Publication ID: 4738291560
Published on: February 2022
Major Revision: May 29, 2024


Our actionable evidence-based practices were designed by world-renowned patient safety experts to serve as proven step-by-step guidelines on eliminating the top causes of preventable harm. This blueprint has a proven track record of ensuring the best patient care. Please note that our guidelines are continually updated and incorporate the latest safety practices recognized as the gold standard of care.
Frontline staff

The following guide outlines the steps that patients and patient families can follow to prevent delirium:

  1. Engage in conversations with a healthcare provider around current potential health conditions, such as stroke, heart attack, or liver disease.
  2. Discuss health history and personal risk factors with healthcare team before
  3. Keep an eye out for any new or worsening mental states that might signal
  4. Clarify any use of or avoid use of sedatives and
  5. Provide familiar objects, such as family photos, and reassuring companionship, such as having friends and family at the bedside.
  6. Encourage physical
  7. Advocate for minimal
  8. Minimize sleep deprivation or overwhelming or overstimulating
  9. Help make sure vision and hearing aids are readily
  10. Participate in medication reconciliation
  11. Check in with healthcare providers for updates to care plan.
  12. Ask to participate in bedside huddles, with healthcare providers.
  13. Act as an extra set of eyes and ears and alert medical staff if something might be
  14. Ask about what to look for that may indicate postoperative delirium, such as restlessness or agitation.
  15. Familiarize yourself with the signs of postoperative delirium and why this condition happens.
  16. Ask when you should call for help, where to seek help, and with whom you should speak when you recognize signs of postoperative delirium.
  17. Ask your team for educational material on postoperative delirium, risks, and preventive measures.
Unit Managers

This guide outlines the steps that unit managers can follow to prevent delirium:

Education and Clinical Workflow

  1. Ensure adequate training and documentation of screening competencies and skills. Train the team on the basic features of delirium as well as the features of any tools that will be used.
  2. Ensure that delirium protocols are embedded into clinical workflows, whether electronic or paper.
  3. Eliminate barriers to making rapid changes to documentation templates and order Standardize order sets and documentation templates and consider data collection and integrity. Ensure cognitive screening and delirium assessments are embedded in clinical records, whether paper or electronic, to ensure access in auditing for prevalence, incidence, and intervention effectiveness and for monitoring the patient course during hospitalization.
  4. Develop a hospital-wide education program, targeted appropriately to relevant clinical areas, with the intent of increasing awareness of the importance of identifying cognitive impairment and delirium, and what strategies can be used to support and best manage such patients. This should incorporate local/national/international recommended best-practice standards and tools where they exist.
  5. Consider a predictive tool that includes use of variables and assessments that are readily available in clinical practice and are feasible to administer without extensive training or
  6. Program electronic medical records to trigger reminders/alerts/order sets.
  7. Establish hospital resources, including protocols and guidelines for delirium prevention and management, by identifying risk factors for delirium, minimizing trigger factors, and optimizing assessment and care in the perioperative environment, including high-dependency units (HDUs) and intensive care units (ICUs), again drawing on any local/national/international standards or resources that may exist. Ascertain what related organizational policies exist and determine areas for alignment. 

Collaboration and Involvement of Staff

  1. Coordinate with relevant local medical practitioners (primary care/family medicine/general practitioners) for pre-hospital and post-discharge Such planning includes assessment, optimization, implementation of appropriate referral pathways, and post-discharge medication management.
  2. Ensure frontline involvement in delirium improvement activities. Maintain their engagement and remove barriers to Continually ensure that all staff are aware of the delirium reduction program and educated in its implementation.
  3. During the development of educational resources and protocols/guidelines, include a Patient and Family Advisory Council (PFAC) representative on the Delirium Workgroups/ In the development of educational materials/handouts and protocols for patients and support persons, engage with the Patient and Family Advisory Council (PFAC) to review educational materials from a patient’s perspective. Incorporate patient and family stories as a powerful way to engage practitioners and transform how they perceive the issue of delirium.
  4. Provide public education on postoperative delirium—to include signs, symptoms, and treatment—through public awareness events and marketing platforms. 

