Delirium: A key challenge for perioperative care

Abstract

Delirium is highly prevalent, occurring in 20% of acute hospital inpatients and up to 62% of surgical patients. It is a significant predictor of poor outcomes including mortality and institutionalisation, however it is often viewed as simply a marker of underlying illness and is frequently overlooked in older adults. Although delirium is commonly comorbid with dementia, it represents a more urgent diagnosis, requiring prompt intervention. Delirium presents most commonly with hypoactive features (e.g. withdrawal and reduced spontaneous movement and speech). The common stereotype of hyperactive delirium tremens (e.g. agitation, hallucinations), although more visible, is less common. All presentations share acute disimprovement of cognitive function. Delirium is a highly predictable and preventable occurrence, however a major barrier to improving delirium care and impacting upon outcomes is that it remains poorly detected, particularly in surgical populations and especially in patients with hypoactive presentations. Routine ward-based screening for delirium, particularly in high-risk populations, and improved staff awareness of the significance of the problem can improve detection rates. Preventative strategies, particularly multicomponent approaches, have been most efficacious in improving patient outcomes. Optimising perioperative risk factors can lead to reduced incidence. Appropriate treatment of delirium requires thorough investigation, management of the underlying illness, avoidance of complications and simplification of the care environment. Studies suggest a role for pharmacological prophylaxis, particularly in relation to anaesthetic and sedative agents used intra- and post-operatively. Furthermore, gathering evidence suggests that judicious use of antipsychotic medications may be helpful in delirium prevention and treatment.

Delirium the under‐recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units

“…However, they did not give any account on the serious complications of delirium such as increased rate of mortality, prolonged ICU and hospital stay, higher costs of care and cognitive impairment as confirmed by several studies (Davis & MaClullich , O'Regan et al . ).…”

Enhanced recovery after surgery: Pain management

“…The risk factors for delirium can be conveniently divided into predisposing factors (such as cognitive impairment, age greater than 65 years, multiple co‐morbidities, poly‐pharmacy, frailty, impaired functional status, malnutrition, and sensory deficits) and precipitating factors of which major surgery, poorly controlled pain and the use of opioids are over‐represented . Delirium is not just a nuisance for the patients and staff but carries important clinical consequences: it increases the incidence of post‐operative complications, for example, falls and pneumonia, and is associated with increased mortality, institutionalization and deteriorating cognition …”

Incidence and risk factors for delirium development in ICU patients - a prospective observational study

“…Some authors suggest that delirium due to alcohol withdrawal is more likely to be of the hyperactive type, while delirium due to a metabolic cause is more likely to be of the hypoactive type 21,40 . Some authors also distinguish between postoperative delirium and delirium due to alcohol withdrawal 49,50 . Alcohol abuse did show as a strong risk factor in our study.…”