AGS Guideline for Postoperative Delirium in Older Adults
AGS Guideline for Postoperative Delirium in Older Adults
The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.
Postoperative delirium is a common, life-threatening problem in older adults and is recognized as the most common postoperative complication in this age group.* Delirium has been shown to be preventable in up to 40% of cases in some hospitalized older adult populations, a fact that makes delirium a prime candidate for prevention interventions targeted to improve the outcomes of older adults after surgery.
The clinical presentation of delirium varies. Motoric subtypes can vary from hypoactive (e.g., withdrawn, decreased motor activity) to hyperactive (e.g., agitation, heightened arousal, aggression). Mixed delirium presents with the range of both hyperactive and hypoactive symptoms. Delirium is reported to remain undiagnosed in more than half of clinical cases, largely because hypoactive delirium is typically unrecognized or misattributed to dementia.
A recent survey of surgical specialists carried out by the American Geriatrics Society Geriatrics-for-Specialists Initiative (AGS-GSI) identified delirium as the most "essential" topic in the care of older adults, and as the least understood geriatric clinical issue for which the knowledge gap for optimal management was greatest. This survey, along with a wealth of recent new evidence, prompted the AGS to initiate this practice guideline project with support from a grant to the AGS-GSI from the John A. Hartford Foundation.
The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 AGS Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at www.GeriatricsCareOnline.org. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety, and improve outcomes.
The guideline is limited to the aims described. Some of these recommendations will not apply to specific areas of care, such as intensive care unit (ICU) sedation, palliative care, and nursing home settings. Diagnosis and screening are not addressed in these guidelines. Other topics, such as prescription of melatonin to prevent delirium, were considered but not addressed due to a lack of evidence. Since delirium is a burgeoning area of clinical investigation, regular updates of the recommendations are planned as new evidence becomes available.
*ET (Evidence Table).
Abstract and Introduction
Abstract
The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.
Introduction
Postoperative delirium is a common, life-threatening problem in older adults and is recognized as the most common postoperative complication in this age group.* Delirium has been shown to be preventable in up to 40% of cases in some hospitalized older adult populations, a fact that makes delirium a prime candidate for prevention interventions targeted to improve the outcomes of older adults after surgery.
The clinical presentation of delirium varies. Motoric subtypes can vary from hypoactive (e.g., withdrawn, decreased motor activity) to hyperactive (e.g., agitation, heightened arousal, aggression). Mixed delirium presents with the range of both hyperactive and hypoactive symptoms. Delirium is reported to remain undiagnosed in more than half of clinical cases, largely because hypoactive delirium is typically unrecognized or misattributed to dementia.
A recent survey of surgical specialists carried out by the American Geriatrics Society Geriatrics-for-Specialists Initiative (AGS-GSI) identified delirium as the most "essential" topic in the care of older adults, and as the least understood geriatric clinical issue for which the knowledge gap for optimal management was greatest. This survey, along with a wealth of recent new evidence, prompted the AGS to initiate this practice guideline project with support from a grant to the AGS-GSI from the John A. Hartford Foundation.
The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 AGS Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at www.GeriatricsCareOnline.org. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety, and improve outcomes.
The guideline is limited to the aims described. Some of these recommendations will not apply to specific areas of care, such as intensive care unit (ICU) sedation, palliative care, and nursing home settings. Diagnosis and screening are not addressed in these guidelines. Other topics, such as prescription of melatonin to prevent delirium, were considered but not addressed due to a lack of evidence. Since delirium is a burgeoning area of clinical investigation, regular updates of the recommendations are planned as new evidence becomes available.
*ET (Evidence Table).
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