Implementation and Measurement

  1. Measure and report delirium incidence monthly. Routinely assess outcomes.
  2. In order to gain buy-in from hospital administration and leadership, calculate potential cost savings based on performance gap.
  3. Initiate a PI (performance improvement) project. Routinely reassess to identify gaps and ensure integration of the data collected.
  4. Expect that when the organization starts tracking safety events, there will be an initial increase in reported events before organizational improvement work begins to reduce error rates over time.
    1. Ensure that the frontline staff and leaders understand this so they don’t become demotivated to improve.
    2. Map time course for implementation with an expectation of months to years, but be ready to adjust the plan as needed. 

Sustainment and Continuous Improvement

  1. Ensure that leaders have a simple process to oversee delirium improvement work while also considering how it aligns with other initiatives across the organization. Establish an Oversight Committee which oversees pre-hospital and admission screening programs, multidisciplinary care programs, and perioperative assessment, prevention, and care strategies. The committee reports through safety and quality care pathways.
  2. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed. Conduct regular program auditing.
  3. Consider implementing fast track surgery (ERAS program) with early mobilization and discharge to prevent postoperative delirium.
  4. Hold staff accountable for providing the standard of care and reward success. 

Performance Improvement Plan

  1. Gather the right project team.
  2. Form two teams:
    1. An oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
    2. The actual project team consists of 5–7 representatives who are most impacted by the process.
    3. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization.
    4. Patients and family members need to be involved in all improvement projects, as there are many ways they can contribute to safer care.
  3. Understand what is currently happening and why.
    1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe.
    2. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
  4. Prioritize the gaps to be addressed and develop an action plan.
  5. Consider the cost effectiveness, time requirements, potential outcomes, and realistic possibilities for each gap identified.
  6. Determine which are priorities of focus for the organization.
    1. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
  7. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
  8. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
  9. Measure both process and outcome metrics.
    1. Outcome metrics include the rates outlined below.
    2. Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow changes.
    3. Compare your outcomes against other related metrics your organization is tracking.
  10. Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is not.
  11. Identify barriers to completion of action plans and adjust the plan if necessary.
  12. Once you have the desired outcomes in the trial area, consider spreading to other areas.
  13. Be nimble and move quickly to keep team momentum going and so that people can see the results of their labor. At the same time, don’t move so quickly that you don’t consider the larger, organizational ramifications of a change in your plan.
  14. Be sure to have a good understanding of the other, similar improvement projects that are taking place so that your efforts are not duplicated or inefficient. 

The action plan should include the following steps:

  1. Assess the ability of the culture to change and adopt appropriate strategies.
  2. Revise policies and procedures.
  3. Redesign forms and electronic record pages.
  4. Clarify patient and family education sources and content.
  5. Create a plan for changing documentation forms and systems.
  6. Develop the communication plan.
  7. Design the education plan.
  8. Clarify how and when people will be held accountable. 

Delirium processes to consider assessing:

  1. Preoperative
    1. Clinical risk assessment and documentation in clinical record
      1. Patient and family education and engagement in monitoring and reporting delirium symptoms
      2. Protocols for perioperative fluid management across care settings
      3. Frequency and accuracy of nursing delirium assessment with validated instrument
      4. Medication reconciliation
  1. Intraoperative
    1. Use of intraoperative brain monitoring strategies
    2. Avoidance of Beers criteria medications
    3. Avoidance of pharmacological restraints
  2. PACU
    1. Screening for postoperative delirium in PACU prior to release
  3. Postoperative
    1. Process for allied health staff to query patients/family members during bedside encounters and report symptoms of delirium
    2. Surgical orders for increased postoperative monitoring of at-risk patients
    3. Appropriate referral pathways for patients with postoperative delirium
    4. Use of nursing guidelines to minimize postoperative delirium risks (e.g., use of physical restraints, withdrawal from prescribed and illicit substances, inadequate pain management, sleep disturbances, dehydration, metabolic disturbances, electrolyte imbalances, etc.) 

