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Postoperative delirium
Acute disorder of cognition and attention
after operation
Anytime in perioperative periodMost commonly occurs during postsurgical
period
Underdiagnosed 78%40% routinely screen for delirium
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Postoperative delirium
Associated with
Poor cognitive and functional recovery
Longer hospital stayGreater hospital costs
Risk factor for institutionalization and
morbidityReduced risk by early identification,assessment and treatment
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Incidence/ prevalence of adult older than 65 year experience
delirium during hospitalization
Wide range estimate of postoperativedelirium pending on type of operation
Delirium is likely to increase in future
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Pathogenesis
CNS changes with age
Loss of nerve cells
Decreased in cerebral blood flowChanges in neurotransmitter system
Decreased acetylcholinesterase activity
Carbonic anhydrase activityMuscarinic receptor
Serotonin receptors
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Pathogenesis
Abnormal levels of endorphins, serotonin,
neuropeptides in CSF
EEG : slowing of dominant posterior alpharhythm and abnormal slow wave activity
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Cause of CNS dysfunction after surgery
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Risk factors
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Risk factors
Older ageCognitive impairment
Functional impairment
Decreased postoperative hemoglobin
Markedly abnormal sodium, potassium and glucoseAlcohol abuse
Noncardiac thoracic operation
History of delirium
Preoperative used of narcoticPreoperative used of benzodiazepine
Low postoperative oxygen saturation
History of cardiovascular disease
Untreated pain
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Drug associated withdelirium
Drugs with anticholinergic activityTricyclic antidepressants
Cimetidine
Corticosteroids
Digoxin
Diphenhydramine
Belladonna
DipyridamoleTheophylline
Promethazine
Amantadine
Oxybutyrin
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Drugs associated withdelirium
Analgesics
Narcotics (especially meperidine)NSAIDs
Benzodiazepines
Antiparkinsonian agents
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Diagnosis
Modified from Diagnostic and Statistical Manual of Mental Disorder, 4THed
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features depression delirium dementia
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Clinical features
Change of consciousness and recognition
Cognitive abnormalities
DisorientationLanguage difficulty
Impairment of learning and memory
Fluctuating course
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Clinical features
Emotional disturbances
Anxiety
Fear
Anger
Irritability
Depression
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Clinical features
4 different types
Hypoactive delirium
Hyperactive deliriumMixed delirium
Delirium without psychomotor change
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History
Description of patients behavior
Earlier episode of delirium
Evidence of cognitive impairmentInformation to rule out alcohol or drug
withdrawal
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Physical examination
Vital signs
Oxygen saturation
Sign of trauma or infectionState of hydration
New neurological signs
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Confusion assessmentmethod
Item 1 and 2 and 3 or 4Sensitivity 94-100%Specificity 90-95%
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Diagnostic tests
To identify potentially correctable factors
CBC, electrolytes, creatinine, glucose,
and urinalysisNeuroimaging may be used selectively
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Prevention
Tarketing modifiable risk factors prevent
some case of delirium*
Standardized protocols of known risk factorsfor delirium
Reduction in delirium episodes (15%9.9%)
No effect on delirium severity and rate ofrecurrence
*N Engl J Med 1999;340:669-676
Sleep deprivation
Immobility
DehydrationVisual impairment
Cognitive impairment
Hearing impairment
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Prevention
Patients with fracture neck of femur
Outcome : Postoperative delirium ??
Pre and postoperative geriatric assessments,Oxygen therapy
Early operation
Prevention treatment of perioperative BP fall
Treatment of postoperative complication
J Am Geriatr Soc 1991;39:655-62
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Prevention
Interventions
Decreased postoperative deliriumfrom 61% to 48%
J Am Geriatr Soc 1991;39:655-62
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Prevention
Identify and reduce risk factors can decrease
postoperative delirium in elderly
Preoperative educate the patients
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Management
Treat contributing illness
Providing supportive measures
Symptom control
Identify causes
and treat
Safe environment
Appropiate stimulation
NutritionReserve for agitated ordisruptive individuals
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Supportive measures
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Medication for symptomcontrol
Antipsychotics
Haloperidol or newer antipsychotic agent ??
Goal is to control disruptive symptoms and avoid
obtundation
Taper in 3-5 days
Benzodiazepine
Paradoxical agitation
Treat withdrawal from alcohol of sedative drugs
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Prevention and treatment of postoperative delirium
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Outcome
Sequels of delirium can persist for 6 months
Risk for future cognitive decline
Associated with increase mortality (10-65%)Longer hospital stay and higher nursing
home placement
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Outcomes of delirium
Relationship between delirium and dementia
in 3 years with 203 patients age 65 in
medical services
Incidenceof dementia
5.6% per year in patient without delirium18.1% per year in delirium group
Age aging 1999;28:551-556
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Outcomes of delirium
78 patients with femoral neck fractures
J Am Geriatr Soc 2003;51:1002-1006
Postoperativedelirium
WithoutPostoperative delirium
Dementia
69% 20%5 years
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Conclusion
Risk of postoperative delirium can be
reduced with careful attention to risk factors
Intervention to target problemsSystemic approach to diagnostic workup
Early identification, assessment and
management