Prevention Program Cuts Likelihood, Length of Delirium in Seniors After Elective Surgery

By Linda Carroll

December 20, 2021

NEW YORK (Reuters Health) - A multidisciplinary intervention cut the rate and duration of postoperative delirium in seniors who underwent elective surgical procedures, according to new study findings.

Data from nearly 1,500 patients revealed that the program resulted in a 13% drop in the risk of delirium and a decrease in the number of days with delirium in patients undergoing abdominal surgery and orthopedic surgery, but not cardiac surgery, researchers report in JAMA Surgery.

"To our knowledge, this trial is the largest multicenter study showing effective delirium prevention in elective surgery in older adults and the only one to examine a wide range of surgical procedures," Dr. Christine Thomas of the Klinikum Stuttgart in Stuttgart Germany and colleagues write.

"Our AKTIVER delirium prevention program combined evidence-based best practice components ranging from preadmission risk-stratifying ongoing assessments and follow-up at hospital discharge. We combined strategic education and knowledge dissemination techniques with daily prevention," they explain. "To these interventions, adapted to individual needs as described in medical settings, we added caregiver presence, reassurance to minimize anxiety, and the provision of humane support in unknown surroundings, based on the German The Older Person in the Operating Room model."

To take a closer look at whether a prevention program could impact the number of seniors who developed delirium after surgery and the length of time spent in delirium in those who did, Dr. Thomas and her colleagues conducted a stepped-wedge cluster randomization trial including 1,470 patients 70 and older, 52% of whom were male.

The patients underwent elective orthopedic, general, or cardiac surgery from 2017 to 2019 at five German tertiary medical centers. They were randomized in five clusters to receive the patient-centered intervention or routine care.

The intervention used in the AKTIVER study included seven best-practice delirium-prevention modules: cognitive, motor, and sensory stimulation; meal companionship; diagnostic test and operation room accompaniment; stress relaxation; and sleep promotion. The program individualized which modules patients received according to the patients' needs.

Delirium occurred in 318 patients (22%), 36% of whom had undergone cardiac procedures. The intervention significantly reduced postoperative delirium incidence (odds ratio, 0.87) and percentage of days with delirium (5.3% vs. 6.9%).

In subgroup analyses, the effect of the intervention was significant in patients undergoing orthopedic or abdominal surgery (OR, 0.59) but not cardiac surgery (OR, 1.18; P =0.54).

Dr. Fred Rubin, a geriatrician and chairman of the department of medicine at UPMC Shadyside, in Pittsburgh, suspects that the effects seen in the study would be generally applicable.

"This is a very well-designed prospective cluster randomized trial of a detailed delirium prevention program for post-op surgical patients," Dr. Rubin, who was not involved in the study, told Reuters Health by email. "The intervention was modeled after similar programs already being used in the United Kingdom (the NICE guidelines) and in the United States (the Hospital Elder Life Program)."

"The intervention was provided at the bedside by trained nurses and volunteers," Dr. Rubin said. "They monitored adherence to the prescribed interventions, which is important. They found that the program did reduce the incidence of delirium among patients undergoing noncardiac surgery, but not among patients undergoing cardiac surgery. This is not surprising, and is consistent with other work. Cardiac surgery constitutes greater physiologic stress, and involves spending time in an intensive-care unit."

The authors did not respond to requests for comment.

SOURCE: JAMA Surgery, online December 15, 2021.