Editor—Postoperative delirium is characterised by acute and usually reversible cognitive disturbance with fluctuating changes in attention and level of consciousness, with an incidence of ∼20% in older patients after major, non-emergent surgery.1 It is recognised as a significant contributor to adverse outcomes in older hospitalised patients, as delirium is associated with prolonged hospitalisation, discharge to skilled care facilities, and persistent cognitive decline.2,3 As surgical populations continue to age, the incidence of postoperative delirium and related complications will likely increase.
Given the deleterious outcomes associated with delirium, patient awareness is an important part of the informed consent and shared decision-making processes. Increased patient understanding of delirium may also be helpful with the approach to postoperative care, including engagement with support systems such as the Hospital Elder Life Program.4 However, the extent to which older surgical patients are routinely counselled regarding postoperative delirium is unclear. We thus conducted a prospective cross-sectional survey to determine the extent to which older surgical patients are preoperatively counselled regarding the nature and risks of postoperative delirium. We also assessed delirium perceptions and patient-level understanding of the syndrome.
This was a single-centre, cross-sectional survey study conducted at Michigan Medicine, and approval was obtained from the Institutional Review Board (HUM00192498). Participants included were 70 yr and older presenting for major noncardiac surgery requiring inpatient admission. Participants were screened using preoperative clinic schedules, and charts were accessed through the electronic health records system. Eligible patients were contacted by telephone 1 week before their preoperative clinic assessment date. After informed consent was obtained, participants were surveyed about their knowledge of, and concern for, postoperative delirium (see Supplementary Digital Content 1 for survey questions). An opportunity was then offered to consult formally with an anaesthesiologist further about postoperative delirium. In those seeking additional information, an anaesthesiologist from the preoperative clinic conducted a focused discussion based on a standardised checklist regarding the nature and individualised risks of delirium. The National Surgical Quality Improvement Program Geriatric Outcomes risk calculator was also incorporated into the discussion to provide quantitative estimates.5 Patients were then informed about methods of delirium mitigation in the postoperative period, highlighting the role of family and hospital services such as the Hospital Elder Life Program.4 Participants were also asked if they would like to be seen by the Hospital Elder Life Program while admitted postoperatively, as this program is part of routine practice at our institution. The final sample size (n=100) was a convenience sample based on preoperative clinic schedules, though this aligns with similar survey studies focused on patient perspectives in the perioperative setting.6
After surgery, patients were contacted within 3 days after hospital discharge to enquire about cognitive status and whether expanded preoperative delirium consultation, if conducted, had been helpful. Likely presence of delirium was also recorded based on any of the following three criteria: (1) subjective reporting during postoperative survey; (2) positive Confusion Assessment Method7 screen in the medical record; or (3) language suggestive of an acute confusional state in the medical record, based on a structured chart review method.8 Results were recorded from 100 participants with a median age of 74 yr (inter-quartile range, 72–79 yr; participant characteristics are available in Supplementary Table S1). A high proportion of patients (83/100, 83%) reported awareness of delirium, and 16/100 (16%) reported previous personal experiences with delirium (Table 1). Only 24/100 (24%) respondents reported previous counselling regarding postoperative delirium by a healthcare professional.
Table 1.
Cross-sectional survey results (n=100 participants). ∗Based on chart review screening or subjective reporting, as described in the text. Of note, for eight participants who subjectively reported delirium, there was no official documentation to corroborate a delirium diagnosis. Nine surgeries were cancelled, leaving a total of 91 participants for postoperative review. Of those that expressed an interest in expanded delirium counselling by an anaesthesiologist (n=26), three participants had their surgeries cancelled, and one could not be reached for preoperative counselling. Of the remaining 22 participants that underwent preoperative counselling, 18 were successfully contacted after surgery (n=3 lost to follow-up, n=1 discharged to a skilled care facility). †Five participants did not recall the preoperative consultation session. HELP, Hospital Elder Life Program.
