Interventions to Prevent Delirium in Post-operative Older Patients

Interventions to Prevent Delirium in Post-operative Older Patients Fifteen–Twenty High-Yield Points Scale of the problem

Postoperative delirium is one of the commonest surgical complications in older people. Incidence in hospitalised older patients may reach one-third, and anaesthesia poses a special risk.

Prevention is far more effective than treatment. Up to a third of episodes are preventable, and there is growing awareness of the importance of preventing, or at least minimising, postoperative delirium.

Four items are independently associated with postoperative delirium: prior stroke or TIA, Mini-Mental State Examination score, abnormal serum albumin, and Geriatric Depression Scale score.

Frailty — assessed by unintentional weight loss, reduced grip strength, low energy and motivation, low physical activity and slow walking speed — independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted living facility.

Other preoperative predictors of six-month mortality and poor outcome are impaired cognition, recent falls, low albumin, greater anaemia, functional dependence and increased comorbidity.

Six well-known risk factors are targeted by preventive programmes: cognitive impairment, visual impairment, hearing impairment, sleep deprivation, immobility and dehydration.

The Hospital Elder Life Program (HELP) is the model intervention. In the landmark controlled trial, addressing the six risk factors comprehensively through a trained interdisciplinary team reduced delirium incidence from 15% with usual care to 9.9% (matched odds ratio 0.60, p = 0.02).

The methods used in each HELP protocol were simple, commonsense measures that arguably should form part of best practice and good, empathetic care for all elderly patients. HELP has been shown to be sustainable and scalable in community hospitals.

Multifactorial interventions succeed only when supported by strong leadership and robust measurement and reporting — the same principle that underpins successful falls reduction.

Orientation and therapeutic activities for cognitive impairment — orientation boards, clocks, calendars, familiar objects, and daily cognitive stimulation.

Early mobilisation — ambulation or active range-of-movement exercises at least three times daily, and minimising immobilising equipment such as catheters and restraints.

Non-pharmacological sleep protocol — warm drink, relaxation, quiet environment, noise reduction and rescheduling of night-time observations and medications, instead of hypnotics.

Vision protocol — spectacles, magnifiers, adequate lighting, large-print material.

Hearing protocol — hearing aids, portable amplifiers, and removal of cerumen, which is a simple and frequently overlooked intervention.

Volume repletion — early recognition of dehydration and encouragement of oral fluid intake.

Medication review is central: the regimen should be scrutinised to determine which drugs should be continued or withheld. Every drug that may worsen cognition should be avoided or discontinued.

Anaesthetic technique: many surgeons and anaesthetists favour regional over general anaesthesia in geriatric patients, but regional anaesthesia has disadvantages — added intravenous sedation and analgesia may increase cardiovascular and mental status changes, and significant cardiovascular changes can occur during regional anaesthesia. The choice must be individualised.

Adequate analgesia is protective, since uncontrolled pain is itself a potent precipitant; opioid-sparing multimodal analgesia is preferred and pethidine should be avoided.

Other peri-operative essentials: prophylaxis against thromboembolism and infection, avoidance of hypoxia and hypotension, correction of anaemia and electrolyte disturbance, early removal of urinary catheters, early feeding, and treatment of constipation and urinary retention.

Comprehensive Geriatric Assessment identifies the frailest patients at highest risk of adverse outcomes, and when combined with strong and sustained interventions achieves better long-term outcomes.