Kaunas 2020-2021
Master of Medicine
Lithuanian University of Health Sciences Faculty of Medicine
Department of Psychiatry
POSTOPERATIVE DELIRIUM: SOCIAL DEMOGRAPHIC
FACTORS, CLINICAL SYMPTOMS, AND LINK TO SURGICAL
PATHOLOGIES
Author Karim Makarem
Supervisor
Prof. Dr. Darius Leskauskas Lithuanian University of Health Sciences
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TABLE OF CONTENTS
TABLE OF CONTENTS ... 2 1. ABSTRACT ... 3 2. ACKNOWLEDGMENTS ... 5 3. CONFLICTS OF INTERSET ... 6 4. ABBREVIATIONS ... 7 5. INTRODUCTION ... 86. AIM AND OBJECTIVES ... 10
7. RESEARCH METHODOLOGY ... 11 8. RESULTS ... 13 9. DISCUSSION ... 32 10. CONCLUSION ... 39 12. PRACTICAL RECOMMENDATIONS ... 40 13. REFERENCES ... 41
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1. ABSTRACT
Author name: Karim MakaremResearch title: Postoperative delirium: social demographic factors, clinical symptoms, and link to surgical pathologies.
Aim: The literature review aimed at evaluating the clinical symptoms of post-operative delirium and its relation with social demographic factors and surgical pathologies, and treatment tactics for better prognosis
Objectives: To evaluate clinical symptoms and diagnostic methods of postoperative delirium. To determine the link with social demographics. To determine a link to surgical pathologies. To find the optimal treatment tactics for a better prognosis.
Materials and methods: A PubMed search was conducted from 2015 to 2021 for observational studies, Randomized Controlled Trials, and systematic literature reviews using the keywords;
“postoperative delirium”, “transurethral”, “geriatric”, “nephrectomy”, “spinal surgery”, “percutaneous nephrolithotomy”, “social demographic factors”, “clinical symptoms”, “polypharmacy”, “risk factors”, “surgical pathologies”, “management” and “prevention”. Studies referring to Postoperative Delirium (POD), social demographic factors, clinical symptoms, and link to surgical pathologies written in the English language were included.
Results: The evaluation of clinical symptoms and diagnostic methods of postoperative delirium (POD) is dependent on recognition and knowledge of symptoms such as agitation, confusion and memory loss. Screening for factors like intraoperative blood transfusion, specific anesthesia agents, monitoring of systemic arterial pressure, general versus regional anesthesia, and use of statin medications or dexamethasone provide better insight for the diagnosis of POD. Diagnostic screening tools for cognition such as CAM, NDSS are proven valuable. The algorithmic approach has helped to extract certain social demographic factors with the consideration of clinical symptoms, and link to surgical pathologies of postoperative delirium in geriatric patients. The most common risk factors associated with POD include age factor of 65 years and older, dementia, and the presence of deterrence experienced by the patient. In case of link with surgical pathologies, there is a significant association of POD with surgery-related risk factors such as excessive bleeding and several drugs, including ketamine, propofol, and atropine. The optimal treatment tactics have better helped to determine the
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POD treatment with relation to the type of surgery, modes of therapy, anesthesia, and patient population.
Conclusions:
The clinical symptoms and diagnosis methods of postoperative delirium helped to get a better understanding of the approaches that are required for a faster and better diagnosis and management of POD.
The link with social demographics has better been achieved through the evaluation of an algorithm for the social demographic factors with certain clinical symptoms. Proving multiple risk factors for postoperative delirium such as age, drug and alcohol abuse, and any preexisting mental disorder. The occurrence of POD is also associated with more complex surgeries, likely because of the multiple medications' and heavy anesthesia’s psychoactive properties within the patient’s regimen.
Patients who are associated with severe agitation, distress, or substantial harm threat may be treated with antipsychotics at the lowest effective dose. Only in cases where behavioral treatment approaches have failed or are not possible should healthcare professionals use benzodiazepine or antipsychotic medications.
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2. ACKNOWLEDGMENTS
Thanks to my supportersThanks to my supervisor Dr. Darius Leskauskas Thanks to LSMU for their support
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3. CONFLICTS OF INTERSET
The author reports no conflicts of interest.7
4. ABBREVIATIONS
1. Postoperative delirium (POD)2. Post anesthesia care unit (PACU)
3. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) 4. Lithuanian University of Health Sciences (LSMU)
5. Odds ratio (OR)
6. Confidence interval (CI) 7. Intensive care unit (ICU)
8. Confusion Assessment Method for ICU (CAM-ICU) 9. Nursing Delirium Screening Scale (NDSS)
10. International Classification of Diseases (ICD) 11. Intensive Care Delirium Screening (ICDS) 12. Bispectral Index (BIS)
13. International Study of Post-Operative Cognitive Dysfunction 1 (ISPOCD1) 14. Postoperative Cognitive Dysfunction (POCD)
15. Richmond Agitation Sedation Scale (RASS) 16. Brief Confusion Assessment Method (BCAM) 17. Delirium Detection Score (DDS)
18. Memorial Delirium Assessment Scale (MDAS) 19. Food and Drug Administration (FDA)
20. Nil Per Os (NPO)
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5. INTRODUCTION
Delirium is referred to as a neurocognitive syndrome commonly initiated by a condition involving neural disruption brought about by an underlying systemic perturbation. According to Delvin, the number of older people experiencing Postoperative Delirium (POD) is increasing steadily with the increase in the adult population, especially in Lithuania and adjacent regions. Many studies and research show that during the early postoperative period, it is difficult to make a distinction of POD from the residual anesthesia effects, especially the hypoactive Delirium.1 Inouye illustrates that optimal perioperative care offered to elderly surgical patients who are in jeopardy of POD is achieved through incidence and POD risk factors clinical studies. This can also be achieved through threat identification to help healthcare practitioners in this particular setting provide their patients with patient-specific management during the risk incurrence period. Due to the expertise demand in this clinical area, only a trained and well-qualified physician – a psychiatrist and geriatrician can accomplish POD diagnosis. The gold standard diagnostic manual discussed in this review sets criteria for diagnosis, referred to as the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). This tool helps during evaluation by the physician to maximize POD discovery. During the perioperative period, careful anesthesia techniques and proactive geriatric consultation can reduce POD incidence and its associated adverse effects for patients with high delirium risk. [2]
A series or set of symptoms mainly associated with neuropsychiatric characterize POD incidence, which includes attention and consciousness qualitative disturbances, which can show symptoms intensity fluctuations mostly reaching apogee at night. POD diagnosis should therefore be based on updated DSM criteria. It is a difficult tool to read for nonpsychiatric people who are experienced in the subject.
