Author: Carol J. Peden, M.D
A new paper defines the key practical steps that can be taken before, during, and after surgery to reduce patients’ risk of developing delirium and related problems that have long-term implications for brain health. Due to their unique role in perioperative care, physician anesthesiologists are ideally suited to lead multidisciplinary teams to implement these recommendations devoted to ensuring safety for all patients.
These are the findings of a consensus review paper put together by an international group of experts, published today in the British Journal of Anaesthesia, (@BJAJournals) the peer-reviewed journal of the Royal College of Anaesthetists.
Delirium and postoperative neurocognitive disorder (PND) are the most common perioperative complications in patients over 65 years of age. Patients who experience delirium have longer hospital stays, more complications, and increased costs.
The Perioperative Brain Health Initiative of the American Society of Anesthesiologists (ASA) convened the group to review published best practices. In all, the experts reviewed a total of eight publications that included 88 best practice statements and guidelines to create their recommendations.
The Perioperative Brain Health Initiative’s six recommendations address:
1. Training and Education. Anesthesiologists should guide initiatives to ensure that all staff who work with older patients having surgery receive training in how to identify and manage older patients with delirium.
2. Preoperative Cognitive Screening. All older adult patients having surgery should receive baseline cognitive screening using a recognized test. Physician anesthesiologists should choose a simple test such as the Mini-Cog® suited to busy preoperative environments.
3. Postoperative Delirium Screening. All older adult patients having surgery should be screened for delirium before leaving the recovery unit. Again, physician anesthesiologists should choose a simple, recognized test. This test should be repeated twice daily during hospitalization.
4. Non-pharmacologic Interventions to Prevent Delirium. The entire perioperative care team should work together to support older patients. This includes getting patients walking, periodically orienting them to where they are, and providing physical therapy. Additionally, glasses, dentures and hearing aids should be returned to patients as soon as possible after surgery.
5. Pain Control. Patients whose pain is well-controlled after surgery are less likely to develop delirium. Physician anesthesiologists should work with surgeons to optimize postoperative pain control, preferably with minimally sedating pain relief and using multimodal techniques.
6. Treating Delirium without Anti-psychotic Drugs. Physicians should generally not treat delirium with antipsychotic drugs and benzodiazepines as a first response. Instead, staff should involve family members to help reorient the patient and focus on pain relief and other treatable factors. All health professionals throughout the patient’s stay should understand and follow this approach.
Lead author Carol J. Peden, M.D., adjunct professor of Clinical Anesthesiology at Keck Medicine of the University of Southern California and the University of Pennsylvania, notes that none of the six recommendations require new equipment or new drugs. “The recommendations are relatively simple evidence-based statements, which if widely implemented could reduce the incidence of delirium in older patients having surgery,” she said. “Reducing the incidence of delirium is not in the hands of physician anesthesiologists alone, but we are well-placed to help lead the organizational initiatives needed to address the problem.”