Postoperative delirium

Acute disorder of cognition and attention after operation Anytime in perioperative period Most commonly occurs during postsurgical period Underdiagnosed 78% 40% routinely screen for delirium

Postoperative delirium
Associated with Poor cognitive and functional recovery Longer hospital stay Greater hospital costs Risk factor for institutionalization and morbidity Reduced risk by early identification, assessment and treatment

Incidence/ prevalence
of adult older than 65 year experience delirium during hospitalization Wide range estimate of postoperative delirium pending on type of operation Delirium is likely to increase in future

Pathogenesis
CNS changes with age Loss of nerve cells Decreased in cerebral blood flow Changes in neurotransmitter system
Decreased acetylcholinesterase activity Carbonic anhydrase activity Muscarinic receptor Serotonin receptors

Pathogenesis
Abnormal levels of endorphins, serotonin, neuropeptides in CSF EEG : slowing of dominant posterior alpha rhythm and abnormal slow wave activity

Cause of CNS dysfunction after surgery

Risk factors

Risk factors
Older age Cognitive impairment Functional impairment Decreased postoperative hemoglobin Markedly abnormal sodium, potassium and glucose Alcohol abuse Noncardiac thoracic operation History of delirium Preoperative used of narcotic Preoperative used of benzodiazepine Low postoperative oxygen saturation History of cardiovascular disease Untreated pain

Drug associated with delirium

Drugs with anticholinergic activity
Tricyclic antidepressants Cimetidine Corticosteroids Digoxin Diphenhydramine Belladonna Dipyridamole Theophylline Promethazine Amantadine Oxybutyrin

Drugs associated with delirium

Analgesics
Narcotics (especially meperidine) NSAIDs

Benzodiazepines Antiparkinsonian agents

Diagnosis

Modified from Diagnostic and Statistical Manual of Mental Disorder, 4TH ed

features

depression

delirium

dementia

Clinical features
Change of consciousness and recognition Cognitive abnormalities
Disorientation Language difficulty Impairment of learning and memory

Fluctuating course

Clinical features
Emotional disturbances
Anxiety Fear Anger Irritability Depression

Clinical features
4 different types
Hypoactive delirium Hyperactive delirium Mixed delirium Delirium without psychomotor change

History
Description of patients behavior Earlier episode of delirium Evidence of cognitive impairment Information to rule out alcohol or drug withdrawal

Physical examination
Vital signs Oxygen saturation Sign of trauma or infection State of hydration New neurological signs

Confusion assessment method

Item 1 94-100% Sensitivity and 2 and 3 or 4 Specificity 90-95%

Diagnostic tests
To identify potentially correctable factors CBC, electrolytes, creatinine, glucose, and urinalysis Neuroimaging may be used selectively

Prevention
Tarketing modifiable risk factors prevent some case of delirium* Standardized protocols of known risk factors for delirium Sleep deprivation Reduction in delirium episodes (15%9.9%) Immobility No effect on delirium severity and rate of Dehydration Visual impairment recurrence
*N Engl J Med 1999;340:669-676 Cognitive impairment Hearing impairment

Prevention
Patients with fracture neck of femur Outcome : Postoperative delirium ??
Pre and postoperative geriatric assessments, Oxygen therapy Early operation Prevention treatment of perioperative BP fall Treatment of postoperative complication

J Am Geriatr Soc 1991;39:655-62

Prevention
Interventions

Decreased postoperative delirium from 61% to 48%

J Am Geriatr Soc 1991;39:655-62

Prevention
Identify and reduce risk factors can decrease postoperative delirium in elderly

Preoperative educate the patients

Management
Identify causes and treat

Treat contributing illness Providing supportive measures Symptom control

Safe environment Appropiate stimulation Nutrition Reserve for agitated or disruptive individuals

Supportive measures

Medication for symptom control

Antipsychotics
Haloperidol or newer antipsychotic agent ?? Goal is to control disruptive symptoms and avoid obtundation Taper in 3-5 days

Benzodiazepine
Paradoxical agitation Treat withdrawal from alcohol of sedative drugs

Prevention and treatment of postoperative delirium

Outcome
Sequels of delirium can persist for 6 months Risk for future cognitive decline Associated with increase mortality (10-65%) Longer hospital stay and higher nursing home placement

Outcomes of delirium
Relationship between delirium and dementia in 3 years with 203 patients age 65 in medical services Incidence of dementia 5.6% per year in patient without delirium 18.1% per year in delirium group
Age aging 1999;28:551-556

Outcomes of delirium
78 patients with femoral neck fractures

Postoperative delirium

Without Postoperative delirium

69%

5 years

20%

Dementia
J Am Geriatr Soc 2003;51:1002-1006

Conclusion
Risk of postoperative delirium can be reduced with careful attention to risk factors Intervention to target problems Systemic approach to diagnostic workup Early identification, assessment and management