Journal of Clinical Anesthesia xxx (xxxx) xxx

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Journal of Clinical Anesthesia

journal homepage: www.elsevier.com/locate/jclinane

Which interventions can reduce post-operative delirium in the elderly?

Synthesis of multidisciplinary and pharmacological intervention data
JaredA. Herman, DO a, Richard D. Urman, MD b, *, Ivan Urits, MD c, Alan D. Kaye, MD PhD d,
Omar Viswanath, MD e, f
a
Mount Sinai Medical Center, Miami Beach, FL, United States of America
b
Brigham and Women’s Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
c
Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
d
Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, United States of America
e
Valley Anesthesiology and Pain Consultants – Envision Physician Services, Phoenix, AZ, United States of America
f
Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, United States of America

1. Infographic summary respectively. There were a total of nine non-pharmacological, multi­

Post-operative delirium (POD) leads to poor outcomes, morbidity,
and mortality. The elderly are a particularly high risk group, with as
many as 80% of older individuals developing POD following surgery.
With the global increase of the aging population, this will subsequently
lead to a parallel increase in POD, and the increased financial burden
associated with it. While the pathophysiology of POD is likely multi­
factorial and is still poorly understood, age over 65 years, acute hip
fracture, coexisting serious illness and pre-existing cognitive impair­
ment are the major risk factors for POD development. This infographic
(Fig. 1) summarizes a recently published systematic literature review
and meta-analysis that aimed to synthesize data on pharmacological and
non-pharmacological interventions to reduce POD among older patients
undergoing elective and emergency surgery [1]. Systematic literature
searches of CINAHL, Medline, Web of Science and Cochrane Library
were conducted to identify studies published in the English language up
to December 2018 on interventions aimed at reducing POD among older
patients. The inclusion criteria for studies were as follows: Study pop­
ulation participants were aged 65 years and older undergoing a surgical
procedure requiring anesthesia; there was information about pharma­
cological and non-pharmacological (including multidisciplinary ap­
proaches) interventions to reduce POD with a comparator, if used; a
primary or secondary outcome of each included study was incidence/
prevalence of POD; studies that used the prospective quasi-experimental
or randomized controlled trial study design; and studies published in the
English language. Overall, 25 studies met inclusion criteria. There were
16 pharmacological interventions included in the analysis. Haloperidol
and dexmedetomidine were commonly studied in 4 and 2 studies,
disciplinary studies. These consisted of continuous monitoring of older
people undergoing surgery, screening for POD, avoidance of poly­
pharmacy, geriatric consultation and nurse-led prevention strategies
across different surgical wards. Overall, there was more consistency
among the non-pharmacological interventions than the pharmacolog­
ical interventions, where results were occasionally contradictory. In
general, there was no consensus on specific non-pharmacological in­
terventions that were more effective in preventing or reducing POD. A
recurring theme among the pharmacological interventions was con­
trolling pain in order to reduce POD. Dexmedetomidine was shown to
reduce the incidence of POD in older patients. Pregabalin was shown to
also reduce POD incidence. While the use of anti-psychotics is used all
too often in managing POD, meta-analysis of four studies showed that it
had no effect on reducing POD. Of the non-pharmacological, multidis­
ciplinary interventions, 8 of the 9 showed significant reductions in the
incidence and prevalence of POD. There is a need for a general
consensus on the most effective ways to prevent and manage POD,
especially among older patients where there is higher incidence and
prevalence rates.
Funding
None.
Declaration of Competing Interest
Jared A Herman: declares no conflicts of interest.
Ivan Urits: declares no conflicts of interest.

* Corresponding author at: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States of
America.
E-mail address: rurman@bwh.harvard.edu (R.D. Urman).

https://doi.org/10.1016/j.jclinane.2020.110117
Received 12 October 2020; Accepted 24 October 2020
0952-8180/© 2020 Elsevier Inc. All rights reserved.

Please cite this article as: JaredA. Herman, Journal of Clinical Anesthesia, https://doi.org/10.1016/j.jclinane.2020.110117
JaredA. Herman et al. Journal of Clinical Anesthesia xxx (xxxx) xxx

Fig. 1. Which Interventions can Reduce Post-Operative Delirium in the Elderly? Synthesis of Multidisciplinary and Pharmacological Intervention Data.

Richard D. Urman: declares unrelated research funding from Merck, References

Medtronic, AcelRx, Acacia. Also consulting fees from Takeda pharma
and Heron.
Alan D. Kaye: declares consulting fees from Merck.
Omar Viswanath: declares no conflicts of interest.
[1] Igwe EO, Nealon J, Mohammed M, et al. Multi-disciplinary and pharmacological
interventions to reduce post-operative delirium in elderly patients: a systematic
review and meta-analysis. J Clin Anesth 2020;67(June):110004. https://doi.org/
10.1016/j.jclinane.2020.110004.

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