Wayne C. McCormick

American Geriatrics Society Response to Letter to the Editor from Marc S. Berger “Misuse of Beers Criteria” July 2014

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New Guidance on the Prevention and Treatment of Postoperative Delirium in Older Adults

Postoperative delirium in older adults is a common and lifethreatening condition that often poses a challenge to nursing staff and other members of the interdisciplinary health care team. Studies have shown that the condition can be prevented in up to 40 percent of some hospitalized older adult populations 1,2 ; thus it is an ideal candidate for interventions targeted to improving the outcomes of older adults in the perioperative setting. 3 Delirium is a serious complication for older adults because an episode of delirium can initiate a cascade of potentially harmful clinical events, including other major postoperative complications, prolonged hospitalization, loss of functional independence, reduced cognitive function, and death. Delirium is usually the result of a physiologic stressor (e.g., an operation) and predisposing patient risk factors. Postoperative precipitants may include medications, infection, electrolyte abnormalities, and environmental causes. A Clinical Practice Guideline and Best Practice Statement was recently developed and released by the American Geriatrics Society’s Geriatrics-for-Specialists Initiative (AGS-GSI) to provide a framework that will enable hospital systems and health care professionals to implement actionable, evidence-based measures to improve delirium prevention and treatment. The AGS-GSI council, with additional input from the expert panel co-chairs, Sharon Inouye, MD, MPH, and Thomas Robinson, MD, created a 23-member, interdisciplinary panel of experts on delirium. Represented disciplines included geriatric medicine, general surgery, anesthesiology, emergency medicine, geriatric surgery, gynecology, hospital medicine, critical care medicine, neurology, neurosurgery, nursing, obstetrics and gynecology, orthopedic surgery, ophthalmology, otolaryngology, palliative care, pharmacology, psychiatry, physical medicine and rehabilitation, thoracic surgery, urology and vascular surgery. The expert panel utilized a proven framework for clinical practice guideline development including a systematic literature review, an evaluation of the evidence based on the Cochrane Risk of Bias and Jadad scoring system, and ratings of the quality of evidence and strength of recommendation for each recommendation statement using the American College of Physicians’ Guideline Grading System. An extensive review by organizations with expertise in this area and an open public comment period were also part of the guideline development process. The Best Practice Statement was developed as a companion piece to the clinical practice guideline, with the goal of providing practical guidance to surgical and related health care specialists who wish to improve knowledge of assessing, preventing and managing postoperative delirium. The clinical practice guideline includes eight recommendation statements for which the panel found “strong” evidence. The panel determined that the benefits clearly outweighed the risks, or that the risks clearly outweighed the benefits, for these recommendations: