Focusing on Perioperative Delirium

Hospitalists who are assisting in preoperative and perioperative care need to consider the likelihood of delirium in patients, which can have an increased role in morbidity and mortality, according to Neil Winawer, MD, the director of the hospital medicine service at Grady Memorial Hospital in Atlanta, GA.

Winawer says that although delirium can be as likely to result in morbidity and mortality as other diseases, hospitalists generally minimize its significance in patients before and after surgery.

He adds that hospitalists must pay more attention to patients who seem to be suffering from delirium, as it can decrease the patient’s willingness to properly follow treatment and participate in post-operative care.

Winawer discussed two specific groups of patients in his article—elderly patients and those who may be suffering from either drug or alcohol withdrawal.

“In older patients, you sometimes can perform a series of tweaks and the delirium may be much better the next day,” Winawer says. For younger patients with less comorbidities, delirium can signal a “much larger insult,” like an infection or substance withdrawal.

Winawer discussed studies in his interview, which show that delirium can develop in anywhere from 14 to 56 percent of elderly patients. Those patients are twice as likely to die within a year of their hospitalization and have a rate of in-hospital mortality of 22 to 76 percent.

Asking patients before admission to the hospital can help hospitalists determine whether or not they are at risk for withdrawal, Winawer says.

Also, because patients may not think of OTC products as “drugs,” it is important for hospitalists to assess what OTC medications patients use. Certain classes of these drugs, such as the antihistamines Benadryl and Tylenol-PM, are associated with a higher risk of delirium.

Questions that are covered during a routine patient history—underlying dementias or psychiatric issues and renal and liver function—can also contribute to delirium and may help hospitalists uncover risk levels before any procedures.

Dr. Winawer suggests that the following strategies may help prevent the progression of delirium in hospitalized patients who are at high risk for the illness:

- Regularly orient the patient. That includes raising window shades during the day, writing the date and day of the week on a blackboard in the room, and advising families to be at the bedside as often as possible.

- Keep the environment as quiet and non-stressful as possible. Make sure that patients are not woken up during the night for non-emergency care, such as taking vital signs.

- Other recommendations include mobilizing early and minimizing the use of restraints; making sure patients with sensory deprivation have their hearing aids and glasses; and ordering adequate hydration.