PSMF Targets Problem of Postoperative Delirium in Older Adults

By Jay Kumar

As it works toward its goal of eliminating preventable in-hospital deaths, the Patient Safety Movement Foundation (PSMF) has identified a new challenge to target: postoperative delirium.

Speaking in January at the 7^th annual meeting of the World Patient Safety Science & Technology Summit in Huntington Beach, California, a panel of experts discussed the issues around postoperative delirium and how to detect and prevent it. The PSMF has named postoperative delirium as its 18^th patient safety challenge, collecting solutions for organizations to implement to reduce the number of preventable deaths from the condition.

Delirium is a condition of acute cerebral dysfunction that may be seen in patients in the early postoperative period or in patients in the intensive care unit (ICU). The condition is found frequently in elderly patients, but the diagnosis is often missed. In some patients, it manifests in hyperactivity and requires immediate intervention.

The audience heard the story of Audrey Curtis, an Australian retiree, who was in the hospital in March 2017 to undergo an operation to replace her aortic valve. After 48 hours in the ICU postoperatively, Curtis was moved back to a general ward. She began hallucinating and, believing she had been kidnapped and tied up with rope, pulled out all the tubes attached to her body. Curtis said the nursing staff never mentioned the incident after the initial nurse responded. Nearly two years later, she still remembers the visions vividly and is hesitant to undergo any further surgery.

“Delirium is a manifestation of brain organ dysfunction,” said Pratik Pandharipande, MD, MSCI, professor and chief of anesthesiology critical care medicine, Vanderbilt University Medical Center.

Delirium occurs in 62% to 80% of mechanically ventilated patients, and it has ramifications months to years later, he said.

Assessing delirium

One way to check for delirium in patients is to use the Confusion Assessment Method for the ICU (CAM-ICU), a tool that can help clinicians determine whether delirium is present.

“Delirium is associated with four times the risk of mortality in the ICU,” said David A. Scott, MD, PhD, FANZCA, FFPMANZCA, director of anesthesia and acute pain medicine, St. Vincent’s Hospital Melbourne in Australia. “If your brain is not functioning well, everything else follows.”

Seventy-five percent of delirium cases are hypoactive, he said. In these instances, patients are quiet, don’t tell nurses about problems, and forget instructions.

Lee Fleisher, MD, professor and chair of anesthesiology and critical care, Perelman School of Medicine, University of Pennsylvania, said one of his facility’s patients describes the condition as “the brain fog.”

To help raise awareness with patients, Fleisher added, there’s an effort to develop infographics to give to providers working with the AARP. “Patients thought they were demented, or had a stroke,” he said. “We need to tell patients that this could happen.”

Fleisher also said there’s increasing evidence that delirium may have a downstream effect on increased dementia. If healthcare providers can prevent delirium, there’s a chance it may lead to reduced cases of Alzheimer’s disease, he added.

The latest estimates are that there are 12 million delirium patients per year globally, said Adrian Gelb, MD, MBChB, FRCPC, secretary, World Federation Societies of Anaesthesiologists. “If you factor people who don’t come to the ICU, that’s 20 million people,” he noted.

Middle- or low-income countries don’t know about this condition, so there’s also an effort to create a global challenge to implement strategies, said Gelb.

It’s also important to educate and bring members of various hospital departments together to prevent delirium. It’s dealt with by staff from Psychology, Patient Safety, and Surgery/anesthesia, Gelb said.

Prevention

Delirium may be associated to some medications administered to patients, Pandharipande said, so clinicians should take the following steps:

• Mobilize patients instead of giving them heavy sedation
• Choose the right sedative
• Assess for delirium
• Get the family involved so they’re prepared for the possibility of delirium symptoms

Another new step is to add support groups for delirium, he suggested, noting that some patients have compared postoperative delirium to alien abduction.

“Surprisingly, the alien abductees have a support group, but our delirium patients don’t,” Pandharipande said.

Sedation is a key factor in causing delirium, said Daniel Arnal Velasco, MD, patient safety and quality committee chair, European Society of Anesthesiology. He recommended monitoring the electroencephalogram (EEG) during surgery to avoid sedating patients too deeply. Afterward, it’s important to keep screening for delirium until five days after surgery because there could be delayed onset of delirium.

There are still many unknowns about delirium, said Scott. “We don’t know how long it lasts,” he said. “It still occurs even after five days…What we don’t want happening is a patient being discharged with delirium.”

Scott recommended implementing a screening test for delirium as one of the criteria for discharge, as well as preoperative screening. Gelb, who is also distinguished professor (emeritus), University of California, San Francisco (UCSF), said UCSF has put in place preoperative screening that includes having patients spell “world” backwards and naming animals as they go through the alphabet. Implementation didn’t go well until the facility offered incentives to residents, who then responded well.