Anticipating and managing postoperative delirium and cognitive decline in adultsBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4331 (Published 20 July 2011) Cite this as: BMJ 2011;343:d4331
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I was pleasantly surprised to see a review on delirium from the field
of anaesthesia. It is indeed a laudable and welcome effort and the review
made interesting reading, especially for me- a psychiatrist with interest
in the field of delirium.
Herein, I would like to share my thoughts on some specific issues
discussed by the authors.
The authors highlight the importance of post-operative delirium and
it being more common in the elderly. They also provide data showing its
link with major surgeries; especially hip surgery.
This is in keeping with evidence that the highest at-risk individuals for
developing delirium in general are: elderly with cognitive impairment and
undergoing hip surgery(1).
Risk factors have been provided and categorised into modifiable and
non-modifiable. I wonder as to what criteria and/or approach has been
adopted to arrive at this conclusion. It seems conceptually flawed as
depression is an extremely treatable condition (and hence, not a non-
modifiable factor), and there are some dementias that are potentially
reversible with appropriate intervention/management.
As part of the assessment, CAM has been advised. It may be helpful to
further add that there is an instrument (a modification of the CAM) known
as CAM-ICU(2), which is especially useful in the ICU and related
settings(1) for use in non-verbal (i.e. mechanically ventilated) patients
and when administered by a trained health care professional, the CAM-ICU
takes only 1 to 2 minutes.
The management of post-operative delirium has been presented in a
succinct yet reasonably comprehensive manner; especially the role of good
nursing care. In my opinion, the omission of the emphasis on
multidisciplinary working and specialist (psychiatrists, geriatricians
etc.) involvement is disappointing.
My assertion is based on the following i.e. delirium is a syndrome that is
ubiquitous across all specialities and specialists, it is extremely common
and associated with high morbidity and mortality(1,3), and there are
sufficient number of reviews and guidelines' in recent years emphasizing
the need for multi-speciality working and multi-component interventions
for managing delirium(1,4).
It is important for me to also mention that one of the key components of
management, especially on very busy acute care inpatient settings, is-
training of nursing staff in the recognition and appropriate
identification of delirium, It is easier said than done, and has been
highlighted so in the NICE guidance too(1).
One of the biggest challenges faced in the clinical management and
research into delirium has been the difficulty in its recognition by
various specialists(5,6) and the lack of joint, multidisciplinary working.
I sincerely hope that my thoughts are seen as an addendum to this
particular clinical review, as they are in keeping with the spirit and
concept of a multidisciplinary approach towards delirium.
1.NICE. Delirium: Diagnosis, prevention and management (NICE Clinical
Guidance 103). National Institute for Health and Clinical Excellence,
2.Ely EW, Inouye SK, Bernanrd GR, Gordon S, Francis J, May L et al.
Delirium in mechanically ventilated patients: validity and reliability of
the confusion assessment method for the intensive care unit (CAM-ICU).
JAMA 2001; 286: 2703-10.
3.The Royal College of Psychiatrists. Who Cares Wins: improving the
outcome for older people admitted to the general hospital. Report of a
working group for the Faculty of Old Age Psychiatry, London: Royal College
of Psychiatrists, 2005.
4.British Geriatrics Society and Royal College of Physicians.
Guidelines for the prevention, diagnosis and management of delirium in
older people. Concise Guidance to good practice series, No 6, London: RCP,
5.Trzepacz P, Meagher D. Neuropsychiatric aspects of Delirium. In:
The American Psychiatric Publishing Textbook of Neuropsychiatry and
Behavioural Neurosciences-5th Edition. Yudofsky SC, Hales RE (editors).
APPI, Arlington, 2007.
6.Gupta N, Sharma P, Meagher D. Predictors of delayed identification
of delirium in a general hospital liaison psychiatry service: A study from
North India. Asian J Psychiatry 2010; 3: 31-2.
Competing interests: No competing interests
As a respiratory registrar on my current ITU attachment, I have recently come across elderly post surgical patients on the High Dependency Unit who have become extremely agitated a short time after extubation in theatre. Never have there been any signs of sepsis and physiological parameters have always been stable. They have, however, been unmanageable. All the suggested measures of patient orientation and protection, good analgesic control, correction of electrolyte abnormalities, stopping deliriogenic drugs and good nursing care did not work and as they were at risk of pulling various drains and lines out, they were sedated with haloperidol, propofol or even sometimes midazolam. It was a very time and labour consuming task to keep them safe and occasional night shifts were almost completely taken up by looking after the confused patient. The next day however, they were invariably absolutely fine with full orientation to time place and person and recoveries to date have been uncomplicated.
I had never come across this clinical entity previously and hence this article is very welcome.
Competing interests: No competing interests