Perioperative delirium
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Perioperative Delirium. Review the evidence on risk stratification, prevention, screening and management.
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Perioperative delirium
- 1. C A M I L L A W O N G Nov 2, 2019 Perioperative Risk Stratification, Prevention and Identification DELIRIUM
- 2. I have NO relevant financial relationships with any commercial interests. Financial Disclosures (over past 24 months) I have received research grant funding from the Ministry of Health and Long Term Care of Ontario (MOHLTC) and the Canadian Orthopedic Foundation for work related to perioperative geriatric models of care. I have received a speaker honorarium from the Ontario Association of General Surgeons for a presentation on perioperative geriatrics.
- 3. Objectives 1 2 3 4 To review based on the best available evidence, how to focus prevention risk stratify manage screen
- 4. Objectives 1 To review based on the best available evidence, how to risk stratify
- 5. BMJ Open 2018;8:e019223. RISK STRATIFICATION Informs shared- decision making about risks and benefits. Focuses evidence- based prevention strategies. 1 2
- 6. Adverse Outcomes Death, longer length of stay, hospital-acquired complications, persistent cognitive deficits, functional decline, discharge to long term care. NEJM 2017; 377:1456-1466.
- 7. Risk Factor Points age ≥ 70 1 alcohol abuse 1 cognitive impairment 1 severe physical impairment 1 markedly abnormal preoperative labs 1 AAA surgery 2 noncardiac thoracic surgery 1 Low risk: 0 points Moderate risk: 1-2 points High risk: ≥3 points Κ = 0.90 ROC 0.78 ± 0.04 JAMA 1994; 271:134-139. Delirium after non-cardiac surgery (example)
- 8. Risk Factor Points MMSE ≤ 23 1 MMSE 24-27 1 history of TIA/stroke 1 Geriatric Depression Scale (15-item) score > 4 1 abnormal albumin 1 Low risk: 0 points Moderate risk: 1-2 points High risk: ≥3 points C-statistic 0.75 Circulation. 2009;119:229-236. Delirium after cardiac surgery (example)
- 10. J Gen Intern Med. 2018;33(4):500-509.
- 11. “The risk calculators are meant to serve as decision aids. Numbers, whether taken in isolation or as an index, are NOT a substitute for clinical evaluation and clinical judgment.” JAMA Intern Med. 2019
- 12. Objectives 2 To review based on the best available evidence, how to focus prevention
- 13. using processed EEG to help deliver the optimal depth of anaesthesia MAY reduce delirium incidence: RR 0.71 (95% CI 0.59 to 0.85), NNTB=17 (95% CI 11 to 34) Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD011283.
- 14. PLoS One. 2019 Aug 16;14(8):e0218088. D E X M E D E T O M I D I N E may reduce postoperative delirium RR = 0.61, 95% CI 0.34–0.76, P = 0.001
- 15. Ann Intern Med. 2019;171:474-484. “There is limited evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but more research is needed.”
- 16. cholinesterase inhibitors gabapentin melatonin ketamine simvastatin tryptophan fail verb be unsuccessful in achieving one's goal in·trigue verb arouse the curiosity or interest of parecoxib methylprednisolone IV acetaminophen
- 17. “Why is it acceptable care if the physical therapist doesn’t come every day but not acceptable care if antibiotics are not given daily? Or acceptable to miss meals all day waiting for procedures that are often cancelled? Why do the alarms go off in the patient’s room if it is the nurse who should be notified? For debilitated patients, why can’t testing and procedures be done in the afternoon, so the mornings and evenings can be used for physical therapy, optimizing nutrition, self-care, rest, and time with family? Why does medical treatment trump recovery?” JAMA. 2019;321(13):1253-1254.
- 19. Relative Risk 0.71 (95% CI, 0.59-0.85) Strength of evidence: Strong Cochrane Database Syst Rev. 2016;3:CD005563. Cochrane Database Syst Rev. 2016;3:CD005563. multicomponent interventions
- 20. NNP = 6 JAMA Intern Med 2019; ahead of print.
- 21. Objectives 3 To review based on the best available evidence, how to screen
- 22. Feature 1 Acute onset or fluctuations in mental status Feature 2 Inattention Feature 3 Disorganized thinking Feature 4 Altered Level of Consciousness Confusion Assessment Method (CAM) and and either or DELIRIUM JAMA. 2010;304:779-786. +LR = 9.6 -LR = 0.16
- 24. 2 1 8 5 4 FEATURE 2
- 25. 4 5 8 1 2 FEATURE 2
- 26. Objectives 4 To review based on the best available evidence, how to manage
- 27. S h o u l d a n t i p s y c h o t i c s b e u s e d f o r d e l i r i u m ?
- 28. Cochrane Database Syst Rev. 2018;6:CD005594. Antipsychotics have NO significant effect on: • delirium duration • delirium severity • symptom resolution
- 29. Look for underlying causes. Delirium is a symptom, not a diagnosis.
