Postoperative delirium in older adults- American Geriatrics Society abstracted clinical practice guideline

Nonpharmacologic interventions were defined as including behavioral interventions, monitoring devices, rehabilitation, environmental adaptations, psychological and social supports, medication reductions, complementary and alternative medicine, and system and process changes.

1. Education Targeted to Healthcare Professionals about Delirium (Recommendation) -Healthcare systems and hospitals should implement formal educational programs with ongoing formal and/or informal refresher sessions for healthcare professionals on delirium in at-risk older surgical adults to improve understanding of its epidemiology, assessment, prevention, and treatment (strength of recommendation: strong; quality of evidence: low)


2. Multicomponent Nonpharmacologic Interventions Performed by an Interdisciplinary Team for Prevention of Delirium (Recommendation)-Healthcare systems and hospitals should implement multicomponent nonpharmacologic intervention programs delivered by an interdisciplinary team (including physicians, nurses, and possibly other healthcare professionals) for the entire hospitalization in at-risk older adults undergoing surgery to prevent delirium (strength of recommendation: strong; quality of evidence: moderate).


3. Multicomponent Nonpharmacologic Interventions Performed by an Interdisciplinary Team for Management of Delirium (Recommendation)-Healthcare professionals should consider multicomponent interventions implemented by an interdisciplinary team in older adults diagnosed with postoperative delirium to improve clinical outcomes (strength of recommendation: weak; quality of evidence: low).


4. Identify and Manage Causes of Delirium Recommendation -The healthcare professional should perform a medical evaluation, make medication and/or environmental adjustments, and order appropriate diagnostic tests and clinical consultations after an older adult has been diagnosed with postoperative delirium to identify and manage underlying contributors to delirium (strength of recommendation: strong; quality of evidence: low).


5. Specialized Hospital Units RecommendationThere is insufficient evidence to recommend for or against hospitals creating, and healthcare professionals using, specialized hospital units for the inpatient care of older adults with postoperative delirium to improve clinical outcomes (strength of recommendation: not applicable; quality of evidence: low).

Pharmacologic Treatments/Interventions Used Perioperatively to Prevent Postoperative Delirium in Older Surgical Patients

6. Anaesthesia Depth Recommendation-The anesthesia practitioner may use processed electroencephalographic (EEG) monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium (strength of recommendation: insufficient evidence; quality of evidence: low).


7. Regional Anesthesia Recommendation-A healthcare professional trained in regional anesthetic injection may consider providing regional anesthetic at the time of surgery and postoperatively to improve pain control and prevent delirium in older adults (strength of recommendation: weak; quality of evidence: low).


8. Analgesia Recommendation-Healthcare professionals should optimize postoperative pain control, preferably with nonopioid pain medications, to minimize pain in older adults to prevent delirium (strength of recommendation: strong; quality of evidence: low).


9. Avoidance of Inappropriate Medications Recommendation-The prescribing practitioner should avoid medications that induce delirium postoperatively in older adults to prevent delirium (strength of recommendation: strong; quality of evidence: low).


10. Antipsychotics Used Prophylactically to Prevent Delirium (Recommendation) There is insufficient evidence to recommend for or against the use of antipsychotic medications prophylactically in older surgical patients to prevent delirium (strength of recommendation: not applicable; quality of evidence: low).


11. Cholinesterase Inhibitors (Recommendation) In older adults not currently taking cholinesterase inhibitors, the prescribing practitioner should not newly prescribe cholinesterase inhibitors perioperatively to older adults to prevent or treat delirium (strength of recommendation: strong; quality of evidence: low).

Pharmacologic Treatments/Interventions Used to Treat Postoperative Delirium in Older Surgical Patients

12. Antipsychotics in the Setting of Severe Agitation Recommendation-The prescribing practitioner may use antipsychotics at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated or distressed, and are threatening substantial harm to self and/or others. In all cases, treatment with antipsychotics should be employed only if behavioral interventions have failed or are not possible, and ongoing use should be evaluated daily with in-person examination of patients (strength of recommendation: weak; quality of evidence: low).


13. Benzodiazepines Recommendation-The prescribing practitioner should not use benzodiazepines as a first-line treatment of the agitated postoperative delirious patient who is threatening substantial harm to self and/or others to treat postoperative delirium except when benzodiazepines are specifically indicated (including, but not limited to, treatment of alcohol or benzodiazepine withdrawal). Treatment with benzodiazepines should be at the lowest effective dose for the shortest possible duration, and should be employed only if behavioral measures have failed or are not possible and ongoing use should be evaluated daily with in-person examination of the patient (strength of recommendation: strong; quality of evidence: low).


14. Pharmacologic Treatment of Hypoactive Delirium Recommendation-The prescribing practitioner should not prescribe antipsychotic or benzodiazepine medications for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others (strength of recommendation: strong; quality of evidence: low).