Aging

Pinpointing Risk Factors to Prevent Postoperative Delirium

by Lauren Woods


With rising surgery demands among the growing population of older adults, the UConn Center on Aging and UConn John Dempsey Hospital are teaming up to identify older patients at the greatest risk of developing postoperative delirium in order to prevent it.

Patients with delirium have an altered level of alertness and are sometimes excessively drowsy, hyper-alert, or agitated. Although postoperative delirium is usually short-term, lasting hours or days, the brain may not recover for weeks or months in older adults. If the condition is not identified and addressed, delirium can lead to a decline in an older patient’s surgical recovery and cognitive and physical health, a need for caregiver or nursing home care, or potentially an increased risk of death.

“Our goal is to do everything in our power to screen older patients before surgery for delirium’s risk factors and to prevent it after surgery — or at least minimize its duration and effect,” says UConn Center on Aging’s Dr. Patrick Coll, who has been working closely with surgeons and anesthesiologists to modify preoperative delirium screening protocols at UConn Health. “All doctors really should be adding delirium-risk-factor screening to their preoperative evaluations for patients age 75 and above.”

Risk factors for postoperative delirium in older patients include prior delirium after a surgery, underlying or existing cognitive impairment such as dementia or Alzheimer’s disease, heavy alcohol consumption that increases withdrawal risk, depression, frailty, malnutrition, immobility, infection, or taking certain medications.

Historically, surgery risk-prevention primarily focused on such areas as cardiac or pulmonary health. Last year, the American College of Surgeons and the American Geriatric Society issued new guidelines for optimal geriatric surgery patient management, which for the first time included screening for delirium risk before and after surgery.

“If a patient is deemed high-risk, the patient should have a geriatric assessment prior to surgery to help mitigate their risk and, after surgery, the hospital care team should plan to very closely monitor the patient,” said Coll.

The hospital care team can take simple, proactive steps to quickly reorient an older patient after surgery, Coll says. Even having a patient’s reading glasses and hearing aids readily available can make a big difference, as well as avoiding or limiting medications that can contribute to delirium, such as opioids.

With the help of aging expert Dr. Lavern Wright, UConn Health’s NICHE (Nurses Improving Care for Healthsystem Elders) program is expanding its scope to the surgical floors of the hospital to reduce older patients’ risk of delirium and other health complications. Further, all nurses now have access to the Confusion Assessment Method (CAM) tool and an electronic medical record order set to guide them in decreasing delirium’s impact.

In addition, Dr. Richard Fortinsky and his team are studying the effect of visiting clinical care teams at the homes of older adults with a history of delirium and other cognitive vulnerabilities to improve patient outcomes. This study, funded by the Patient-Centered Outcomes Research Institute, involves an in-home care program featuring a nurse practitioner who assesses older adults for delirium using a brief version of the CAM. The nurse practitioner also assesses for depression and dementia and teaches the patient and family members how to manage these conditions at home.

Blood Test Can Alert Doctors to Delirium Risk

artsy photo depicting two nurses walking down hospital corridor in the view point of someone experiencing the effects of confusion or delirium


Researchers at UConn Health and Beth Israel Deaconess Medical Center have found that a blood test could make it easier to identify patients at risk for delirium, the sudden, acute state of confusion that most often affects older adults and incurs $6.9 billion in medical costs each year in the U.S. Their study, published online in The Journal of Gerontology: Medical Sciences, reports that elevated blood levels of specific proteins called cytokines can hint that a patient will develop delirium during a hospital stay.

If you do things such as improve a patient’s vision and hearing, reorient them to where they are regularly, promote restful sleep, increase mobility, and stop medications that could be making the delirium worse, all that can help.

Dr. George Kuchel, director of the UConn Center on Aging and one of the authors of the study, says the suspected blood signature for delirium shows two cytokines at higher-than-normal levels in patients who develop delirium. Both cytokines are associated with inflammation.

Researchers don’t yet know exactly how inflammation and delirium are linked. The two cytokines the researchers saw in the blood signature, interleukin-6 and interleukin-2, can cause swelling of the membrane around the brain. Chronic stress from low-level illness can also elevate both cytokines and stress hormones such as cortisol, which over the long term can shrink part of the brain and perhaps increase an elderly person’s susceptibility to delirium.

Kuchel and his colleagues worked with patients who participated in the Successful Aging after Elective Surgery (SAGES) study to get a better handle on the relationship between inflammation and delirium. This large study, sponsored by the National Institute on Aging, has been following 566 surgical patients over the age of 70 for the past five years, with the goal of finding new approaches to prevent delirium and its long-term consequences in older adults.

The UConn study found that patients who developed delirium had higher levels of interleukin-2 than non-delirium patients at all times they were tested: before surgery, in the first two days afterward, and one month later.

This is the first study to look at cytokine levels in older surgical patients at several points in time, both before and after surgery. The results need to be replicated in other studies, but if they prove to be generally true, the blood signature could provide a quick way to alert doctors and nurses to seniors at higher risk of delirium. They can then take extra precautions to keep the patients oriented.

“If you do things such as improve a patient’s vision and hearing, reorient them to where they are regularly, promote restful sleep, increase mobility, and stop medications that could be making the delirium worse, all that can help,” says Kuchel.