common Pitfalls to Avoid

• Do not rely on single-component interventions—nutrition or hydration alone without other components has not been shown to prevent delirium. 1

• Do not delay implementation of nonpharmacologic interventions while waiting for diagnostic workup. 6

• Do not use physical restraints to manage behavioral symptoms, as they may exacerbate delirium. 1

• Avoid overuse of neuroimaging (CT/MRI) unless clinically indicated, as sedation required for agitated patients may worsen delirium. 1

Clinical Significance

• Approximately one-third of delirium cases can be prevented or reversed through multicomponent risk-factor modification. 6, 4

• Delirium is associated with increased mortality, prolonged hospitalization, development of long-term cognitive impairment, and increased healthcare costs. 6, 4, 3

• The multicomponent nonpharmacologic approach is cost-effective and improves health outcomes compared with usual care. 4