Suspect Meds in Geriatric Patients' Postop Delirium


SAN DIEGO — A prospective study found 17.5% of geriatric patients developed delirium after surgery for gynecologic malignancies, Dr. Jessica N. McAlpine reported at the annual meeting of the Society of Gynecologic Oncologists.

The women diagnosed with postoperative delirium were older, took more medications, and received additional doses of narcotic, said Dr. McAlpine of the University of British Columbia, Vancouver.

Gynecologic surgery patients may also be at special risk from hypoalbuminemia, prolonged catheter use, and prolonged oxygen use, she said. All three were significantly associated with delirium in univariate but not multivariate analysis.

Dr. McAlpine described the study as the first to look at postoperative delirium in gynecologic oncology patients. She called the results comparable to those recorded in other fields with adult surgical patients.

Postoperative delirium is a particular concern for gynecologic oncologists, Dr. McAlpine said, because it is more common in the elderly, as are gynecologic cancers. Building on the study, she and her colleagues plan to develop interventions to prevent delirium in patients operated on for gynecologic cancers.

“I think for a long time we just attributed it [delirium] to sundowning without any formal diagnosis,” she added in an interview after her presentation. “It usually self-resolves, but long-term sequelae have not been properly addressed and need to be addressed as the population ages.”

The study enrolled 103 women, aged 60 years and older, who were scheduled for surgery for suspected cancers. After surgery, 88 women had confirmed malignancies, including 59 with advanced-stage disease. Using the Mini-Mental State Examination (MMSE) before and after surgery and the postoperative Confusion Assessment Method, the investigators diagnosed postoperative delirium in 18 women.

The women who developed delirium had a mean age of 77 years vs. 69 years for the patients who did not have delirium. They also had significantly higher scores on the Charlson's Comorbidity Index (4.2 vs. 1.3), worse performance status as measured by the Karnofsky score (67 vs. 86), and less education (12.2 years vs. 14.6 years).

Their mean albumin was significantly lower (2.66 vs. 3.33), and they took more preoperative medications on average (6.3 vs. 3.7). They also had a much greater change in their mental status tests (−7 vs. −0.12), and spent much more time on oxygen (4 days vs. 1.5 days).

Most of the women who became delirious had postoperative transfusions, received additional doses of narcotics, were restricted to bed rest, and had Foley catheters inserted for more than 2 days. This was significantly different among the nondelirious patients, a minority of whom required these measures. Additional narcotic use and bed rest were documented, respectively, in only two and three of the nondelirious patients.

Looking at the factors that remained significant with multivariate analysis, the investigators calculated the odds ratios for dementia as 1.2 with advanced age, 1.7 with multiple medications, and 107 with additional narcotics.

They called for improved care, suggesting preoperative screening to find patients vulnerable to delirium, minimization of factors known to be associated with postoperative delirium, and use of multidisciplinary teams for postoperative care that would include representatives of geriatric service, anesthesia, psychiatry, and pharmacy. While the age factor cannot be reduced, Dr. McAlpine said it could be given greater emphasis when counseling patients and their families before surgery.

In a discussion of the presentation, Dr. Susan C. Modesitt of the University of Virginia, Charlottesville, called the study innovative, relevant, and timely. Citing the ongoing aging of the population, she said, “This is something we are going to see, and we are going to have to learn how to deal with it adequately.”

Odds ratios for dementia were 1.2 with older age, 1.7 with multiple drugs, and 107 with additional narcotics. DR. MCALPINE

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