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Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery

Nazemi, Alireza K. MS; Gowd, Anirudh K. BS; Carmouche, Jonathan J. MD; Kates, Stephen L. MD; Albert, Todd J. MD; Behrend, Caleb J. MD

doi: 10.1097/BSD.0000000000000467

Study Design: This study is a systematic review.

Objective: Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery.

Summary of Background Data: Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%–24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available.

Methods: A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015.

Results: Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05).

Conclusions: An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed.

Level of Evidence: Level II.

*Virginia Tech Carilion School of Medicine

Carilion Clinic, Institute for Orthopaedics and Neurosciences, Roanoke

Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA

§Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY

The authors declare no conflict of interest.

Reprints: Alireza K. Nazemi, MS, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016 (e-mail:

Received April 9, 2016

Accepted October 25, 2016

© 2017 by Lippincott Williams & Wilkins, Inc.