Langenbeck's Archives of Surgery

, Volume 398, Issue 7, pp 947–955

Perioperative management of delirium and dementia in the geriatric surgical patient

Review Article

Abstract

Background

Older adults undergo operations as our population ages. Increasing life expectancy and disease burden, along with decreased functional status and organ reserve, place the elderly surgical patient at higher general risk in the perioperative state. In particular, these patients have more diseases including dementia and medications that put them specifically at higher risk of delirium.

Purpose

This overview describes the diagnosis, pathophysiology, and treatment of delirium and its interface with depression and dementia, and explains aging changes based on the picture of perioperative management in surgical interventions.

Conclusions

Today, surgeons must be equipped to attend the geriatric patient's needs. Early recognition of comorbidities such as dementia and delirium as well as speedy and competent therapeutic treatment can limit consequences and impact.

Keywords

Delirium Dementia Neurotransmitter Surgery Geriatric Depression 

References

  1. 1.
    Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA Jr, Dittus R, Ely EW (2008) Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma 65(1):34–41PubMedCrossRefGoogle Scholar
  2. 2.
    Hewer W, Forstl H (1994) Confusional states in advanced age—a current review of the literature. Psychiatr Prax 21:131–138PubMedGoogle Scholar
  3. 3.
    Erkinjuntti T, Wikstrom J, Palo J, Autio L (1986) Dementia among medical inpatients. Evaluation of 2000 consecutive admissions. Arch Intern Med 146:1923–1926PubMedCrossRefGoogle Scholar
  4. 4.
    Levkoff S, Cleary P, Liptzin B, Evans DA (1991) Epidemiology of delirium: an overview of research issues and findings. Int Psychogeriatr 3:149–167PubMedCrossRefGoogle Scholar
  5. 5.
    Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762PubMedCrossRefGoogle Scholar
  6. 6.
    McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS, Inouye SK (2006) Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc 54:1245–1250PubMedCrossRefGoogle Scholar
  7. 7.
    Gustafson Y, Brannstrom B, Norberg A, Bucht G, Winblad B (1991) Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc 39:760–765PubMedGoogle Scholar
  8. 8.
    McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E (2002) Delirium predicts 12-month mortality. Arch Intern Med 162:457–463PubMedCrossRefGoogle Scholar
  9. 9.
    Trzepacz PT (2000) Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatr 5:132–148Google Scholar
  10. 10.
    Flacker JM, Cummings V, Mach JR Jr, Bettin K, Kiely DK, Wei J (1998) The association of serum anticholinergic activity with delirium in elderly medical patients. Am J Geriatr Psychiatr 6:31–41Google Scholar
  11. 11.
    Flacker JM, Lipsitz LA (1999) Neural mechanisms of delirium: current hypotheses and evolving concepts. J Gerontol A Biol Sci Med Sci 54:B239–B246PubMedCrossRefGoogle Scholar
  12. 12.
    Trzepacz PT (1996) Delirium. Advances in diagnosis, pathophysiology, and treatment. Psychiatr Clin North Am 19:429–448PubMedCrossRefGoogle Scholar
  13. 13.
    Golinger RC, Peet T, Tune LE (1987) Association of elevated plasma anticholinergic activity with delirium in surgical patients. Am J Psychiatry 144:1218–1220PubMedGoogle Scholar
  14. 14.
    Tejera CA, Saravay SM, Goldman E, Gluck L (1994) Diphenhydramine-induced delirium in elderly hospitalized patients with mild dementia. Psychosomatics 35:399–402PubMedCrossRefGoogle Scholar
  15. 15.
    Picotte-Prillmayer D, DiMaggio JR, Baile WF (1995) H2 blocker delirium. Psychosomatics 36:74–77PubMedCrossRefGoogle Scholar
  16. 16.
    Lipton SA, Gendelman HE (1995) Seminars in medicine of the Beth Israel Hospital, Boston. Dementia associated with the acquired immunodeficiency syndrome. N Engl J Med 332:934–940PubMedCrossRefGoogle Scholar
