CRITICAL CARE CONNECTION

Preventing Delirium in PostoperativePatients

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

DELIRIUM ISANACUTE confusion disorder char-

acterized by altered mental status, inattention,

disorganized thinking, and altered level of con-

sciousness, and it is potentially preventable.1,2

This acute confusional state was described byHippocrates more than 2,500 years ago and

remains an important clinical problem today.3 Sig-

nificant strides have been made in identifying and

treating the condition; however, the science to

guide practice remains young.3

What is known about delirium is that it affects

12,500,000 patients and has significant adverse out-comes for these patients; specifically, longer me-

chanical ventilation and length of hospitalization,

functional decline, and higher risk of morbidity

and mortality after hospitalization.1-5 Additionally,

it is estimated that delirium occurs in 14% to 56%

of the postoperative, hospitalized elderly persons,

making it one of the most common postoperative

complications for the older patient.6,7 Peri-anesthesia nurses are in an ideal position to

identify patients at risk of developing delirium post-

operatively and to implement strategies to mitigate

the severity of the acute confusional state.

Delirium

The Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, defines delirium as an

acute and fluctuating brain organ dysfunction pre-

senting with a disturbance of consciousness with

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is a Re-

search Nurse Scientist, Critical Care, University of Colorado

Hospital, and an Associate Professor, University of Colorado

College of Nursing, Aurora, CO.

Conflict of interest: None to report.

Address correspondence to Mary Beth Flynn Makic, Univer-

sity of Colorado Hospital, 12401 E 17th Avenue, Campus Box

901, Leprino Building, Aurora, CO 80045; e-mail address:

marybeth.makic@uchealth.org.

� 2013 by American Society of PeriAnesthesia Nurses

1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2013.09.002

404 Journal o

reduced ability to focus, sustain, or shift atten-

tion.8 Delirium is a change in cognition that is

not accounted for by a previously diagnosed con-

dition such as dementia. This change in cognition

or perceptual disturbance develops over a shortperiod of time (hours to days) and may fluctuate

over the course of a day. Delirium can be classified

into three subtypes, namely hyperactive, hy-

poactive, or mixed.3,8,9 Hyperactive delirium is

the most frequently recognized form as it is

characterized by agitation, acute disorientation,

restlessness, and emotional liability. Hypoactive

delirium occurs more commonly, but is oftenunrecognized as the patient usually presents

with a flat affect and is withdrawn, lethargic,

quiet, but disoriented and confused. Mixed

delirium is a combination of hyperactive and

hypoactive types in which the patient’s be-

haviors swing from agitated to calm moods

commonly associated with daytime sedation and

nighttime agitation.10

The pathophysiologic process of delirium is not

completely understood; however, there are several

theories that attempt to explain postoperative de-

lirium. The medication theory focuses on the

drugs delivered and associated neurotoxicity.3,11

The surgical theory identifies inflammation from

both anesthetics and surgical interventions as theetiology of neuronal changes.11 Stress responses,

release of inflammatory cytokines, increased cir-

culation of cortisol, and sleep deprivation are

believed to cause changes in neuronal pathways

triggering delirium.9,11 The patient theory exami-

nes factors such as the frailty and cognitive

deficits of the patient before the surgical event.

The environmental theory credits disorientationand unfamiliar surroundings as the contributory

factor in postoperative delirium.3 Current research

continues to examine the role of several neuro-

transmitters believed to play a role in acute delir-

ium. These neurotransmitters are acetylcholine,

dopamine, serotonin, and gamma-aminobutyric

acid. Fluctuating levels of these neurotransmitters

f PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 404-408

CRITICAL CARE CONNECTION 405

and interactions with medications, specifically

benzodiazepine agents, are an area of active re-

search in the efforts to more clearly understand

what triggers postoperative delirium.

Which Patients Are at Risk forPostoperative Delirium?