Typical gaps identified in delirium:

  1. Lack of policies, procedures, and protocols for prevention and management of delirium
  2. Failures of communications among siloed providers
  3. Slow response to critical lab alerts
  4. Inadequate or incomplete handoffs
  5. Lack of documentation
  6. Lapses in identifying delirium, particularly hypoactive delirium (the most common form)
  7. Lapses in identifying cognitive impairment (particularly subtle impairment)
  8. Lack of resources required for sustained recovery post-discharge
  9. Failure to understand patient’s ability to implement care plan post-discharge, considering their built environment and social determinants 

Postoperative delirium metrics to consider assessing:

  1. Fall and fall with injury
  2. Restraint use
  3. Healthcare attendant use
  4. Outpatient support group attendance
  5. Mobility levels
  6. Emergency versus elective patients with postoperative delirium
  7. Patients with postoperative delirium based on surgical specialty
  8. Escalation of care with a prior episode of delirium
  9. Post-hospitalization support group attendance
  10. Number of surgical patients, 65 years and older, who require readmission within 30 days of surgery who have experienced postoperative delirium in their primary care episode
  11. Number of surgical patients, 65 years and older, who are screened pre-operatively for cognitive impairment and/or delirium
  12. Number of surgical patients, 65 years and older, who are evaluated post-operatively for delirium at prescribed intervals using standardized clinical assessment tool
  13. Number of surgical patients, 65 years and older, with positive delirium screens who receive postoperative preventative interventions (pharmacologic and nonpharmacologic)
  14. Time from onset of delirium symptoms postoperatively to implementation of treatment protocols/guidelines

To delve deeper into delirium detection, prevention, and assessment tools, we encourage reviewing the resource document for comprehensive information.

Hospital Executives

This protocol outlines the steps that executives can follow to prevent delirium: 

Delirium in older patients following anesthesia and surgery is a frequent occurrence that often goes undiagnosed. Delirium can lead to both short- and long-term morbidity, including cognitive impairment, and mortality. Up to 65% of older postoperative patients suffer some form of delirium following a surgical procedure, especially if requiring ICU admission. It is associated with serious consequences for hospitals, including increased rates of surgical complications, increased costs resulting from escalations in care, longer hospital stays, additional medications, increased laboratory tests, increased 30-day readmissions, and an increased ratio of observed/expected mortality.

Every year, postoperative delirium adds $125 billion to the cost of healthcare in the United States and $182 billion in 18 European countries combined. By 2050, it is estimated that half of all anesthetics and surgical procedures will be provided to those aged 65 years or more. Thus, millions of individuals at high risk of delirium and its consequences will undergo the precipitating event of surgery and anesthesia every year. The cost of an episode of acute care is increased 2.5 times by the occurrence of delirium. It is estimated that up to 40% of hospital-related episodes of delirium are preventable.

Hospital executives can significantly help with reducing the burden of post-op delirium in older adults by:

  1. Ensuring that medical and managerial staff are up-to-date with evidence-based practices.
  2. Educating a sufficient number of medical staff on delirium detection and prevention measures.
Patient & Families

This handbook outlines the steps that patients can follow to prevent Central Line-Associated Bloodstream Infections.

  1. Your central line catheter is a potential source of infection to your body, so always ensure that whoever accesses the line does so in a sterile manner.
  2. Do not be afraid to ask if physicians or nurses have washed their hands, have sterile gloves, and that they “scrub the hub” before accessing an injection port.
  3. If the port is a stopcock, ensure that it is capped off after access with a sterile cap.
  4. Your central line gives direct access to your heart, so always check with the nurse or physician to find out what medication is being administered.
  5. If the dressing on the line access becomes loose or soiled, call the nurse to come and replace it.

Abbott, T. E. F., et al.  Depth of Anesthesia and Postoperative Delirium. Jama, (2019).

Brown, C. H., et al. Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients. (2019)

Brown C, et al. Shaping anesthetic techniques to reduce post-operative delirium (SHARP) study: a protocol for a prospective pragmatic randomized controlled trial to evaluate spinal anesthesia with targeted sedation compared with general anesthesia in older adults undergoing lumbar spine fusion surgery. (2019)

Evered L, et al. ​​Anaesthetic depth and delirium after major surgery: a randomised clinical trial. (2021)

Evered L, et al. Acute peri-operative neurocognitive disorders: a narrative review. (2022)

Herman J, et al. Which interventions can reduce post-operative delirium in the elderly? Synthesis of multidisciplinary and pharmacological intervention data. (2022)

Mahanna-Gabrielli, E., et al. (2019). State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. British Journal of Anaesthesia, 123(4), 464–478. doi: 10.1016/j.bja.2019.07.004

Partridge, JSL. et al. Measuring the distress related to delirium in older surgical patients and their relatives. (2019)

Patel, V., et al. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. (2018).

