Recent Advances in Preventing and Managing Postoperative Delirium

Abstract

Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.

Keywords: Anesthesia; Cognitive Dysfunction; Cognitive Reserve; Delirium; Neurocognitive; Neurophysiology; Postoperative; Surgery.

Figure 1.. Meta-analysis summarizing four trials in which the intervention group received electroencephalogram-guided anesthesia.

This analysis was conducted by using OpenMetaAnalyst and was based on a binary, random effects, Hartung–Knapp–Sidik–Jonkman model ^, . The I ² = 74%, tau ² = 0.08, Q(df = 3) = 13.234, and heterogeneity P value = 0.004. The estimated odds ratio for delirium with intervention (electroencephalogram-guided [reduction in] anesthesia) = 0.764 (95% confidence interval 0.549 to 1.061, P = 0.108). BAG-RECALL, Bispectral Index or Anesthesia Gas to Reduce Explicit Recall; C.I., confidence interval; CODA, Cognitive Dysfunction after Anesthesia; ENGAGES, Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes; SuDoCo-PP, Surgery Depth of Anaesthesia and Cognitive Outcome per-protocol.