Protocol Lacking for Post-op Delirium

While 70% of anesthesiologists say they “frequently” or “occasionally” encounter postoperative delirium in their practices, more than three-fourths (77%) lack a process to screen for at-risk patients.

A survey of nearly 300 anesthesiologists revealed that postoperative delirium is extraordinarily common worldwide, with 95% of respondents reporting they have had such a patient. However, 60% said they did not commonly discuss possible neurologic complications with their patients prior to surgery. In addition, 84% said their hospital or clinic did not have protocols to prevent postoperative delirium and 73% said their facility lacked protocols to manage delirium when it occurred. Of anesthesiologists without a screening process, 88% said they would consider implementing one.

“We are shocked and disappointed to discover that the majority of hospitals and clinics do not have any protocols in place to screen for, detect or manage postoperative delirium,” said Guy d’Auriol, founder of POND Awareness (www.pondawareness.org), which commissioned the survey of attendees of the 16th World Congress of Anaesthesiologists, in Hong Kong last year. POND, or postoperative neurobehavioral disturbance, was deemed a significant underlying cause of death of Sandra d’Auriol, a 53-year-old British socialite, Mr. d-Auriol’s sister-in-law, who fell from a height to her death following lengthy cosmetic surgery at a clinic in Beverly Hills, Calif., in 2014.

Survey Finds High Awareness

The survey was sent to a convenience sample of about 3,000 registered conference attendees between Aug. 30, 2016 and Sept. 15, 2016, and 284 responded, said Michael G. Irwin, MD, head of anesthesiology at the University of Hong Kong, who helped conduct the study. Although the low response rate makes it difficult to extrapolate the findings to clinical practice, “from these results and my own personal experience, I do feel that the awareness of postoperative delirium and postoperative cognitive dysfunction—these are distinct entities—is actually very high among anesthesiologists,” Dr. Irwin told Anesthesiology News.

Postoperative delirium is considered to be the most common surgical complication in older adults, occurring in 5% to 50% of these patients after an operation (Lancet 2014;383:911-922). Delirium is especially serious for older adults because a single episode can initiate a cascade of deleterious clinical events, including prolonged hospitalization, loss of functional independence, reduced cognitive function and death (N Engl J Med 2012;367:30-39). Delirium is also particularly costly, responsible for an estimated $150 billion in annual direct health care costs in the United States, rivaling those caused by falls and diabetes (Arch Intern Med 2008;168:27-32).

According to a best practice statement issued recently by an expert panel from the American Geriatrics Society (Am Coll Surgeons 2015;220:136-148.e1), “Delirium is particularly compelling as a quality improvement target, because it is preventable in up to 40% of patients; therefore, it is an ideal candidate for preventive interventions targeted to improve the outcomes of older adults in the perioperative setting.”

The panel also published a clinical practice guideline (J Am Geriatr Soc2015;63:142-150) addressing the pharmacologic and nonpharmacologic interventions that should be implemented perioperatively to prevent postoperative delirium, as well as interventions to treat it if it occurs.

“Health care professionals competent in diagnosing delirium should perform a full clinical assessment in any patient suspected of having symptoms of delirium, found positive on a delirium screening test or having an acute cognitive change on repeated cognitive testing,” the best practice statement recommends. The diagnosis should be informed by use of a validated delirium diagnostic instrument, or through such recognized criteria as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases, Tenth Revision, or Confusion Assessment Method diagnostic algorithm.

“To date, the only intervention proven to be effective at reducing postoperative delirium is a preoperative geriatric consultation,” said Terri G. Monk, MD, professor of clinical anesthesiology at the University of Missouri School of Medicine, in Columbia. “There is growing evidence that simple preoperative cognitive tests that can be administered in less than five minutes are useful in predicting patients at risk for postoperative delirium,” Dr. Monk told Anesthesiology News. Although there is no agreement on which specific tests are best, “preoperative anesthesia clinics should routinely screen elders for cognitive impairment in order to identify those at risk for postoperative delirium,” she said.

Is Delirium Related to Anesthetic?

In the POND survey, about two-thirds of responding anesthesiologists (66%) believed that postoperative delirium was related to the type of anesthesia used, despite the fact that some studies have found only a weak correlation. For example, delirium rates after vascular surgery were similar for local, regional or general anesthesia techniques (J Cardiothorac Vasc Anesth 2014;28:458-461). “The presence of risk factors for the development of postoperative delirium should not influence the type of anesthesia provided,” the study authors concluded. However, among pediatric patients, the halogenated anesthetics sevoflurane, isoflurane and desflurane may alter brain activity and upset the balance between central nervous system neuronal synaptic excitation and inhibition (Anesthesiology 1999;91:1596-1603).

Despite “widespread misinformation that delirium is related to the type of anesthesia used …, most anesthesiologists feel that they would be open to implementing delirium screening in their practice,” said Stacie G. Deiner, MD, associate professor in the Department of Anesthesiology, Geriatrics and Palliative Care, and Neurosurgery, Icahn School of Medicine at Mount Sinai, in New York City.

Dr. Deiner urged anesthesiologists to “stay tuned” for information and best practice protocols expected from the American Society of Anesthesiologists’ Brain Health Initiative. This multistakeholder effort, initiated in mid-2016, focuses on delirium education for patients and providers. The goal is to create a toolbox to accelerate implementation of strategies associated with reducing postoperative delirium, including reducing or eliminating the administration of drugs known to increase the risk, according to Lee A. Fleisher, MD, chair of the Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, and chair of the ASA’s ad hoc Brain Health Initiative committee.

“We also hope to develop both patient and provider material to help recognize signs and symptoms of delirium and changes in cognitive function after surgery,” Dr. Fleisher wrote (ASA Monitor 2016;80:10-11). “The hope is that this material will be used to better inform patients about risks and help families and other providers ensure there are optimal safeguards available after discharge from the hospital.” The committee held its first brain health summit in September 2016.