Pun, B. T., et al. Caring for Critically Ill Patients with the ABCDEF Bundle. (2019)

Ross J, et al. Neurophysiologic predictors of individual risk for post-operative delirium after elective surgery. (2023)

White, S., et al.  Guidelines for the peri-operative care of people with dementia. Anaesthesia

Wiredu K, et al. Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium. (2023)

Wahba N, et al. Genome-wide DNA methylation analysis of post-operative delirium with brain, blood, saliva, and buccal samples from neurosurgery patients. (2022)

We encourage frontline staff to carefully review the detailed steps provided below to gain a deeper understanding of delirium detection and prevention.

 Explain why delirium prevention strategies are important. A member of the healthcare team should elaborate on the need for post-operative delirium strategies and should provide a basic overview of post-operative family engagement strategies. Include the patient’s family and/or support persons (friends and other support) in a patient’s care planning preoperatively and while in the hospital to provide complete care for the patient and provide an opportunity to implement delirium prevention strategies.

Indicate what to watch out for. Family members can serve as an extra pair of eyes and ears and can alert medical staff if something might be wrong. Family members should have an understanding of what to look for that may indicate postoperative delirium, such as restlessness or agitation. In order to adequately welcome patients and family members into the care team, it is not enough to explain “what” patients and family members should look for or “what” is going to happen in their care. The “what” must always be followed with a “why” to aid in genuine understanding.

Additionally, family members should know exactly when to call for help, where to go for help, and with whom they should speak. It is essential that patients and family members understand that they should not be ashamed to ask any of their questions and that many patients in similar situations often have similar questions.

Instead of employing a directive conversation style, an active, engaging conversation should take place, leaving capacity for questions and repeat-back strategies. When patients and family members understand the signs and symptoms that could be indicative of a problem, they are able to serve as an extra set of eyes in order to elevate this concern as early as possible.

For patients identified at risk in the preoperative period, provide education to the patient and support persons on postoperative delirium, potential risks and preventative measures. Informed consent should include risks of postoperative delirium based on pre-operative screening

Describe what can be anticipated. In addition to explaining when to call for help in the case of a potential emergency, healthcare providers should also thoroughly explain the typical treatment that can be expected before, during, and after the operation. Additionally, it is important to discuss potential postoperative delirium complications.

Clinicians should provide a high-level overview of the processes in place at their organization to ensure usage of screening for the risk of developing delirium before the operation. This demonstrates competence of the organization, will likely bolster patient and family comfort, and will provide the patient and family members with information for which to reference if they may be suspicious of a problem post-operation.

By engaging in these conversations before a problem arises, family members can be prepared in the circumstance of necessary treatment and will have an understanding of where to go to find out more information about their loved one’s condition.

Explain what is expected of them during their care. By giving patients and family members a “job” while they are in the hospital, they can be immersed fully in the routine care, can hold other team members accountable, can feel more confident voicing their concerns or opinions, and can serve as an extra set of informed and vigilant eyes to optimize delirium prevention and treatment. This team involvement can also reduce their anxiety by transforming concern into proactive action.

Risk reduction strategies include inviting a carer or family member to be with the patient at risk of delirium throughout as much of the perioperative period as possible. This includes accompanying the patient to the OR holding/preparation area and being present in the post-anaesthesia care unit (recovery room) as they emerge from anaesthesia. The benefits of orientation at these times with a familiar person present may be significant:

  1. Describe the organization’s postoperative delirium precaution standards that were
    1. If any of the protocols changed due to this specific patient’s circumstance, articulate that to the patient and family members.
  2. Have a discussion with the patient and family around end of life care and advanced
    1. Make an attempt to thoroughly understand the religious or cultural nuances in any of the patient’s or family members’ decisions or questions.
  3. Ensure thorough explanation of necessary post-discharge appointments, therapies, medications, and potential complications.
    1. Assess for patient preference in time and location of follow-up appointments, if possible.
  4. Provide patients and family members resources, including direct contact phone numbers, to the hospital for post-discharge questions.
    1. Make sure the resources are in their own
  5. Provide thorough instructions to the patient and family members in the days leading up to discharge regarding procedures if the patient were to become delirious after operation and recovery after discharge.
    1. If delirium care is required after discharge, set aside time with the patient and family member more than once to ensure their understanding and confidence.