  17. 17.
    Kapfhammer HP (2001) Organic dementia syndrome. Organic mental disorders. Internist 42:1387–1404, quiz 1404–1405PubMedCrossRefGoogle Scholar
  18. 18.
    Babińska D, Barczyński M, Stefaniak T, Osęka T, Babińska A, Babiński D, Sworczak K, Lachiński AJ, Nowak W, Sledziński Z (2012) Evaluation of selected cognitive functions before and after surgery for primary hyperparathyroidism. Langenbecks Arch Surg 397(5):825–831PubMedCrossRefGoogle Scholar
  19. 19.
    Gopinath P, Sadler GP, Mihai R (2010) Persistent symptomatic improvement in the majority of patients undergoing parathyroidectomy for primary hyperparathyroidism. Langenbecks Arch Surg 395(7):941–946PubMedCrossRefGoogle Scholar
  20. 20.
    Inouye SK, Zhang Y, Jones RN, Kiely DK, Yang F, Marcantonio ER (2007) Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med 167:1406–1413PubMedCrossRefGoogle Scholar
  21. 21.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH (2003) Updating the beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163:2716–2724PubMedCrossRefGoogle Scholar
  22. 22.
    Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 157:1531–1536PubMedCrossRefGoogle Scholar
  23. 23.
    The American Geriatrics Society, New York, New York (2012) American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. JAGS 60:616–631CrossRefGoogle Scholar
  24. 24.
    STOPP and START http://www.ncbi.nlm.nih.gov/pubmed/18218287 (Accessed 15 Mar 2013) Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D (2008) STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 46(2):72–83Google Scholar
  25. 25.
    STOPP http://ageing.oxfordjournals.org/content/37/6/673.full.pdf+html (Accessed 15 Mar 2013) Gallagher P, O'Mahony D (2008) STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing 37(6):673–679Google Scholar
  26. 26.
    Kornitzer BS, Manace LC, Fischberg DJ, Leipzig RM (2006) Prevalence of meperidine use in older surgical patients. Arch Surg 141:76–81PubMedCrossRefGoogle Scholar
  27. 27.
    Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME (1992) Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc 40:759–767PubMedGoogle Scholar
  28. 28.
    Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676PubMedCrossRefGoogle Scholar
  29. 29.
    Rowe JW, Shock NW, DeFronzo RA (1976) The influence of age on the renal response to water deprivation in man. Nephron 17:270–278PubMedCrossRefGoogle Scholar
  30. 30.
    Miller JH, Shock NW (1953) Age differences in the renal tubular response to antidiuretic hormone. J Gerontol 8:446–450PubMedCrossRefGoogle Scholar
  31. 31.
    Phillips PA, Rolls BJ, Ledingham JG, Forsling ML, Morton JJ, Crowe MJ, Wollner L (1984) Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 311:753–759PubMedCrossRefGoogle Scholar
  32. 32.
    Rowe JW, Andres R, Tobin JD, Norris AH, Shock NW (1976) The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. J Gerontol 31:155–163PubMedCrossRefGoogle Scholar
  33. 33.
    Wynne HA, Cope LH, Mutch E, Rawlins MD, Woodhouse KW, James OF (1989) The effect of age upon liver volume and apparent liver blood flow in healthy man. Hepatology 9:297–301PubMedCrossRefGoogle Scholar
  34. 34.
    Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 130:461–470PubMedCrossRefGoogle Scholar
  35. 35.
    Lamb EJ, Webb MC, Simpson DE, Coakley AJ, Newman DJ, O'Riordan SE (2003) Estimation of glomerular filtration rate in older patients with chronic renal insufficiency: is the modification of diet in renal disease formula an improvement? J Am Geriatr Soc 51(7):1012–1017PubMedCrossRefGoogle Scholar
  36. 36.
    Pequignot R, Belmin J, Chauvelier S, Gaubert JY, Konrat C, Duron E, Hanon O (2009) Renal function in older hospital patients is more accurately estimated using the Cockcroft-Gault formula than the modification diet in renal disease formula. J Am Geriatr Soc 57(9):1638–1643PubMedCrossRefGoogle Scholar
