Transcript Postoperative Delirium in the older patient.

Postoperative Delirium
in the older patient.
Topic review 26/5/48
Suthinee Ithimakin, MD
Postoperative delirium
Acute disorder of cognition and attention
after operation
Anytime in perioperative period
Most commonly occurs during postsurgical
period
Underdiagnosed 78%
40% routinely screen for delirium
Postoperative delirium
Associated with
Poor cognitive and functional recovery
Longer hospital stay
Greater hospital costs
Risk factor for institutionalization and
morbidity
Reduced risk by early identification,
assessment and treatment
Incidence/ prevalence
¼ of adult older than 65 year experience
delirium during hospitalization
Wide range estimate of postoperative
delirium pending on type of operation
Delirium is likely to increase in future
Pathogenesis
CNS changes with age
Loss of nerve cells
Decreased in cerebral blood flow
Changes in neurotransmitter system
Decreased acetylcholinesterase activity
Carbonic anhydrase activity
Muscarinic receptor
Serotonin receptors
Pathogenesis
Abnormal levels of endorphins, serotonin,
neuropeptides in CSF
EEG : slowing of dominant posterior alpha
rhythm and abnormal slow wave activity
Cause of CNS dysfunction after surgery
Risk factors
Risk factors
Older age
Cognitive impairment
Functional impairment
Decreased postoperative hemoglobin
Markedly abnormal sodium, potassium and glucose
Alcohol abuse
Noncardiac thoracic operation
History of delirium
Preoperative used of narcotic
Preoperative used of benzodiazepine
Low postoperative oxygen saturation
History of cardiovascular disease
Untreated pain
Drug associated with
delirium
Drugs with anticholinergic activity
Tricyclic antidepressants
Cimetidine
Corticosteroids
Digoxin
Diphenhydramine
Belladonna
Dipyridamole
Theophylline
Promethazine
Amantadine
Oxybutyrin
Drugs associated with
delirium
Analgesics
Narcotics (especially meperidine)
NSAIDs
Benzodiazepines
Antiparkinsonian agents
Diagnosis
Modified from Diagnostic and Statistical Manual of Mental Disorder, 4TH ed
features
depression
delirium
dementia
Clinical features
Change of consciousness and recognition
Cognitive abnormalities
Disorientation
Language difficulty
Impairment of learning and memory
Fluctuating course
Clinical features
Emotional disturbances
Anxiety
Fear
Anger
Irritability
Depression
Clinical features
4 different types
Hypoactive delirium
Hyperactive delirium
Mixed delirium
Delirium without psychomotor change
History
Description of patient’s behavior
Earlier episode of delirium
Evidence of cognitive impairment
Information to rule out alcohol or drug
withdrawal
Physical examination
Vital signs
Oxygen saturation
Sign of trauma or infection
State of hydration
New neurological signs
Confusion assessment
method
Item 1 and
2 and 3 or 4
Sensitivity
94-100%
Specificity 90-95%
Diagnostic tests
To identify potentially correctable factors
CBC, electrolytes, creatinine, glucose,
and urinalysis
Neuroimaging may be used selectively
Prevention
Tarketing modifiable risk factors prevent
some case of delirium*
Standardized protocols of known risk factors
for delirium
Sleep deprivation
Reduction in delirium episodes (15%9.9%)
Immobility
No effect on delirium severity and
rate of
Dehydration
Visual impairment
recurrence
Cognitive impairment
Hearing impairment
*N Engl J Med 1999;340:669-676
Prevention
Patients with fracture neck of femur
Outcome : Postoperative delirium ??
Pre and postoperative geriatric assessments,
Oxygen therapy
Early operation
Prevention treatment of perioperative BP fall
Treatment of postoperative complication
J Am Geriatr Soc 1991;39:655-62
Prevention
Interventions
Decreased postoperative delirium
from 61% to 48%
J Am Geriatr Soc 1991;39:655-62
Prevention
Identify and reduce risk factors can decrease
postoperative delirium in elderly
Preoperative educate the patients
Management
Identify causes
and treat
Treat contributing illness
Providing supportive measures
Symptom control
Safe environment
Appropiate stimulation
Nutrition
Reserve for agitated or
disruptive individuals
Supportive measures
Medication for symptom
control
Antipsychotics
Haloperidol or newer antipsychotic agent ??
Goal is to control disruptive symptoms and avoid
obtundation
Taper in 3-5 days
Benzodiazepine
Paradoxical agitation
Treat withdrawal from alcohol of sedative drugs
Prevention and treatment of postoperative delirium
Outcome
Sequels of delirium can persist for 6 months
Risk for future cognitive decline
Associated with increase mortality (10-65%)
Longer hospital stay and higher nursing
home placement
Outcomes of delirium
Relationship between delirium and dementia
in 3 years with 203 patients age ≥ 65 in
medical services
Incidence
of dementia
5.6% per year in patient without delirium
18.1% per year in delirium group
Age aging 1999;28:551-556
Outcomes of delirium
78 patients with femoral neck fractures
Postoperative
delirium
69%
Without
Postoperative delirium
5 years
20%
Dementia
J Am Geriatr Soc 2003;51:1002-1006
Conclusion
Risk of postoperative delirium can be
reduced with careful attention to risk factors
Intervention to target problems
Systemic approach to diagnostic workup
Early identification, assessment and
management