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Post-operative Delirium


... Delirium. Kyle C. Moylan, MD. Assistant Professor of Clinical Medicine ... May be a substitute for physical restraints. Oral therapy is preferred when possible ... – PowerPoint PPT presentation

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Title: Post-operative Delirium

Post-operative Delirium
  • Kyle C. Moylan, MD
  • Assistant Professor of Clinical Medicine
  • University of Missouri - Columbia

  • Delirium is common
  • Delirium is often unrecognized
  • Delirium is life-threatening
  • Delirium is potentially predictable and

  • Increased morbidity
  • Increased mortality
  • Increased costs
  • Often a trigger of a downward spiral resulting
    in loss of independence, disability, and

Delirium is Common
  • Complicates the course of 20 of the 12.5 million
    patients over age 65 hospitalized every year
  • Prevalence at admission 14-24
  • Incidence during hospitalization 6-56
  • Post-operative incidence 15-53
  • ICU incidence - 70-87
  • Incidence in post-acute care - 60

Delirium is Costly
  • Adds 2500 to hospitalization per patient
  • Accounts for 6.9 billion of Medicare hospital
  • Increases cost for institutionalization,
    rehabilitation, home health services, and
    informal caregiving

Delirium is Underdiagnosed
  • Diagnosis is clinical
  • Requires careful bedside evaluation and cognitive
  • Fluctuating nature
  • Confused with dementia
  • Significance underappreciated
  • Diagnosis is not considered or sought

Delirium Diagnostic Criteria
  • Confusion Assessment Method (CAM)
  • Requires -
  • Acute Onset and Fluctuating Course
  • Inattention
  • AND Either
  • Disorganized thinking OR
  • Altered Level of Consciousness
  • Sensitivity 94-100
  • Specificity 90-95
  • Used as gold standard in almost every study
  • Only or so does not distinguish levels of
  • CAM-ICU has also been developed

Inouye SK. Ann Intern Med 1990
Confusion Assessment Method
  • CAM positive IF 1 and 2, plus 3a or 3b
  • 1. Acute Onset and Fluctuating Course
  • Is there evidence of an acute change in mental
    status from the patients baseline?
  • Did the (abnormal) behavior fluctuate during the
    day (tend to come and go, or increase and
    decrease in severity)?
  • 2. Inattention
  • Did the patient have difficulty focusing
    attention (e.g. being easily distractible) or
    have difficulty keeping track of what was being
  • 3a. Disorganized Thinking
  • Was the patients thinking disorganized or
    incoherent such as rambling or irrelevant
    conversation, unclear or illogical flow of ideas,
    or unpredictable switching from subject to
  • 3b. Altered Level of Consciousness
  • Overall, how would you rate this patients level
    of consciousness? (alert normal, vigilant
    hyper-alert, lethargic drowsy, easily
    aroused, stupor difficult to arouse, or coma
    un-arousable). Positive for any answer other
    than alert.

Delirium subtypes
  • Hyperactive
  • More easily recognized
  • Tends to be more severe and associated with worse
  • Hypoactive
  • Less recognized but more common
  • up to 70 of cases in post-hip fracture repair
  • Can coexist in a single patient over time

  • Complex interaction of the patient, predisposing
    and precipitating factors
  • More susceptible patients may require minimal
  • Less susceptible patients will require more
    substantial insults
  • Often multifactorial
  • Pathophysiology poorly understood

Risk Factors for Post-Op Delirium
  • Older age
  • Cognitive impairment
  • Functional impairment
  • Decreased post-op hemoglobin
  • Markedly abnormal Na, K, glucose
  • BUN/Cr gt18
  • Alcohol abuse
  • Noncardiac thoracic surgery
  • Aortic aneurysm surgery
  • History of delirium
  • Preoperative use of narcotics
  • Low postoperative oxygen saturation
  • History of cerebrovascular disease
  • Untreated pain

Marcantonio JAMA 1994 Kalisvaart J Am Geriatr
Soc 2006
Drugs Implicated in Post-Op Delirium
  • Anticholinergic medications
  • Diphenhydramine, antispasmodics, TCAs,
  • Opiates
  • Meperidine
  • Benzodiazepines
  • Antiparkinsonian drugs

