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Delirium

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Perioperative Psychiatry

Abstract

Delirium can be identified by the four A’s: acute change in mentation, impaired attention, reduced awareness of environment (“confusion”), and another cognitive deficit. Level of arousal is also typically altered in delirium and may present as hypoactive, hyperactive, or mixed level of activity. Postoperative delirium incidence ranges widely—10–80%—and reflects the range of surgical invasiveness and cognitive vulnerability of surgical cohorts. Delirium and its severity are associated with a higher risk of subsequent cognitive and functional decline as well as mortality.

Confusion is common upon anesthesia emergence. Whereas this early confusion usually clears within hours, it predicts the development of postoperative delirium, thereby serving as a convenient stress test of cognitive vulnerability. Classically defined, postoperative delirium peaks on postoperative day 2 and lasts 2–5 days. Confusional states that do not meet full delirium criteria (i.e., subsyndromal delirium) are more common than delirium proper and predict outcomes of intermediate severity relative to those of delirium.

Universal risk factors for delirium include advanced age, cognitive and functional impairment, multimorbidity, and surgical invasiveness. Additional risk factors vary by surgical cohort and procedure. Delirium risk stratification is important because non-pharmacological interventions can prevent up to a third of delirium in sufficiently at-risk patients. Routine use of validated delirium screening instruments is recommended to enhance delirium detection. Once delirium is identified, reversible contributors should be remediated promptly. Non-pharmacological interventions are first-line management of the neuropsychiatric symptoms associated with delirium. Judicious use of neuroleptics may be considered to manage severe or dangerous symptoms.

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  1. Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA

    Mark A. Oldham

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  1. Department of Psychiatry, New Haven, CT, USA

    Paula C. Zimbrean

  2. Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA

    Mark A. Oldham

  3. Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA

    Hochang Benjamin Lee

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Oldham, M.A. (2019). Delirium. In: Zimbrean, P., Oldham, M., Lee, H. (eds) Perioperative Psychiatry. Springer, Cham. https://doi.org/10.1007/978-3-319-99774-2_4

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