Postoperative delirium in seniors: Recognizing the symptoms, reducing the risks
January 23, 2020
Immediately after surgery that requires anesthesia, it is normal for older patients to feel somewhat sleepy or a little out of sorts. But when patients experience marked changes in mental function – such as confusion, disorientation, persistent sleepiness, hallucinations, agitation, or aggression – they might be experiencing post-operative delirium.
Post-operative delirium is the most common complication of surgery for older adults, according to the American Geriatric Society, affecting up to 50% of seniors. If not identified early and treated, post-operative delirium can lead to long-term health issues, including cognitive decline and functional decline. Patients are also at increased risk of physical injury, hospitalization, and transfer to long-term care facilities.
Symptoms can appear within hours to weeks after surgery. Unfortunately, post-operative delirium symptoms are often mistaken as signs of dementia, which is an umbrella term for irreversible conditions that cause memory loss and decreased cognitive function. While some symptoms are similar, delirium is not the same as dementia and can be prevented in approximately 40% of cases.
UT Southwestern has implemented two innovative programs to better identify patients at risk for delirium and support healthier recovery. In these programs, we help caregivers prevent and identify delirium symptoms and help patients maintain their independence after diagnosis through comforting care and rehabilitation.
Risk factors of post-operative delirium
Most cases of delirium last a week or less, with symptoms that gradually decline as the patient recovers from surgery. However, the condition can last for weeks or months in patients with underlying memory or cognitive challenges such as dementia, vision, or hearing impairment, or a history of post-operative delirium. Other risk factors can include infection, recent trauma, or an adverse reaction to medication.
As part of our presurgical process with senior patients, we screen for these risk factors. After surgery, we watch for particular symptoms of delirium, which can include:
- Difficulty focusing
- Fatigue and sluggishness
- Slurred speech
- Rapid mood swings
- Uncooperative or aggressive behavior
It's important for patients and family members to discuss their health history and personal risk factors with their doctor before surgery to potentially avoid delirium. In that spirit, we've implemented two programs focused on post-operative delirium: one to help identify patients who are at risk and another to help patients and families manage the condition if it develops.
Programs and treatments
Pre-surgery evaluation and risk assessment
The UT Southwestern Perioperative Optimization of Senior Health (POSH) is designed to evaluate patients before surgery for their potential risk of developing complications, including post-operative delirium. This work has been made possible in part through a collaboration with the team that developed the original POSH Program at Duke University.
The care team works with patients and families to create a plan leading up to surgery to help avoid complications and achieve the best outcomes, including pre-surgery referral to physical therapy, nutrition services, or connections to get in-home health care.
UT Southwestern POSH providers' tips to help patients safely transition out of the hospital include:
- Provide family support: During recovery, familiar faces and soothing voices can help calm the patient. Family members can even prevent delirium by providing personal support such as feeding and sleep safety, according to an October 2019 study published in JAMA Internal Medicine.
- Ensure patients have reading glasses and hearing aids: Assistive devices help patients communicate and ground them in their environment.
- Manage medications: Certain drugs used to treat anxiety, depression, insomnia, Parkinson’s disease, and allergies can contribute to delirium risk.
- Get enough sleep: Research suggests there is be a link between sleep disruption and delirium. After surgery, maintain a regular sleep cycle. Families can help, for example, by leaving window shades open so patients can distinguish between day and night.
- Participate in brain-stimulating activities: Reading, solving crossword puzzles, and visiting with family and friends can stimulate the brain and help patients avoid delirium.
Support to maintain independence
The Acute Care for Elders (ACE) Unit at UT Southwestern works with health care teams across the hospital to help reduce the effects of delirium and other functional complications in older patients. Our ACE team is designated by The Nurses Improving Care for Healthsystem Elders (NICHE). NICHE is the only international designation that highlights a hospital's commitment to excellence in elder care.
ACE joins geriatric doctors, social workers, pharmacists, occupational therapists, and other providers who help patients maintain their independence after they leave the hospital. These providers help patients with pain management, diet and nutrition, and exercise to keep the mind and body strong and active. Patients in our ACE Unit have access to music therapy, pet therapy, and volunteers who visit the hospital to play games with patients, talk with them, and encourage them during their recovery.
There is no medication to treat postoperative delirium, and prevention is key. Antipsychotic drugs to control hallucinations or agitation can interrupt the brain’s natural healing processes. This can delay recovery and worsen the condition in some cases.
The first step to treat a patient with delirium is to identify the cause of their symptoms. Often, we can trace symptoms back to unmanaged pain, an infection, a reaction to a medication, or lack of sleep. While we work to resolve the underlying issue, we also work with the patient's family to provide general comfort and support such as encouraging proper eating, exercising, and sleeping.
UT Southwestern has recently implemented the Hospital Elder Life Program (HELP) program on our ACE unit to care for older patients with or at risk for delirium.
If more advanced care is needed, the doctor will talk with you about the potential for healthcare help at home or rehabilitation. The goal is to reduce the risk of delirium-related hospitalizations and prevent the need for transfer to a long-term care facility.
It can be unnerving when an older loved one develops post-operative delirium. If a senior in your life is preparing for surgery, talk with them and their doctor about steps to prevent delirium. The better prepared you are for the possibility, the better your loved one's chances at achieving the best outcomes after surgery.