Purpose of review Postoperative delirium (POD) is one of the most severe complications after surgery. The consequences are dramatic: longer hospitalization, a doubling of mortality and almost all cases develop permanent, yet subtle, cognitive deficits specific to everyday life. Actually, no global guideline with standardized concepts of management exists. Advances in prevention, diagnosis and treatment can improve recognition and risk stratification of delirium and its consequences. Recent findings Management of POD is a multiprofessional approach and consists of different parts: First, the detection of high-risk patients with a validated tool, preventive nonpharmacological concepts and an intraoperative anesthetic management plan that is individualized to the older patient (e.g. avoiding large swings in blood pressure, vigilance in maintaining normothermia, ensuring adequate analgesia and monitoring of anesthetic depth). In addition to preventive standards, treatment and diagnostic concepts must also be available, both pharmaceutical and nonpharmacological. Summary Not every POD can be prevented. It is important to detect patients with high risk for POD and have standardized concepts of management. The most important predisposing risk factors are a higher age, preexisting cognitive deficits, multimorbidity and an associated prodelirious polypharmacy. In view of demographic change, the implementation of multidisciplinary approaches to pharmacological and nonpharmacological POD management is highly recommended.

Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.

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BackgroundDelirium is a common and severe condition. In particular for older patients the adverse effects lead to cognitive impairments in everyday functioning with substantial healthcare costs. The mortality is 20-fold increased. Irreversible cognitive deficits are proven in 50% of cases.The age, the cognition and the multimorbidity, combined with polypharmacy are the most predisposing risk factors to a delirium.PurposeOur university hospital established a multidisciplinary department, which developed nonpharmacological and pharmacological guidelines for diagnosis, prevention and treatment of delirium.The primary objective of our open randomised controlled trial was to compare the effectiveness of multidisciplinary approaches in reducing the risk of delirium in surgical and nonsurgical patients aged 65 years and over.Material and methodsFrom January 2016 to October 2017, 1694 patients aged 65 years and over were screened on admission by using the Montreal Cognitive Assessment (MoCA). A total of 1089 patients (64%) had an elevated risk for delirium (MoCA <26 points) and 66% (723) of these patients could be included and randomised.The intervention group (370 patients) received our standardised treatments, such as constant detection of delirium, specialised nursing and medication optimisation by pharmacists, whereas the control group (353 patients) was treated as usual without any standardised strategies.The cognitive outcome for each patient was assessed by a second MoCA before discharge.ResultsThe risk of a manifest delirium during hopitalisation was more than 50% higher in the control group compared to the intervention group: (15% control group vs. 6% intervention group (OR 0.35, 95% CI: 0.21 to 0.60, p<0. 001)).The duration of delirium in the intervention group was reduced by half, compared to the control group (4 vs. 8 days (p<0.001)).ConclusionThe results of our study have proven that not every delirium can be prevented, but the rate and the duration of delirium can be significantly reduced.Furthermore, the results emphasise the importance of clinical pharmacists. The inappropriate use of non-evidence-based medication of delirium (e.g. inappropriate application of antipsychotics, benzodiazepines and anticholinergic substances) could be reduced by intensive training of medical staff and pharmaceutical counselling.Considering the demographic changes, we recommend the implementation of a multidisciplinary approach for the consistent and standardised management of delirium.Nothing to declare.No conflict of interest