  • Physical Exam
  • Blood sugar, pulse oximetry
  • Targeted evaluation for underlying causes
  • Exclude focal neurologic process
  • Electrolytes, CBC, LFTs, urinalysis, ECG, PCXR,
  • Non-constrast head CT in select patients
  • Patients with trauma, anticoagulants, metastatic
    disease, focal neuro findings or unable to
    complete adequate neuro exam
  • EEG rarely helpful

Quick Mental Status Screen
Six Item Screener
  • Questions
  • What year is this?
  • What month is this?
  • What day of the week is this?
  • Three item recall (1 minute) 
  • Apple
  • Table 
  • Penny
  • Total possible
  • Point Value
  • 1
  • 1
  • 1
  • 1
  • 1
  • 1
  • 6

Delirium Management
  • Treat underlying causes
  • Dont stop looking after finding one potential
  • Supportive Care and Environment
  • Targeted symptom-based treatment
  • First have to make the diagnosis

Supportive Measures
  • Remove unnecessary intrusions
  • Indwelling urinary catheters, telemetry, IVs
  • Avoid interrupting sleep
  • Are the 3am vitals really needed for this
  • Sensory Aids (hearing aids, glasses)
  • Family support
  • Early mobilization, avoid restraints
  • Provide reorientation (view of clock, calendars,
    familiar objects)
  • Adequate lighting and temperature
  • Include Fall Prevention protocols

  • Numerous studies showing successful
    multifactorial interventions to prevent and
    reduce the severity of delirium (Inouye et al.
    NEJM 1999)
  • Generally address non-pharmacologic factors
  • Sensory enhancement, hydration, mobilization,
    improved sleep, avoiding problem medications
  • Difficult for a single person to implement
  • Often led by teams of geriatricians, nurse
    partners, others
  • May be part of an ACE unit

Pharmacologic Management
  • Usually NOT indicated
  • Reserve for patients whose symptoms threaten
    their own safety or that of others
  • May be a substitute for physical restraints
  • Oral therapy is preferred when possible
  • Stopping medications may be more effective
  • Outcomes of intervention studies are disappointing

DR. NO Approach
  • D Describe the behavior, Document
  • R Reason for the behavior
  • N Non-pharmacologic management
  • O Order medications last
  • Assess the effect

  • NOT first line therapy
  • May paradoxically worsen delirium
  • Implicated as etiology of delirium in many
  • Benzo use predicts development of delirium in
    post-op and ICU patients
  • Can cause oversedation or respiratory depression
  • Lorazepam 0.5-1.0mg orally, repeated every 4H
    as needed

  • No controlled studies
  • Preferred by some experts
  • May cause oversedation
  • 25-50mg orally at bedtime, plus every 4-6H as

Typical Antipsychotics
  • Haloperidol is the drug of choice
  • Effective in RCTs
  • 0.5-1.0mg oral BID or at bedtime
  • Repeat Q4H PRN
  • Peak effect 4-6H
  • Same dose can be given IM with peak effect in
    20-40 minutes
  • IV not FDA approved and should be avoided
  • EPS, prolonged QT. Contraindicated in PD pts

Haloperidol Prophylaxis for Elderly Hip-Surgery
Patients at Risk for Delirium A Randomized
Placebo-Controlled Study (Kalisvaart KJ et al.
J Am Geriatr Soc. 2005531658-1666)
  • Patients - 430 pts. in the Netherlands
  • Aged 70 and older at risk for delirium
  • Mostly elective hip replacements (75)
  • Intervention Haloperidol 1.5mg/daily or
  • Started on admit and continued to POD 3.
  • All patients with geriatrics consult.
  • Results No difference in rate of delirium
    (15.1vs. 16.5)
  • Decreased severity and duration (5.4 vs 11.8
  • Decreased LOS (17.1 vs 22.6 days)
  • No adverse effects of haloperidol were noted
  • Limitations
  • Lower than expected incidence of delirium
  • Cognitively intact elective surgery patients
  • Geriatrics consultation may have benefited both
  • LOS longer than most US hospitals for this surgery

