New Clinical Practice Guideline on Postoperative Delirium in Older Adults

Published online ahead of print December 1, 2014.

Postoperative delirium is recognized as the most common postoperative complication in older adults. The American Geriatrics Society’s Geriatrics-for-Specialists Initiative (AGS-GSI) recently released a Clinical Practice Guideline and Best Practice Statement that offer a framework for healthcare facilities and professionals to implement actionable, evidence-based measures to improve delirium prevention and treatment. This work was funded through a grant from the John A. Hartford Foundation in support of the AGS-GSI. 

Studies have shown that postoperative delirium can be prevented in up to 40% of cases in some hospitalized senior populations. Surgical and related medical specialists, together with the entire multi-disciplinary healthcare team, can play an integral role in prevention. The AGS-GSI Council, with additional input from the guideline expert panel co-chairs, Sharon Inouye, MD, MPH, and Thomas Robinson, MD, created a 23-member interdisciplinary expert panel. “Our panel completed an extensive review of the literature while developing these recommendations,” noted AGS President Wayne C. McCormick, MD, MPH, AGSF. “The process also included review by organizations with expertise in this area and an open public comment period.”

The comprehensive guideline and evidence tables are now available for free on GeriatricsCareOnline.org. In early December, a guideline summary will be available online in the Journal of the American Geriatrics Society (JAGS). The Best Practice Statement is now available through open access on the American College of Surgeons website and will be published in the Journal of the American College of Surgeons in early 2015. 

Evidence-based recommendations include:
• Nonpharmacologic interventions delivered by an interdisciplinary team should be administered to at-risk older adults to prevent delirium.
• Ongoing educational programs regarding delirium should be provided for healthcare professionals.
• A medical evaluation should be performed to identify and manage underlying contributors to delirium.
• Pain management (preferably with nonopioid medications) should be optimized to prevent postoperative delirium.
• Medications with high risk for precipitating delirium should be avoided.
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat postoperative delirium.
• Benzodiazepines should not be used as first-line treatment of agitation associated with delirium.
• Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium.

Health professionals in long-term care (LTC) facilities can play a key role in continuing to implement interventions to prevent postoperative delirium. This is particularly important with regard to rehabilitation activities, as delirium can result in complications that delay initiation and implementation of rehabilitation and other factors that can adversely affect an older person’s surgical recovery and longer-term mental and physical health.
LTC personnel should be aware of delirium risk factors and communicate these to the hospital staff when transferring a resident to the hospital for scheduled surgery. These risk factors include age >65 years, chronic cognitive decline or dementia, poor vision or hearing, and serious illness or infection. Particularly important is communicating information on residents’ cognitive status, making note of any behavioral symptoms associated with dementia, and sharing the residents’ likes and dislikes and daily habits so these can be used in the hospital setting to decrease delirium risks. 

Well-established care transition practices can also help prevent postoperative delirium once a resident has returned to the LTC setting. These include medication reconciliation; good communication between the hospital and LTC staff, including receiving and reviewing a resident’s discharge summary in advance of being transferred; ensuring that residents have immediate access to hearing aids and glasses and are re-oriented to their surroundings; identifying any current or new medications that could contribute to delirium risk; and instituting a daily delirium screening of postoperative residents with a plan to initiate delirium interventions as early as possible.

Educating family members about the signs of delirium and strategies to help manage it is also key. The AGS Health in Aging Foundation offers companion public education materials in English and Spanish that can aid LTC personnel in engaging caregivers. In addition to the new AGS guidelines on delirium, be sure to utilize the just updated Geriatrics Evaluation and Management Tool on Delirium—which will appear in the December issue of Annals of Long-Term Care.