Treatment Of Postoperative Delirium Research Articles

The Safety of Spinal Surgery in Patients over 80 Years of Age: Propensity Score Matching Study.

Retrospective cohort study. Using propensity match score to remove those confounding bias and focuses on age factor to compare clinical outcomes and perioperative complications following spinal surgery in cohort of Korean octogenarians treated at a single tertiary hospital. We classified patients of 80s as the octogenarian group (group O), those 65 and older, and under 80 as the elderly group (group E). We strategically employed the Propensity Score Matching (PSM) analysis as a method to counteract potential confounding variables. 1: 1 nearest-neighbor PSM for fusion level, estimated blood loss (EBL), transfusion, body mass index (BMI), American society of anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI) surgical method and operation time was performed. After PSM, 98 patients are categorized each group evenly (group O, n = 49 vs group E, n = 49). Demographics, clinical, radiologic and postoperative complications were analyzed. The clinical outcomes showed no significant differences in the VAS and ODI preoperatively or postoperatively. And most of hospitalization related factors shows no differences between 2 groups. However, follow-up period was longer in group E (1053.37 ± 684.14 days) than group O (640.29 ± 496.68, P = 0.001) and group O has higher incidences of medical complication (38.77% vs 16.32%, P = 0.013), especially in delirium (34.69% vs 6.12%, P = 0.001) than group E. With the preparation for the prevention and treatment of postoperative delirium, age itself should not be a reason to hesitate in performing the spinal surgery.

Diagnostics, prevention and treatment of postoperative delirium: a literature review

Eidininkienė Mantė1, Stankevičiūtė Radvilė1, Kazlauskaitė Karolina2, Eidininkas Mantas1, Gudaitytė Jūratė3 1 Lithuanian University of Health Sciences, Faculty of Medicine 2 Medical Center of the Ministry of the Interior of the Republic of Lithuania 3 Lithuanian University of Health Sciences, Medical Academy, Department of Anesthesiology Abstract Background: Postoperative delirium (POD) is one of the most […]

Prognostic Implications of Delirium After Left Ventricular Assist Device (LVAD) Implantation: A Retrospective Study

<h3>Purpose</h3> Heart failure is a risk factor for delirium with a prevalence of up to 35%. While historically thought to be a benign disorder, delirium is now recognized as a condition prognostic for mortality and morbidity. This study investigates the impact of Post-Operative Delirium (PODe) on outcomes after LVAD implantation. <h3>Methods</h3> We reviewed all adult patients receiving LVAD as Bridge to Transplant (BT) or Destination Therapy (DT) between June 2017 and December 2020. We assessed risk factors for PODe; 1-, 6-months, and in-hospital mortality; re-intubation rate; Length of Stay (LoS); discharge disposition and readmission rates. <h3>Results</h3> In total, 360 patients (26.7% women, 75.8% African American) received durable LVAD implants for either BT (n=173, 48%) or DT (n=187, 52%). 94 patients (26.1%) developed PODe. Pre-implantation characteristics of gender, race, past medical or psychiatric conditions, INTERMACS score, and laboratory values did not differ between the two groups with and without PODe; age (55.88 vs 59.00; p=0.031) was associated with development of PODe. PODe was associated with higher 1-month (p=0.007), 6-months (p=0.004), in-hospital mortality (p<0.001), and unplanned re-intubations (p<0.001). Patients with delirium who survived their index admission were less likely to be discharged home (42% vs 60%, p=0.03). There was a clinically significant association of PODe with a longer LoS in hospital by 4.61 days and an earlier re-admission by 5.4 days. Delirium was not associated with a higher number of re-admissions. A subgroup analysis shows that the treatment of PODe with either physical or chemical restraints in the post-LVAD population is associated with higher mortality and adverse hospitalization outcomes. <h3>Conclusion</h3> In this single-center retrospective study, PODe was associated with higher mortality, adverse hospitalization outcomes, and unfavorable discharge disposition. This study highlights the need to identify and aggressively prevent and treat delirium in the LVAD surgical population, with particular emphasis on non-pharmacological strategies. Future prospective studies are needed to identify modifiable delirium risk factors as well as establish the prognostic value of delirium in this vulnerable population.

