Your postop patient is confused and agitated—next steps?
Your older patient exhibits signs and symptoms that suggest delirium. Here’s how to best handle this complication.
Begin treatment with nonpharmacologic measures
Regardless of whether a patient suffers from hyperactive, hypoactive, or mixed delirium, nonpharmacologic interventions are firstline treatment.19 Such interventions can help patients develop a sense of control over their environment, which can help relieve agitation.13 Because environmental shifts contribute to the development of delirium, avoiding transfers and securing a single room can be helpful.19 Patients with delirium have altered perceptions, and may view normal objects and routine clinician actions as harmful and threatening. Therefore, it is helpful to avoid sensory deprivation by making sure patients have access to their eyeglasses and hearing aids, and to provide nonthreatening cognitive/environmental stimulation.1,13,19 Patients should be encouraged to resume walking as soon as possible.1,19 Other nonpharmacologic interventions are listed in the TABLE.1,13,19
Safety issues must also be addressed.17 Patients with mixed or hyperactive delirium may become agitated, which can lead them to pull tubes, drains, or lines, as occurred with Mr. Q. Patients with hypoactive delirium may be prone to wandering, or receive less attention due to their hypoactive state.17 All patients with delirium are at risk of falls.
Patients should be evaluated for these risks to determine whether assigning a "sitter" or transfer to a stepdown unit or intensive care unit is warranted.17 Restraints are not recommended because they can exacerbate delirium and lead to injuries.26
Pharmacologic treatment should be reserved for patients whose behavior compromises their safety, and implemented only when the cause of the delirium is known. The primary objectives of drug therapy are to achieve and maintain safe and rapid behavioral control so the patient can receive necessary medical care, and to enhance functional recovery.14 The choice of a specific medication is individualized and depends on each patient’s clinical condition.14
For a patient with hyperactive delirium, an antipsychotic typically is the treatment of choice because these medications are dopamine receptor antagonists, and excessive dopamine transmission has been implicated in this type of delirium.27 Haloperidol often is the preferred treatment; a low-dose oral form is recommended for older patients who exhibit severe agitation because there is less risk of QT prolongation compared to IV administration.28
Second-generation antipsychotics (eg, risperidone, olanzapine, and quetiapine) are increasingly used due to their lower risk for adverse extrapyramidal symptoms, which are common in older patients.29-31 Despite this, increasing data show that morbidity with these agents may be underestimated, and the risks of adverse effects may vary among the medications in this class.32
For hypoactive or mixed delirium, nonpharmacologic interventions should be the mainstay of treatment. When medications are used, they should be used to target the underlying etiology of delirium (eg, treating a urinary tract infection with an antibiotic).33
A few final words about medication use for delirium ... Most medications that modify symptoms of delirium can actually prolong the delirium.33 Therefore, it's important to carefully consider the balance between effectively managing symptoms and causing adverse effects. Because older adults have increased sensitivity to medications, always start with small dosages and titrate to effect.34 Benzodiazepines and other hypnotics should be avoided in older patients, except when treating alcohol or benzodiazepine withdrawal.35
CASE › Mr. Q’s postop delirium screen is positive, and assessment for underlying causes reveals that he is suffering from postoperative pain and is constipated. Due to roommate noise and insomnia, he is transferred to a private room, where quiet times are observed. He receives oxycodone 5 mg every 4 hours for his pain and senna 30 mg at bedtime and a bisacodyl rectal suppository 10 mg/d for constipation. After 3 days Mr. Q’s postop pain and delirium resolves, and he is discharged home.
CORRESPONDENCE
Jackson Ng, MD, Teresa Lang Research Center, New York Hospital Queens, 56-45 Main St., Flushing, NY 11355; jan9044@nyp.org