The objective of this literature analysis is to discuss and collaboratively explore POD incidence, social demographic factors associated with the condition, POD clinical signs, and the link to surgical pathologies, especially in the high-risk population – elderly people. This review scrutinizes the commonly used POD diagnosis tools, and discusses the risk factors related to the condition, and assesses treatment evidence associated with the disorder. This study does not sustain the use of melatonin, cholinesterase inhibitors, benzodiazepines, and antipsychotics in POD treatment. Finally, this study claims the hallmark of treatment of POD, as at this time in Lithuania and most parts of the world, with the incorporation of non-pharmacological measures and pharmacological factors. The diagnosis and treatment sections will show that as compared to propofol, the use of intraoperative
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Dexmedetomidine in the intensive care unit has not claimed less association regarding POD but has been linked to less Delirium. In Lithuania, delirium management requires continued research in the best strategies possible.[3]
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6. AIM AND OBJECTIVES
The aim of researchThe literature review aimed at evaluating the clinical symptoms of post-operative delirium and its relation with social demographic factors and surgical pathologies, and treatment tactics for better prognosis.
Objectives
1. To evaluate clinical symptoms and diagnosis methods of postoperative delirium. 2. To determine the link with social demographics
3. To determine a link to surgical pathologies
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7. RESEARCH METHODOLOGY
A thorough PubMed search was conducted from 2015 to 2021 as the research was undertaken. For observational studies, Randomized Controlled Trials (RCTs), and systematic literature reviews using the keywords; “postoperative delirium”, “transurethral”, “geriatric”, “nephrectomy”, “spinal surgery”, “percutaneous nephrolithotomy”, “social demographic factors”, “clinical symptoms”, “polypharmacy”, “risk factors”, “surgical pathologies”, “management”. and “prevention”.
References cited in articles were also obtained and reviewed. Inclusion criteria were papers referring to Postoperative Delirium (POD), social demographic factors, clinical symptoms, and link to surgical pathologies written in the English language. Exclusion criteria were case reports, duplicate articles, articles referring to no interest, and Non-English language articles. Systematic literature reviews were examined, and duplications were eliminated.
The initial combination search of the terms; “postoperative delirium”, “transurethral”, “percutaneous nephrolithotomy”, “clinical symptoms”, “social demographic factors” and “link to surgical pathologies” resulted in 85 papers, without any additional papers occurring from the rest of the terms.
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was used as a systematic review guideline. A 4- phase flow diagram aimed to improve the reporting of systematic reviews and meta-analysis. In total, 35 articles were included in the literature review after the application of inclusion and exclusion criteria, as shown in (Fig. 1).
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Fig. 1: A flow diagram showing the screening process of postoperative delirium with inclusion and exclusion criteria . 85 full text articles found in PubMed after search 10 non-English language articles excluded 15 duplicates excluded 60 articles were reviewed 29 no topic of interest articles excluded 35 articles included
13 articles on social demographic factors of postoperative delirium.
12 articles on clinical symptoms, 11 of these identified a link to surgical pathologies
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8. RESULTS
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The first objective is the evaluation of clinical symptoms and diagnosis methods of postoperative delirium (POD).According to Wang and LI et al., the first step in POD evaluation is the determination of the patient's ability to voice arousal. If the patient is not responsive, then he/she is considered to be in a coma. The delirium implements and techniques evaluate the arousal content after determination of arousal level, through the examination of fluctuating modification shown by consciousness level alteration and patient inattention.
According to Wang, POD evaluation begins by risk factors evaluation involving medications prior, during, and after surgery. The most frequent cause that influences POD incidence is the metabolic and toxic factors. The consulting neurologist is responsible for the evaluation of these factors, such as seizures, acute structural brain injury exclusion, and meningoencephalitis.
Even though a lot of evaluations have been made on the many intraoperative factors for postoperative delirium impacts, there are no published topics for an evidence-based recommendation. The previously published topics find them to include intraoperative blood transfusion, specific anesthesia agents, monitoring of systemic arterial pressure, general versus regional anesthesia, and use of statin medications or dexamethasone.
It is noted that POD is usually manifested due to a physiologic stressor and the predisposing threat factors. The postoperative precipitants may include infections, environmental causes, medications, and electrolyte abnormalities together with other postoperative complications such as pulmonary embolus or myocardial infarction
The most common tool used in the determination of arousal level is the Richmond Agitation Sedation Scale (RASS). Unresponsive patients in deep sedation state cannot be assessed further for Delirium. In order to achieve appropriate POD identification and treatment measures, it is advisable for health care personnel to perform evaluations, make proper adjustments, and order procedural tests to manage POD contributors that are basic.[24]
Wang was among the first to describe the evaluation of haloperidol implementation in postoperative delirium prevention one of the first trials. The drug was administered to patients above 65 years of age who underwent elective heap surgery in the trials. The criteria adopted in the research involved four
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basic measures, which are; cognitive impairment, physiology and chronic health evaluation, the severity of the disease, visual impairment, and dehydration index.
POSTOPERATIVE DELIRIUM INCIDENCE DIAGNOSIS
POD, as referred is an acutely altered brain factor exhibiting fluctuating status, which features problematic factors involving altered consciousness level and inattention. Delirium should not be confused with post- operative cognitive dysfunction, which is a disorder in the thought process whose cognition effects affect attention, detail, comprehension, and memory. POD represents a serious complication to patients who have undergone surgery, and the mortality factor is predicted at six months for those in the intensive care unit. Increasing evidence shows that Delirium precedes postoperative cognitive dysfunction after ICU admission. It is often unrecognized, exhibiting both hyperactive and hypoactive types. Validated clinical scales are regarded as the postsurgical diagnosis basis. Most postoperative patients have previously not been assessed for Delirium, and therefore, the symptoms onset time is usually uncertain. In the medical and coronary ICU setting, the commonly used validated tool is the CAM-ICU, commonly referred to as the Confusion Assessment Method for ICU, proving reliability to detect postoperative Delirium.
The diagnostic criteria involve inattention, abrupt and inconsistent course, and either disorganized sophistication or coma. This detection scale is considered substandard in the PACU (post anesthesia care unit) setting to the recently described, the Nursing Delirium Screening Scale (NDSS). The NDSS has five pieces that include psychomotor retardation, disorientation, hallucinations and/or illusions, inappropriate communication, and inappropriate behavior, which are scored from 0-2. It is indicated by > 2. Therefore, POD is diagnosed based on the detection score that includes the stated items adapted to the PACU, which are scored 0-7. These are anxiety, orientation, hallucination, agitation, and paroxysmal sweating. As published by the American Psychiatric Association, the DSM-5 is a medical tool that establishes the descriptions of criteria to guide in POD diagnosis. This study section recommends that healthcare professionals perform a delirium screening test on patients with delirium symptoms or test positive on a screening tool and those who show acute cognitive change.[8] Elderly people who are examined to be at possible risk of POD should be assessed by trained healthcare professionals who should document the POD function frequently and clearly. The caretakers should be trained and knowledgeable on recognizing and documentation signs associated with POD, comprising hypoactive presentations.[9] POD can be caused by a potential secondary injury or primary injury exacerbation. According to DSM-5, Delirium is categorized as follows:
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• Other medical conditions associated with Delirium
• Substance abuse and intoxication associated with Delirium • Substance withdrawal symptoms associated with Delirium • Different etiologies-caused Delirium
Table 1: Symptoms Associated with Delirium[9] “From: Vijitmala, K, Chaiwat, O, Pancharoen, W, Chanidnuan, M. Postoperative
Delirium in Critically Ill Surgical Patients: Incidence, Risk Factors, and Predictive Scores. BMC Anesthesiol. 2019. 19-39.”
