Abstract
Postoperative delirium (POD) is a common and serious condition associated with increased morbidity, mortality, cognitive decline and healthcare utilisation. It is also preventable in some patients. In Australia in 2016–2017, the overall cost associated with delirium was estimated to be AUD$8.8 billion, making it a significant healthcare burden. 1 Moreover, most of this expenditure is consumed treating delirium, highlighting a need for increased preventive measures. In 2023, the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) published an update of the evidence-based and consensus-based guideline on POD in adult patients, which comprised 13 recommendations, to include its risk assessment, prevention and treatment in the perioperative period. 2 The updated European guidelines are the most contemporaneous practice guidelines on POD, incorporating a comprehensive literature review to February 2022, and for this reason they are considered most relevant to current clinical practice.
In order to provide a context for healthcare in Australia and New Zealand (and in the absence of local guidelines) we sought the opinions of a range of experts in POD. We disseminated a questionnaire to preselected POD experts based in Australia and New Zealand to determine the level of agreement with each recommendation and better understand their application to clinical practice. Experts were selected by the senior author based on personal knowledge of extensive clinical and/or research activities in POD, including through Australasian Delirium Association activities, and to include a range of multidisciplinary practitioners. Consent to participate was sought by email explaining the purpose of the questionnaire, followed by a survey tool built and disseminated using research electronic data capture (REDCap). If no response was received, a reminder email was sent 3 weeks after the initial invite. Permission for named collaboration was also sought. Responses were received from 10 practitioners (out of 14 approached), including individuals from anaesthetics, palliative care, geriatrics and nursing staff (see Acknowledgements for POD experts). Agreement was indicated on a five-point Likert scale: strongly disagree, disagree, neutral, agree and strongly agree. Individual responses were identifiable and results were collated within REDCap, both for each recommendation and overall responses.
Responses were largely in agreement with the guideline, with most POD experts in this survey agreeing with 10 out of 13 recommendations (Table 1). Overall, 72.3% of responses were ‘agree’ or ‘strongly agree’, 20.8% were neutral and 6.9% were ‘disagree’ or ‘strongly disagree’. When recommendations in the guideline were graded as ‘strong’ (recommendations 1, 3, 6, 7 and 8), respondents were more likely to agree with the recommendation.
Agreement with recommendations from the European guidelines.
ASA: American Society of Anesthesiologists; CCI: Charlson Comorbidity Index; MMSE: Mini Mental State Examination; POD: postoperative delirium; EEG: electroencephalography.
This survey indicates that the updated 2023 guideline on POD in adult patients is broadly supported by a group of selected experts in POD in Australia and New Zealand. Familiarity with the guideline may assist Australian and New Zealand perioperative team members to minimise the burden of POD. In particular, it is recommended that perioperative practitioners routinely undertake preoperative risk assessment for POD, while addressing modifiable risk and sharing these results with the treating team prior to surgery. It is further recommended that all patients at risk of POD are managed with multicomponent non-pharmacological interventions, for example comprehensive geriatric assessment or ‘delirium prevention bundles’. 2 Changing anaesthetic or surgical practice to prevent POD is not recommended, but intraoperative neuromonitoring or processed electroencephalography (EEG) may play a role. Pharmacological treatment of POD is recommended only when non-pharmacological measures fail; short-term, low-dose haloperidol is preferred, while benzodiazepines should be avoided. With an ageing population and increasing life expectancy in Australia and New Zealand, coupled with an increased need for surgery in older persons, POD is a growing healthcare concern and preventive strategies are an essential component of safe perioperative care.
Within the surveyed group, some recommendations were specifically critiqued. For example, the guidelines were based on evidence and we agree that scales like the Charlson Comorbidity Index (CCI) and Mini Mental State Examination (MMSE) are likely to be suboptimal tools for delirium risk prediction. Alternative tests, which may offer more sensitivity, include National Surgical Quality Improvement Program scores and cognitive tests such as Trail Making Test B or the Montreal Cognitive Assessment. 3 Controversy over the depth of anaesthesia and POD was apparent with a range of opinions proffered (recommendations 9 and 10). This is consistent with prior meta-analysis and trial sequential analysis,4,5 suggesting that the question remains unanswered, and now further fuelled by another large North American study finding no impact of burst suppression avoidance on delirium (ENGAGES-Canada). 6 Similarly, the range of opinions voiced concerning the use of intraoperative dexmedetomidine to prevent postoperative delirium justify ongoing trials such as the DECIDE trial (ACTRN12623001171606).
We acknowledge that this survey does not take into account the opinions of all local POD experts, and its methodology may have led to selection bias and, in turn, response bias. Indeed, despite three invitations to participate, the response rate was 71% and the opinions of other key experts were not known. Nonetheless, those who did respond have a wealth of expertise in POD encompassing multiple perioperative specialties, which offers broad insight into the local relevance of the guidelines. We further acknowledge that the ESAIC guidelines are based on consensus opinion, not universal agreement, and any recommendations are just that. Finally, while almost three-quarters of responses agreed with the guideline, there is still disagreement among local experts, which emphasises the need for further research in POD.
Overall, we propose that perioperative practitioners in Australia and New Zealand should look to the ESAIC guidelines for guidance, recognising the importance of weighing the strength of the recommendation when considering whether to modify practice.
Footnotes
Author Contribution(s)
Acknowledgements
The author(s) are grateful for the expertise of Kaitlin Kramer, Meera Agar, Anita Nitchingham, Amy Gaskell, Gideon Caplan, Tim McCulloch, David A Scott, Carolyn Deng, Jamie Sleigh and Peter Lange in commenting on the ESAIC recommendations.
Declaration of conflicting interests
The author(s) declared the following conflicts of interest: RDS was a co-author on the 2023 ESAIC update of the evidence-based and consensus-based guideline on POD in adult patients. For this reason, RDS was not invited to impart opinion on the Australian and New Zealand perspective. The remaining author(s) have no conflicts of interest to declare.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
