Your postop patient is confused and agitated—next steps?

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Applied Evidence

Your postop patient is confused and agitated—next steps?

J Fam Pract. 2015 June;64(6):361-366

By

Jackson Ng, MD

Cynthia X. Pan, MD

Aleksander Geube, MD

Your older patient exhibits signs and symptoms that suggest delirium. Here’s how to best handle this complication.

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References

1. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015;220:136-148.

2. Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology. 2009;110:1176-1181.

3. O’Keeffe ST, Ní Chonchubhair A. Postoperative delirium in the elderly. Br J Anaesth. 1994;73:673-687.

4. Mangnall LT, Gallagher R, Stein-Parbury J. Postoperative delirium after colorectal surgery in older patients. Am J Crit Care. 2011;20:45-55.

5. American Geriatrics Society. American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults: November 2014. American Geriatrics Society Web site. Available at: http://geriatricscareonline.org/ProductAbstract/americangeriatrics-society-clinical-practice-guideline-for-postoperativedelirium-in-older-adults/CL018. Accessed April 7, 2015.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing: 2013.

7. Potter J, George J; Guideline Development Group. The prevention, diagnosis and management of delirium in older people: concise guidelines. Clin Med. 2006;6:303-308.

8. Alzheimer’s Association. Cognitive Assessment Toolkit: A guide to detect cognitive impairment quickly and efficiently during the Medicare Annual Wellness Visit. 1999. Alzheimer’s Association Web site. Available at: http://www.alz.org/documents_custom/The%20Cognitive%20Assessment%20Toolkit%20Copy_v1.pdf. Accessed April 6, 2015.

9. The Hospital Elder Life Program. Hospital Elder Life Program (HELP) for Prevention of Delirium. The Hospital Elder Life Program Web site. Available at: http://www.hospitalelderlifeprogram.org. Accessed April 9, 2015.

10. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941-948.

11. Wei LA, Fearing MA, Sternberg EJ, et al. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc. 2008;56:823-830.

12. Pisani MA, Araujo KL, Van Ness PH, et al. A research algorithm to improve detection of delirium in the intensive care unit. Crit Care. 2006;10:R121.

13. Simon L, Jewell N, Brokel J. Management of acute delirium in hospitalized elderly: a process improvement project. Geriatr Nurs. 1997;18:150-154.

14. Fish DN. Treatment of delirium in the critically ill patient. Clin Pharm. 1991;10:456-466.

15. Böhner H, Hummel TC, Habel U, et al. Predicting delirium after vascular surgery: a model based on pre- and intraoperative data. Ann Surg. 2003;238:149-156.

16. Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci. 2013;263:353-364.

17. Robinson TN, Eiseman B. Postoperative delirium in the elderly: diagnosis and management. Clin Interven Aging. 2008;3:351-355.

18. Demeure MJ, Fain MJ. The elderly surgical patient and postoperative delirium. J Am Coll Surg. 2006;203:752-757.

19. Ghandour A, Saab R, Mehr DR. Detecting and treating delirium—key interventions you may be missing. J Fam Pract. 2011;60:726-734.

20. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275:852-857.

21. Gaudreau JD, Gagnon P, Roy MA, et al. Association between psychoactive medications and delirium in hospitalized patients: a critical review. Psychosomatics. 2005;46:302-316.

22. Tune L, Carr S, Cooper T, et al. Association of anticholinergic activity of prescribed medications with postoperative delirium. J Neuropsychiatry Clin Neurosci. 1993;5:208-210.

23. Hitzeman N, Belsky K. Appropriate use of polypharmacy for older patients. Am Fam Physician. 2013;87:483-484.

24. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76-81.

25. Ross DD, Alexander CS. Management of common symptoms in terminally ill patients: Part II. Constipation, delirium, and dyspnea. Am Fam Physician. 2001;64:1019-1027.

26. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry. 1999;156:1-20.

27. Mantz J, Hemmings HC, Boddaert J. Case scenario: postoperative delirium in elderly surgical patients. Anesthesiology. 2010;112:189-195.

28. Gleason OC. Delirium. Am Fam Physician. 2003;67:1027-1034.

29. Pae CU, Lee SJ, Lee CU, et al. A pilot trial of quetiapine for the treatment of patients with delirium. Hum Psychopharmacol. 2004;19:125-127.

30. Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics. 2002;43:171-174.

31. Skrobik YK, Bergeron N, Dumont M, et al. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med. 2004;30:444-449.

32. Kohen I, Lester PE, Lam S. Antipsychotic treatments for the elderly: efficacy and safety of aripiprazole. Neuropsychiatr Dis Treat. 2010;6:47-58.

