How do I improve delirium care for older surgical patients?
A serious condition with poor outcomes, delirium is best prevented by early identification and treatment
Delirium is categorised by a sudden onset of fluctuating altered consciousness with changes to perception and cognitive function. It is a serious condition, associated with poor outcomes, but can be prevented and managed effectively with early assessment, identification, simple interventions and early treatment (Partridge et al 2017).
Delirium is common and seen in most hospital settings where older patients receive care. The surgical environment is no different and, while the surgical episode itself can be a potential trigger, many of the risk factors seen in the older medical and surgical population are the same.
When managing delirium, prevention is more effective than cure, so assessments must be tailored to highlight patients with predisposing factors (Table 1). In the surgical setting, this should be done early in the preoperative period or on admission. Often standard pathways and protocols fail to include the correct questions to elicit this information, despite it being obtained relatively easily through discussion with families, patients and reviewing medical information.
Table 1. Predisposing and precipitating factors for delirium
|Predisposing factors||Precipitating factors|
|Age; dementia or cognitive impairment; depression; history of delirium; severe illness or hip fracture; polypharmacy; malnutrition/dehydration; functional dependency; sensory impairment||Change in environment; sleep deprivation; loss of sensory aids/clues; physical restraints; constipation; urinary retention; sepsis; acute illness, for example, myocardial infarction; untreated pain or excess use of analgesics|
|Partridge et al (2017)|
As cognitive impairment is a significant predisposing factor for delirium all surgical patients should have cognitive screening to help identify their risk. Assessment can start with a simple question asking patients if they have noticed any change in memory, but should be supported with a more detailed assessment such as the 4AT, which is validated in the diagnosis of delirium and cognitive impairment and needs little in the way of training (Belleli et al 2014).
Once you have identified that a patient has an increased delirium risk, efforts should be made to modify that risk. While it is unlikely that some of the predisposing factors can be improved, such as cognitive or sensory impairment, single and multicomponent interventions can be used. These might include ensuring that patients are well hydrated while nil by mouth or ensuring they have their glasses or hearing aids to hand. These simple interventions have been shown to reduce delirium incidence (Marcantonio et al 1994, Inouye et al 1999, Belleli et al 2014), with evidence that the early education of patients and families also helps to reduce severity and duration of the delirium episode.
Despite best efforts, patients will still develop delirium and again early identification is important. The Confusion Assessment Method (CAM) is the ‘gold standard’ to identify delirium, and relies on nurses to note subtle changes from baseline behaviour. CAM is a set of four questions that identify whether a patient is delirious (Inouye et al 1990) and should be used as soon as a change in cognition is suspected and repeated regularly, or if the patient’s condition changes.
The delirious patient
Once identified, delirium should be treated as a medical emergency as it is often the first sign that a patient is deteriorating. It requires prompt targeted intervention within the first few hours after diagnosis and must include a medical and medication review. This is enhanced by early involvement/informing of family, falls assessment, HELP-style simple interventions including regular orientation, toileting and hydration (Inouye et al 1999) and regular review.
If patients are safe, sedation is not indicated in the treatment of delirium and should only be used as a last resort. Despite this, it is often the most inconsistent aspect of delirium care. Refer to the National Institute for Health and Care Excellence (2010) for specific guidance on medications, and do not be afraid to question why medication is being used.
The care strategies used when managing any patient at risk of or with delirium should not be dissimilar. What is different for the elective surgical patient is the opportunity to highlight this risk before treatment commences. This empowers nurses to use proactive interventions, including the early education of families and patients, to optimise, prepare and manage patients more effectively.
- Bellelli G, Morandi A, Davis D et al (2014) Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing. 43, 4, 496-502.
- Inouye S, van Dyck C, Alessi C et al (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 113, 12, 941-948.
- Inouye S, Bogardus S Jr, Charpentier P et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine. 340, 9, 669-676.
- Marcantonio E, Goldman L, Mangione C et al (1994) A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 271, 2, 134-139.
- National Institute for Health and Care Excellence (2010) Delirium: Prevention, Diagnosis And Management. Clinical guideline 103.
- Partridge J, Harari D, Martin F et al (2017) Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. British Journal of Surgery. 104, 6, 679-687.
Jason Cross, POPS advanced nurse practitioner, Guy’s and St Thomas’ NHS Foundation Trust, London