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Postoperative Delirium in the older patient.

Postoperative delirium . Acute disorder of cognition and attention after operationAnytime in perioperative period Most commonly occurs during postsurgical period Underdiagnosed 78@% routinely screen for delirium . Postoperative delirium. Associated with Poor cognitive and functional recovery Longer hospital stay Greater hospital costsRisk factor for institutionalization and morbidity Reduced risk by early identification, assessment and treatment.

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Postoperative Delirium in the older patient.

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    1. Postoperative Delirium in the older patient. Topic review 26/5/48 Suthinee Ithimakin, MD

    2. Postoperative delirium Acute disorder of cognition and attention after operation Anytime in perioperative period Most commonly occurs during postsurgical period Underdiagnosed 78% 40% routinely screen for delirium

    3. Postoperative delirium Associated with Poor cognitive and functional recovery Longer hospital stay Greater hospital costs Risk factor for institutionalization and morbidity Reduced risk by early identification, assessment and treatment

    4. Incidence/ prevalence ¼ of adult older than 65 year experience delirium during hospitalization Wide range estimate of postoperative delirium pending on type of operation Delirium is likely to increase in future

    5. Pathogenesis CNS changes with age Loss of nerve cells Decreased in cerebral blood flow Changes in neurotransmitter system Decreased acetylcholinesterase activity Carbonic anhydrase activity Muscarinic receptor Serotonin receptors

    6. Pathogenesis Abnormal levels of endorphins, serotonin, neuropeptides in CSF EEG : slowing of dominant posterior alpha rhythm and abnormal slow wave activity

    8. Risk factors

    9. Risk factors Older age Cognitive impairment Functional impairment Decreased postoperative hemoglobin Markedly abnormal sodium, potassium and glucose Alcohol abuse Noncardiac thoracic operation History of delirium Preoperative used of narcotic Preoperative used of benzodiazepine Low postoperative oxygen saturation History of cardiovascular disease Untreated pain

    10. Drug associated with delirium Drugs with anticholinergic activity Tricyclic antidepressants Cimetidine Corticosteroids Digoxin Diphenhydramine Belladonna Dipyridamole Theophylline Promethazine Amantadine Oxybutyrin

    11. Drugs associated with delirium Analgesics Narcotics (especially meperidine) NSAIDs Benzodiazepines Antiparkinsonian agents

    12. Diagnosis

    14. Clinical features Change of consciousness and recognition Cognitive abnormalities Disorientation Language difficulty Impairment of learning and memory

    15. Clinical features Emotional disturbances Anxiety Fear Anger Irritability Depression

    16. Clinical features 4 different types Hypoactive delirium Hyperactive delirium Mixed delirium Delirium without psychomotor change

    17. History Description of patient’s behavior Earlier episode of delirium Evidence of cognitive impairment Information to rule out alcohol or drug withdrawal

    18. Physical examination Vital signs Oxygen saturation Sign of trauma or infection State of hydration New neurological signs

    19. Confusion assessment method

    20. Diagnostic tests To identify potentially correctable factors CBC, electrolytes, creatinine, glucose, and urinalysis Neuroimaging may be used selectively

    21. Prevention Tarketing modifiable risk factors prevent some case of delirium* Standardized protocols of known risk factors for delirium Reduction in delirium episodes (15%?9.9%) No effect on delirium severity and rate of recurrence

    22. Prevention Patients with fracture neck of femur Outcome : Postoperative delirium ?? Pre and postoperative geriatric assessments, Oxygen therapy Early operation Prevention treatment of perioperative BP fall Treatment of postoperative complication

    23. Prevention

    24. Prevention Identify and reduce risk factors can decrease postoperative delirium in elderly Preoperative educate the patients

    25. Management Treat contributing illness Providing supportive measures Symptom control

    26. Supportive measures

    27. Medication for symptom control Antipsychotics Haloperidol or newer antipsychotic agent ?? Goal is to control disruptive symptoms and avoid obtundation Taper in 3-5 days Benzodiazepine Paradoxical agitation Treat withdrawal from alcohol of sedative drugs

    29. Outcome Sequels of delirium can persist for 6 months Risk for future cognitive decline Associated with increase mortality (10-65%) Longer hospital stay and higher nursing home placement

    30. Outcomes of delirium Relationship between delirium and dementia in 3 years with 203 patients age = 65 in medical services

    31. Outcomes of delirium 78 patients with femoral neck fractures

    32. Conclusion Risk of postoperative delirium can be reduced with careful attention to risk factors Intervention to target problems Systemic approach to diagnostic workup Early identification, assessment and management

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