Postoperative Delirium symptoms
1. The Expression of fresh paranoid thoughts associated with delusions (i.e., beliefs that are false but fixed) 2. Changing emotions at a faster rate, easy irritability, tearfulness, uncharacteristic decline to engage with the responsible postoperative care
3. Thinking and disoriented speech tends to be difficult to follow, whether slow or fast. 4. Difficulty when tracking conversations or notable when following instructions
5. The sudden cognitive change (confusion worsening over time) is associated with attention problems, fresh patient’s disorientation, and new memory problems, together with difficulty concentrating.
6. Fresh perceptual disturbances exhibited as illusions or hallucinations
7. Decline in arousal level: exhibited through drowsiness, or notable hypervigilance occurrence 8. Awakening delay from anesthesia
9. Slowed or decreased movements (slow motor adjustments), restlessness or purposeless fidgeting, fresh difficulties in standing or sitting
10. Fresh incontinence of stool or urine 11. Lower appetite
12. Sleeping cycle and waking cycle changes like day sleeping and increased activity at night 13. Non-stable symptoms and/or arousal level over the course
While performing a complete examination of POD patients, the patients’ vitals such as blood glucose levels as well as arterial blood gases should be checked promptly by a trained and qualified practitioner. This is meant to ensure proper estimation of electrolytes, hemoglobin levels, and blood glucose values. Any signs shown by surgical patients showing the presence of new focal neurologic deficits can be addressed by running a computed tomographic scan of the head. In order to achieve the proper assessment, the following differential diagnosis factors have to be considered, including;
• Hypoglycemia • Hypoxia • Hypercarbia
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• Stroke
• Central cholinergic syndrome • Seizure
• Electrolyte disturbance • Academia
Healthcare professional caring for surgical patients should assess the risk factors in the following criteria example: age exceeding 70 years shown as (OR 3.3; 95% CI 1.9 to 5.9, reduced patient functionality status is shown as (OR 2.5; 95% CI 2.5 to 7.4), the limited cognitive grade is shown as follows (OR 4.2; 95% CI 2.4 - 7.3), abnormal serum glucose, sodium, potassium level (OR 3.4; 95% 1.3 to 8.7), alcohol abuse shown as (OR 3.2; 95% CI 1.4 - 8.3), thoracic surgery has shown as (OR 3.4; 95% CI 1.7 to 7.4), followed by aneurysm surgery recorded as (OR 8.2; 95% CI 3.7 to 18.5). [10] Full clinical assessment should be performed by a qualified and competent practitioner to any patient who shows delirium signs and symptoms, such as having acute cognitive variation, or found to be positive on a screening test by use DSM-5, ICD – 10, or through the delirium diagnostic instrument, or otherwise through Confusion Assessment Method diagnostic algorithm. [11]
The procedure involves informants’ history taking, patient examination, radiological findings, medical records review, and laboratory. The basis of delirium hallmark is the identification of acute cognitive change. Common delirium symptoms are listed in table 3. When dealing with elective surgery, the healthcare practitioner in the setting should perform preoperative cognitive testing to review and document the basics. The following table contains a cognitive screening tool list. [12]
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Figure 2: Assessment and Treatment of Postoperative Delirium [13] “From: Girard, T.D. Sedation, Delirium, and
Cognitive Function after Critical Illness. Crit. Care Clin. 2018. 34, 590- 607.”
Table 2: Cognitive Screening Tools[12] “From: Valchanov, K, Jones, N, Hogue, C. Core Topics in Cardiothoracic Critical Care: Cambridge Medicine. London: Cambridge University Press; 2018”
Common Tools for Cognitive Screening Measures
The Abbreviated Mental Test (AMT): which involves three versions, i.e., 10-item, 6-item, and 4-item Vigilance “A” Test (VAT)
Clinical Dementia Rating (CDR) Blessed Dementia Rating Scale
Comprehensive Geriatric Assessment (CGA) Mini-Cog
Digit Span – noted from forward step and backward step Digit Cancellation Test
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Montreal Cognitive Test (MoCA) Months of the year backward
Verbal articulacy tests like COWA - Controlled Oral Word Association Clock Drawing Test
SOMC - Short Orientation Memory Concentration Test Trail making Test A
Short Portable Mental Status Questionnaire (SPMSQ) Trail making Test B
The Mini-Mental State Exam (MMSE) used previously, though not recommended due to licensing agreement requirements as well as much per use fee.
Clinical suspicion is very relevant in detecting the occurrence of Delirium associated with surgical patients. The prime delirium symptom is patient inattention; therefore, a brief cognitive test is important for an accurate diagnosis.[14] Though easily and commonly overlooked, Delirium's hypoactive form is often linked to lots of the poorest results. POD signs and symptoms recognition familiarity is very vital for clinical personnel. Formal tools such as DSM-5, Confusion Assessment Method illustrated in table 5, or ICD-10, can be used in a hospital setting for delirium diagnosis.
Table 3: Delirium Diagnostic Tools[34] “From:Fong, T., Tulebaev, S., & Inouye, S. (2009, April). Delirium in elderly adults: Diagnosis, prevention and treatment. Retrieved May 05, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/”
Delirium Diagnostic Tools
MDAS - Memorial Delirium Assessment Scale DRS-98R - Delirium Rating Scale-Revised 1998 Confusion Assessment Method abbreviated as (CAM)
CAM is commonly adopted as a screening tool or a diagnostic tool, usually with a long algorithm. Improved dependability is established when implemented by proficient assessors expending on cognitive screening tests instead of a POD screening tool cognizant by POD health care for patients. [15]
PHYSICAL AND HISTORY OF POSTOPERATIVE DELIRIUM
Common features include hyperactive psychomotor activity, withdrawal, and lethargy, frank psychosis as well as fluctuating consciousness level, impaired executive function, and disorientation presented by the patient.
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Consideration should be put to the primary neurological diagnoses, including ischemic infractions commonly in the brainstem or bilateral, nonconvulsive status epilepticus, intracranial hemorrhage (can be subdural, subarachnoid, or intraparenchymal. Management of POD will therefore depend on the causative agent. The only intervention required is often the discontinuation of narcotics or sedatives. Though not clear on which component is responsible for POD favorable outcomes, several studies have reported a decrease in POD incidence associated with delirium duration, hospital stay, hospital discharge, and improved cognitive functions on patients.
