What is the management and treatment of emergence delirium in elderly patients with a history of cognitive impairment after general anesthesia?

Management and Treatment of Emergence Delirium in Elderly Patients with Cognitive Impairment After General Anesthesia

Prioritize non-pharmacological interventions as first-line treatment for emergence delirium in elderly patients with cognitive impairment, reserving low-dose antipsychotics only for severe agitation when non-pharmacological measures fail and the patient poses a safety risk. 1, 2

Immediate Recognition and Assessment

Distinguish emergence delirium from postoperative delirium, though a lucid interval between them is not required for diagnosis but should be documented when present. 1 Emergence delirium occurs during or immediately after emergence from anesthesia, while postoperative delirium can occur up to 1 week post-procedure. 1, 3

• Screen systematically using validated tools such as the Confusion Assessment Method (CAM) or Richmond Agitation-Sedation Scale (RASS) at PACU admission and at regular intervals (30 minutes, 1 hour, and discharge). 2, 4
• Recognize hypoactive presentations, which occur in 56% at PACU admission and 92% during PACU stay—these are frequently missed but equally concerning. 5, 4
• Monitor continuously as delirium signs persist to PACU discharge in approximately 4% of patients, requiring structured monitoring to identify those at risk for worse outcomes. 4

Non-Pharmacological Interventions (First-Line)

Implement multicomponent non-pharmacological strategies immediately, as these can reduce delirium incidence by up to 40%. 1

Environmental and Orientation Measures

• Provide regular reorientation with frequent verbal reminders of location, time, and situation. 1, 5, 2
• Ensure sensory aids are available: hearing aids and glasses must be in place if the patient normally uses them. 5
• Encourage family presence during the perioperative period for familiar faces and reassurance. 5
• Optimize the environment by minimizing noise, maintaining appropriate lighting, and reducing unnecessary stimulation. 2

Sleep Hygiene and Mobilization

• Maintain proper sleep hygiene by minimizing sleep disruptions, avoiding nighttime procedures when possible, and clustering care activities. 1, 5, 2
• Initiate early mobilization as soon as medically safe to prevent functional decline. 2

Pain Management Strategy

Inadequate pain control is a significant trigger for delirium, so aggressive multimodal analgesia is essential. 6, 5, 3

• Use acetaminophen as first-line therapy for pain management. 5
• Implement multimodal opioid-sparing analgesia including tramadol, dexmedetomidine, and pregabalin or gabapentin. 2
• Minimize opioid exposure as perioperative opioids are independently associated with delirium during PACU stay (P=0.02). 4, 3
• Avoid medications with anticholinergic properties including diphenhydramine and hydroxyzine, as anticholinergic premedications increase risk 8.5-fold. 5, 3

Medication Management

Avoid delirium-precipitating medications as careful drug selection is critical in this vulnerable population. 6, 2

Medications to Avoid

• Never use benzodiazepines as they significantly increase delirium risk in elderly patients. 5, 2, 7
• Avoid anticholinergic medications for sedation or nausea management. 5, 3
• Minimize inhalational anesthetics when possible, as they are identified as intraoperative risk factors for emergence delirium. 7

When Pharmacological Treatment is Necessary

• Use low-dose oral antipsychotics cautiously only when non-pharmacological interventions have been exhausted and severe agitation poses safety risks. 2, 8
• Treat the underlying cause rather than just symptoms—address pain, hypoxia, metabolic derangements, urinary retention, or other precipitants. 2

Risk Factor Modification

Address modifiable risk factors proactively in patients with pre-existing cognitive impairment, who have 3.99 times the odds of developing postoperative delirium. 2

• Optimize preoperative hemoglobin levels, as low hemoglobin (AOR: 2.0) is independently associated with emergence delirium. 3
• Remove indwelling catheters (urinary, nasogastric) as soon as medically appropriate, as these are postoperative risk factors. 7
• Avoid tracheal tubes in PACU when possible, as their presence increases delirium risk. 7

Monitoring and Follow-Up

Continue structured delirium screening beyond PACU discharge, as patients over 65 years should receive regular postoperative delirium screening with strong recommendation grade. 1

• Screen at least once per nursing shift using validated tools throughout the hospital stay. 2
• Document cognitive trajectory as delirium is associated with lasting cognitive consequences, with some studies showing changes persisting up to 7.5 years after surgery. 6, 2
• Plan for higher level of care if needed, as failure to detect deterioration and facilitate rapid intervention is associated with worse outcomes. 1

Critical Pitfalls to Avoid

• Do not underestimate delirium risk in elderly patients with cognitive impairment, even after seemingly minor procedures. 5
• Do not assume hyperactive presentation—hypoactive delirium is the predominant subtype during PACU stay and is frequently missed. 5, 4
• Do not use antipsychotics as first-line treatment—exhaust all non-pharmacological options first. 2, 8
• Do not overlook pain as a trigger—postoperative pain (AOR: 3.10) is independently associated with emergence delirium. 3