American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults

Abstract

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Delirium in Older Persons

“…In 2014, the American Geriatrics Society and the American College of Surgeons jointly released clinical practice guidelines for the prevention and treatment of postoperative delirium. 23 The guidelines, developed in accordance with Institute of Medicine standards, highlight the importance of multicomponent nonpharmacologic prevention strategies, education of healthcare professionals, medical evaluation of delirium etiology, optimizing pain management with nonopioids, and avoiding high-risk medications (Table 3). New recommendations included avoidance of drug treatment for hypoactive delirium and avoidance of benzodiazepines for treatment of delirium, except in cases of alcohol or benzodiazepine withdrawal.…”

“…22 While many pharmacologic approaches have been evaluated in clinical trials, at present there is no convincing, reproducible evidence that any of these treatments are effective for either prevention or treatment of delirium. 1, 23 …”

Postoperative Delirium in the Geriatric Patient

“…Considering that delirium represents an acute or subacute change from baseline, it is important that each patient’s baseline cognitive status is well documented. [12, 13] The diagnosis of delirium is based on history, physical examination, laboratory, and radiographic findings. Other neurocognitive disorders should be ruled out to confirm the diagnosis of delirium (Box 1).…”

“…The American Geriatrics Society released a delirium best practices statement this fall. [12] The panel spent a year performing a Cochrane-style review to identify rigorous performed studies of factors to prevent and treat delirium. According to these guidelines, the use of antipsychotics should be reserved for patients who are severely agitated and pose a risk to harm themselves or others.…”

Are Melatonin and its Agonist the Natural Solution for Prevention of Delirium in Critically Ill Patients? A Review of Current Studies

“…Delirium is a neuropsychiatric syndrome, which is a common complication at the intensive care unit (ICU), especially found in older patients, and it is a risk factor for morbidity and mortality in this population (1)(2)(3). Delirium, which is presented in approximately 20% of hospitalized patients (2), is defined as an acute onset, fluctuating change, in mental status characterized by a reduced awareness of the environment and disturbance of attention, according to the diagnostic and statistical manual of mental disorders IV (DSM-IV) (4).…”