The purpose of this guideline is to present evidence-based and consensus-based recommendations for the prevention and treatment of postoperative delirium. The cornerstones of the guideline are the preoperative identification and handling of patients at risk, adequate intraoperative care, postoperative detection of delirium and management of delirious patients. The scope of this guideline is not to cover ICU delirium. Considering that many medical disciplines are involved in the treatment of surgical patients, a team-based approach should be implemented into daily practice. This guideline is aimed to promote knowledge and education in the preoperative, intraoperative and postoperative setting not only among anaesthesiologists but also among all other healthcare professionals involved in the care of surgical patients.

European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium

Summary Postoperative delirium is a relatively common and serious complication. It increases hospital stay by 2–3 days and is associated with a 30-day mortality of 7–10%. It is most prevalent in older patients, those with existing neurocognitive disorders, and those undergoing complex or emergency procedures. Preclinical and clinical research in recent years has uncovered more about the pathophysiology of postoperative delirium and may yield more potential therapeutic options. Using the enhanced recovery pathway framework of risk stratification, risk reduction, and rescue treatment, we have reviewed the current clinical evidence on the validity of delirium prediction scores for the surgical population, the effectiveness of perioperative delirium risk reduction interventions, and management options for established delirium. Effective perioperative interventions include depth of anaesthesia monitoring, intraoperative dexmedetomidine infusion, and multimodal analgesia. Choice of general anaesthetic agent may not be associated with significant difference in delirium risk. Several other factors, such as preoperative fasting, temperature control, and blood pressure management have some association with the risk of postoperative delirium; these will require further studies. Because of the limited treatment options available for established delirium, we propose that risk assessment and perioperative risk reduction may be the most effective approaches in managing postoperative delirium.

Postoperative delirium: perioperative assessment, risk reduction, and management

Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience.

Introduction Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse. Methods and analysis The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. Ethics and dissemination iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals. Trial registration number DRKS00013644; Pre-results

https://bmjopen.bmj.com/content/bmjopen/8/10/e023609.full.pdf

Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia

Purpose of review The aim of this study was to review current literature on identification of patients at risk for postoperative delirium (POD) and to summarize recent findings on prophylaxis and treatment. Recent findings Age and preoperative cognitive impairment are among the most important risk factors of POD. POD is the result of a complex interplay of predisposing and precipitating factors. Thus, both prophylaxis and treatment require multicomponent intervention programs. No single medication to prevent or treat POD is available. Avoiding too deep anesthesia, avoiding additional psychoactive substances including benzodiazepines and intravenous opioids, and effective pain management as well as early mobilization are essential. Summary An increase of the proportion of elderly patients undergoing surgery will lead to a higher incidence of POD. Preoperative assessment should facilitate identification of patients at high risk. Perioperative management should include monitoring depth of anesthesia, preference for nonopioid pain therapy, early regular delirium monitoring starting in the recovery room, avoiding ICU-sedation, early mobilization and exercise, and cognitive training.

Patients prone for postoperative delirium: preoperative assessment, perioperative prophylaxis, postoperative treatment.

BACKGROUNDPosttraumatic stress disorder (PTSD) may appear after hospitalisation for surgery with general anaesthesia in elderly patients. Prevalence and risk factors in this setting are unknown. Postoperative delirium could be a risk factor.OBJECTIVEThe purpose of this study was to identify the prev

Postoperative delirium is an independent risk factor for posttraumatic stress disorder in the elderly patient: a prospective observational study.

Background: Age-related cognitive impairment is rising in prevalence but is not yet fully characterized in terms of its epidemiology Here, we aimed to elucidate the role of obesity, diabetes and hypertension as candidate risk factors Methods: Original baseline data from 3 studies (OCTOPUS, DECS, SuDoCo) were obtained for secondary analysis of cross-sectional associations of diabetes, hypertension, blood pressure, obesity (body mass index [BMI] ≥30 kg/m2) and BMI with presence of cognitive impairment in log-binomial regression analyses Cognitive impairment was defined as scoring more than 2 standard deviations below controls on at least one of 5-11 cognitive tests Underweight participants (BMI<185 kg/m2) were excluded Results were pooled across studies in fixed-effects inverse variance models Results: Analyses totaled 1545 participants with a mean age of 61 years (OCTOPUS) to 70 years (SuDoCo) Cognitive impairment was found in 290% of participants in DECS, 82% in SuDoCo and 456% in OCTOPUS In pooled analyses, after adjustment for age, sex, diabetes and hypertension, obesity was associated with a 129-fold increased prevalence of cognitive impairment (risk ratio [RR] 129; 95% CI 098, 172) Each 1 kg/m2 increment in BMI was associated with 3% increased prevalence (RR 103; 95% CI 100, 106) None of the remaining risk factors were associated with impairment Conclusion: Our results show that older people who are obese have higher prevalence of cognitive impairment compared with normal weight and overweight individuals, and independently of co-morbid hypertension or diabetes Prospective studies are needed to investigate the temporal relationship of the association

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Association of obesity, diabetes and hypertension with cognitive impairment in older age

Background Post-operative delirium (POD) and post-operative neurocognitive disorder (NCD) are frequently seen in the elderly. Development of biomarkers for pre-operative risk prediction is of major relevance. As inflammation present before surgery might predispose to POD and post-operative NCD development, we aim to determine associations between pre-operative C-reactive protein (CRP) and the incidence of POD and post-operative NCD. Methods In this observational study, we analyzed 314 patients enrolled in the SuDoCo trial, who had a pre-operative CRP measurement the day before surgery. Primary outcomes were POD assessed according DSM-4 from day 1 until day 7 after surgery and post-operative NCD assessed 3 months after surgery. We conducted multivariable logistic regression analysis adjusted for age, sex, randomization, body mass index, MMSE, ASA status, infection/autoimmune disease/malignoma and types of surgery to determine associations between CRP with POD and post-operative NCD, respectively. Results Pre-operative CRP was independently associated with POD [OR 1.158 (95% CI 1.040, 1.291); P = .008]. Patients with CRP values ≥5 mg/dL had a 4.8-fold increased POD risk [OR 4.771 (95% CI 1.765, 12.899; P = .002)] compared to patients with lower CRP values. However, no association was seen between pre-operative CRP and post-operative NCD [OR 0.552 (95% CI 0.193, 1.581); P = .269]. Conclusions Pre-operative CRP levels were independently associated with POD but not post-operative NCD after three months. Moreover, higher pre-operative CRP levels showed higher risk for POD. This strengthens the role of inflammation in the development of POD. Assessment of CRP before surgery might allow risk stratification of POD. Trial registration This study was registered with ISRCTN Register 36437985 on 02 March 2009.

https://findresearcher.sdu.dk:8443/ws/files/170676388/aas.13441.pdf

Wolf R. Brockhaus

Papers

Postoperative delirium is an independent risk factor for posttraumatic stress disorder in the elderly patient: a prospective observational study.

Association of obesity, diabetes and hypertension with cognitive impairment in older age

C-reactive protein for risk prediction of post-operative delirium and post-operative neurocognitive disorder.