Терапія післяопераційного делірію

За сучасною класифікацією, післяопераційний делірій визначається як гостре порушення свідомості зі зниженою здатністю зосереджуватися, підтримувати або переключати увагу та супроводжується змінами перцепції. Перебіг післяопераційного періоду знаходиться під багатофакторним впливом різних чинників. Зниження активності гамма-аміномасляної кислоти, аномальні порушення метаболізму мелатоніну та серотоніну поряд із гіперпродукцією норадреналіну призводять до підвищення вивільнення інтерлейкінів-1 (IL-1) та IL-6, внаслідок чого уражаються нейрони, виникає церебральна гіпоперфузія, що є можливим патогенетичним механізмом. В післяопераційному періоді у хворих, які перенесли хірургічні процедури й анестезію, як правило, виникає через 1–3 доби. Частота розвитку делірію у госпіталізованих пацієнтів становить 10–24 % серед усіх госпіталізованих пацієнтів і 37–46 % в хірургічних клініках. У відділенні інтенсивної терапії повідомляється про частоту післяопераційного делірію у 87 % хворих. Загалом частота розвитку делірію в післяопераційному періоді варіює в широких межах — від 9 до 87 % і залежить від віку пацієнта і типу операції. Значною мірою на розвиток делірію впливає ступінь операційного стресу. Крім того, зниження інтелектуальних здібностей у передопераційному періоді та наявність хронічних захворювань є незалежними предикторами розвитку делірію у літніх людей. На сьогодні серед медикаментозних методів лікування та профілактики розвитку делірію в післяопераційному періоді доведеним є застосування галоперидолу й аміназину. Існує достатня кількість як окремих, так і багатоцентрових досліджень, що підтверджують ефективність застосування антипсихотичних препаратів першого покоління. Достатня доказова база дозволяє використовувати ці препарати при дослідженні нових лікарських засобів як еталон і з огляду на їхній відомий та передбачений клінічний ефект. Незважаючи на патогномонічну роль ацетилхолінестерази у генерації умов післяопераційного періоду, спірним залишається клінічна ефективність застосування інгібіторів ацетилхолінестерази. На сьогодні не доведено позитивного впливу ривастигміну, донепезилу та галантаміну на частоту розвитку делірію при їхньому використанні як у доопераційному, так і в післяопераційному періоді. Тобто пошук нових препаратів і схем профілактики залишається актуальним питанням анестезіології.

Postoperative Delirium in Patients After Brain Tumor Surgery

Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium. Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05. Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536). Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.

Related Factors and Treatment of Postoperative Delirium in Old Adult Patients: An Integrative Review.

“Postoperative delirium” is defined as delirium occurring in the hospital up to one week after a procedure or before discharge (whichever occurs first) that meets the DSM-5 diagnostic criteria. Objectives: To describe the risk factors related to this pathology and identify effective non-pharmacological forms of treatment. An integrative review of the available literature was performed. The search results considered included all quantitative studies published between 2011 and 2019 in both English and Spanish. A total of 117 studies were selected. Advanced age was identified as the principal risk factor for postoperative delirium. Nursing interventions appear to be the key to preventing or reducing the seriousness of delirium after an anaesthetic episode. The aetiology of postoperative delirium remains unknown, and no treatment exists to eliminate this pathology. The role of nursing staff is fundamental in the prevention, diagnosis, and management of the pathology.

Management of Frailty and its Challenges in Geriatric Patients on General Abdominal Anesthesia.

Introduction: In that material, we are doing to informed for frailty, how we can measure it, surgical outcome and its management from the anesthesiologist. Frailty is a condition of decreased physiological reserves that often increases with increasing age and decided in adverse outcomes.&#x0D; Frailty in elderly surgical patients may be varied from 25,5 -56.1% and is a strong predictor for surgical outcomes.&#x0D; The anesthetist needs to predict how a geriatric patient will tolerate the stress of surgery and to do what is necessary to protect and save elderly lives.&#x0D; In Albania, there are almost 439 000 elderly people in 2021 and suspect to 626 000 in 2051. According to the WHO, 1 in 25 persons performed surgery, so the number of geriatric patients that done surgery will be very high.&#x0D; According to deficits’ in function, mobility, cognition, chronic diseases, and geriatric syndromes we can use the clinical frailty scale, the Edmonton Frailty Scale, or frailty index for calculation of frailty.&#x0D; We need frailty patients to evaluated preoperative risk-classification, intra-operative care, management of general anesthesia, early immobilization as well as treatment of postoperative delirium because frailty increased intra-operative morbidity, increased postoperative complications especially delirium, extends hospitalization, non – home discharge, and mortality.&#x0D; Anesthesiologists would be always aware to prepare the geriatric patients for surgery, to maintain the intra-operative functional reserve of frailty patients, to manage perfect anesthesia, to realized early mobilization, and discharge back home.&#x0D; Conclusion: Many geriatric patients have multi-organ problems. Frailty is a practical, unifying concept in the care of these older people that directs attention away from organ-specific diagnoses towards a more holistic viewpoint of the patient and their medical medicament. All geriatric patients need to screen for frailty.

