Postoperative Delirium



Postoperative Delirium (PD) is common, costly, and often fatal. The etiology of PD is multifactorial and there are multiple risk factors which predispose and precipitate an episode of PD. Predisposing factors are preoperative and may not be modifiable but serve to increase the index of suspicion for diagnosis. Precipitating factors are often iatrogenic. The incidence of PD ranges from 2% for a patient without any risk factors to more than 50% for someone with multiple risk factors. Delirium in general has been shown to have an independent association with poor outcomes including increased hospital mortality rates, nursing home dispositions, length of the hospitalization, and long term mortality. In certain patients aged 65 and older and those undergoing high risk surgeries such as major orthopedic and cardiac surgery, screening for patients at high risk for PD seems prudent. Although there are multiple single component therapies which may help in preventing or minimizing the severity of PD, multicomponent interventions such as a preemptive geriatric or medical consultation, geared to addressing the multifactorial nature of PD, are likely to have the greatest impact on improving postoperative outcomes.


Postoperative Delirium Clinical Prediction Rule Confusion Assessment Method Multicomponent Intervention Postoperative Cognitive Dysfunction 


  1.  1.
    Inouye SK, Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165.PubMedCrossRefGoogle Scholar
  2.  2.
    Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106(5):565-573.PubMedCrossRefGoogle Scholar
  3.  3.
    Olofsson B, Lundstrom M, Borssen B, et al. Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci. 2005; 19(2):119-127.PubMedCrossRefGoogle Scholar
  4.  4.
    Gruber-Baldini AL, Zimmerman S, Morrison RS, et al. Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up. J Am Geriatr Soc. 2003;51(9):1227-1236.PubMedCrossRefGoogle Scholar
  5.  5.
    Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271(2):134-139.PubMedCrossRefGoogle Scholar
  6.  6.
    Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119(2):229-236.PubMedCrossRefGoogle Scholar
  7.  7.
    Edward Vandenberg M.D. Geriatric pearls at
  8.  8.
    Flaherty JH, Morley JE. Delirium: a call to improve current standards of care. J Gerontol A Biol Sci Med Sci. 2004;59(4):341-343.Google Scholar
  9.  9.
    Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852-857.PubMedCrossRefGoogle Scholar
  10. 10.
    Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58(1):76-81.PubMedGoogle Scholar
  11. 11.
    Kalisvaart KJ, Vreeswijk R, de Jonghe JF, et al. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk ­factor model. J Am Geriatr Soc. 2006;54(5):817-822.PubMedCrossRefGoogle Scholar
  12. 12.
    Freter SH, Dunbar MJ, MacLeod H, Morrison M, MacKnight C, Rockwood K. Predicting post-operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age Ageing. 2005;34(2):169-171.PubMedCrossRefGoogle Scholar
  13. 13.
    Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM Jr. Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001;161(20):2467-2473.PubMedCrossRefGoogle Scholar
  14. 14.
    Wong CL, Holroyd-Leduc J, Simel DL, et al. Does this patient have delirium?: value of bedside instruments. JAMA. 2010;304(7):779-786.PubMedCrossRefGoogle Scholar
  15. 15.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.PubMedGoogle Scholar
  16. 16.
    Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676.PubMedCrossRefGoogle Scholar
  17. 17.
    Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516-522.PubMedCrossRefGoogle Scholar
  18. 18.
    Robert Wood Johnson Medical School. Focus transfusion trigger trial. Accessed May 22, 2010.
  19. 19.
    Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53(10):1658-1666.PubMedCrossRefGoogle Scholar
  20. 20. Perioperative Cognitive Function – Dexmedetomidine and Cognitive Reserve Accessed May 22, 2010.
  21. 21. Supporting the Health of Adults Undergoing Orthopedic Surgery During the Recovery Period (SHARP). Accessed May 22, 2010.
  22. 22.
    Leung JM, Sands LP, Rico M, et al. Pilot clinical trial of gabapentin to decrease postoperative delirium in older patients. Neurology. 2006;67(7):1251-1253.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  1. 1.Hospital Medicine Unit, Section of General Internal MedicineBoston University School of MedicineBostonUSA

Personalised recommendations