What evidence‑based nursing interventions can prevent postoperative delirium in surgical patients?

Evidence-Based Nursing Interventions to Prevent Postoperative Delirium

Implement an immediate multicomponent nonpharmacological intervention protocol for all at-risk postoperative patients, as this approach reduces delirium incidence by 43% and carries strong evidence with essentially no risk of harm. 1, 2

Risk Identification and Screening

Preoperatively identify high-risk patients using validated cognitive screening tools, particularly those over 65 years, with pre-existing cognitive impairment, dementia, or previous delirium history. 1, 3 This screening enables targeted intervention before surgery begins and allows for risk stratification. 4, 5

Core Multicomponent Intervention Protocol

The following interventions should be implemented as a bundle, with nursing staff coordinating daily rounds to ensure adherence across all components:

1. Cognitive Reorientation and Stimulation

• Return glasses and hearing aids immediately post-recovery to address sensory impairments, which are significant contributors to delirium. 1, 2
• Provide easily visible clocks and calendars (including 24-hour clocks in ICU settings without natural light) for temporal orientation. 1
• Engage patients in cognitively stimulating activities at least three times daily, including discussing current events, word games, reminiscence therapy, and therapeutic conversation. 1 In one study of abdominal surgery patients >65 years, this reduced delirium from 16.7% to 0%. 1
• Use familiar objects from home and facilitate regular family visits to provide social support and orientation cues. 1, 4, 6

2. Sleep Enhancement Protocol (Critical Component)

• Implement strict quiet hours by scheduling medication rounds to avoid disturbing sleep periods and reducing noise to minimum during sleep hours. 7
• Minimize nighttime interruptions by clustering nursing care activities and decreasing nighttime vital sign checks to only essential monitoring. 7, 2, 6
• Provide sleep hygiene measures including warm blankets, back massage, relaxation techniques, earplugs, and minimizing light disruption at night. 1, 7, 2
• Establish a consistent bedtime routine to consolidate nighttime sleep. 7
• Increase daytime physical activity and sunlight exposure while decreasing time in bed during the day to promote normal circadian rhythm. 7

3. Early Mobilization and Physical Activity

• Begin sitting at bedside on postoperative day one, progressing to standing/walking by day two if medically appropriate. 1, 2
• Encourage active range-of-motion exercises for all patients, including those unable to walk independently. 1
• Provide appropriate walking aids that are accessible at all times and coordinate with physiotherapy for structured mobilization plans. 1, 2
• Activities such as stationary bicycle and Tai Chi have demonstrated sleep improvement and cognitive benefits in elderly patients. 7

4. Hydration and Nutrition Management

• Ensure adequate fluid intake by encouraging oral hydration and considering subcutaneous or intravenous fluids if necessary, while taking advice for patients with comorbid conditions like heart failure or chronic kidney disease. 1
• Address nutritional needs as part of the multicomponent intervention, since malnutrition is a common contributing factor to delirium. 1
• Prevent constipation through adequate hydration and monitoring bowel function, as this is a common complication that exacerbates delirium risk. 1

5. Pain Management Optimization

• Assess pain regularly using standardized scales and look for nonverbal signs of pain, particularly in patients with communication difficulties. 1, 2
• Provide adequate pain control, as undertreated pain increases delirium risk more than opioid use itself. 2
• Use multimodal analgesia with scheduled acetaminophen (1g IV every 6 hours has shown significant delirium reduction) and titrated opioids as needed. 2, 5
• Avoid NSAIDs in patients with contraindications such as recent GI bleeding. 2

6. Medication Review and Optimization

• Perform comprehensive medication review to identify and discontinue delirium-inducing medications including anticholinergics (antihistamines like cyclizine), benzodiazepines, and unnecessary steroids. 7, 8
• Minimize high-risk medications including dexmedetomidine (wean as soon as possible), zolpidem, zopiclone, and avoid benzodiazepines for sleep or agitation. 2, 8
• Avoid melatonin in dementia patients due to lack of efficacy and potential detrimental effects on mood. 7

7. Environmental and Clinical Optimization

• Maintain adequate oxygenation by assessing for hypoxia and optimizing oxygen saturation as clinically appropriate. 1
• Look for and treat infection while avoiding unnecessary catheterization, as urinary catheters pose both iatrogenic risk and act as physical restraint. 1, 8
• Create a safe, calm environment by minimizing unnecessary equipment and maintaining consistent room assignments when possible. 4

Implementation Strategy and Team Coordination

Engage an interdisciplinary team including nursing, physiotherapy, pharmacy, and family members to implement these interventions consistently. 2 The American Geriatrics Society provides a strong recommendation for this multicomponent approach based on moderate-quality evidence from 10 studies. 1

Nursing staff should lead implementation of sleep protocols, reorientation strategies, mobilization assistance, and the "5W1H procedure" (who, what, when, where, why, how) for patient orientation. 4, 6

Screen for delirium twice daily using validated tools such as the 4AT or CAM-ICU, beginning before discharge from recovery room and continuing through the fifth postoperative day. 2, 6, 5

Evidence Quality and Clinical Impact

This multicomponent approach demonstrates:

• 43% reduction in delirium incidence in surgical wards. 2
• Approximately one-third of delirium cases can be prevented with consistent implementation. 7
• Reduced ICU length of stay and delayed onset of delirium when it does occur. 6
• Cost-effectiveness with improved health outcomes compared to usual care. 7

Critical Pitfalls to Avoid

Never use physical restraints to manage behavioral symptoms, as this worsens delirium and is associated with increased delirium incidence. 1, 8

Do not rely on pharmacological interventions as first-line prevention—antipsychotics should only be considered for severe agitation threatening substantial harm after nonpharmacological approaches have been attempted. 8

Avoid single-component interventions—decades of research targeting isolated interventions have failed to prevent delirium; only multicomponent approaches encompassing all perioperative phases demonstrate effectiveness. 1

Do not delay implementation—interventions should begin preoperatively when possible and continue throughout the postoperative period, as delays in treatment prolong delirium and increase morbidity and mortality. 8, 4