Tools for Screening and Assessment.
Predictive Tools in the General Hospital Surgical Population:

 A number of tools with published performance data have been reviewed (Lindroth et al., 2018). Not all are designed for postoperative risk. Common features included are pre-existing cognitive impairment, age, and general health status. Factors to consider when selecting a tool for routine use in any healthcare environment include use of variables and assessments that are readily available in clinical practice and are feasible to administer without extensive training or interpretation (Lindroth et al., 2018). Examples include:

  1. AWOL (Douglas et , 2013; Brown et al., 2017)
    1. The AWOL prediction rule was derived by assigning 1 point to each of 4 items assessed upon admission that were independently associated with the development of delirium:
    2. A: Age ≥ 80 years
    3. W: Unable to spell “World” backward,
    4. O: Disorientation to place
    5. L: Higher illness severity
    6. Higher scores were associated with higher rates of delirium with a score of 2 or higher indicating a 5% or higher risk of delirium (ROC AUC 69 in the validation cohort).
    7. The AWOL-S variant takes surgical complexity into account (Whitelock et , 2020).
  2. NSQIP-derived predictive risk in hip fracture patients (Kim et , 2019).
    1. This is a 9-feature, 20 point maximum risk index for delirium following surgery for fractured neck of femur (ROC AUC 77):
    2. preoperative delirium (8 points);
    3. preoperative dementia (3 points);
    4. age (0–3 points);
    5. medical co-management (1 point);
    6. American Society of Anesthesiologists (ASA) physical status III–V (1 point);
    7. functional dependence (1 point);
    8. smoking (1 point);
    9. systemic inflammatory response syndrome/ sepsis/septic shock (1 point);
    10. and preoperative use of mobility aid (1 point);
  3. Screening for Cognitive Impairment
    1. Cognitive impairment is a well-validated risk factor for developing postoperative delirium. A number of tools and resources are available. Commonly used tests such as the Mini-Mental State Examination are able to detect possible dementia but are less sensitive to milder forms of cognitive impairment. Simple tests include the Montreal Cognitive Assessment (MoCA) (Ciesielska et al., 2016), MiniCog (Quitoriano et al., 2017), IQCODE-16, and TICS (Cook et al., 2009) which are more sensitive to subtle impairment.
  4. Tests for the Presence of Delirium
    1. Opinions vary widely on the most appropriate screening tool for delirium in hospitalized patients, noting that patients may manifest hypoactive or hyperactive psychomotor forms. It should be noted that a screening tool is not diagnostic and needs to be sensitive rather than specific. Any tool should also be easy and quick to administer, have a high inter-rater reliability and ideally need minimal training. A patient who screens positive for delirium should have an escalated care plan including appropriate support and treatment strategies, have the managing medical team notified, and be considered for geriatric, neuropsychiatric or psychological referral.
    2. There are many screening tools available of varying ease of use, and sensitivity and specificity (Scottish Intercollegiate Guidelines Network, 2019). Screening tools aid risk assessment and can guide ‘next steps’ including clinical intervention and support and/or referral. Simple one or two questions tests such as the Single Question to Identify Delirium (SQID) are usually based on orientation to time and place (Hendry et al., 2016) and have only moderate sensitivity and specificity.
    3. When applying tests for delirium, especially in the perioperative/ICU setting, an assessment of the state of alertness of the patient should be part of this and made using a tool such as the Richmond Agitation and Sedation Scale (RASS) (Aldecoa et al., 2017). This is because delirium can present in different psychomotor forms (ie hyperactive versus hypocative (and mixed). Some specific tests for delirium can then be applied and include:
      1. 4AT
        1. The 4AT is a screening instrument designed for rapid (< 2 mins) initial assessment of delirium and cognitive impairment using 4 test domains. A total score of 4 or more (maximum 12) suggests delirium but is not diagnostic. Sensitivity is 86-100%; specificity is 65-82%. Any score >0 suggests possible cognitive impairment (www.
      2. 3D-CAM
        1. The 3D-CAM is a derivative of the Confusion Assessment Method CAM, taking less time (under 5 mins) and requiring less operator training. Sensitivity is 66-100%; specificity is 90-99% (Marcantonio et al., 2014).
      3.  Nu-DESC
        1. The Nursing Delirium Screening Scale (Nu-DESC) is designed to be completed quickly with minimal training using nurse administration. It comprises an observational five-item scale. Sensitivity is 32-96%; specificity is 69-92%.
    4. The gold standard for diagnosis of POD is by an appropriately qualified physician according to the DSM-5 criteria. For suitably trained experts (or research), tools that may be used include the CAM, Comprehensive Geriatric Assessment or DRS-R-98 (Delirium Rating Scale- Revised). For non-experts options include (with appropriate training): 3D-CAM; CAM-ICU (only validated in ICU).