- 30. 10. If it is delirium, call it delirium. 9. Ask the family "Is this a change?" 8. Test for inattention. 7. Antipsychotics treat the provider rather than serve the best interest of the patient. 6. Ask WHY are they delirious? 5. Risk calculators may inform but do not replace clinical judgement. 4. Make friends with the anesthesiologists. 3. Make friends with the allied health team. 2. Empower the family. Top 10 Tips
- 31. #1
- 33. C A M I L L A W O N G @camilla_wong Thank you.
- 34. Cochrane Database Syst Rev. 2018 Jan 31;1:CD012485. Comprehensive Geriatric Assessment may reduce delirium
Editor's Notes
- Delirium, defined as an acute disorder of attention and cognition, is a common, life-threatening, and often preventable clinical syndrome in older persons. Often occurring after acute illness, surgery, or hospitalization, the development of delirium initiates a cascade of events culminating in loss of independence, increased morbidity and mortality, institutionalization, and high health care costs. Postoperative cognitive dysfunction is a separate condition that refers to a decline in cognitive function following surgery as measured by neuropsychological testing. There has been significant recent work to redefine this condition to align with geriatric research. Medical associations such as the UK’s National Institute for Health and Care Excellence, the European Society of Anaesthesiology, and the American Geriatrics Society offer evidence-based guidelines for postoperative delirium management
- A delirium prediction model is a statistical model that either stratified individuals for their level of delirium risk, or assigned a risk score to an individual based on the number and/or weighted value of predetermined modifiable and non-modifiable risk factors of delirium present. BMJ Open 2018;8:e019223. variable definitions for the risk factors assessment of outcome variable, delirium, was largely non-systematic and once daily some include precipitating factors, which if collected after onset of delirium would exaggerate model performance not all have external validation, and those that did were often narrow validation studies
- The prevalence of postoperative delirium (POD) in elderly patients after noncardiac surgery is approximately 13% to 50% A systematic review showed that incident hospital delirium persisted at hospital discharge in 45% of cases and 1 month later in 33% of cases
- Ideally, prospectively derived, independently externally validated, easy to use, and have good psychometric properties
- Systematic review of twenty-three delirium prediction models were identified, 14 were externally validated and 3 were internally validated. The following populations were represented: 11 medical, 3 medical/surgical and 13 surgical. The assessment of delirium was often nonsystematic, resulting in varied incidence. Fourteen models were externally validated with an area under the receiver operating curve range from 0.52 to 0.94. Limitations in design, data collection methods and model metric reporting statistics were identified. demonstrates the frequency of variable use in the 14 externally validated delirium prediction models variable definitions for the risk factors assessment of outcome variable, delirium, was largely non-systematic and once daily some include precipitating factors, which if collected after onset of delirium would exaggerate model performance not all have external validation, and those that did were often narrow validation studies
- Another approach is to identify prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery from cohort studies. That is what was done with this systematic review.
- The risk calculators are meant to serve as decision aids. Numbers, whether taken in isolation or as an index, are NOT a substitute for clinical evaluation and clinical judgment.
- The American Geriatric Society, the European Society of Anesthesiologists, and the UK’s National Institute for Health and Care Excellence all recommend that intraoperative electroencephalogram monitoring should be considered to prevent excessive anesthetic administration to patients at high risk of postoperative delirium. Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95%CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome: (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence). STRIDE and ENGAGES trial since this review. Contradicting results. One of the most important baseline patient-related factors contributing to adverse postoperative cognitive outcomes is preexisting cognitive impairment. Therefore, the depth of anesthesia may simply be a marker for patient’s baseline brain vulnerability to the effects of anesthetics. The differentiation between direct effects of anesthetic effects on the brain versus patients’ baseline vulnerability is critical to understanding the relationship between delirium and the role of the use of processed electroencephalogram-guided anesthesia. Two trials underway: ENGAGES-Canada Trial Balanced Anesthesia Trial (primary outcome of mortality was just reported in the Lancet in Oct 2019)
- Dexmedetomidine for the prevention of postoperative delirium in elderly patients undergoing noncardiac surgery: A meta-analysis of randomized controlled trials. PLoS One. 2019 Aug 16;14(8):e0218088. Dexmedetomidine, a highly selective alpha-2 adrenoreceptor agonist, has the positive sedation, anti-anxiety, and analgesic effects A total of 6 RCTs with 2102 participants were included. Compared with PLACEBO, dexmedetomidine significantly reduced the prevalence of POD (RR = 0.61, 95% CI 0.34–0.76, P = 0.001, I2 = 66%), and the risk of tachycardia (RR = 0.48, 95% CI 0.30–0.76, P = 0.002, I2 = 0%), hypertension (RR = 0.59, 95% CI 0.44–0.79, P < 0.001, I2 = 20%), stroke (RR = 0.22, 95% CI 0.06–0.76, P = 0.02, I2 = 0%), and hypoxaemia (RR = 0.50, 95% CI 0.32–0.78, P = 0.002, I2 = 0%) in elderly patients who underwent noncardiac surgery. However, dexmedetomidine accelerated the occurrence of bradycardia (RR = 1.36, 95% CI 1.11–1.67, P = 0.003, I2 = 0%). Furthermore, no significant differences were observed in the incidence of hypotension, myocardial infarction, and all-cause mortality between the dexmedetomidine and placebo groups. moderate heterogeneity among the included trials, including in variables such as intervention time (intraoperative, intraoperative plus postoperative, and postoperative), type of surgery, sedative dose and rate of dexmedetomidine infusion, and patient characteristics
- In a systematic review published in September 2019 in the Annals of Internal Medicine. 2 cardiac surgery (risperidone) 1 ortho join replacement (olanzapine) – in those that developed delirium, longer and more severe.
