Recent Advances in Preventing and Managing Postoperative Delirium

Abstract

Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.

Delirium

“…Although once regarded as an appropriate treatment for delirium, benzo diazepines increase the risk for transition to delirium in ICU patients 181,182 . Several studies now suggest that dexmedetomidine is less deliriogenic than GABAergic sedatives in ICU and surgical patients but this evidence has not yet reached consensus 183,184 .…”

<p>Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers</p>

“…Evidence concerning risk factors is growing: next to pathophysiological factors like certain drugs, 8 comorbid conditions, 15 and anesthetic management, [16][17][18] psychosocial factors such as age, multi-morbidity and frailty, low cognitive reserve, 19 and preexisting dementia 9 predispose patients to cognitive dysfunction and delirium in the context of hospitalization. Delirium itself is a risk factor for POCD.…”

Analysis of intravenous sedation for dental treatment in elderly patients with severe dementia-a retrospective cohort study of a Japanese population

“…Propofol, another GABA receptor agonist, may exert similar effects. 5 , 6 , 7 Unlike GABA receptor agonists, DEX acts on central α2-adrenergic receptors. Sedation with DEX has a minimal effect on respiratory rate and percutaneous arterial oxygen saturation (SpO 2 ) and is associated with fast recovery from sedation with physical stimulation if needed.…”

“… 8 , 9 , 10 A factor that may trigger POD and POCD is inflammation from surgery that spreads to the central nervous system. 5 , 6 , 7 The anti-inflammatory effect of DEX is responsible for a low incidence rate of POD and POCD after cardiac and non-cardiac surgeries. 11 , 12 …”