EDITORIAL
Postoperative Delirium in Older Adults Alfred Bent, MD
T
he American Geriatrics Society published a Clinical Practice Guideline in October 2014 for postoperative delirium in older adults. The premise for the development of the guideline was based on the fact that 5% of low-risk older adults having minor surgical procedures and up to 50% of high-risk older adults having high-risk operations develop postoperative delirium. The sequelae include cognitive impairment, lack of functionality, and prolonged hospitalization with other associated morbidity. If 40% of these events can be prevented, there would be a great financial saving as well as reduced disability and suffering in these patients. Symptoms of delirium can include hyperactive or hypoactive behavior. Prevention is the main management intervention that commences by identifying high-risk patients who are aged 65 years or older, with past or present cognitive impairment, with current hip fracture, and with severe illness. The precipitating event would be the extent of the surgical intervention and its immediate complications. Prevention strategy commences with an intense educational program for the health care team. This would allow an interdisciplinary team to provide a multicomponent nonpharmacologic intervention for the entire hospitalization of the identified at risk patient. The team would also provide interventions for those patients diagnosed with postoperative delirium to improve clinical outcomes. The health care provider would need to use available resources to identify and manage the causes of delirium. While supporting evidence was of low quality, there was a strong recommendation that postoperative pain control should be optimized preferably with nonopioid medications. Similarly, there was low-quality evidence but strong recommendation to avoid medications associated with delirium such as anticholinergic drugs and benzodiazepines, as well as use of multiple medications, that is, 5 or more. There were 3 other strong recommendations with low-level supporting evidence. Benzodiazepines should not be used as first-line treatment of agitation associated with delirium. Older adults currently not taking cholinesterase inhibitors should not have them newly prescribed to prevent or treat delirium. Antipsychotics and benzodiazepines should be avoided in treatment of hypoactive delirium. This summary of the guidelines notes the limitations of a number of recommendations based on lack of available evidence and the extrapolation of some evidence not directly related to postoperative patients. The comprehensive guidelines and evidence tables are available for free online at GeriatricsCareOnline.org. You do need to sign in and register if you are not a registered user, but there is no cost for viewing the complete guideline.
From the Department of Obstetrics and Gynecology, Dalhousie University, IWK Health Center, Halifax, Nova Scotia, Canada. Reprints: Alfred Bent, MD, 455 Cottage Ln, PO Box 367, Brookfield, Nova Scotia B0N 1C0 Canada. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000197
Female Pelvic Medicine & Reconstructive Surgery • Volume 21, Number 4, July/August 2015
www.fpmrs.net
181
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Postoperative Delirium in Older Adults Alfred Bent, MD
T
he American Geriatrics Society published a Clinical Practice Guideline in October 2014 for postoperative delirium in older adults. The premise for the development of the guideline was based on the fact that 5% of low-risk older adults having minor surgical procedures and up to 50% of high-risk older adults having high-risk operations develop postoperative delirium. The sequelae include cognitive impairment, lack of functionality, and prolonged hospitalization with other associated morbidity. If 40% of these events can be prevented, there would be a great financial saving as well as reduced disability and suffering in these patients. Symptoms of delirium can include hyperactive or hypoactive behavior. Prevention is the main management intervention that commences by identifying high-risk patients who are aged 65 years or older, with past or present cognitive impairment, with current hip fracture, and with severe illness. The precipitating event would be the extent of the surgical intervention and its immediate complications. Prevention strategy commences with an intense educational program for the health care team. This would allow an interdisciplinary team to provide a multicomponent nonpharmacologic intervention for the entire hospitalization of the identified at risk patient. The team would also provide interventions for those patients diagnosed with postoperative delirium to improve clinical outcomes. The health care provider would need to use available resources to identify and manage the causes of delirium. While supporting evidence was of low quality, there was a strong recommendation that postoperative pain control should be optimized preferably with nonopioid medications. Similarly, there was low-quality evidence but strong recommendation to avoid medications associated with delirium such as anticholinergic drugs and benzodiazepines, as well as use of multiple medications, that is, 5 or more. There were 3 other strong recommendations with low-level supporting evidence. Benzodiazepines should not be used as first-line treatment of agitation associated with delirium. Older adults currently not taking cholinesterase inhibitors should not have them newly prescribed to prevent or treat delirium. Antipsychotics and benzodiazepines should be avoided in treatment of hypoactive delirium. This summary of the guidelines notes the limitations of a number of recommendations based on lack of available evidence and the extrapolation of some evidence not directly related to postoperative patients. The comprehensive guidelines and evidence tables are available for free online at GeriatricsCareOnline.org. You do need to sign in and register if you are not a registered user, but there is no cost for viewing the complete guideline.
From the Department of Obstetrics and Gynecology, Dalhousie University, IWK Health Center, Halifax, Nova Scotia, Canada. Reprints: Alfred Bent, MD, 455 Cottage Ln, PO Box 367, Brookfield, Nova Scotia B0N 1C0 Canada. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000197
Female Pelvic Medicine & Reconstructive Surgery • Volume 21, Number 4, July/August 2015
www.fpmrs.net
181
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
