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Post- Operative Delirium in the Elderly Thomas Robinson, MD Surgery Grand Rounds March 10 th , 2008
Post- Operative Deliriumin the Elderly
Thomas Robinson, MD
Surgery Grand RoundsMarch 10th, 2008
What is the most common post-operative complication in
elderly patients?
What is the most common post-operative complication in
elderly patients?
Marcantonio et al. JAMA (1994) 271:134.
DELIRIUM
Diagnostic Criteria for Delirium
1.Disturbance of Consciousness
2. Change in Cognition
3. Acute Onset
4. Coexisting Physiologic Disturbance
Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994)
In 2004, what percent of all operations in the United States were performed
on patient older than 65 years?
In 2004, what percent of all operations in the United States were performed
on patient older than 65 years?
55% (Age > 65) 45% (Age < 65)
GRS: A Core Curriculum in Geriatric Medicine – 6th Ed. (2006)
U.S. Population Aged 65 and Over
0
20
40
60
80
1900 1930 1960 1980 2002 2030
Population(Millions)
Calendar Year
U.S. Population Aged 65 and Over
0
20
40
60
80
1900 1930 1960 1980 2002 2030
Population(Millions)
0
5
10
15
20
25
Percent Total
Population
Calendar Year
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Treatment
Organic Causes of Delirium
DELIRIUMS (mnemonic)
DEL I R I U MSS
rugs (anticholinergics, polypharmacy)motional (depression)ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis)etention of urine or stoolctal states (seizure, post-ictal)nder-nutrition/under-hydration etabolic (electrolytes, glucose)ubdural (acute CNS processes) ensory (impaired vision & hearing)
Etiology of Post-Operative Delirium
• Consecutive patients older than 50 years being admitted post-operatively to the SICU.
• 88% (56/64) - No underlying cause identified.
• 12% (8/64) - Organic cause identified.
75% - Sepsis
12% - Stroke
12% - Alcohol Withdrawal
DVAMC
Age and Post-Operative Delirium
DVAMC
0
20
40
60
80
100
50 - 59 60 - 69 70 - 79 80 - 89
Age by Decade(years)
Incidence of Delirium
(%)
DVAMC
Pre-Operative Risk Factors
*p=.00918%82%History of Alcohol Abuse
*p<.0011.8±1.44.6±2.4Co-Morbidities (Charlson Index)
*p<.0014.6±0.72.8±1.6Dementia (Mini-Cog Test)
*p<.00199±391±11Functional Status(Barthel Index)
*p<.00144±438±7Hematocrit (%)
*p<.0013.9±0.43.3±0.8Albumin (g/dL)
*p<.00161±669±9Age (years)
Absent(n= 80)
Present(n=64)
DELIRIUM
DVAMC
Intra- and Post- Operative Risk Factors
*p=0.0011.3±2.13.1±3.3Blood Transfusion (units)
POST-OPERATIVE
*p<0.00127%88%Intra-Op Hypotension (SBP<90)p=.44282±105298±137OR time (minutes)p=.73655±1515752±1033Blood loss (ml)
INTRA-OPERATIVE
Absent(n= 80)
Present(n=64)
DELIRIUM
Strongest Risk Factors for the Development of Post-Operative Delirium
Pre-Existing Dementia
Functional Impairment
Older Age
More Co-Morbidities
Lower Albumin
Intra-Operative Hypotension
DVAMC
Frailty Predicts Delirium
Given a similar surgical stress, the core components of frailty are stronger predictors of developing post-operative delirium than the specific details of the operation.
Strongest Risk Factors for the Development of Post-Operative Delirium
Pre-Existing Dementia
Functional Impairment
Older Age
More Co-Morbidities
Lower Albumin
Intra-Operative Hypotension
DVAMC
“Threshold Theory” of Cognitive Decline
The hypothetical construct of reduced brain reserve capacity represented by changes in the brain’s actual neurons or the milieu of neurotransmitters which makes an individual more vulnerable to a cognitive clinical deficit such as delirium.
Satz P. Neuropsych (1993) 7:273.