Diagnostic Value of Cholinesterase Activity for the Development of Postoperative Delirium after Cardiac Surgery.

Depression of cholinesterase (CHE) activity has been reported to lead to an amplified neuroinflammatory response, which clinically manifests as postoperative delirium (PD). This observational study investigates the association between CHE activity and the development of PD following elective cardiac surgery. Patients with preexisting neurologic deficits or carotid artery disease as well as patients undergoing reoperations or procedures under circulatory arrest have been excluded from this study. The Mini-Mental State Examination, the Confusion Assessment Method for the Intensive Care Unit, and the Intensive Care Delirium Screening Checklist were performed at regular intervals. CHE activity was estimated pre- and postoperatively until postoperative day (POD) 5 and at discharge. A total of 107 patients were included. PD was diagnosed in 34 (31.8%) patients, who have been compared with those without PD. Time on ventilator, length of ICU, and hospital stay were longer in patients with PD (p = 0.001, p < 0.001, and p = 0.004, respectively). MMSE scores were lower in patients with PD (p < 0.001; p = 0.015). CHE activity on POD 1 to 4 as well as at discharge were lower in the delirium group (p = 0.041; p = 0.029; p = 0.015; p = 0.035; p = 0.028, respectively). A perioperative drop of CHE activity of more than 50% and a postoperative CHE activity below 4,800 U/L (on POD 0) were independently associated with an increased risk of development of PD (p = 0.038; p = 0.008, respectively). In addition to the established functional tests, routine estimation of CHE activity may serve as an additional diagnostic tool allowing for the timely diagnosis and treatment of PD in cardiac surgery patients.

Research progress on the perioperative application of lung ultrasound in pulmonary disease

With the rapid development and huge progress of surgery, more and more patients choose to undergo surgery. Post- operative delirium is a common complication which has attracted increasing attention. However, the pathogenesis of postoperative delir- ium remains unclear, and it is still not easy to diagnose the disease. Postoperative delirium has diverse manifestations and is easy to be misdiagnosed, without specific biochemical markers. The treatment of postoperative delirium is still difficult, especially the lack of effective drugs. This paper summarized the diagnosis, pathogenesis, prevention and treatment of postoperative delirium, so as to facilitate future research. Key words: Postoperative delirium; Cognitive disorder

Research progress on risk factors, clinical prevention and treatment of postoperative delirium in patients undergoing spinal surgery

Postoperative delirium is a common complication after spinal surgery, and it is a complex issue involving multiple factors. However, there is currently insufficient understanding of postoperative delirium in patients undergoing spinal surgery, and there is still a lack of clear regulation in prevention and treatment. Although the literature and research on postoperative delirium have been comprehensive, there are still few studies on postoperative delirium in patients undergoing spinal surgery. This article mainly reviews the incidence, social and economic problems, risk factors, prevention and treatment of postoperative delirium in patients undergoing spinal surgery.

Predictive Factors of Postoperative Delirium in Patients After Pancreaticoduodenectomy

