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For years, weve proposed that the 3 most
important elements of a preoperative evaluation are assessment for (1) delirium
risk, (2) frailty, and (3) obstructive sleep apnea. And weve done numerous
columns, listed below, on the prevention and management of delirium and
perioperative cognitive issues. So, we were quite delighted when the American
Society of Anesthesiologists launched its Perioperative Brain
Health Initiative in
2015.
This month, Vacas et al. published an excellent review on perioperative brain health in the older adult in Anesthesia & Analgesia (Vacas 2022). They categorize perioperative neurocognitive disorders (PNDs) according to the ASA Nomenclature Consensus Working Group:
1. Preoperative cognitive impairment
2. Postoperative delirium (POD)
3. Delayed neurocognitive recoveryimpairment
within the first 30 days of surgery
4. PNDoccurring between 30 days and 12 months
after surgery
They begin with the preoperative risk assessment, which includes consideration of both predisposing factors and precipitating factors. While you cant modify risk factors such as age, there are some risk factors that can be modified or potentially optimized. These include frailty, polypharmacy, sleep, pain, vision and/or hearing impairment, diabetes, infection, neuropsychiatric conditions, and poor nutrition.
Preoperative interventions include education on lifestyle modifications and possibly neurocognitive rehabilitation. The Neurobics randomized clinical trial showed that an electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions reduced the incidence of postoperative delirium from 23.0% to 14.4% (Humeidan 2021). They also noted that incorporation of elements from the Hospital Elder Life Program (HELP), which we have discussed so often, may be part of a preoperative program.
Perhaps the most important preop intervention is a focus on medications, including those medications known to be risk factors for delirium (such as benzodiazepines) and other potentially inappropriate medications (PIMs) from Beers Criteria List. They also recommend identifying sleep disturbances, such as obstructive sleep apnea (note: theyve hit our 3 most important points: delirium risk, frailty, and OSA!).
Lastly, they recommend involvement of a physician with expertise in geriatric medicine throughout the perioperative period.
The risk of perioperative neurocognitive disorders should be discussed with older patients and their families as part of the informed consent process.
During the intraoperative period, it does not appear that the
type of anesthesia is a significant contributor to PND. And studies of
EEG-guided hypnotic administration have yielded conflicting results on the
occurrence of post-op delirium or PND. It makes sense to avoid hypotension
during surgery, though evidence of the impact of intraoperative hypotension on
delirium is soft. Though some studies
have found no association, a recent retrospective study found an association
between intraoperative hypotension, particularly duration of hypotension, and
delirium occurrence (Vlessides 2022).
Weve already discussed in many columns the post-operative interventions we do to reduce the likelihood of delirium or manage delirium that has already occurred.
We should avoid medications that commonly induce delirium, especially anticholinergic drugs, sedative/hypnotics, diphenhydramine, and benzodiazepines. Some pain medications may contribute to delirium, but so does inadequate pain control. Most recommend use of non-opioid analgesics where possible.
Multimodal interventions, such as those included in the Hospital
Elder Life Program (HELP), are important. These include return of the
patients visual and hearing aids, early mobilization, and resumption of a
normal diet, and attempts to create a more normal sleep/waking cycle. See our March 16, 2021 Patient Safety Tip of the Week
Sleep Program Successfully
Reduces Delirium for several sleep-promoting programs that
have been used in prevention and management of delirium.
Vacas et al. also acknowledge the importance of early family engagement and social support. We always recommend families bring in familiar objects from home (like their clock radio).
Though the anesthesiologist may no longer be involved directly in the patients care, Vacas et al. remind us that we must be vigilant for the occurrence of delirium or any form of PND. That would include frequent use of screening tools like the Confusion Assessment Method (CAM), Confusion Assessment Method for the ICU (CAM-ICU), and others.
The Vacas article goes on to discuss future directions for
research on perioperative
neurocognitive disorders. This article is a nice summary of the current state of affairs for perioperative neurocognitive disorders.
We hope that youll also go back to some of our many columns on prevention and
management of delirium listed below.
Note that there are some newer ancillary
studies touted to be predictors of delirium, such as EEG (Kronemyer 2022),
ocular-based screenings (Anesthesiology
News 2020),
and measurement of preoperative plasma concentrations of Tau-PT217 and
Tau-PT181 (Liang
2022),
but these are not yet ready for widespread adoption.
Some of our prior columns on delirium
assessment and management:
·
February
12, 2019 2
ER Drug Studies: Reassurances and Reservations
·
September
17, 2019 American
College of Surgeons Geriatric Surgery Verification Program
·
March
2021 The
Fiscal Costs of Delirium
References:
ASA (American Society of Anesthesiologists).
Perioperative Brain Health Initiative
https://www.asahq.org/brainhealthinitiative
Vacas S. Canales C, Deiner SG, et al. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative, Anesthesia & Analgesia 2022; 135(2): 316-328
Humeidan ML, Reyes JC, Mavarez-Martinez A, et al. Effect of cognitive prehabilitation on the incidence of postoperative delirium among older adults undergoing major noncardiac surgery: the Neurobics randomized clinical trial. JAMA Surg 2021;156:148156
https://jamanetwork.com/journals/jamasurgery/fullarticle/2772853
Vlessides M. Post-op Delirium Linked to Intra-op Arterial
Hypotension. Anesthesiology News 2022; February 8, 2022
Kronemyer B. Post-op Delirium Detected With Peri-op EEG Monitoring Of Older Patients. Anesthesiology News 2022; April 13, 2022
Liang F, Baldyga K, Quan Q, et al. Preoperative Plasma Tau-PT217 and Tau-PT181 Are Associated With Postoperative Delirium, Annals of Surgery 2022; July 6, 2022
Anesthesiology News. 60-Second Abstracts: A
Novel Pre-op Method for Identifying Post-op Cognitive Delirium. Anesthesiology
News 2020; December 22, 2020
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