  37. 37.
    Cockroft DL (1976) Comparison of in vitro and in vivo development of rat foetuses. Dev Biol 48:163–172PubMedCrossRefGoogle Scholar
  38. 38.
    Wynne HA, Mutch E, James OF, Wright P, Rawlins MD, Woodhouse KW (1988) The effect of age upon the affinity of microsomal mono-oxygenase enzymes for substrate in human liver. Age Ageing 17:401–405PubMedCrossRefGoogle Scholar
  39. 39.
    Chutka DS, Evans JM, Fleming KC, Mikkelson KG (1995) Symposium on geriatrics—part I: drug prescribing for elderly patients. Mayo Clin Proc 70:685–693PubMedCrossRefGoogle Scholar
  40. 40.
    Lau WY, Fan ST, Yiu TF, Chu KW, Lee JM (1985) Acute appendicitis in the elderly. Surg Gynecol Obstet 161:157–160PubMedGoogle Scholar
  41. 41.
    Coleman PD, Flood DG (1987) Neuron numbers and dendritic extent in normal aging and Alzheimer's disease. Neurobiol Aging 8:521–545PubMedCrossRefGoogle Scholar
  42. 42.
    American Psychiatric Association, ed. (2000) Diagnostic and statistical manual of mental disorders. IV-TR ed. Washington, DC: American Psychiatric AssociationGoogle Scholar
  43. 43.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113:941–948PubMedCrossRefGoogle Scholar
  44. 44.
    Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 275:852–857PubMedCrossRefGoogle Scholar
  45. 45.
    Lipowski ZJ (1983) Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am J Psychiatry 140:1426–1436PubMedGoogle Scholar
  46. 46.
    Pajonk FG, Fleiter B (2003) Psychopharmacological treatment in the pre-clinical emergency medicine. Anaesthesist 52:577–585PubMedCrossRefGoogle Scholar
  47. 47.
    Meagher DJ, McLoughlin L, Leonard M, Hannon N, Dunne C, O'Regan N (2013) What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy. Am J Geriatr Psychiatr. doi:10.1016/j.jagp.2012.09.008 Google Scholar
  48. 48.
    Bohner H, Hummel T, Sandmann W, Schneider F (2001) Current diagnosis and therapy of postoperative delirium. Dtsch Med Wochenschr 126:504–506PubMedCrossRefGoogle Scholar
  49. 49.
    Sink KM, Holden KF, Yaffe K (2005) Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 293:596–608PubMedCrossRefGoogle Scholar
  50. 50.
    Jain FA, Brooks JO 3rd, Larsen KA, Kelly SE, Bode RH, Sweeney GA, Stern TA (2011) Individual risk profiles for postoperative delirium after joint replacement surgery. Psychosomatics 52(5):410–416PubMedCrossRefGoogle Scholar
  51. 51.
    Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, Eikelenboom P, van Gool WA (2005) Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 53:1658–1666PubMedCrossRefGoogle Scholar
  52. 52.
    Wang W, Li HL, Wang DX, Zhu X, Li SL, Yao GQ, Chen KS, Gu XE, Zhu SN (2012) Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial*. Crit Care Med 40(3):731–739PubMedCrossRefGoogle Scholar
  53. 53.
    Liptzin B, Laki A, Garb JL, Fingeroth R, Krushell R (2005) Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry 13:1100–1106PubMedGoogle Scholar
  54. 54.
    Marcantonio ER, Palihnich K, Appleton P, Davis RB (2011) Pilot randomized trial of donepezil hydrochloride for delirium after hip fracture. J Am Geriatr Soc 59(Suppl 2):S282–S288PubMedCrossRefGoogle Scholar
  55. 55.
    Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP (2003) Geriatrics at your fingertips. Blackwell, New YorkGoogle Scholar
  56. 56.
    Leslie JB (2007) Alvimopan: a peripherally acting mu-opioid receptor antagonist. Drugs Today (Barc) 43:611–625CrossRefGoogle Scholar
  57. 57.
    Choi YS, Billings JA (2002) Opioid antagonists: a review of their role in palliative care, focusing on use in opioid-related constipation. J Pain Symptom Manage 24:71–90PubMedCrossRefGoogle Scholar
  58. 58.