From the tabulated data illustrated above, it is recommended that neuroimaging have to be restricted to patients who recently experienced central neurological signs, current head trauma, fever, or use of anticoagulation without further explanation.
When using DSM-5, the following characterizes the criteria to be used.
1. Attention (reduced abilities to attention, direct or change attention) and responsiveness (reduced environmental coordination) disturbance.
2. Cognition disturbance (perception, visuospatial ability, memory deficit, language, disorientation).
3. Historical evidence, laboratory findings, physical examination, substance inebriation or extraction, toxin exposure, or multiple etiologies.
In Lithuania, many delirium assessment tools have been validated for different hospital locations and patient populations associated with (ICU) or postoperatively in the hospital ward. These tools include; • DSI - Delirium Symptom Interview
• ICDSC – Intensive Care Delirium Screening Checklist
• CAM-ICU - Confusion Assessment Method for the Intensive Care Unit) • CAM - Confusion Assessment Method
Wang and Li et al. show that the utmost commonly used methods are the CAM and its variations. A moment in time delirium assessment can be performed by the brief versions, including 3D-CAM and CAM-ICU. In the non-ICU setting, validation has been made for BCAM, the Brief Confusion
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Assessment Method. For the intubated patients currently undergoing mechanical ventilation, validation is made for the CAM-ICU, as shown in figure 3 below. The DDS and the MDAS can be used for the assessment of delirium severity as practiced mainly in Lithuania. [25]
Figure 3: Delirium between Comas as Shown With the Delirium Assessment Tool CAM-ICU[33]”From:
Ncbi.nlm.nih.gov. 2021. [Figure, Delineation between delirium and coma...] - StatPearls - NCBI Bookshelf. [online] Available at:
https://www.ncbi.nlm.nih.gov/books/NBK534831/figure/article-27529.image.f1/”
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Next objective is to determine the link with social demographics. An algorithm for the social demographic factors, clinical symptoms, and link to surgical pathologies of postoperative delirium in geriatric patients undergoing elective spine surgery was developed based on findings from literature with an assigned level of evidence-based on the Journal of Levenson, JL. High Dose Intravenous Haloperidol for Agitated Delirium Following Lung Transplantation. Psychom. J. Consult. Liason Psychiatry. 2015. 68-73). Healthcare experts on surgical patients usually perform a preoperative evaluation to determine the prevalent postoperative delirium risk factors. The most common risk factors associated with POD include age factor of 65 years and older, dementia, also known as chronic cognitive decline, and the presence of deterrence experienced by the patient. Development of POD effects after surgery is best termed as a predisposing risk factor that has a relationship with physiological stressor for patients. As illustrated in the following table, these factors are then divided into three collective categories consisting of the preoperative, postoperative, and intraoperative causes.21
Table 4: Postoperative Delirium Risk Factors[35] “From: Reddy S, Irkal J, Srinivasamurthy A. Postoperative delirium in elderly
citizens and current practice. J Anaesthesiol Clin Pharmacol. 2017;33(3):291”
Preoperative factors Age above 65 years
Dementia, also referred to as chronic cognitive outline Poor vision
Infection presence Current hip fracture Severe illness
Comorbidity burden or severe illness Cognitive impairment
Alcohol and abuse (OR 3.3; 95% CI 1.4 to 8.3)(16) Depression
Anemia Dehydration
Limited mobility or immobilization Sleep disturbance and deprivation
Psychotropic medications use and polypharmacy (antihistamines, benzodiazepines, antipsychotics, anticholinergics)6
Constipation Urinary retention risk
Aortic procedures (OR 8.3; 95% CI 3.6 to 9.4) Urinary catheter presence
Postoperative factors Hypoxemia
Pain
Low hemoglobin count Liver failure
Prolonged intubation Sleep-wake disturbances Hypoalbuminemia
Renal complications (BUN/Cr greater than 18) Intraoperative factors Cardiac surgery Emergency surgery Shock Blood transfusion Arrhythmias
Increased surgical duration Blood transfusion
Hip surgery Vascular surgery
Hypothermia/ hyperthermia Hypotension
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The Health Care Institute of excellence established in Lithuania issues guidelines that expose delirium risk factors reported with odds ratios (OR), as shown in table 4. In the hospitals’ emergency setting, the patients experiencing delirium symptoms or/and additional risk factors ought to be considered at greater risk of being affected than the patients who experience no or a single risk, as correlated with the elective setting. [7]
POD risk factors can be divided into two main precipitating and predisposing factors. The precipitating factors are characterized by fluctuation in the current state in the therapy or hospitalization setting. The predisposing factors are characterized by the degree of control for demographic conditions and variables that associate with the addition of disease burden. The elderly patients tend to show more POD susceptibility. Other risk factors associated with POD include chronic psychotic disorders such as dementia or depression; malnutrition; anemia; severe infections; hypoperfusion; intra and postoperative hypotension; acid-base electrolyte imbalances; water-electrolyte imbalance. Delirium is also accompanied by intoxication, which interferes with neurotransmitters metabolism, hypoxic, and impaired cerebral flow.
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The third objective is about finding out the link with surgical pathologies. According to Wang’s research study, it is clear that there is a significant association of Intraoperative POD risk factors with surgery-related risk factors such as excessive bleeding, which in turn leads to postoperative hematocrit that requires postoperative blood transfusions and acute anemia. Several drugs, including ketamine, propofol, and atropine, show a higher POD incidence association as compared to sevoflurane. [30] Also, intraoperative tight glucose control is not recommended as it accelerates POD incidence occurrence, especially after cardiac surgery.To avoid delirium incidence in older patients, the responsible prescribing health care practitioners have to avoid postoperative Delirium inducing prescriptions that upsurge the risk of delirium incidence considerably, such as sedative-hypnotics, anticholinergic medications, and meperidine. These medications have been shown to double the probability of POD incidence in older patients. Table 5 shows clinical guidelines for medication safety improvement in older patients and recommends avoiding medications prone to delirium risk increment. Benzodiazepines show amplified odds of 3.1 (95% CI 1.4 to 3.6). Meperidine is associated with odds of 2.7 (95% CI 1.3 to 5.5).
Diphenhydramine increases the POD development ratio to 2.3 (95% CI 1.4 to 3.6). As a result, the medication's specific needs may outweigh potential risks, and therefore, individual evaluation of the
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patient is necessary. For example, a patient with a benzodiazepine or alcohol dependence history can be treated with benzodiazepine medications even though it should be typically avoided.[19]
POSTOPERATIVE MEDICATION RISK FACTORS
Table 5: Commonly Used Medications Methods in the Perioperative Setting for Delirium[30] “From” Pluta,
MP, Dziech, M, Czempik, P, Szczepanska, A, Krzych, LJ. Antipsychotic Drugs in Prevention of Postoperative Delirium. What is known in 2020? Int J
Env Res Pub Health. 2020, 1, 1-14.”