BackgroundPostoperative delirium is a common serious complication after various types of surgery. However, the incidence and predictive factors associated with delirium after pancreaticoduodenectomy (PD) have not been investigated. Thus, this study aimed to investigate the incidence and predictive factors of postoperative delirium in patients who underwent PD. MethodsThis study included 155 consecutive patients who underwent PD. Patients with and without postoperative delirium were compared to identify differential patient characteristics. Multivariate regression analysis was used to statistically identify independent predictive factors significantly associated with the development of postoperative delirium. ResultsPostoperative delirium developed in 27 (22.4%) of 155 patients. The majority of incidents occurred on postoperative day 2, and the mean delirium duration was 4.6±4.8 days. Patients with postoperative delirium had an older age and a previous history of benzodiazepine use. A multivariate analysis revealed that the development of delirium was significantly correlated with these two factors. Receiver-operator characteristics (ROC) curve analysis of the two factors yielded an area under the ROC curve of 0.823 (0.750–0.896), suggesting good discrimination power. ConclusionsThis study reports on the incidence of postoperative delirium after PD. Furthermore, we identified age and use of benzodiazepines as significant predictive factors for developing delirium after PD. These results contribute to the prediction and treatment of postoperative delirium.

Delirium in geriatric urology patients

Delirium is acommon but often undiagnosed complication in geriatric patients following amajor or minor operation. With 14-56% in patients over 70 years of age, it is one of the most frequent complications seen in hospitals. The link between the prescription of drugs with antimuscarinic effects and cognitive disturbance is also well known. Recognizing the presence of delirium and the criteria to establish the diagnosis of delirium will improve aclinician's ability to detect this complication. Treating delirium with non-pharmacologic, reduces the incidence and side effects of postoperative delirium. The purpose of this article is to describe the diagnosis and treatment of postoperative delirium. Asudden rise following fluctuating symptoms with decreased attentiveness, awareness and thinking are typical symptoms of delirium. The organic origin is not focused and must be considered. Transurethral resection (TUR) of the prostate and the bladder can increase the risk of bleeding, delirium and TUR syndrome. As simple instruments to assess signs and symptoms, the Clinical Assessment Method (CAM) and the Nurses Delirium Screening Scale (Nu-DESC) in the clinical setting are well examined. Preoperatively screening and execution of ageriatric assessment to detect vulnerable elderly could be afirst step in reduction of complication. Regularly screening for delirium reduces the pre-, post-, and perioperative complications in patients with delirium.

Prevention and treatment of postoperative delirium in the elderly, non-critically ill people: A literature review

Delirium is a common yet severely underdiagnosed neuropsychiatric condition with short and long spanning implications regarding the risk of death, quality of life and economic burden. There is a moderate body of evidence when it comes to delirium in an ICU or medical setting, whereas data on this pathology in a surgical setting is sparse. In this article, we aim to converge all the relevant and up-to-date evidence on preventing and treating postoperative delirium. We have searched the PubMed and Cochrane databases with the following keywords: “delirium”, “postoperative”, “prevention”, “treatment”, “surgery”, “elderly”. There are currently no validated markers to determine the persons at risk of developing postoperative delirium. No current guidelines exist on preventing or treating postoperative delirium. Even so, multicomponent nonpharmacological interventions like early mobilization, hearing and visual orientation, healthy sleeping routines etc. seem to have positive results in preventing delirium, but have no effect in treating it once it develops. Hitherto, there is currently no consensus when it comes to pharmacological prevention or treatment with the literature being divided due to a low number of randomized controlled studies with different terminology, high heterogeneity and poorly reported adverse effects. Amid this debate, there are still promising molecules like suvorexant and dexmedetomidine with positive outcomes in preventing postoperative delirium but they are still far away from clinical validation. In conclusion, this important and often missed topic needs further study in a more homogenous and controlled manner at all levels – basic science, translational science and clinical trials.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This review contains 3 highly rendered figures, 12 tables, and 68 references.

Modern view on the problem of acute postoperative delirium in trauma and orthopedic patients in the intensive care unit

The purpose of the present literature review is a systematization of known evidence on the problem of postoperative delirium as a frequent complication in elderly and senile patients during extensive reconstructive surgery on the spine and large joints. The review, which is based on publications of foreign and native authors, provides insights into current understanding of the pathogenesis, risk factors, diagnosis, methods of treatment, and prevention of these complications. The number of operations in traumatology and orthopedy is increasing. Accordingly with this fact, we are seeing an increase the number of cases of postoperative delirium. We know that the risk of delirium is linked with patient age. The interest to this problem is growing and has clinical and economical background. The etiology of delirium is considered to be multivariate. The development of diagnostic tools is playing a very important role and provides control of delirium in intensive care unit. Common understanding of this state’s pathophysiology and the opportunity to participate another physician leads to correct organization of treatment process. The knowledge of acute postoperative delirium in intensive care unit is being formed. The basic concept of postoperative delirium varies from its definition psychiatry and narcology due to differences in how different specialties treat the disorder. The risk factors of treatment are estimated. The controlled sedation is a clear trend. The experience of practical application dexmedetomidin for prevention and treatment of postoperative delirium is accumulated. Although the value of drug- therapy is difficult to overestimate the great influence on the result have non- pharmalogical methods.