 Prediction of Delirium in ICU

There are several assessment tools that can, with variable precision, predict the development of delirium in ICU patients (including postoperative patients) from various weighted clinical features. All models have been found to have moderate to good predictive abilities. While the features in Pre-DELIRIC (recalibrated) were most accurate, the early predictive model (Table 1, center column although slightly less sensitive had the benefit that it could be applied early in the ICU admission and may allow for timely preventive measures (Green et al., 2019).


Table 1. Variables included in selected predictive models of ICU delirium (Green et al., 2019)

We encourage unit managers to carefully review the detailed steps provided below to gain a deeper understanding of delirium detection and prevention.

 Anesthesia Strategies

  1. Type of anesthesia. There is a lack of evidence to support that type of anesthesia (regional versus general) has a substantial impact on the incidence of POD. This is likely due to many factors involved including the presence of multiple risk factors and the use of sedatives to decrease psychological stress for patients. There is no consistent evidence to suggest a difference exists regarding delirium outcomes to guide choice regarding the administration of total intravenous anesthesia (TIVA) versus volatile agents.
  2. Depth of anesthesia (dose of anesthetic). Avoiding excessively deep anesthesia by titrating anesthetic agents can be achieved clinically, or supported by processed frontal EEG-based (pEEG) neuromonitoring or age-adjusted minimum alveolar concentration for volatile agents. This has been recommended in a number of guidelines. The use of pEEG guided anesthesia results in lower doses of anesthetic agents being administered and decreased burst-suppression activity on the EEG, and a meta-analysis suggested a benefit in its use in reducing incident delirium. Subsequently, a large randomized controlled trial failed to confirm a benefit in this outcome – noting that the intervention was confined to volatile agents, and burst- suppression still occurred frequently in both groups. Similarly, a study in patients having hip fracture repair did not find a difference in incident delirium in patients undergoing deep or light sedation (with BIS pEEG monitoring in both groups). Possible benefit in POD reduction with the use of intraoperative EEG monitoring awaits clarification by further studies comparing the specific targeting of pEEG and/or burst-suppression levels in appropriately controlled and randomized groups.
  3. Cerebral perfusion. Cerebral perfusion monitoring and support has a plausible physiological basis, and hypotension has been associated with increased incidence of. A 2018 best practices statement published by the American Society of Anesthesiologists Brain Health Initiative also suggested that optimizing intraoperative cerebral perfusion may improve outcomes. Limited trial data suggests that avoidance of significant blood pressure excursions (either hyper- or hypo-tension) may be important. Near infrared spectroscopy-based (NIRS) regional cerebral perfusion monitoring may be used to provide an indirect indicator of frontal cortex perfusion. To date there are limited studies of sufficient size or quality to confirm a strong beneficial impact of NIRS on delirium or neurocognitive outcomes either during surgery or in the ICU.
  4. Specific Drugs. Dexmedetomidine is a potent alpha-2 adrenoceptor agonist with sedative and analgesic properties. Dexmedetomidine given postoperatively, predominantly in the ICU, has been shown to reduce the incidence of postoperative delirium in cardiac and non-cardiac surgery patients (Duan et al., 2018). It is still uncertain that intraoperative administration on its own is of benefit, and further trials are awaited There is growing evidence that perioperative administration of an alpha-2 agonist (dexmedetomidine) may have efficacy in the prevention and treatment of post-operative delirium in ICU patients. A meta-analysis and a large RCT failed to demonstrate any benefit in delirium reduction in major surgery with the use of single- low dose ketamine.