Universally commonly used prescriptions for Delirium in the perioperative setting Drug or Drug class Drug Examples
Sedative hypnotics Sedative-hypnotics: zaleplon zolpidem
Benzodiazepines: midazolam, alphazolam, diazepam, lorazepam
Corticosteroids Prednisone Methylpredn isolone Drugs with anticholinergic properties
Antihistamines: hydroxyzine, cyproheptadine, diphenhydramine First-generation antipsychotics: thioridazine chlorpromazine Antimuscarinics: oxybutynin, tolterodine
Tricyclic antidepressants: (doxepin, amitriptyline, imipramine ) Antispasmodics: hyoscyamine , scopolamine
Skeletal muscle relaxants: tizanidine, cyclobenzaprine, Antiemetics: promethazine H2-receptor antagonists: (cimetidine, ranitidine) Paroxetine
Olanzapine
Polypharmacy The first five prescriptions upsurge delirium risk.
Meperidine Meperidine
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In order to find the optimal treatment tactics for a better prognosis we have researched many studies that claimed an association between POD and significantly worse patient outcomes and increased death risk. Emerging evidence claims the existence of POD association with early dementia, postoperative cognitive dysfunction, cognitive deterioration acceleration of patients who have Alzheimer’s syndrome, and prolonged brain dysfunction. Current analytical studies show considerable heterogeneity associated with pharmacological procedures in POD treatment with relation to the type of surgery, modes of therapy, anesthesia, and patient population.24
POSTOPERATIVE DELIRIUM INTRAOPERATIVE PREVENTION MEASURES
Processes encephalographic monitors are reliable for general anesthesia or intravenous sedation of elderly patients to reduce POD occurrence. This is the only topic with adequate quality research to form a reliable recommendation on the subject matter. Providing anesthesia in lighter depth will reduce POD occurrence as compared to deep sedation. Research in hip fracture patients shows that there is an increased POD incidence associated with deep sedation. This finding consistently associates with a nonrandomized retrospective observation. Randomized anesthesia patients show lower POD incidence rates when the Bispectral Index (BIS) guide data is used compared to those whose care was given with no BIS data. In this case, intraoperative call and excessive stimulation – leading to tachycardia and hypertension – pose serious concerns. [18]
NONPHARMACOLOGICAL AND PHARMACOLOGICAL APPROACHES FOR
POSTOPERATIVE DELIRIUM TREATMENT
Wang explains that patients who are associated with severe agitation, distress, or substantial harm threat may be treated with antipsychotics at the lowest effective dose. Only in cases where behavioral treatment approaches have failed or are not possible should healthcare professionals use benzodiazepine or antipsychotic medications. Together with this, the daily evaluation must be conducted on the patients. Patients who do not show POD delirium agitation signs and who show no substantial threat of harm should not be treated with benzodiazepine or antipsychotic medications. Emergent pharmacologic intervention is required only when dangerous agitation is associated with Delirium, whereas trained Health care professionals should consider alternative strategies such as searching for an organic cause. It is advisable to start with effecting small doses and titration because elderly people exhibit increased sensitivity to drugs. For sedation purposes, neuroleptics such as haloperidol can be used or a well-tolerated nonrespiratory depressant butyrophenone antipsychotic. According to Wang, for high-risk elderly patients undergoing hip surgery, delirium duration and severity are decreased when haloperidol prophylaxis is used in a randomized trial controlled by placebo. By considerably reducing delirium dosage and treatment duration, the delirium assessment tool in the ICU reduces haloperidol use. Some of the factors involved in POD incidence reduction processes involve cognitive dysfunction management in terms of immobility, sleep deprivation, dehydration, and visual and hearing impairment.
Other protective strategies can be implemented, such as multimodal physiotherapy and sleep preservation. Another strategy that has been shown to reduce delirium incidence is rehabilitation,
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which consists of physical and occupational therapy and sedation disruption during early days of critical illness. For ICU patients who display both quantitative and qualitative sleep adjustments, sleep deprivation is a common causative agent for postoperative Delirium. Therefore, refining sleep quality is essential because sleep disorders can predispose to cognitive dysfunction development in ICU patients. According to referred studies, the a2-adrenoceptor agonist dexmedetomidine tends to increase delirium-free days in an automatically ventilated ICU setting and is thus recommended as the hospital's desired sedation approach setting.
The daily evaluation must be conducted on the patients. Patients who do not show POD delirium agitation signs and who show no substantial threat of harm should not be treated with benzodiazepine or antipsychotic medications.[26] Unless specifically indicated (benzodiazepine withdrawal, alcohol treatment), should benzodiazepines be considered as first-line treatment of the agitated POD patients. Several factors limit the recommendation evidence for POD treatment with antipsychotic medication because of the interpretation difficulties in terms of drug heterogeneity, patient populations, outcomes examined, and the administered dosages. The only potential benefit of antipsychotic medication implementation is decreased POD severity, even though there exist inconsistencies in clinical trials. Numerous are the potential health threats associated with antipsychotic medications use in the hospital setting. There is no basic evidence of any importance of treating a patient experiencing no agitation with antipsychotic medications[27] and should be reserved only short-term management to a setting where possible substantial harm and acute agitation, i.e., for treatment of POD in elderly patients who show agitation behavior and threaten the safety of other patients at a substantial level. In fact, there is existing evidence that clearly highlights the association of benzodiazepine medications uses with promotion POD incidence occurrence, but no such evidence is available to claim routine treatment of POD with benzodiazepines. However, for alcohol withdrawal treatment, benzodiazepine is the available medication recommended in most hospital settings in Lithuania and most parts of the world. The following points suggest perioperative options to reduce brain dysfunction and as well reduce Delirium.
• Using light sedation whenever possible with the consideration of proper safety protocols. • Avoid deliria triggering medications such as benzodiazepines, meperidine, and anticholinergic
medications.
• Use of non-opioid adjuncts and ensuring regional techniques for adequate pain control. • Use of Dexmedetomidine in the postoperative sedation period.
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• Use of multi-component bundles for delirium reduction such as; early mobility, hydration, and electrolytes attention, and restoring eyeglasses and hearing aids postoperatively.
• Treatment of the patients showing symptoms refractory to non-pharmacological methods. Intravenous droperidol is shown to reduce agitated agitation, even though it is more likely to inhibit hypotension because it is high potency a1-adrenergic receptor antagonist. Other parenteral neuroleptic drugs that are considered as a treatment for agitated Delirium are chlorpromazine and perphenazine. Unfortunately, these medications tend to result in cardiac output decline or hypotension because of their potent a1-adrenergic antagonism.
These phenothiazines tend to lower seizure threshold and prolong QTc because they are relatively anticholinergic. However, when applied by a trained healthcare professional in low doses, they can be effective and safe for delirium prevention and management implementation. A little dose of lorazepam (1-2mg i.v. every 2-4 hours) can be added to haloperidol when managing agitated Delirium because lorazepam has the ability to reduce the haloperidol extrapyramidal side effects.
