Kathleen Louden

June 10, 2015

NATIONAL HARBOR, Maryland — Nonpharmacologic interventions are recommended to prevent postoperative delirium in older surgical patients, according to the new guideline issued jointly by the American Geriatrics Society (AGS) and the American College of Surgeons.

Because healthcare costs related to postoperative delirium exceed $150 billion a year in the United States, it is critical to use the evidence-based guideline, said panel cochair Sharon Inouye, MD, from Harvard Medical School in Boston.

The incidence of postoperative delirium, which occurs in 5% to 50% of postoperative patients, could be reduced if clinicians adhere to the new guideline, said Dr Inouye.

"While the multicomponent preventive strategies recommended by the guideline have upfront costs to implement, they have been consistently demonstrated to be cost-effective, and even cost-saving, for older patients," she told Medscape Medical News.

The guideline was reviewed during a plenary symposium here at the AGS 2015 Annual Scientific Meeting by several panel members. Presentations focused on guideline recommendations dealing with interdisciplinary prevention and management of postoperative delirium.

Dementia Is Greatest Risk Factor

The most common risk factors for postoperative delirium are chronic cognitive impairment or dementia, which increases the odds sixfold, and being older than 65 years, which increased the odds threefold, said cochair Thomas Robinson, MD, from the University of Colorado School of Medicine, Aurora.

According to the guideline, potentially preventable risk factors for postoperative delirium include immobilization, lack of orientation to surroundings, disrupted sleep, dehydration, inadequately controlled pain, and infection.

In addition, practitioners should avoid medications that have been shown to raise the risk for postoperative delirium in older adults, including sedative-hypnotics and meperidine. Furthermore, older adults not already receiving cholinesterase inhibitors should not receive them perioperatively, said panel member Lisa Hutchinson, PharmD, from the University of Arkansas in Little Rock.

She explained that studies have shown no benefit when patients receive therapy or preventive treatment for postoperative delirium with medications such as donepezil or rivastigmine. Other anticholinergic agents to avoid are cyclobenzaprine, oxybutynin, prochlorperazine, promethazine, tricyclic antidepressants, paroxetine, diphenhydramine, hydroxyzine, and drugs with strong anticholinergic properties, she added. Cases in which benefits outweigh the risks are exceptions, such as diphenhydramine to treat a severe acute allergic reaction.

Panel member Stacie Deiner, MD, from the Mount Sinai School of Medicine in New York City, discussed perioperative analgesia. To prevent delirium after surgery, older adults should receive optimal postoperative pain control, preferably with nonopioid pain medications, she said.

A member of the audience asked about restricted drugs in older patients with dementia. "Generally, anesthesiologists give single doses to treat a specific condition or situation, which may be different from prescribing these medications for long-term use," said Dr Deiner.

Nonpharmacologic Prevention

Multicomponent nonpharmacologic interventions are recommended to prevent postoperative delirium in older surgical patients with delirium risk factors, said Donna Fick, PhD, RN, from the Pennsylvania State University College of Nursing in University Park, who was not involved in the guideline development.

Dr Fick said her hospital uses a sleep regimen consisting of a 5-minute backrub, herbal tea, and soothing music before bedtime in at-risk patients.

Dr Robinson explained that because not all at-risk patients in his hospital were receiving multicomponent nonpharmacologic care, they simplified risk to include all patients older than 65 years.

"We can integrate this guideline into practice," he said.

Adherence to the AGS delirium guideline will be required for all hospitals seeking to become a Geriatric Surgery Center of Excellence, an initiative under development by the American College of Surgeons National Surgical Quality Improvement Program, according to Dr Robinson.

The new program should be implemented in 4 years, he told Medscape Medical News.

Medications to Reserve for Severe Cases

For older patients with mild to moderate postoperative delirium who are not agitated and do not pose a threat of personal harm or harm to others, antipsychotics or benzodiazepines should be avoided, Dr Hutchinson explained. Cases involving the treatment of alcohol or benzodiazepine withdrawal are exceptions.

This recommendation is difficult for physicians to follow, Dr Inouye told Medscape Medical News.

It seems that many physicians reach for one of these medications, even though "there is evidence of worsening confusion and prolonging agitation and potentially worse clinical outcomes," she said. "We are hoping the guideline will help to provide education that this is not the optimal approach."

It is common to use benzodiazepines and antipsychotics in delirium cases that are not extreme, said Penny Webster, MD, from Hunter New England Health in Newcastle, Australia, who was not involved in the development of the guideline.

 
It's absolutely appropriate to start low and go slow.
 

Dr Webster told Medscape Medical News that she considers this recommendation important, given the lack of scientific evidence of benefit from these medications in mild and moderate postoperative delirium.

She said she agrees with the recommendation to use antipsychotics at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated or distressed and are threatening harm. "It's absolutely appropriate to start low and go slow," she explained.

She said she appreciates the comment from Dr Fick on the use of behavioral techniques to reduce the risk for postoperative delirium in older patients at risk.

"This takes time to do, which may be difficult because of staffing challenges and nurses being increasingly stretched," Dr Webster said. "I think we could enlist family members who are at the bedside" to perform some of those services.

This work received funding from the John A. Hartford Foundation. Dr Inouye, Dr Deiner, and Dr Webster have disclosed no relevant financial relationships. Dr Robinson is a principal investigator for Covidien Inc., which is now part of Medtronic, and is a research grant recipient from Medtronic. Dr Fick is a paid consultant for SLACK Incorporated.

American Geriatrics Society (AGS) 2015 Annual Scientific Meeting. Presented May 17, 2015.

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