Multimodal Prevention of Postoperative Delirium
Postoperative delirium is a concerning and urgent complication in all surgical patients but especially in older patients. The reported incidence following major surgery ranges from 17-61% (Janssen et al., 2019). While delirium is particularly a concern for older postoperative patients, other risk factors for developing delirium include cognitive or functional impairment, multiple comorbidities, a history of falls, and sensory impairment. Inpatient factors that can contribute to development of delirium include polypharmacy, malnutrition, pain, ICU admission, length of hospital stay, type of surgery and many other factors (Janssen et al., 2019). Delirium is associated with increased mortality, loss of autonomy, prolonged hospital stay, and cognitive decline (Deeken et al., 2021). Interventions to prevent postoperative delirium can occur preoperatively, intraoperatively, and postoperatively, and a multimodal approach may be most effective prevention method.
Pharmacologic prevention strategies have shown potential for the prevention of postoperative delirium and are an important component of a multimodal strategy. For patients aged 65 or older undergoing non-cardiac surgery in Beijing, researchers found that prophylactic low-dose dexmedetomidine significantly decreased the incidence of postoperative delirium (Su et al., 2016). A meta-analysis of studies using dexmedetomidine as a pharmacologic intervention to prevent delirium showed a significant reduction in incidence, including when compared to propofol or benzodiazepines. However, some research on dexmedetomidine is mixed on its effectiveness, and a larger sample may be needed to determine what populations would benefit most from dexmedetomidine (Janssen et al., 2019).
The data on the use of antipsychotics to prevent postoperative delirium has been contradictory and heterogeneous. Some pooled results do not support the use of antipsychotics, but sensitivity analysis supports that antipsychotics can prevent delirium. For example, while olanzapine reduced incidence of delirium, it had negative effects on delirium duration and severity when occurring. Haloperidol did not reduce incidence of delirium significantly but reduced severity and duration. This is thought to be because olanzapine has a larger anticholinergic side effect profile (Janssen et al, 2019).
The effectiveness of multimodal prevention strategies to address postoperative delirium has been debated. A meta-analysis study found that multicomponent interventions do not successfully lower the incidence of postoperative delirium (Janssen et al., 2019). However, detection of high-risk patients can begin with a validated tool. Further intraoperative measures to reduce post-operative delirium include avoiding large swings in blood pressure, maintaining normothermia, and monitoring depth of anesthesia (Duning et al., 2021). A large multicenter study examining a wide range of surgical procedures found that their nonpharmacologic delirium prevention program was effective in reducing postoperative delirium risk in noncardiac surgery patients aged 70 or older. The patient-centered evidence-based intervention included personalized stimulation, company, and relaxation. The program included caregiver education, delirium risk assessment, and personalized prevention strategies (Deeken et al., 2022).
Ultimately, delirium is a serious complication of surgery, and unfortunately, there are not enough high-quality studies to understand how multicomponent programs and pharmacological interventions can reduce the incidence of postoperative delirium in high-risk patients. Nevertheless, these interventions must begin in the pre-admission period by assessing and accounting for patient risk and continue into the intraoperative and postoperative periods. They must also build on existing programs to address patient needs effectively and individually, and employ pharmacological interventions when indicated (Janssen et al., 2019).
References
Su, X., Meng, Z. T., Wu, X. H., Cui, F., Li, H. L., Wang, D. X., Zhu, X., Zhu, S. N., Maze, M., & Ma, D. (2016). Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. Lancet (London, England), 388(10054), 1893–1902. https://doi.org/10.1016/S0140-6736(16)30580-3
Janssen, T. L., Alberts, A. R., Hooft, L., Mattace-Raso, F., Mosk, C. A., & van der Laan, L. (2019). Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis. Clinical interventions in aging, 14, 1095–1117. https://doi.org/10.2147/CIA.S201323
Duning, T., Ilting-Reuke, K., Beckhuis, M., & Oswald, D. (2021). Postoperative delirium – treatment and prevention. Current opinion in anaesthesiology, 34(1), 27–32. https://doi.org/10.1097/ACO.0000000000000939
Deeken, F., Sánchez, A., Rapp, M. A., Denkinger, M., Brefka, S., Spank, J., Bruns, C., von Arnim, C., Küster, O. C., Conzelmann, L. O., Metz, B. R., Maurer, C., Skrobik, Y., Forkavets, O., Eschweiler, G. W., Thomas, C., & PAWEL Study Group (2022). Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA surgery, 157(2), e216370. https://doi.org/10.1001/jamasurg.2021.6370