33. Farrell TW, Dosa D. The assessment and management of hypoactive delirium. Geriatrics for the Practicing Physician. 2007;90:393-395.

34. Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology. 2009;110:1176-1181.

35. Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J. 2004;80:388-393.

PRACTICE RECOMMENDATIONS

› Conduct a baseline cognitive assessment during your patient’s routine visits and preoperative assessments to gauge his or her risk for delirium. A
› Work with the hospital team to implement nonpharmacologic interventions, such as reorienting the patient to day and time and avoiding sensory deprivation, as an initial treatment for delirium. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Your patient, Mark Q, age 80, is admitted to the hospital to undergo hemicolectomy for colon cancer. His medical history includes hypertension, benign prostatic hyperplasia, and colon cancer. He did well immediately postop, but when you make morning rounds the day after his surgery, you notice that he is confused and agitated. Mr. Q’s chart reveals that earlier that morning, he pulled out his Foley catheter and intravenous (IV) line when his nurse declined his request to walk him to the bathroom.

How would you proceed?

Up to 50% of older adults who undergo surgical procedures develop delirium—a disturbance in attention and awareness accompanied by changes in cognition.¹ Older adults are at heightened risk for this postoperative complication for several reasons. For one thing, older patients have a reduced capacity for homeostatic regulation when they undergo anesthesia and surgery.² For another, age-related changes in brain neurochemistry and drug metabolism increase the likelihood of adverse drug effects, including those that could precipitate delirirum.³

Risk factors for postop delirium include age >65 years, dementia, poor vision, decreased hearing, severe illness, and infection.

Although postop delirium is a common complication in older patients, it sometimes goes unrecognized. Missed or delayed diagnosis of delirium can result in patients exhibiting behaviors that can compromise their safety, delay recuperation, and result in longer hospital stays, a greater financial burden, and increased morbidity and mortality.⁴ The American Geriatric Society recently published clinical guidelines and a best practices statement for preventing and treating postop delirium in patients ages >65 years.^1,5 This article describes steps family physicians can take to assess their patients’ risk of delirium before they undergo surgery, and to recognize and treat delirium in the postop period.

Defining delirium

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the criteria for delirium are:⁶
A. A disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (eg, memory deficits, disorientation, language, visuospatial ability, perception).
D. The disturbances in attention, awareness, and cognition aren’t better explained by another preexisting or evolving neurocognitive disorder and don’t occur in the context of a severely reduced level of arousal.
E. History, physical, or laboratory findings show that the disturbance is caused by the direct physiologic consequences of a general medical condition, substance intoxication/withdrawal, exposure to a toxin, or multiple etiologies.

The 3 subtypes of delirium are based on patients’ psychomotor activity.⁷ In hyperactive delirium, patients exhibit heightened arousal, restlessness, agitation, hallucinations, and inappropriate behavior. Hypoactive delirium is characterized by lethargy, reduced motor activity, incoherent speech, and lack of interest. Mixed delirium consists of a combination of hyperactive and hypoactive signs and symptoms.

Gauge risk before patients undergo surgery

Family physicians can assess their patients’ risk for developing delirium by conducting baseline screening during routine office visits as well as during preoperative evaluations. Factors that increase postop delirium risk include:¹
• age >65 years
• dementia
• poor vision
• decreased hearing
• severe illness
• infection.

Routine cognitive screening can be done easily and efficiently using readily available tools such as the Alzheimer Association’s Cognitive Assessment Toolkit.⁸ This toolkit includes 3 brief, validated screening tools to identify patients with probable cognitive impairment: the General Practitioner Assessment of Cognition, the Memory Impairment Screen, and the Mini-Cog.

If preop screening indicates that the patient is at increased risk for delirium, the family physician should work with hospital’s interdisciplinary teams to institute prevention measures, such as the Hospital Elder Life Program (HELP).⁹ This program offers a structured curriculum for instructing volunteers to deliver daily orientation, early mobilization, feeding assistance, therapeutic activities, and other measures to help prevent delirium.

Prompt screening after surgery is essential, too

In addition to preop delirium risk assessment, all patients who undergo surgery should receive daily delirium screening during the first postoperative week. The Confusion Assessment Method (CAM) is a quick screening tool for assessing a patient’s level of arousal and consciousness.¹⁰ Based on the results of 7 high-quality studies (N=1071), CAM has a sensitivity of 94% (95% confidence interval [CI], 91%-97%) and specificity of 89% (95% CI, 85%-94%).^11,12