| Preoperative survey | |||||
|---|---|---|---|---|---|
| Yes | No | Unsure | |||
| Aware of delirium, n (%) | 83 (83) | 16 (16) | 1 (1) | ||
| Personal history of delirium, n (%) | 16 (16) | 75 (75) | 9 (9) | ||
| Previous preoperative delirium counselling, n (%) | 24 (24) | 66 (66) | 10 (10) | ||
| Interest expressed in expanded delirium counselling, n (%) | 26 (26) | 74 (74) | 0 (0) | ||
| Strongly agree | Agree | Neutral | Disagree | Strongly disagree | |
| Worried about problems with thinking and memory after surgery, n (%) | 0 (0) | 15 (15) | 12 (12) | 54 (54) | 19 (19) |
| Worried about problems with thinking and memory after hospital discharge, n (%) | 0 (0) | 10 (10) | 13 (13) | 58 (58) | 19 (19) |
| Not concerned | Low-level concern | Mid-level concern | High concern | ||
| Level of concern about cognitive dysfunction after surgery, n (%) | 54 (54) | 38 (38) | 7 (7) | 1 (1) | |
| Yes | No | Unsure | |||
| Interest in HELP assistance before anaesthesiologist counselling, n (%) | 31 (31) | 56 (56) | 13 (13) | ||
| Interest in HELP assistance after anaesthesiologist counselling (n=22), n (%) |
12 (55) |
6 (27) |
4 (18) |
||
|
Postoperative Survey | |||||
| Yes | No | ||||
| Likely occurrence of delirium after surgery (n=91),∗ n (%) | 19 (21) | 72 (79) | |||
| Strongly Agree | Agree | Neutral | Disagree | Strongly Disagree | |
| Preoperative discussion about delirium helpful (n=18), n (%)† | 4 (22) | 6 (33) | 3 (17) | 0 (0) | 0 (0) |
| Yes | No | Does not recall conversation | |||
| Would prefer similar preoperative discussion in future (n=18), n (%)† | 8 (44) | 5 (33) | 5 (33) | ||
Concern for delirium was low, with 92/100 (92%) of respondents expressing, at most, low-level concern for this complication. Likewise, only 10/100 (10%) of respondents voiced concern for residual cognitive dysfunction after hospital discharge. Twenty-six percent (26/100) of respondents expressed interest in further delirium consultation before their planned surgical procedures. Participant interest in delirium mitigation services such as the Hospital Elder Life Program was limited (31/100, 31%) on initial questioning. In those who received expanded delirium counselling by an anaesthesiologist, the level of interest in such services was higher (12/22, 55%), with the remainder of participants unsure or expressing a preference for family presence exclusively postoperatively.
We were then able to contact 74/100 (74%) patients for the postoperative survey. Nine participants had their surgeries cancelled, and the remaining participants were either transferred to other facilities (n=6), could not be reached (n=9), or declined further participation (n=2). After surgery, 19/91 (21%) of participants likely experienced delirium, as determined by postoperative survey or through examination of patient medical records (focused postoperative survey results are available in Supplementary Table S2). Seven participants (7/74, 9%) reported problems with thinking or memory that were not present before surgery. Of the participants who received focused preoperative counselling, had their scheduled surgeries, and were then successfully contacted after surgery, the majority (10/18, 56%) reported preoperative counselling as having been helpful. Eight participants (8/18, 44%) preferred to have a similar process with future surgical procedures.
Our results suggest that delirium is not widely discussed by healthcare professionals before surgical procedures as part of the consent process. This practice is discrepant with current guidelines, which recommend preoperative cognitive screening and education for older adults.9,10 Although there was broad awareness of delirium in the population sampled, the overall level of concern was low for most (>90%) respondents, which may be a result of limited understanding, counselling, or both. Participants frequently requested additional delirium consultation preoperatively, a service that preoperative anaesthesia clinics are well placed to provide. Such expanded consultation was also associated with increased interest in delirium mitigation services such as the Hospital Elder Life Program.