Although any patient is at risk of developing post-

operative delirium, certain factors place the pa-tient at increased risk. These risk factors include:

advanced age (risk increases with age), alcohol

use, smoking history, chronic disease states, un-

derlying cognitive disorder (eg, dementia), pulmo-

nary disease, history of depression, polypharmacy,

medications (anticholinergics, benzodiazepines,

and central nervous system depressant agents),

electrolyte imbalances, hyper/hypoglycemia, acid-base imbalances, infection, blood loss, dehydration,

hypoxia, end-organ failure, hyper/hypothermia,

hypoalbuminemia, sleep deprivation, and unre-

lieved pain. Some risk factors are specific to certain

surgeries, such as cardiac and orthopaedic sur-

geries.3 Although the list of possible triggers is ex-

tensive, the perianesthesia nurses’ awareness of

the multiple risk elements coupled with assess-ment of subtle changes in the patient’s cognition

is essential to early recognition and treatment of

the syndrome.

Assessing Postoperative Delirium

Diagnosis of delirium in the critically ill postopera-

tive patient can be challenging because of the sub-

tle and fluctuating nature of the cognitive

dysfunction. Current practice standards endorse

the use of valid and reliable tools developed to

more objectively identify patients with delirium.

Delirium assessment tools should be used fre-quently and consistently to allow for early identifi-

cation of the syndrome and appropriate treatment

interventions. The two most widely used and

adopted delirium assessment tools are the Confu-

sion Assessment Method for the Intensive Care

Unit (CAM-ICU) and Intensive Care Delirium

Screening Checklist (ICDSC).10 Both tools have re-

cently been recommended by the Society of Criti-cal Care Medicine as the most valid and reliable

tools for use in the routine monitoring of ICU pa-

tients for the presence of delirium.12 The tools

are also appropriate for use in the perioperative

practice setting.3

The CAM-ICU was developed specifically for the

ICU patient population to include mechanically

ventilated individuals.13 This tool has the assessor

determine if the patient exhibits acute and fluctu-

ating changes in cognition; it then measures the in-dividual’s level of inattention, overall cognitive

function, and disorganized thinking (Figure 1).13

Resources for how to use the CAM-ICU are

available at http://www.mc.vanderbilt.edu/icude

lirium/assessment.html.

The ICDSC uses a checklist format and scoring sys-

tem to assess the presence of delirium. The scoringsystem assigns a ‘‘1’’ to the presence of altered level

of consciousness, inattention, disorientation,

hallucinations, inappropriate speech or mood,

psychomotor changes, sleep-wake cycle distur-

bances, and symptom fluctuation.14 If a score

greater than or equal to four is assessed, the pro-

vider performs a clinical assessment to confirm

the diagnosis of delirium.14

Given the high prevalence of delirium in postoper-

ative patients, especially elderly patients, assess-

ment of patients for acute cognitive dysfunction

postoperatively using a valid and reliable delirium

assessment tool should be a critical element of

ongoing surveillance. Several interventions have

been found to be beneficial in the preventionand treatment of patients with delirium. However,

effectiveness of interventions continues to be an

area of active research.3,12

Pain Management

Managing pain is a priority for perianesthesia

nurses. Ensuring effective pain management, espe-

cially in the first 48 hours postoperatively, hasbeen found to significantly reduce the incidence

of postoperative delirium.6 Current guidelines ad-

vocate for treatment of pain to include preemptive

analgesia before procedures and/or interventions

expected to cause discomfort.12 Although opiate

agents increase the risk of postoperative delirium,

untreated pain is also a known risk factor for cog-

nitive dysfunction.1-7,12,15 Perianesthesia nursesshould collaborate with the prescribing provider

and pharmacist to develop a patient-specific pain

relief regimen that augments opioid agents with

nonopioid agents and nonpharmacologic interven-

tions (ie, relaxation and music therapy) and limit

administration of sedating agents.

Figure 1. Vanderbilt. ICU Delirium Group.CAM-ICU pocket card. Available at: http://www.mc.vanderbilt.edu/

icudelirium/docs/PocketCards.pdf. ICU, intensity care unit; CAM-ICU, Confusion Assessment Method for the Inten-

sive Care Unit. Copyright � 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved.