Technology Plan

Technology is an enabler of good clinical care. In some cases, technology is the only practical means by which some objectives can be achieved (eg EMR medication alerts or audit; online tools). In many cases recommendations for the use of technology are based on ‘best practice’ recommendations, awaiting further evidence (eg pEEG monitoring) and in others, possible applications of technology are listed as they are ‘emerging’ (eg motion tracking or regional cerebral oximetry).

Technology can support

  1. EMR – linkages / alerts
  2. On-line tools (home assessment / tablet)
  3. clinical assessment of cognitive impairment
  4. bedside diagnosis of POD
  5. risk minimization strategies, including:
    1. Preoperative risk assessment and postoperative diagnosis checklists
    2. Electronic medication management (with warnings)
Preoperative clinical risk assessment and screening of cognitive impairment should be performed and documented in patients > 65 years of age

or at high risk of postoperative cognitive impairment

  • On-line risk assessment questionnaire
  • On-line / tablet-based cognitive tests
    • For use by clinical staff and / or patients
Screening for Postoperative Delirium

  • Simple tests
  • Quick to apply
  • Minimal training needed
  • Sensitive (not necessarily specific)

Diagnosis of postoperative delirium should:

  • Be performed by a healthcare provider trained to perform delirium assessments using accepted diagnostic tools (listed above)
  • Include assessments for hyperactive, hypoactive, and mixed subtypes (includes application of the Richmond Agitation and Sedation Scale)
  • On-line / tablet-based delirium tests
    • For use by clinical staff
Employing brain monitoring strategies:

  • Avoidance of deep anesthesia (and sedation) during surgery
  • Optimize cerebral perfusion
    • Monitoring for low cerebral perfusion / oxygenation (intra-operative and ICU)
  • Titrate volatile and intravenous anesthesia using processed EEG- based technology (best practice recommendations based on limited evidence)
  • Avoidance of burst-suppression EEG which may reflect anesthesia excess
  • Optimize cerebral perfusion (best practice recommendation)
    • specific technology eg regional Cerebral Oximetry (NIRS) (low level evidence currently)
  • Limited ICU evidence only for post-operative use
Titrate volatile anesthesia to appropriate age-adjusted minimum alveolar concentration (MAC)
  • End-tidal anesthetic agent monitoring
    • (best practice recommendation)
Future technologies:

  • Activity monitoring
  • Eye tracking
  • Motion / activity tracking
Patient management pathways and processesElectronic Health Record (EHR / EMR) System

  • Documentation of delirium screening
  • Positive screening notification – alerts
  • Computerized Provider Order Entry (CPOE)
  • Drug-drug interaction check
  • Drug-allergy interaction check
  • Clinical Decision Support tools (CDS)
  • Discharge letters / communication
Audit and review

  • Include assessments for hyperactive, hypoactive, and mixed subtypes (includes application of the Richmond Agitation and Sedation Scale)
  • Built into EMR system reports
Employing brain monitoring strategies:

  • Avoidance of deep anesthesia (and sedation) during surgery
  • Optimize cerebral perfusion
    • Monitoring for low cerebral perfusion / oxygenation (intra-operative and ICU)
  • Titrate volatile and intravenous anesthesia using processed EEG- based technology (best practice recommendations based on limited evidence)
  • Avoidance of burst-suppression EEG which may reflect anesthesia excess
  • Optimize cerebral perfusion (best practice recommendation)
    • specific technology eg regional Cerebral Oximetry (NIRS) (low level evidence currently)
  • Limited ICU evidence only for post-operative use
Titrate volatile anesthesia to appropriate age-adjusted minimum alveolar concentration (MAC)
  • End-tidal anesthetic agent monitoring
    • (best practice recommendation)
Future technologies:

  • Activity monitoring
  • Eye tracking
  • Motion / activity tracking
Patient management pathways and processesElectronic Health Record (EHR / EMR) System

  • Documentation of delirium screening
  • Positive screening notification – alerts
  • Computerized Provider Order Entry (CPOE)
  • Drug-drug interaction check
  • Drug-allergy interaction check
  • Clinical Decision Support tools (CDS)
  • Discharge letters / communication
Audit and review
  • Built into EMR system reports