Research on the prediction of comprehensive geriatric assessment on postoperative delirium in elderly patients in cardiac surgery department

Objective To explore the prediction of comprehensive geriatric assessment (CGA) on postoperative delirium (POD) in elderly patients after cardiac surgery. Methods A total of 276 patients from cardiac surgery department were selected from January 2015 to December 2016 by convenience sampling method. The general clinical data of the subjects were recorded and the CGA was conducted. POD assessment was performed on the 1st to the 7th day postoperatively using Confusion Assessment Method-Intensive Care Unit (CAM-ICU) or Confusion Assessment Method (CAM) . Single factor analysis and multiple Logistic regression analysis were applied to analyze the factors influencing the incidence of POD after cardiac surgery in elderly patients. Results A total of 98 cases showed POD, with the incidence of 35.5%. Compared with the non-POD patients, the patients with POD were older; the proportion of history of cerebrovascular disease, atrial fibrillation, cardiopulmonary bypass, intraoperative blood transfusion was higher; the mechanical ventilation duration was longer; the score of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) , the postoperative pain score, the level of serum creatinine and C-reactive protein (CRP) were higher; the proportion of patients with CGA score over 15 was significantly higher, and all the differences were statistically significant (P<0.05) . Logistic multivariate regression analysis showed that the history of cerebrovascular disease, cardiopulmonary bypass, APACHE Ⅱ score, postoperative pain score and CGA score over 15 were independent risk factors for POD. Conclusions CGA can predict patients with cardiac surgery with high risk of postoperative delirium, which has a certain significance for the prevention and treatment of postoperative delirium and improve the prognosis. Key words: Aged; Cardiac surgery; Delirium; Comprehensive geriatric assessment

Incidence and risk factor analysis of the postoperative delirium after gastrointestinal surgery: An exploratory analysis of a prospective, randomized phase II trial.

30 Background: The postoperative complications, delirium are a particularly common morbidity after gastrointestinal surgery. Postoperative delirium makes patient management much more difficult, increases costs, and causes severe discomfort to the patient. The aim of this study was to evaluate the incidence of the postoperative delirium and a predictor for postoperative delirium using phase II clinical trial data. Methods: We analyzed the cases that were enrolled to randomized clinical trials of the efficacy and safety of TJ-54 (Yokukansan; a traditional Japanese medicine [Kampo]) for the prevention and/or treatment of postoperative delirium in a randomized phase II trial of patients receiving surgery for gastrointestinal and lung malignancies (UMIN000005423). The American Psychiatric Association’s the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was used to assess. A uni- and multivariate logistic regression analyses was performed to identify risk factors for morbidity. Results: Between October 2009 and July 2011, a total of 186 patients were registered to the Yokukansan trial. Among them, 167 patients received surgery for gastrointestinal malignancy and were eligible for the present study. The incidence of postoperative delirium was 9.0% (15 patients) and postoperative delirium was the most common postoperative complication in the study. Risk factors for postoperative delirium were analyzed by uni- and multi-variate analyses using clinical factors determined before the enrollment of the study. Among these, high patients’ age ( &gt; 80 years) and low MMSE score ( &lt; 27) were identified as significant independent risk factor for postoperative delirium (Odds ratio: 3.90, 95% CI; 1.25-12.16, p = 0.013 and Odds ratio: 0.24, 95% CI; 0.08-0.73, p = 0.013). Conclusions: The major of the findings were that high patients’ age (≥ 80 years) and low MMSE score ( &lt; 27) were significant independent risk factors for predicting postoperative delirium. Careful attention for postoperative delirium is required in patients with high patients’ age and MMSE score when surgeons perform surgery for gastrointestinal malignancies. Clinical trial information: 000005423.