406 MARY BETH FLYNN MAKIC

Orientation

Providing ongoing reorientation to the patient at

risk of postoperative delirium is an important and

easy step for the nurse to implement. Ongoing ori-

entation encompasses maximizing social interac-

tion and family visitation for the patient as soon as

possible after the procedure.2,3 Other strategies

CRITICAL CARE CONNECTION 407

include the presence of calendars, clocks, news-

papers, and other time-oriented references. During

daytime hours, have the lights on and dim or turn

off lights during evening/night hours to replicate

a normal day-night schedule for the patient. Ensurethat any sensory-assistive devices are in use by the

patient as soon as possible to help prevent sensory

deprivation and disorientation (ie, hearing and vi-

sual aids). Lastly, remove all unnecessary invasive

devices and lines (ie, excessive intravenous tubing

or indwelling urinary catheters). Invasive devices

increase an older patient’s risk of delirium; thus,

efforts should be made to remove unnecessarydevices as soon as clinically feasible.1,2,9 For

mechanically ventilated patients, daily evaluation

of the patient’s readiness to wean or extubate

(spontaneous breathing trials) coupled with spon-

taneous awakening trials (cessation of sedation

agents) have been found to enhance the patient’s

orientation and reduce acute delirium.12

Sleep Hygiene

Promoting sleep and re-establishing normal sleep

patterns for the patient while hospitalized is an im-

portant intervention in both the prevention andtreatment of delirium.9,12 Sleep also restores the

body’s immune protection, improves metabolism,

and reduces pain.16 Sleep hygiene protocols strive

to restore the patient’s normal sleep cycle by

encouraging daytime and nighttime routines

within the care structure and functions of a busy

nursing unit. Normal sleep cycles are typically 90

minutes; thus, efforts to provide uninterruptedsleep postoperatively is important in the treatment

and prevention of postoperative delirium. Benzo-

diazapine agents should be avoided when possible

as these agents alter the sleep architecture de-

creasing effectiveness of the restorative stages

of deep sleep.15,16 Current evidence has found

that continuous sedative infusions for sleep

promotion does not enhance restorative sleep

and actually results in higher delirium rates and

greater risk of mortality in ICU patients.16 Strate-

gies found to be effective in promoting sleep

include reducing ambient lights and noise, cluster-ing nighttime care to minimize interruptions, re-

thinking the practice environment, and routine

tasks to prevent awaking the patient (eg, timing

labs and bathing during awake hours rather than

middle of the night).

Early Mobility

Several studies have found that promotion of

patient mobility is an effective intervention in re-

ducing and treating delirium.12,17 Mobility re-

establishes both a physical and cognitive function

for the patient. Early mobility protocols for criti-cally ill patients encourage gradual and progressive

mobility that begins with passive range of motion

from moving to sitting at the edge of the bed to

full mobilization. For the perianesthesia practice

environment, encouraging patient mobility as

much as possible and as soon as possible, to in-

clude mobilizing the mechanically ventilated pa-

tients, is an important intervention addressingpostoperative delirium. Nurses often lead the ef-

forts changing the culture of ‘‘immobility’’ to one

that embraces and encourages early and progres-

sive patient mobility.

Summary

Perianesthesia nurses are vital in the effort to rec-ognize risk factors that may increase a patient’s

risk of developing postoperative delirium. Early

recognition of patients who have acute cognitive

dysfunction and implementation of strategies to

prevent or minimize this complication are needed

to reduce the adverse outcomes associated with

postoperative delirium.

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408 MARY BETH FLYNN MAKIC

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omission in the abstract. This mistake resulted in th

quote from the original article by Dileo C, Bradt JCochrane Database of Systematic Reviews 2008, Is

The corrections mentioned in this erratum have alr

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um

Systematic Approach for Adoption Into Peri-

323-330), there was an unintentional reference

e failure to cite and properly attribute a direct

, Murphy K, ‘‘Music for preoperative anxiety,’’sue 1. Art.

eady been made to the article online.