- Other drugs
- JAMA Intern Med. Published online October 21, 2019. doi:10.1001/jamainternmed.2019.4914
- Sensory – glasses, hearing Cognitive stimulation and orientation – default position for hospitalized, not antagonistic Fluid and nutrition – n.p.o. with spine precautions, constipation, urinary retention Mobility – one-point restraint (IV), two-point restraint (Foley). Sleep – ear plugs, noise reduction, avoiding tests/meds at night, by the window Medication review – avoiding anticholinergics (Gravol), sedatives (benzos, zopiclone) Pain – multimodal pain strategies including fascia iliaca blocks, standing acetaminophen
- Surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants) consistent, reproducible intervention for preventing Delirium Future directions: cognitive prehabilitation
- The Tailored, Family-Involved Hospital Elder Life Program may be beneficial for older patients who undergo noncardiac surgical treatment as it appears to help in reducing postoperative delirium, maintaining physical and cognitive functions, and shortening the length of hospital stay.
- There are no randomized controlled trials examining routine delirium screening in hospitalized patients. Risks of routine delirium screening include misdiagnosis, costs and risks of evaluation, and inappropriate treatment such as with antipsychotic medications. But if screening is done, it has to be done using a validated instrument by a trained clinician.
- The word “confused” does not provide any clarification to the underlying problem. If it’s delirium, call it delirium. Sensitivity: 94-100% Specificity: 90-95% +LR = 9.6 -LR = 0.16
- The cornerstone of diagnosis is determining the patient’s baseline mental status and the acuity of any changes; with delirium, the changes typically occur over hours to days. This step is critical and requires obtaining the history from a knowledgeable informant. Neglecting the baseline mental status assessment is a leading reason for a missed diagnosis, since the acute change might otherwise be missed. An acute change in mental status from baseline may distinguish delirium from other conditions. Furthermore, inattention, while common in delirium, tends to occur in later stages of dementia. For accurate differential diagnosis, knowledge of the patient’s baseline is essential to make the diagnosis. Alteration in the level of consciousness is another feature unique to delirium that is less common with dementia, depression, or psychosis.
- Inattention is the sine qua non of delirium, with difficulties sustaining, focusing, or shifting attention. It must be formally tested.
- A systematic review of 9 low quality trials with 727 participants concluded antipsychotics did NOT reduce delirium severity, resolve symptoms, or alter mortality: Delirium duration Not reported in trials Delirium severity SMD -1.08 (-2.55 to 0.39) Delirium symptom resolution RR 0.95 (95% CI 0.30 to 2.98) Mortality RR 1.29 (0.73 to 2.27) Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD005594
- Medication, pain, infection, bleed, traumatic brain injury, PE, etc Delirium is a symptom, not a diagnosis.
- 10 .If it is delirium, call it delirium. The word “confused” does not provide any clarification to the underlying problem. 9. Ask the family "Is this a change?” Then educate and empower the family. 8. Test for inattention. Formally. 7. Antipsychotics treat the provider rather than serve the best interest of the patient. 6. Ask why are they delirious? Delirium is a symptom, not a diagnosis. Precipitants are frequently iatrogenic. 5. Risk calculators may inform but do not replace clinical judgment. Allows for focusing prevention efforts. 4. Make friends with the anesthesiologists. They can, at their discretion use different monitoring systems, administer peripheral nerve blocks, use non-benzodiazepine based sedation strategies. 3. Make friends with the allied health team. Best evidence supports multicomponent prevention interventions. 2. Empower the family. Multicomponent prevention interventions may be even better when delivered by family. 1. An ounce of prevention is worth a pound of cure.
- An evidence-based approach to perioperative delirium necessitates interdisciplinary and cross-specialty collaboration.
- The intervention may make little or no difference for delirium rates (RR 0.75,95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence).