“Patients may look calm or like they’re sleeping. In reality, however, they may have delirium in the hypoactive form, which can have the same poor outcome as hyperactive delirium.”
Founded over 200 years ago, Tufts Medical Center, located in downtown Boston, is a 415-bed academic medical center that is taking a leadership role to prevent post-operative delirium and cognitive dysfunction. We talked with Ruben J. Azocar, M.D., M.H.C.M., FASA, FCCM, professor and chair in the Department of Anesthesiology and Perioperative Medicine at Tufts Medical Center & Tufts University School of Medicine to learn more about the delirium prevention program underway there.
May 2, 2018 updated May 10, 2018
by Sandra Gordon for ASA
Q: What perioperative steps are being taken to prevent post-operative delirium?
RA: In our preop clinic, we assess surgical patients over 65 for preoperatively for delirium, using the Delirium Elderly At-Risk (DEAR) assessment tool. If a patient is at risk, we include the information in the preoperative note, discuss the risk with the patients and their families, alert the surgical team and notify the geriatric medicine team. The geriatric team will follow up the patient in the postoperative period.
During surgery, we do everything we can to prevent postoperative delirium by minimizing the use of medications like benzodiazepines and opioids for pain control. We provide preemptive analgesia with different medications taken by mouth, provide regional analgesia when possible and also might opt to use regional anesthesia techniques —maybe a spinal or epidural, even though the data isn’t completely strong on these techniques preventing delirium.
In the recovery room, we make sure patients get their eyeglasses and hearing aids and get a family member as soon as possible to the bedside. We try to minimize the use of urinary catheters or nasogastric tubes or remove them as soon as possible. Once patients are on the floor, the geriatric team will touch base with the primary surgical team. The nurses also assess patients daily for delirium, using the CAM screening tool. This protocol as part of our Total Joint Surgery Program.
Q: Have you had a lot of success with this protocol?
RA: The overall result of our Total Joint Surgery Program pilot was extremely positive. We saw a significant decrease on blood transfusion, decreased length of stay and ICU admissions and more patients went home instead of to a nursing facility after their operation. We estimated a decreased the cost of care for total joints—both hips and knees—around $3,000 per case.
Q: How important is CAM scoring for assessing delirium risk post-operatively?
RA: The daily assessment is key to identifying delirium on the wards, regardless of the patient’s baseline or appearance, because delirium is easy to diagnose when patients have hyperactive delirium. They’re typically agitated and combative. But if you don’t do the assessment, you might miss patients with hypoactive delirium. Patients may appear calm or look like they’re sleeping. In reality, however, they may have delirium in the hypoactive form, which can have the same poor outcome as hyperactive delirium.
Q: In addition to your Total Joint Surgery Program, is delirium risk being addressed in other service lines?
RA: Last fall, we started working with our neurosurgeons for laminectomy patients who are 55 years and older. For these patients, we might do a spinal anesthetic with aims to minimize delirium and potentially cognitive dysfunction. We’ve done about 60 cases that way. We’re in the midst of analyzing the data, comparing postsurgical delirium outcomes with spinals versus general anesthesia.
Q: At the ANESTHESIOLOGY® 2018 annual meeting in October, you’ll be presenting on the merits of exercise and cognitive therapy before surgery. To wrap up, can you give us a preview?
RA: In my talk, I’ll be addressing cognitive dysfunction, which is more long term and difficult to assess, compared with delirium. From a broad perspective, however, we know that older frail adults tend to have worse surgical outcomes than nonfrail older adults. There’s literature supporting the idea that if we can make adults less frail by increasing their physical capacity before surgery with prehabilitation, there could be a benefit in terms of outcomes.
Similarly, there’s some evidence that older adults at risk for cognitive dysfunction might benefit with some sort of brain prehabilitation program—to improve outcomes, such as having patients do cognitive exercises on brain-training apps. I’ll be presenting research that supports my argument that we should start thinking about cognitive and physical prehab for any surgical patient 55 years and older to reduce the incidence of cognitive dysfunction.
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