Appendix A

  1. Leaders should establish hospital resources including protocols and guidelines for delirium prevention and The following may be appropriate and should be tailored to organizational need, context, and resources:
  2. Screening tools administered by suitably trained personnel prior to or on admission and during the postoperative period for cognitive decline and delirium
  3. Checklists for risk identification (Predisposing factors)
    1. Conduct discussions with patients and caregivers about the possibility of postoperative delirium, the risks associated with delirium and the importance of its prevention.
  4. Checklists for trigger factor minimization (Precipitating Factors)
    1. emphasizing multicomponent / multidisciplinary interventions in high-risk patients [4]; including surgery, geriatrics, anesthesiology, nursing, allied health practitioners and carers/family members
  5. Intraoperative and perioperative guidelines which use best practice and evidence-based strategies to minimize the risk of postoperative delirium
  6. Assessment tools for ICU and ward use for bedside (point of care) delirium screening; include awareness of hyperactive, hypoactive and mixed presentations
  7. Management guidelines for delirium once diagnosed, based on the diagnosis and treatment of contributing factors; including minimization of restraints or antipsychotic medications unless the patient or staff are at risk of harm.
  8. Discharge protocols to communicate to patients and caregivers relevant issues relating to perioperative
  9. Discharge protocols for primary caregivers and other
  10. Referral pathways for psychogeriatric consultation or memory clinics if concerns are identified as appropriate
  1. All Phases
    1. Hospital / health system leadership
      1. Support, time, funding
    2. Patient and family and/or carers
  2. Prior to Admission
    1. Anesthesia preoperative clinic
      1. Screening for frailty, cognitive dysfunction, nutritional status, etc; delirium prevention education
    2. Surgical clinics
      1. Screening for frailty, cognitive dysfunction, nutritional status, etc; delirium prevention education
    3. Pharmacy review of medications
    4. Social workers, case workers
      1. Discharge planning
    5. Dieticians, Physiotherapy, Occupational Therapy
      1. Preoperative optimization
    6. Geriatricians, palliative care providers
      1. Medical optimization, surgical decision-making and goals of care support
    7. Perioperative
      1. Perioperative nursing
        1. Screening or identification of high-risk patients, keeping sensory aids accessible to patient, patient/family education
      2. Anesthesia providers
        1. Choice of anesthetic technique, use of appropriate monitoring, best-practice intraoperative care
      3. Recovery room nursing
        1. Delirium screening, appropriate medication administration, non-pharmacologic delirium prevention measures, communicating delirium risk to ward or ICU nurse, patient/family education
  1. Postoperative
    1. Surgical teams, ICU teams/ Acute Care teams
      1. Ordering of diagnostic / prevention measures, appropriate medication prescribing, appropriate consultation and hand-over
      2. Assess for metabolic disturbances and infection
      3. Ensure adequate hydration
    2. Ward and ICU nursing
      1. Delirium screening, non-pharmacologic delirium prevention/treatment measures, patient/family education
    3. Physiotherapy / Occupational Therapy staff
      1. Early mobilization, discharge planning
    4.  Pharmacists
      1. Medication Review
    5.  Dieticians
      1. Nutrition advice
    6. Case workers/social workers
      1. Discharge planning
    7. Geriatricians, palliative care providers
      1. Medical consultation, assistance with goals of care and symptom management
    8. Caregivers and family members of the patient
      1. Monitor and report changes in mental status, actively support early mobilization and other non- pharmacological prevention measures

 Precipitating Factors for Postoperative Delirium

There are many factors which may precipitate delirium, especially in patients already at risk. Many are preventable, so a delirium care-plan needs to identify and manage as many of these as possible

  1. Pain
    1. Poorly controlled pain
    2. Sedating analgesics, especially opioids
  2. Disorientation
    1. An unfamiliar environment
    2. Unfamiliar people and little/no family support
    3. Lack of sensory aids, for example, glasses or hearing aids
    4. Loss of sense of time and place
  3. Sleep disturbance
  4. Sedating drugs
    1. Especially benzodiazepines
    2. Care with tramadol and gabapentinoids
  5. Polypharmacy
    1. Especially drugs with anticholinergic side effects
  6. Drug withdrawal
    1. g benzodiazepines, opioids, gabapentinoids
  7. Dehydration and metabolic disturbances
  8. Local Infections and Sepsis
  9. Indwelling catheters
    1. especially urinary catheters
  10. Physical restraints