In Lithuania and most parts of the world, the nonpharmacological intervention has been tried and credited in terms of effectiveness. The most notable examples in the Lithuanian hospital setting are the HELP versions known as the Hospital Elder Life Program as well as its improved version. Multidisciplinary teams use these programs to work on reorienting the patient. The processes involved include frequent family visits, socialization, reducing noise, nutritional balance, early mobilization, sensory aids provision, and managing sleep cycles. Oral nutritional assistance, communication orientation, and early mobilization performed daily demonstrate delirium incidence reduction significantly.[28]
In the ICU, the ABCDEF bundle has also been linked to enhanced functionality of the brain, stated as follows;
A. Breathing trials and daily awakening and
B. Sedation choice, avoidance of benzodiazepines and light sedation, C. Assessment and management of pain
D. Family involvement E. Early mobility
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F. Non-pharmacological intervention, Routine assessment of Delirium, and cautious use of medications for delirium treatment
As notable, this research argues that the patients receiving a daily mobility program are free of Delirium, have shorter hospital stay durations, are more independent at discharge in terms of functionality, and are more likely to be discharged from the hospital. Early intercession and management should be assessed to institute strategies for POD risk prevention. Physical factors, including hypoventilation, uncomfortable position, distended bladder, and pain should be addressed promptly. Also, immediate reorientation should be started in the PACU, like saying the type of surgery, patient’s name, and current location.[29]
Several pharmacological agents have been adopted for implementation and use in a high-risk population like Lithuania, inhibition, and Delirium treatment. Retrogressive anesthetic agents’ effect should manage the aggressive response of persistent Delirium. In Lithuania, the drugs Flumazenil with a dosage of 0.2-mg additions, as well as Naloxone with a dosage of 0.04-mg additions, and physostigmine are known to have reverse anesthetist effects associated with muscle relaxants, in some cases opioids, and benzodiazepines, because of abilities to cross the blood- brain barrier to a limited dosage of 1- to 2-mg additions. Haldol effectiveness is not guaranteed in such a setting because it shortens delirium episodes’ severity and lacks prophylaxis effectiveness. A useful adjunct is Dexmedetomidine. Its intraoperative infusion is shown to decrease POD occurrence, especially in high-risk aging people. In ICU setting and in children, Dexmedetomidine has been revealed to decrease postoperative pain, vomiting, nausea, and emergence agitation, though boluses, infusions, and its ideal intraoperative prescribed amount has not been clearly proven.
In patients who agitated Delirium prevented extubation, Dexmedetomine is effective because of delirium resolution acceleration, less oversedation, shorter ICU stay, and less necessity for noninvasive ventilation compared to those patients on psychotic drugs such as haloperidol. However, haloperidol, a drug used to increase acetylcholinesterase availability, has benefited from delirium treatment over placebo. Dexmedetomidine and propofol have achieved ICU mainstay since there exists a strong tie of benzodiazepine sedation to Delirium. Inouye et al. established that patients on Dexmedetomidine achieved a lesser extent of delirium incidence as compared to those on propofol. [30]
NONPHARMACOLOGIC POSTOPERATIVE DELIRIUM PREVENTION AND TREATMENT MEASURES
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This research suggests the implementation of educational programs in formal and informal refresher sessions to improve understanding POD related topics such as assessment, epidemiology, and delirium prevention and treatment. Lithuanian healthcare systems have to implement risk reduction procedures when dealing with adults undergoing surgery through the multi-component non-pharmacological programs of intervention.[20] This helps in clinical outcomes improvement when applied by an interdisciplinary health care professional responsible for caring for adults established with POD. Currently, there is no evidence in suffice to recommend for or against the current units in hospitals for clinical outcome improvement. In the treatment and prevention of POD, many research studies show that an essential part of the process is education, primarily focusing on POD risk factors, outcomes, tools, and nonpharmacologic and pharmacologic approaches to manage and prevent the disorder. With the implementation of education in the management and treatment process, it would be more effective with reinforcement, peer support, booster and feedback sessions, and personal interactions. Table 6 below lists some of the precipitating factors for the management and treatment of POD and the evaluation recommended for the process.
As outlined in table 7, at least 10 nonpharmacological approaches from high-quality studies that, when implemented and managed by a qualified interdisciplinary team, successfully reduce POD incidence by about 40% to 50% in previous studies. The benefits of nonpharmacological approaches are demonstrated with evidence of more moderate quality studies, though the evidence is weaker for the management of POD. There is similarity in the studies on POD prevention and strategies for proactive geriatric consultation, reduction and reescalation of agitation factor, and health care personnel education. As shown in the table, there is insufficient evidence for recommendation purposes, and only 6 studies nonrandomized and heterogeneous studies were listed with high-risk prevalence bias. [21]
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Table 6: POD Triggering Factors and Their Suggested Evaluation[21] “Dogyun LK, Cunningham J. Post-operative
Delirium: a Review of Diagnosis and Treatment Strategies. J Xia Med [internet]. 2018 [cited 2021 Feb 09]; 4(2):1-6.”
Triggering factors and assessment contemplations for postoperative Delirium Postoperative delirium precipitant Environmental Postoperative delirium factors Ø Sleep disturbance Ø Use of bladder catheterization Ø Ineffectually controlled pain Ø Use of physical curbs Ø Poor visualization and/or hearing Infection Ø Urosepsis Ø Bacteremia Ø Pneumonia Ø Surgical site infection Metabolic derangement Ø Hypoxia Ø Acidosis Ø Dehydration Ø Electrolyte instability Ø Hypoglycemia Ø Acute blood loss anemia Ø Sock or rather hypotension Ø Delirium-inducing medications Substance withdrawal Ø Benzodiazepines Ø Alcohol Ø Illicit drugs Evaluation considerations Ø Physical analysis Ø Medical records review, including nursing follow-ups Ø Physical investigation Ø Chest radiograph Ø Count of white blood cell and urinalysis Ø Urine cultures, sputum, and blood Ø Indicated site of surgery imaging Ø Delirium vital signs identification procedures such as pulse oximetry Ø Conducting laboratory evaluation, which may include Ø Serum hematocrit Ø Blood urea nitrogen, electrolytes, creatinine Ø Analysis of Blood gas Ø Analysis of Serum glucose Medication resolution Ø Social history Ø Social history Ø Physical examination Ø Preadmission medication reconciliation
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Table 7: POD Inhibition Nonpharmacological and Behavioral Strategies[21] “From: Dogyun LK,
Cunningham J. Post-operative Delirium: a Review of Diagnosis and Treatment Strategies. J Xia Med [internet]. 2018; 4(2):1-6.”
