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Analysis

How You Can Curb Postoperative Delirium

By Christopher Cheney  
   February 07, 2019

For patients at high risk of postoperative delirium, interventions include medication management and family education.

Preoperative cognitive assessments can identify patients at high risk of postoperative delirium and prompt interventions, recent research shows.

Postoperative delirium (POD) is disturbance of consciousness with impaired attention, and it is the most common surgical complication for older adults. While most deliriums are reversible, they are associated with increased morbidity and mortality, as well as longer length of stay.

The recent research focused on 173 vascular surgery patients who underwent the Montreal Cognitive Assessment (MoCA) before their procedures. After surgery, 11.6% of the patients experienced POD.

"MoCA scores can be used in the preoperative period to identify patients at high risk of POD, which can provide important predictive information to the clinician but also to the patient and family," the researchers wrote.

The research team also identified predictors of POD—some major surgical procedures such as lower limb amputation and open aortic repair, MoCA scores showing moderate to severe cognitive impairment, and previous delirium.

Intervening to limit delirium
 

The lead author of the research, Rima Styra, MD, MEd, told HealthLeaders there are three primary interventions after a surgical patient has been deemed at high risk for POD.

  • Medication management: A top priority is discontinuing benzodiazepines and reviewing over-the-counter sleeping drugs. Some patients also have substance abuse issues. If patients can be screened early for delirium risk, care teams can make changes in medications or help with substance abuse.
     
  • Anesthesia: Anesthesiologists can make adjustments in care to avoid exacerbating risk factors for POD.
     
  • Family education: Many family members are unaware of delirium and need to be educated about the risk. They often don't understand how someone could have surgery and end up confused and paranoid. One-on-one educational conversations with family members are ideal, usually the day when the patient arrives for surgery.

Conducting cognitive assessments
 

Beyond identifying high-risk patients, there are a pair of significant benefits from administering preoperative cognitive assessments, said Styra, who is affiliated with the Peter Munk Cardiac Center at University Health Network in Toronto, Ontario, Canada, and the Department of Psychiatry at University of Toronto.

"First, you can find out about the patient's cognitive functioning prior to it being affected by surgery—you find out about the overall functioning prior to surgery. It gives a baseline that you want the patient to return to. You also get an opportunity to obtain information from the patient. Many patients have been prescribed medications that they do not take. It's important to know whether they are taking their medications or not."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Delirium is associated with increased morbidity and mortality, as well as higher costs of care such as longer length of stay.

Preoperative cognitive assessments have benefits beyond screening for delirium risk, including establishment of baseline cognitive functioning.

Predictors of postoperative delirium include prior history of delirium and some major surgeries such as lower limb amputation.


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