Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article

Abstract

Background Postoperative delirium is the highest prevalence and life-threatening complication following geriatric surgery. The overall incidence rate varies from 5% to 52% of hospitalized surgical patients based on the type of surgery that often began in the postanesthesia care unit and continues up to 5 days post-surgery. Postoperative delirium manifests as a hypoactive, hyperactive and mixed subtype. The mechanism of delirium development is not clear, but it is accepted that delirium is a result of the patient’s underlying vulnerabilities or risk factors combined with an outside stressor such as infection or surgery. Objective To develop evidence-based recommendations for the prevention, diagnosis, and treatment of postoperative delirium. Methods Literature was searched from PubMed, CINAH, Google Scholar, and Cochrane databases that are published from 2010 to 2021 by formulating inclusion and exclusion criteria. Filtering was made depending on methodological quality, outcome, and data on population. Finally, 11 meta-analysis, 11 systematic reviews, 7 interventional studies, 11 observational studies, and recommendations of the previous clinical practice guideline developed by the American and European are included in this review. Results A total of 43 studies were considered in this evaluation. The development of this guideline was based on nine studies on risk stratification for postoperative delirium, eighteen studies on risk minimization and prevention for postoperative delirium, five studies on diagnosis for postoperative delirium, and eleven studies on treatments for postoperative delirium. Conclusion Postoperative delirium management can be categorized into risk assessment, risk minimization, early diagnosis, and treatment. Early diagnosis is critical to trigger focused and effective treatment. Non-pharmacological interventions are the first-line management for both hypoactive and hyperactive postoperative with considering contributory factors and underlying causes. Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves. Current evidence suggested that dexmedetomidine can be used as a treatment option for postoperative delirium.

Bibliometric Analysis of 100 Most-Cited Articles in Delirium

“…However, our study found that cohort studies are the main cited articles in this field, and there are a large number of systematic reviews or meta-analyses of cohort studies. In order to evaluate the assessment of delirium and predict its risk factors, a cohort study is a more appropriate method, which we think is the reason for the large number of articles cited in this type of article ( 22 , 23 ). There is only one non-clinically relevant article, which introduces a hypothetical model of delirium that suggests that drugs that restore microglial choline to control or directly inhibit neuroinflammation need clinical trials ( 24 ).…”

Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study

“…Hence, it comprises risk assessment and stratification, risk reduction, and early identification and management. Prevention is the most effective management of delirium [15,16].…”

Delirium in cardiac surgery - risk factors and prevention

“…Delirium is defined as an acute change in mental status that leads to disturbance of perception, thinking, memory, attention, emotional status, as well as sleep rhythm disorders and is most often reversible [1]. According to the American Psychiatric Association, the diagnosis of delirium can be made if the patient has a disorder of attention, a disorganized flow of thoughts, or an altered level of consciousness that develops over a short period of time and has a fluctuating course during the day [2].…”

“…It can develop in all age groups, but more often after a surgery performed in older patients, with an incidence rate of 5 -52%, depending on the general condition of the patient and the extent of the surgery. It usually occurs in the first five postoperative days [1,3].…”

“…All this affects the health condition and quality of life of both the patients and their families, and from the economic aspect, leads to higher costs of treatment [4,5]. Due to these facts, it is very important to prevent the development of delirium, especially in patients who, due to their age, health condition or type of surgical intervention, are at increased risk for developing POD [1,[4][5][6].…”