Therapeutic Advances in the Prevention and Treatment of Delirium in the Hospital Setting

Background: Delirium is one of the most common, costly, and devastating complications affecting up to 56% of hospitalized older patients, with an associated hospital mortality rate of 25%–33%, and annual health care expenditures exceeding $152 billion. Areas of Uncertainty: Despite its high prevalence and poor outcomes, there is a significant gap in therapeutic interventions for the prevention and treatment of delirium. Therapeutic Interventions: Nonpharmacologic multicomponent prevention interventions such as the hospital elder life program (HELP) and early mobilization and reorientation remain first line, and they have consistently demonstrated a reduction in the incidence of delirium. There is currently no evidence to support the use of antipsychotics, cholinesterase inhibitors, or psychostimulants for the prevention of delirium across all health care settings, including the intensive care unit. Avoiding sedation, and specifically benzodiazepines, is an important modality to prevent delirium. Given the lack of evidence to support the use of antipsychotics along with the adverse event profile, including a black box warning for an increase in cardiovascular mortality, these medications should only be used for the treatment of delirium with features of severe agitation and psychosis. In the intensive care unit setting, dexmedetomidine in lieu of propofol or other classic sedatives may prevent and shorten the duration of delirium. Finally, dexmedetomidine and general anesthetics, such as sevoflurane and desflurane, are being evaluated in the prevention and treatment of postoperative delirium. Conclusion: Multicomponent nonpharmacologic interventions are currently the most effective modality for the prevention and treatment of delirium.

Randomized phase II study of TJ-54 (Yokukansan) for postoperative delirium in gastrointestinal and lung malignancy patients.

The present study evaluated the efficacy and safety of TJ-54 (Yokukansan; a traditional Japanese medicine) for the prevention and/or treatment of postoperative delirium in a randomized phase II trial of patients receiving surgery for gastrointestinal and lung malignancies. Patients ≥70 years of age who underwent surgery for gastrointestinal or lung malignancy were eligible for participation in the study. The 186 eligible patients were randomly assigned at a 1:1 ratio to receive TJ-54 or control during their peri-operative care (between 7 days prior to surgery and 4 days following surgery, except for the operation day). The signs and symptoms of delirium were assessed using the Diagnostic and Statistical Manual of Mental Disorders-IV by the investigator during the peri-operative period. A total of 186 eligible gastrointestinal or lung malignancy patients were analyzed (93, TJ-54; 93, control). There were no marked differences between the two randomized groups. The incidence of delirium was 6.5% (6 patients) in the TJ-54 group and 9.7% (9 patients) in the control group, with no significant difference (P=0.419). However, of the patients categorized with a mini-mental state examination (MMSE) score of ≤26, the incidence of postoperative delirium was 9.1% in the TJ-54 group and 26.9% in the control group [risk ratio, 0.338; 95% confidence interval (0.078–1.462), P=0.115]. Treatment with TJ-54 reduced the incidence of postoperative delirium compared with the control group. Although TJ-54 did not demonstrate any contribution to preventing or treating postoperative delirium in patients following surgery for gastrointestinal or lung malignancy, TJ-54 reduced the risk of postoperative delirium in the patients who were classified as MMSE ≤26. Further phase III studies with a larger sample size are required in order to clarify the effects of TJ-54 against postoperative delirium.

Loxapine for Management of Delirium in Older Adult Surgical Patients

The use of antipsychotics for the treatment of post-operative delirium is often practiced after non-pharmacologic methods of re-orientation have failed. Loxapine is a drug with medium-potency antagonism at dopamine receptors and is used frequently at our institution for delirium. In this small uncontrolled open-label study, we provide early findings that it is effective at reducing the severity and duration of delirium in an older population and may be a reasonable alternative for management. Delirium Rating Scale (DRS-R-98) scores were recorded in 31 older adult surgical patients (mean age 72, 2/3 male). Treating physicians ordered loxapine according to clinical judgment. We monitored for extrapyramidal side-effects, QTc changes, and other adverse events. The mean maximum cumulative loxapine dose per day was 44mg (s.d. 31). DRS-R-98 score after 2 days of treatment (mean 10.19, s.d. 6.61) was significantly reduced compared to DRS-R-98 score at time of diagnosis (mean 18.68, s.d. 4.66) [t(30) = 6.65, p 0.5]. Although there are several limitations to this small uncontrolled open-label study, the findings suggest loxapine is a reasonable alternative in treating delirium in older adult surgical patients.