This study is limited by its focus on elective inpatient cases and, through the nature of its recruitment process, by not including patients who were not scheduled to attend the preoperative assessment clinic. Many participants (∼45%) were consented to surgery before the survey. Delirium discussions may have occurred during the surgical consent process, which could have affected survey answers for these participants. Fifteen participants who underwent surgery were lost to follow-up, and it is possible that some of these patients may have been experiencing neurocognitive problems postoperatively. The extent of services offered to participants by the Hospital Elder Life Program was not tracked in the current study. We were also unable to follow-up on participants who had been transferred to rehabilitation facilities or other hospitals, some of whom may have been impacted by delirium. The delirium screening methodology in this study (i.e. chart review paired with subjective reporting) may have a reduced sensitivity compared with prospective, expert-based delirium screening strategies. Lastly, generalisability may also be limited, given that no additional patient cohorts were surveyed.
In summary, the results of this study suggest a tendency by health professionals to overlook postoperative delirium during the informed consent process. In addition, patients may underestimate delirium likelihood and associated risks. Many participants sought additional consultation for postoperative delirium, which appeared to increase receptiveness towards postoperative delirium mitigation services. Adoption of standardised preoperative delirium counselling may help to improve delirium awareness, anticipation, and engagement with services known to reduce the impact of this debilitating condition.
Declarations of interest
The authors declare that they have no conflicts of interest.
Funding
US National Institutes of Health (K23GM126317to PEV) and Department of Anesthesiology, Michigan Medicine.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2021.12.047.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
References
- 1.Avidan M.S., Maybrier H.R., Abdallah A.B., et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet. 2017;390:267–275. doi: 10.1016/S0140-6736(17)31467-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gleason L.J., Schmitt E.M., Kosar C.M., et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg. 2015;150:1134–1140. doi: 10.1001/jamasurg.2015.2606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Saczynski J.S., Marcantonio E.R., Quach L., et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30–39. doi: 10.1056/NEJMoa1112923. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Inouye S.K., Bogardus S.T., Jr., Baker D.I., Leo-Summers L., Cooney L.M., Jr. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. J Am Geriatr Soc. 2000;48:1697–1706. doi: 10.1111/j.1532-5415.2000.tb03885.x. [DOI] [PubMed] [Google Scholar]
- 5.Bilimoria K.Y., Liu Y., Paruch J.L., et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217 doi: 10.1016/j.jamcollsurg.2013.07.385. 833–42.e1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.de Beer J., Petruccelli D., Adili A., Piccirillo L., Wismer D., Winemaker M. Patient perspective survey of total hip vs total knee arthroplasty surgery. J Arthroplasty. 2012;27 doi: 10.1016/j.arth.2011.12.031. 865–69.e1–5. [DOI] [PubMed] [Google Scholar]
- 7.Inouye S.K., van Dyck C.H., Alessi C.A., Balkin S., Siegal A.P., Horwitz R.I. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–948. doi: 10.7326/0003-4819-113-12-941. [DOI] [PubMed] [Google Scholar]
- 8.Inouye S.K., Leo-Summers L., Zhang Y., Bogardus S.T., Jr., Leslie D.L., Agostini J.V. A chart-based method for identification of delirium: validation compared with interviewer ratings using the Confusion Assessment Method. J Am Geriatr Soc. 2005;53:312–318. doi: 10.1111/j.1532-5415.2005.53120.x. [DOI] [PubMed] [Google Scholar]
- 9.Berger M., Schenning K.J., Brown C.H., et al. Best practices for postoperative brain health: recommendations from the fifth international perioperative neurotoxicity working group. Anesth Analg. 2018;127:1406–1413. doi: 10.1213/ANE.0000000000003841. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Deiner S., Fleisher L.A., Leung J.M., Peden C., Miller T., Neuman M.D. Adherence to recommended practices for perioperative anesthesia care for older adults among us anesthesiologists: results from the ASA Committee on Geriatric Anesthesia-Perioperative Brain Health Initiative ASA member survey. Perioper Med (Lond) 2020;9:6. doi: 10.1186/s13741-020-0136-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.