INTRODUCTION

During rounds on my trauma surgery rotation, we discussed our plan for Ms. H, an elderly woman admitted to our service after sustaining several nonoperative fractures after a fall. As we entered her room, we were startled to see her sitting straight up in bed, energetic and expressive. We were surprised – the Ms. H who we’d met yesterday had been discombobulated and disoriented, unable to articulate her needs clearly. What had prompted the sudden turnaround in her mental status?

The day prior, Ms. H had been seen by our comanaging geriatrics service, who made several recommendations for delirium management, including moving our patient to a bed closer to a window. Could our delirium prevention strategies have led to this drastic change? My co-interns – all surgical and anesthesiology residents training in fields where quick and sometimes drastic actions are commonplace – marveled at the idea that simply exposing a patient to sunlight could lead to such changes in mental status. Our curiosity was piqued. From then on, whenever we’d round on a patient who seemed confused, we’d report during multidisciplinary rounds the need to implement delirium precautions, including getting patients into what we called a “prophylactic window bed.” Of course, our patients’ improvement in mental status was likely multifactorial, but it was clear that implementation of quick and easy precautions had swift and staggering benefits.

Delirium remains one of the most common complications faced by hospitalized older adults and is associated with increased mortality, longer hospital stays, and decreased functional capacity.1 Up to around 50% of postoperative non-cardiac surgical patients can experience postoperative delirium.2 Despite its impact, delirium prevention is underemphasized within surgical training.3 I’m writing this article as an anesthesiology resident for my fellow perioperative and surgical trainees, so that we can identify and prevent delirium while patients are under our care.

IDENTIFYING DELIRIUM IN SURGICAL PATIENTS

Delirium may be underrecognized and undertreated due to uncertainty regarding its diagnosis and subsequent management. Although several validated delirium risk assessments for surgical patients exist,4 the cornerstone of delirium management is the recognition of a fluctuating mental status. The best time to get an understanding and documentation of a patient’s baseline mental status is before surgery; of course, cognition and capacity should always be ascertained as part of the consent process. For patients who are arriving at the hospital for emergency procedures, for example, after a fall, many of the risk factors leading to delirium discussed below, such as pain, dehydration, or infection, may already have triggered its onset; in this scenario, collateral from family and caregivers will be incredibly important to confirm a change in mental status.

MANAGEMENT OF DELIRIUM IN SURGICAL PATIENTS

The etiology of delirium is multifactorial, and treatment courses will vary based on the underlying cause. Although not an exhaustive list of recommendations, highlighted below are several common causes of delirium in surgical patients and simple, nonpharmacological interventions that can be applied as a trainee for its management.

  1. Orientation: After confirming with the patient and their caregivers the baseline mental status, take every opportunity to remind the patient of the date, location, and time of day.

  2. Medications: Medication reconciliation of the patient’s home medications should be conducted with patients, caregivers, or pharmacists. Perioperative providers should familiarize themselves with the Beers criteria,5 guidelines that highlight medications to use with caution, including common perioperative medications like opioids or anticholinergics. Consider discussing a patient’s current home medication regimen with a primary care provider if concerned about polypharmacy, which can increase rates of postoperative delirium.6

  3. Sensory input: Ensure that patients receive all sensory devices, such as glasses or hearing aids, in the recovery room. If the patient is planned for admission after surgery, ask family or caregivers if they can bring in all sensory aids for use during their stay.

  4. Seizures and strokes: Consider structural causes when a change in mental status is observed and imaging if patients have focal neurological exam changes; about one in four stroke patients will have signs of delirium at the onset of their symptoms.7

  5. Infection: Some studies estimate almost 50% of delirium cases are associated with infection, most commonly UTI or pneumonias.8

  6. Urinary and stool retention: If surgery was unexpectedly long or complex without preoperative foley placement, consider straight catheterization of the patient prior to emergence from anesthesia to avoid immediate post-op bladder discomfort. As always, keep a close eye on trial of void and post-void residuals, as well as bowel movements postoperatively.

  7. Nutrition, dehydration, and electrolytes: Ensure regular mealtimes and fluid intake as appropriate perioperatively. Metabolic derangements of any kind can contribute to delirium. For patients in the immediate postoperative period, include hypercarbia and hypoxia in your differential for altered mental status and determine the need for reversal of certain anesthetic agents such as opioids or neuromuscular blockade if present.

  8. Early mobilization: Studies among surgical intensive care patients have shown that early, daily mobility exercises can decrease delirium and allow patients to remain more functionally independent after discharge.9 If your institution has a Hospital Elder Life Program (HELP), see if they can get involved with your surgical patients and help conduct mobility activities with patients in addition to formal physical therapy.2

  9. Sleep: Ensure the patient has access to daylight, and minimize nighttime interruptions by decreasing alarms and scheduling medications such that patients don’t need to be awakened throughout the night. Engage family in keeping the patient stimulated during the day.

Finally, education and awareness among providers itself has been shown to reduce the incidence of delirium,1 and surgical trainees who do receive training on delirium management agree that it should be a cornerstone of surgical education.3 Surgical residents are often responsible for coordinating care and can play an instrumental role in bringing integrative and comprehensive care to older adults. Residents should engage with nurses, social workers, physical therapists, and family to promote opportunities for mobility, pain control, sleep, and orientation. Cultivating an awareness of delirium and developing habits for its prevention and timely management will allow surgeons-in-training to become advocates for delirium prevention.