Delirium prevention Behavioral and Nonpharmacologic Strategies 1. Sensory enhancement (hearing aids, ensuring glasses) 2. Enhancement of mobility (ambulating frequently)
3. Review of Medication together with suitable medication management 4. Pain control associated with planned acetaminophen
5. Cognitive positioning as well as therapeutic activities 6. Cognitive stimulation
7. Daily round checking by an interdisciplinary team to strengthen the strategies of interventions
8. Simple standards of communication and behavior escalation prevention approaches 9. Sleep enhancement (nonpharmacologic sleep protocol, relaxation, night routine, daytime sleep hygiene)
10. Fluid repletion and communication enhancement
Strategic approaches should include the listed elements even though the list is nonexclusive. [22]
POD PREVENTION AND TREATMENT MEASURES FOR PHARMACOLOGIC
POSTOPERATIVE SETTING
While offering health care to high-risk older adults, responsible health care trained professionals at the time of surgery, regional anesthetic injection may be considered postoperative to prevent POD incidence through pain control improvement in elderly patients. To inhibit Delirium in elderly adults, postoperative pain control should be optimized by the health care professionals, preferably through the use of non-opioid pain medications to reduce pain.
There exists insufficient evidence-based recommendations of antipsychotic medications used to prevent Delirium. The health care physician should not recommend or propose cholinesterase inhibitors perioperatively on elderly adults who are currently not on cholinesterase. This is because Delirium is contributed by insufficient analgesia postoperatively. Most research evidence suggests minimum delirium incidence with non-opioid alternatives compared to opioid-only pain regimens. Two of these studies show that the use of regional anesthesia is associated with reduced Delirium. This literature shows to have inconsistent and contradictory support in prescribing antipsychotic
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medications for delirium risk reduction and prevention. Several studies show that there is a decrease in delirium incidence associated with phylactic antipsychotics. Therefore, this medication class shows considerable potential harms, and therefore antipsychotics are not recommended for postoperative delirium prevention. Also, prophylactic administrations of cholinesterase inhibitors are considered to increase harm, including mortality, and are not effective in POD reductions.
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9. DISCUSSION
As a major adverse effect, postoperative Delirium occurs commonly in elderly patients after anesthesia and surgery, and therefore, once diagnosis establishment is due, delirium therapy deems important. According to Santarpino and Graham, the manual – DSM-5 – delirium diagnosis criteria offers a procedure that involves evaluation of attention disturbance and awareness of the cognition factor with an inconsistent course. POD experts have recognized three POD types as delirium presence, hyperactive, hypoactive, and mixed POD varieties. POD occurrence will commonly range from a short period after anesthesia up to the time of discharge. This disorder is commonly recognized as fluctuating but sudden. It occurs commonly at the mental status disturbance, commonly experienced in the post- anesthesia care unit (PACU). This occurs because of the brain's adjustment in the functioning process, which is often mixed up with deep sedation at the surgery or reduced arousal associated with a little level of patient inattentiveness. The most type of POD experienced in Lithuania as well as another relation is hypoactive Delirium. In order to limit the pharmacological interventions and the non-pharmacological intervention scope in initial searches, the most excluded topics are etiology, pathophysiology, predisposing factors, risk factors, prognostic methods, predictive models, assessment, pediatric factors, traumatic brain injury, acute stroke, alcohol and substance abuse withdrawal symptoms, psychosis or dementia.[4]
Table 8: Best Practice Delirium[5] “From: Oladeji, P, Rizk, P, Huo, M, Morris, W. Review of Postoperative Ddelirium in Getriatric
Patients Undergoing Hip Surgery. Geriatr. Orthop. Surg. Rehabil. 2016. 7, 101-106.”
Best Practice Delirium Delirium diagnosis
POD incidence risk factors Intraoperative prevention measures Postoperative Delirium screening
Postoperative Delirium pharmacological measures Postoperative Delirium nonpharmacological measures Postoperative delirium medications threat and risk factors Postoperative delirium medical evaluation
POD pharmacological treatment
Table 8 above addresses a list of the specific topics to provide a set of statements that are meant for approvals to healthcare experts in the healthcare specialized setting related to POD regarding the older surgical patients with risk of Postoperative Delirium.[5]
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POD SCREENING
For optimal detection of the POD factor, a screening instrument that is validated should be used. It is recommended that the screening should be done daily by the health care professional for early detection and treatment initiation for older patients. Numerous research studies have ascertained that physicians and nurses do not diagnose Delirium accurately on the bedside evaluation basis, in the wards, and in the ICU. These tests may vary significantly depending on the patient population group or the screening tool used. Numerous instruments are available for use by non-specialized bedside personnel, as shown in table 9. According to Van, the instruments used should be validated counter to a reference standard at any surgical setting, as shown and illustrated in table 9. There are no randomized measured trials used to examine screening results in the hospital setting, and therefore, risks may occur associated with inappropriate treatment (antipsychotic medications) and misdiagnosis. Therefore, delirium screening has several benefits that result in implementing medical techniques appropriate treatment of POD achieved through early diagnosis. Delayed in POD treatment is associated with a greater rate of mortality. Table 10 shows systematic reviews and current screening guidelines. [16]
Table 9: Delirium Screening Tools[16] “From: Bourgeois, J. Delirium: Prevention, Symptoms and Treatment. New York: Nova
Science Publishers; 2017.”
Delirium Screening Tools (designed for the nonexpert and easy to use) (Nu-DESC) Nursing Delirium Screening Scale
CAM - Confusion Assessment Method Confusion Rating Scale (CRS) Bedside Confusion Scale
Cognitive Test for Delirium (CTD)
CGI-D (Clinical Global Impressions – Delirium) SQiD - Single Question in Delirium
NEECHAM Confusion Scale Delirium Index
Intensive Care Delirium Screening Checklist (ICDSC) Clinical Assessment of Confusion (CAC)
Delirium-O-Meter (DOM) 4AT
Delirium Symptom Interview (DSI) Delirium Observation Screening (DOS)
CAM-ICU - Confusion Assessment Method-ICU version Delirium Diagnostic Test- Provisional (DDT-Pro)
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Barr states that many hospitals use CAM in Lithuania and other countries to be a diagnostic instrument and a screening tool. Increased dependability is established when used by qualified assessors by cognitive screening tests fairly rather than established as a screening tool cognizant solitary by monotonous health patient care habits. ICDSC and CAM-ICU both have established high indifference in a situation dealing with critically ill patients. Nevertheless, all of them were established and developed as simple screening tools, whereby they are adopted for use frequently as assessing options for diagnostic results in the hospital, specifically in the ICU setting for the elderly and critically ill patients.
Table 10: Outline of Validated Instruments for Delirium Screening[16] “From: Bourgeois, J. Delirium: Prevention, Symptoms and Treatment. New York: Nova Science Publishers; 2017.”
