The American Geriatrics Society (AGS) has released a new practice guideline for preventing and treating postoperative delirium in patients aged 65 years or older. The guideline was published onlineNovember 4 on the AGS website. An additional best practices document containing almost all guideline recommendations plus additional clinical recommendations was published in the Journal of the American College of Surgeons.
The expert panel members represented 20 disciplines and included both a representative of the National Committee for Quality Assurance and a caregiver representative.
“Our panel completed an extensive review of the literature while developing these recommendations,” AGS President Wayne C. McCormick, MD, MPH, noted in a news release. “The process also included review by organizations with expertise in this area and an open public comment period.”
“Delirium is among the most common post-operative complications for older adults undergoing surgery,” Andrew G. Lee, MD, chair of the AGS Section for Surgical and Related Medical Specialists, said in the news release. “It is upsetting for patients and families, and can be harmful if not recognized and treated. Studies have shown that delirium can be prevented in up to 40% of cases in some hospitalized older adult populations. We believe that surgical and related medical specialists, together with the multi-disciplinary members of their teams, can play an integral role in prevention.”
The recommendations in the best practices article range from what to do before, during, and after surgery to what not to do to prevent and treat delirium in postoperative patients. They include:
· Clinicians should perform a preoperative and postoperative assessment of delirium risk factors, including age older than 65 years, poor vision or hearing, severe illness, and presence of infection or chronic cognitive decline or dementia.
· Healthcare professionals should be trained in the recognition and documentation of delirium signs and symptoms.
· Anesthesiologists “may use processed electroencephalographic monitors of anesthetic depth during sedation or general anesthesia,” with the reasoning that administering fewer or lower doses will reduce postoperative delirium compared with deeper sedation.
· Prescribers should avoid medications that may induce postoperative delirium, including anticholinergics, corticosteroids, meperidine, and hypnotics. The use of five or more medications increases the risk for delirium.
· Clinicians should consider providing regional anesthesia during and after surgery for pain control.
· Hospitals and healthcare systems should implement formal educational programs and refresher sessions and should develop multicomponent interventions to be delivered by multidisciplinary teams.
· Prescribers should not prescribe antipsychotics or benzodiazepines to older patients who are not a threat for personal harm or harm to others and should not prescribe benzodiazepines as first-line treatment for such a patient.
· Prescribers should use the lowest effective dose of benzodiazepines and antipsychotics for the shortest duration, and only after behavioral interventions have failed.
The panel structured recommendations based on the Institute of Medicine’s guideline development advistory publication. To develop the best practices article, panel members subjected statements to extensive peer review by surgical and nonsurgical experts and organizations with special interest and expertise in preventing and treating postoperative delirium in older patients.
The panel members conclude, “Successful postoperative management of delirium for older adults requires knowledge of approaches for screening, diagnosis, risk factor assessment, and nonpharmacologic and pharmacologic interventions aimed to prevent and treat delirium. The recommendation statements within provide a framework to allow hospital systems and health care professionals to implement actionable, evidence-based measures to address the highly morbid problem of delirium in perioperative patients.”