What Older Patients Can Do To Avoid Post-Op Delirium

Guest Contributor

Three days after having surgery for a suspicious colon polyp, Mrs. R lost her sense of reality. The 76-year-old therapist seemed confused about everything, including why she was in the hospital. She spiked a high fever and spent the next four days in the intensive care unit.

A month later, seemingly recovered, she went for a routine follow-up procedure, and again slipped into delirium, forgetting basic facts about her world and becoming so depressed that she had to be hospitalized.

Although Mrs. R is now driving and optimistic again and doesn’t remember much from that time, her daughter told doctors it was terrifying to watch.

Somewhere between 15 and more than 50 percent of older patients develop such severe confusion after major surgery – and although it is a common problem, care for delirium is spotty at best.

Many families, like Mrs. R’s, struggle to get hospital staff to listen to their concerns and to figure out how to help patients.

Two new studies released this week, one about Mrs. R in yesterday’s Journal of the American Medical Association, address this issue of delirium and what can be done about it.

“I don’t think we do as good of a job as we might in informing patients and family members of the possibility of acute confusion or delirium after surgery,” said Dr. Edward R. Marcantonio, director of the Aging Research Program at Beth Israel Deaconess Medical Center, and an author on both studies. “I think that we can improve care and improve outcomes for older patients – particularly surgery patients.”

There are still a lot of open questions about what causes delirium, and what its consequences are. Some research, including the second study, published today in The New England Journal of Medicine, suggests that once mom has a bout of delirium, she is more prone to it again, and possibly to long-term consequences like dementia.

Marcantonio, also a professor at Harvard Medical School, said the study was designed in part to ask the question: “Is it the delirium itself causing the bad outcome or the things that cause the delirium?” Although the study of 225 older coronary artery bypass and valve replacement patients can’t prove anything definitively, Marcantonio says it “suggests that it in fact is the delirium associated with the bad outcomes.”

There is some suggestion that delirium causes brain inflammation which then does further damage, he said. Also, because delirium tends to strike right after major surgery – around the same time as most rehabilitation – it’s possible that delirium patients have worse long-term outcomes because they’ve missed out on that rehab, he said.

Luckily, there are things doctors and family members can do to minimize the risks of delirium, and to help people pop out of it faster, hopefully minimizing the damage.

“I think 40 maybe 50 percent of delirium is preventable,” said Sharon Inouye, director of the aging brain center at Hebrew Senior Life, who developed an elder care program now in dozens of hospitals nationwide.

The first step is recognizing who is most at risk. The more health problems someone has, the more vulnerable they are to delirium, with common risk factors including: dementia or mild cognitive impairment; significant hearing or vision problems; dehydration or kidney problems when admitted to the hospital; multiple medications; and being over 80.

“I have a hypothesis that it’s not the specific stimuli but the combination of stressors that accumulate,” said Inouye, also a professor at Harvard Medical School and a co-author on the New England Journal paper, along with researchers at the University of Massachusetts Medical School. “It reaches a critical mass for that patient and they get tipped over into the delirium.”

The first step is recognizing who is most at risk. The more health problems someone has, the more vulnerable they are to delirium, with common risk factors including: dementia or mild cognitive impairment; significant hearing or vision problems; dehydration or kidney problems when admitted to the hospital; multiple medications; and being over 80.

“I have a hypothesis that it’s not the specific stimuli but the combination of stressors that accumulate,” said Inouye, also a professor at Harvard Medical School. “It reaches a critical mass for that patient and they get tipped over into the delirium.”

It’s also likely that sedation plays a role, with patients who receive more sedation, either with general or regional anesthesia, being most vulnerable. One 2010 study at Johns Hopkins University found that hip fracture patients given light sedation during surgery were less likely to become delirious than those put into a deeper sleep.

Once someone has slipped into delirium, removing some of those risk factors will help, she said: taper off or eliminate medications, address electrolyte imbalances, replenish fluids, and make sure patients have their glasses, hearing aids and dentures so they can see, hear and eat. Friendly faces, voices and mementos of home can also help reorient patients who are confused. Some hospitals will even allow family members to spend the night with a patient who has delirium, to comfort them. Getting up and walking around three times a day is also important, she said.

Inouye and Marcantonio said there are still some major open questions about delirium, including what exactly is causing it, how it manifests in the biology (there’s no lab test yet for dementia, only observation of the person), whether it leads to dementia, and whether any medications can eliminate delirium or minimize its consequences.

In the meantime, if you or anyone you love is over 70 and needs major surgery, try to minimize the risk factors and respond quickly if you notice serious confusion.

Karen Weintraub is a Cambridge-based Health and Science journalist and frequent contributor to CommonHealth.