Screening Instruments for use in Intensive care unit
CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) Instruments for use in general delirium
screening NuDESC (Nursing Delirium Screening Scale)
DSI (Delirium Symptom Interview) CAM - Confusion Assessment Method
ICDSC (Intensive Care Delirium Screening Checklist)
The screening instrument CAM is commonly adopted in many establishments as a diagnostic instrument through its application as a screening tool and therefore the greater than before dependability is established when implemented by skilled assessors using cognitive screening tests instead of those using the CAM screening tool, which happens to be cognizant only by the monotonous patient’s health care team.[17]
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Table 11: Guidelines Established as Recommendations Guidelines for Routine Delirium Screening[17] “From: Page, V Ely, W. Delirium in Critical Care: Cambridge Medicine, Core Critical Care. London: Cambridge
University Press; 2015.”
Recommendations established to advise on routine screening for Delirium
Guidelines Conclusive recommendations
Delirium: Diagnosis – A review of the Evidence Screening, treatment, and Inhibition
VA Evidence-based Synthesis Program Reports
Determine that evidence is insufficient to acclaim for or counter delirium screening among all hospitalized or intensive care patients.
Excessive randomized trials will help in the delirium screening evaluation if screening on outcomes is needed.
(NICE) guidelines – POD identification, POD management, and POD prevention.
Acclaims delirium assessment at the exhibition for all
Delirium threatened patients successively at least daily for all patients admitted to hospital or long-
term care. Society of Critical Care Medicine – pain control
Clinical practice guidelines nervousness, and Delirium in
adult patients in the intensive care unit
Acclaims monotonous checking for Delirium the elderly ICU patients.
POSTOPERATIVE DELIRIUM EPIDEMIOLOGY
With the increase in surgical insults, POD incidence prevalence increases. This review states that in non-cardiac surgery, incidence, according to DSM-5, is shown to be between 15% and 58% dependent on the screening test used. This percentage is similarly high in cardiac surgery patients – between 24% and 53%. These risk factors greatly influence surgical insult severity, sedatives and analgesic exposure to the patient, and comorbidities. The most common POD, the hypoactive Delirium, is considered by decreased responsiveness, lethargy, and declined level of activity, typically recognized in (PACU) as the patient becomes agitated and pulls tubes and lines.
POSTOPERATIVE DELIRIUM PATHOPHYSIOLOGY
The postoperative delirium pathophysiology after anesthesia and surgery is multifactorial and remain obscure. There are several tools for hypothetical Delirium, which comprise inflammation, disordered neurotransmission, as well as trauma. Much evidence related to Delirium supports the role of excessive dopaminergic tone or reduced cholinergic transmission in delirium pathophysiology. The use of implicated interleukin-1 or tumor necrosis factor-a and other proinflammatory cytokines can alter neurotransmission, increase blood-brain barrier permeability, and enhance neurotoxicity. In elderly
36
patients, inherited factors are also recognized as POD development threat factors. This is because the elderly brain exhibits multiple changes – mutually qualitative and quantitative fluctuations in neural circuitry, which establishes greater delirium sensitivity.
As concluded by the ISPOCD1 (International Study of Post-Operative Cognitive Dysfunction 1), we can note that general anesthesia is the main accountable cause of postoperative cognitive dysfunction (POCD). However, a similar incidence has been shown in late studies as in regional anesthesia cases and sedation. Development of Delirium may be contributed by surgery, which causes releases in psychoactive inflammatory markers, including IL-1 beta, IL-6 (tumor interleukin 6), and the TNF-alpha (necrosis factor-TNF-alpha). [23] This happens through GABA, dopamine, or pathways that are cholinergic-mediated. General anesthesia correspondingly depicts the brain cognition to the active drugs, which are innumerable, therefore altering the sleep and arousal pathway's chemical balance. Patients exposed to deep sedation tend to experience higher delirium incidence compared to those exposed to light sedation.
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Figure 4: Etiologies and a Pathophysiological Model of Delirium[32] “From Fricchione GL, Nejad SH, Esses JA,
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POSTOPERATIVE DELIRIUM SIDE EFFECTS AND TOXICITY MANAGEMENT
On no account has FDA has approved any drug for treatment and inhibition of Delirium. Initial therapies and prophylactic agents have limited data for effective measures. Despite this efficacy limit in data, atypical antipsychotics (quetiapine, risperidone, olanzapine) and haloperidol are commonly used. Some of these limitations are that Dexmedetomidine requires ICU stay and involves infusion, while the antipsychotics may cause effects such as respiratory depression incidence, oversedation, persistent QT, hypoactive Delirium, and the neuroleptic malignant syndrome.
POSTOPERATIVE DELIRIUM COMPLICATIONS
POD patients tend to be at high risk exclusively in the common surgery setting, especially in cases where the NPO (nil per os) recommended guidelines were not monitored appropriately. Increased hospital stay, disability risk, prolonged hospital stay, and increased institutionalization risk after discharge. [31]
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10.
CONCLUSION
The clinical symptoms and diagnosis methods of postoperative delirium helped to get a better understanding of the approaches that are required for a faster and better diagnosis and management of POD.
The link with social demographics has better been achieved through the evaluation of an algorithm for the social demographic factors with certain clinical symptoms. Proving multiple risk factors for postoperative delirium such as age, drug and alcohol abuse, and any preexisting mental disorder. The occurrence of POD is also associated with more complex surgeries, likely because of the multiple medications' and heavy anesthesia’s psychoactive properties within the patient’s regimen.
Patients who are associated with severe agitation, distress, or substantial harm threat may be treated with antipsychotics at the lowest effective dose. Only in cases where behavioral treatment approaches have failed or are not possible should healthcare professionals use benzodiazepine or antipsychotic medications.
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11.
PRACTICAL RECOMMENDATIONS
From POD diagnosis to the POD management processes, the development of guidelines for POD is the first and most vital section. This process allows for accurate and quick measures to be applied on patients both before and after an operation. Through barrier recognition and evidence-based knowledge implementation, new emerging “implementation science” such as the implementation of current POD guidelines may accelerate pre-diagnosis processes. Lithuanian health care professionals need to consider the translation of the current guidelines into locally sensitive application tools, helping the real-world practice within each health care system.
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12.
REFERENCES
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2. Wang, L, Xu, F.Y, Liu, M, Zhang, H, Shi, X.Y. Strategies for Prevention of Postoperative Delirium: A Systematic Review and Meta-analysis of Randomized Trials. Crit. Care. 2013. 17:R47. 3. Ben E, Thomas NR. Postoperative Delirium in the Elderly: Diagnosis and Management. Clin Int Ag [internet]. 2020 [cited 2021 Feb 09]; 3(2):28-66. Available from: https://www.ncbinim.nih.gov 4. Ely, W. Delirium in Critical Care: Cambridge Medicine, Core Critical Care. London:
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5. Oladeji, P, Rizk, P, Huo, M, Morris, W. Review of Postoperative Ddelirium in Getriatric Patients Undergoing Hip Surgery. Geriatr. Orthop. Surg. Rehabil. 2016. 7, 101-106.
6. Iamaroon A, Chaiwat O, Wongviriyawong T, et al. Incidence of and Risk Factors for
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