Changing Cognitive Function in the Elderly
0
20
40
60
80
100
50 60 70 80 90 100
Age (Years)
Brain Reserve Capacity
Dementia
Threshold Theory of Cognitive Decline
0
20
40
60
80
100
50 60 70 80 90 100
Age (Years)
Dementia
Brain Reserve Capacity
Threshold Theory of Cognitive Decline
0
20
40
60
80
100
50 60 70 80 90 100
DementiaDelirium
Age (Years)
Brain Reserve Capacity
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Treatment
40%Hip Fracture3
44%DVAMC SICU6
59%DHMC Trauma ICU7
< 5%Cataract Surgery5
72%Medical ICU2
36%Vascular Operation4
15%Medial Ward1
Incidence of Delirium
1NEJM (1999) 340(9):669.2JAGS (2006) 54:479.3JAGS (2002) 50:850
4Gen Hosp Psych (2002) 24:28.5Int Psych (2002) 14:301.6DVAMC
7DHMC
44%Incidence
2.4±1.9Time to Onset (days)
4.0±5.1Duration (days)
Natural History of Delirium
DVAMC
Cumulative Incidence of Post-Operative Delirium
DVAMC
CumulativeIncidence
(%)
0
20
40
60
80
100
1 2 3 4 5 6 7
Post-Operative Day
The Biphasic Distribution of Post-Operative Delirium
*p=0.021.9±0.95.6±3.5Initial Presentation of Delirium (Post-Operative Days)
No Identifiable
Cause
Organic Identifiable
Cause
DELIRIUM
DVAMC
The Biphasic Distribution of Post-Operative Delirium
DVAMC
0
5
10
15
20
25
30
1 3 5 7 9 112 4 6 8 10 12
Post-Operative Day
No identifiable cause of delirium
Delirium due to an organic cause
Number of Subjects
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Treatment
Outcomes and Delirium
*p<0.0011%33%Post-Discharge Institutionalization
*p<0.00131.6±14.150.1±33.6Cost of Hospitalization ($ in 1,000s)
*p<0.0017.9±3.916.3±10.9Length of Hospital Stay (days)
*p<0.0014.6±2.19.7±8.0Length of ICU Stay (days)
Absent(n= 80)
Present(n=64)
DELIRIUM
DVAMC
Mortality and Delirium
*p=0.0013%a20%Six Month Mortality
*p=0.0451%9%30 Day Mortality
p=0.0860%5%Hospital Mortality
Absent(n= 80)
Present(n=64)
DELIRIUM
a n=78 – two patients lost to 6 month follow up
DVAMC
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Treatment
Motor Subtypes of Delirium
• A spectrum of psychomotor behavior is found in delirium.
• Delirium Motor Subtypes Hypoactive HyperactiveMixed Type
Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.
Motor Subtypes of Delirium
Hypoactive Pure lethargy, somnolence
Hyperactive Pure agitation
Mixed Type Fluctuation between lethargy and agitation
Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.
Incidence - Motor Subtypes of Delirium
DVAMC
Trauma ICU
33%
1%
66%
Post-Op SICU
Mixed Type
Hyperactive
Hypoactive
Medical ICU
Incidence - Motor Subtypes of Delirium
DHMC
39%
15%
46%
Trauma ICU
33%
1%
66%
Post-Op SICU
Mixed Type
Hyperactive
Hypoactive
Medical ICU
Incidence - Motor Subtypes of Delirium
39%
15%
46%
Trauma ICU
33%
1%
66%
Post-Op SICU
55%Mixed Type
2%Hyperactive
44%Hypoactive
Medical ICU
Peterson et al. JAGS (2006) 54:479.
Adverse Events - Motor Subtypes of Delirium
• 23% (17/74) incidence of adverse events
• 21 events occurred in 17 subjects
• Adverse Events 52% (11/21) Pulled tube/line 29% (6/21) Sacral decubitus ulcer 20% (2/21) Falls 5% (1/21) Extubation
DVAMC
Adverse Events - Motor Subtypes of Delirium
DVAMC
*p=0.001075%Sacral Decubitus Ulcer
p=0.02482%25%Pulled line/tube
Mixed(n=11)
Hypoactive(n=8)
MOTOR SUBTYPE
Outcomes - Motor Subtypes of Delirium
DVAMC
MOTOR SUBTYPE
32%*
71±9*
Hypoactiven=50
9%*
65±9*
Mixedn=23
3%
60±6
No Deliriumn=98
*p=0.0416 Month Mortality
*p=0.001Age (years)
Post-Operative Delirium in the Elderly
Risk Factors
Natural History
Outcomes
Motor Subtypes
Treatment
Haldoperidol 2 mg q20 min(while agitation persists)
OR
4-8mgSevere
2-4mgModerate
0.25-2mgMild
Initial Dose HaldoperidolPO, IM or IV
Degree of Agitation
Pharmacologic Treatment - ICU
Jacobi et al. Crit Care Med (2002) 30(1):119.
Pharmacologic Treatment - ICU
Maintenance Dose: 50% of total loading dose is the
maintenance dose divided every 6-8 hours daily
Continue maintenance dose for 24-48 hours before tapering
Taper: Taper maintenance dose by 20-
30% daily until off.
Pharmacologic Treatment - ICU
0.5mg PO BID for 24 hrs. then DCTaper
Order 1mg TID IV or PO x 24 hrs.Keep daily dose for 24 – 48 hrs.
Maintain
Moderate Agitation2:00AM – 2mg IV2:30AM – 2mg IV3:00AM – 2mg IV3:30AM – Agitation controlled
Control
Haldoperidol Administration
General Recommendation:Haldoperidol 1-2 mg q2-4 hrs PRNMay be administered PO/IM/IV
For Elderly Patients:Haldoperidol 0.25-0.5mg q4hrs PRN
Pharmacologic Treatment - Ward
Practice Guideline for Treatment of Patients with Delirium (1999) American Psychiatric Association
Post-Operative Delirium in the Elderly
Dementia is the strongest risk factor for delirium.
Delirium resulting from an organic cause occurs later in the post-op course compared to “geriatric” delirium.
Outcomes are worse in subjects who develop delirium.
Delirium presents in three distinct motor subtypes.
Hypoactive delirium has the worst prognosis.
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