Atypical Antipsychotics
  • Little data available but frequently used
  • No evidence of superiority to haloperidol
  • Concerns about increased risk of death in studies
    of dementia related behavioral problems
    (Schneider et al, JAMA 2005)
  • Typical doses
  • Risperidone 0.5 mg BID
  • Olanzapine 2.5-5.0 mg daily
  • Quetiapine 25 mg twice daily

Post-Discharge Care
  • Delirium may persists for weeks or even months
  • Should have regular follow-up of mental status
    until back to baseline
  • Diagnosis and current mental status needs to be
    communicated to post-acute physician (and
  • Poorer rehab outcomes
  • 30 Rehospitalized from post-acute facilities
    (Marcantonio JAGS 2005)
  • Risk of new diagnosis of dementia increased at
    least threefold
  • 18 at one year (vs 5) (Rockwood Age Ageing
  • 69 at five years (vs 20) (Lundstrom JAGS 2003)
  • Likely to have substantial long term needs
  • Only 1/3 will still live independently at 2 years
    (McCusker CMAJ 2001)

Prevention Elective Surgery
  • Add to pre-op evaluation for elderly pts
  • Baseline MMSE
  • Get family and caregivers involved
  • Bring glasses, hearing aids to hospital
  • Medication review
  • Discuss with anesthesia

  • If you arent making the diagnosis frequently,
    look harder
  • Try using a simple screen for cognitive
    impairment for the next month
  • Set an example for learners by evaluating for
    delirium and cognitive impairment
  • Include delirium in the perioperative management
    of your patients
  • Document and communicate the problem with other

  • Inouye SK. Current Concepts Delirium in Older
    Persons. N Engl J Med. 20063541157-1165a.
  • Amador LF, Goodwin JS. Postoperative Delirium in
    the Older Patient. J Am Coll Surg.
  • Inouye SK, et al. Clarifying confusion The
    Confusion Assessment Method. A new method for
    detection of delirium. Ann Intern Med. 1990113
  • Callahan CM, Unverzagt FW, Hui SL, Perkins AJ,
    Hendrie HC. Six-item screener to identify
    cognitive impairment among potential subjects for
    clinical research. Med Care. 200240 771-781.
  • Marcantonio ER, Goldman L, Mangione C, et al. A
    Clinical Prediction Rule for Delirium After
    Elective Noncardiac Surgery. JAMA.
  • Kalisvaart KJ, Vreeswijk R, deJonghe JF et al.
    Risk Factors and Prediction of Postoperative
    Delirium in Elderly Hip-Surgery Patients
    Implementation and Validation of a Medical Risk
    Factor Model. J Am Geriatr Soc. 200654817-822.
  • Marcantonio ER, Juarez G, Goldman L, et al. The
    Relationship of Postoperative Delirium with
    Psychoactive Medications. JAMA.
  • Inouye SK, Bogardus ST, Charpentier PA, et al. A
    Multicomponent Intervention to Prevent Delirium
    in Hospitalized Older Patients. N Engl J Med.
  • Kalisvaart KJ et al. Haloperidol Prophylaxis for
    Elderly Hip-Surgery Patients at Risk for
    Delirium A Randomized Placebo-Controlled Study.
    J Am Geriatr Soc. 2005531658-1666.
  • Rockwood K, Cosway S, Carver D, et al. The Risk
    of Dementia and Death after Delirium. Age
    Ageing. 199928551-556.
  • Lundstrom M, Edlund A, Bucht G, et al. Dementia
    after Delirium in Patients with Femoral Neck
    Fractures. J Am Geriatr Soc. 2003511002-1006.
  • McCusker J, Cole M, Dendukuri N, et al. Delirium
    in Older Medical Inpatients and Subsequent
    Cognitive and Functional Status a Prospective
    Study. CMAJ 2001165575-593.
  • Marcantonio ER, Kiely DK, Simon SE, et al.
    Outcomes of Older People Admitted to Postacute
    Facilities with Delirium. J Am Geriatr Soc.