    Rubin FH, Williams JT, Lescisin DA, Mook WJ, Hassan S, Inouye SK (2006) Replicating the hospital elder life program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr Soc 54:969–974PubMedCrossRefGoogle Scholar
  59. 59.
    Chen CC, Lin MT, Tien YW, Yen CJ, Huang GH, Inouye SK (2011) Modified hospital elder life program: effects on abdominal surgery patients. J Am Coll Surg 213(2):245–252PubMedCrossRefGoogle Scholar
  60. 60.
    Marcantonio ER, Flacker JM, Wright RJ, Resnick NM (2001) Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 49:516–522PubMedCrossRefGoogle Scholar
  61. 61.
    Mohs RC, Breitner JC, Silverman JM, Davis KL (1987) Alzheimer's disease. Morbid risk among first-degree relatives approximates 50% by 90 years of age. Arch Gen Psychiatry 44:405–408PubMedCrossRefGoogle Scholar
  62. 62.
    Ott A, Breteler MM, van Harskamp F, Claus JJ, van der Cammen TJ, Grobbee DE, Hofman A (1995) Prevalence of Alzheimer's disease and vascular dementia: association with education. The Rotterdam study. BMJ 310:970–973PubMedCrossRefGoogle Scholar
  63. 63.
    Manton KG, Corder L, Stallard E (1997) Chronic disability trends in elderly United States populations: 1982–1994. Proc Natl Acad Sci U S A 94:2593–2598PubMedCrossRefGoogle Scholar
  64. 64.
    Rudolph JL, Jones RN, Grande LJ, Milberg WP, King EG, Lipsitz LA, Levkoff SE, Marcantonio ER (2006) Impaired executive function is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 54:937–941PubMedCrossRefGoogle Scholar
  65. 65.
    Clarfield AM (2003) The decreasing prevalence of reversible dementias: an updated meta-analysis. Arch Intern Med 163(18):2219–2229PubMedCrossRefGoogle Scholar
  66. 66.
    Folstein MF, Folstein SE, McHugh PR (1975) Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198PubMedCrossRefGoogle Scholar
  67. 67.
    Doody RS, Massman P, Dunn JK (2001) A method for estimating progression rates in Alzheimer disease. Arch Neurol 58:449–454PubMedCrossRefGoogle Scholar
  68. 68.
    Reisberg B, Ferris SH, Shulman E, Steinberg G, Buttinger C, Sinaiko E, Borenstein J, de Leon MJ, Cohen J (1986) Longitudinal course of normal aging and progressive dementia of the Alzheimer's type: a prospective study of 106 subjects over a 3.6 year mean interval. Prog Neuropsychopharmacol Biol Psychiatry 10:571–578PubMedCrossRefGoogle Scholar
  69. 69.
    Tuokko H, Hadjistavropoulos T, Miller JA, Beattie BL (1992) The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease. J Am Geriatr Soc 40:579–584PubMedGoogle Scholar
  70. 70.
    Reisberg B, Doody R, Stoffler A, Schmitt F, Ferris S, Mobius HJ (2003) Memantine in moderate-to-severe Alzheimer's disease. N Engl J Med 348:1333–1341PubMedCrossRefGoogle Scholar
  71. 71.
    Tariot PN, Farlow MR, Grossberg GT, Graham SM, McDonald S, Gergel I (2004) Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA 291:317–324PubMedCrossRefGoogle Scholar
  72. 72.
    Sheikh JI, Yesavage JA, Brooks JO 3rd, Friedman L, Gratzinger P, Hill RD, Zadeik A, Crook T (1991) Proposed factor structure of the geriatric depression scale. Int Psychogeriatr 3:23–28PubMedCrossRefGoogle Scholar
  73. 73.
    Arroll B, Khin N, Kerse N (2003) Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 327:1144–1146PubMedCrossRefGoogle Scholar
  74. 74.
    Dyer CB, Ashton CM, Teasdale TA (1995) Postoperative delirium. A review of 80 primary data-collection studies. Arch Intern Med 155:461–465PubMedCrossRefGoogle Scholar
  75. 75.
    Whitbeck MG, Charnigo RJ, Khairy P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, Elayi CS (2013) Increased mortality among patients taking digoxin—analysis from the AFFIRM study. Eur Heart J 34(20):1481–148PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Geriatric Services, Department of Family MedicineUniversity of WisconsinMadisonUSA
  2. 2.Department of General, Abdominal and Vascular SurgeryMagdeburg University HospitalMagdeburgGermany

Personalised recommendations