Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery
Authors: Friederike Deeken, Alba Sánchez, Michael A. Rapp, Michael Denkinger, Simone Brefka, Juliane Spank, Carola Bruns, Christine A. F. von Arnim, Olivia C. Küster, Lars O. Conzelmann, Brigitte R. Metz, Christoph Maurer, Yoanna Skrobik, Oksana Forkavets, Gerhard W. Eschweiler, Christine Thomas, Cindy Boden, Stefanie Joos, Felix Kentischer, Eva F. Mennig, Sören Wagner, Jürgen Wasem, Stefan Blumenrode, Cathleen Koch, Bernd Förstner, Andreas Häusler, Susanne Schulze, Anja Neumann, Felix Bausenhart, Manuel Czornik, Matthias Herrmann, Andreas Kirschniak, Tobias Krüger, Marvin Metzner, Christian Mychajliw, Petra Renz, Yuki Schneider, Andreas Straub, Heidrun Sturm, Katrin Markgräfe-Weisser, Lorenz Sutter, Sarah Weller, Kathrin Wunder, Fatma Ashkanani, Dhayana Dallmeier, Clara Dettlinger, Jill Holbrook, Anita Junginger, Helene Maucher, Cornelia Ribeill, Annika Rösch, Marius Sabau, Karl Träger, Cynthia Vazquez, Ingeborg Cuvelier, Natalie Dudkiewicz, Janine Peiter, Zvjezdana Peric, Pavel Nikolov, Samina Shah, Nina Stober, Elke Wächter, Hermann Zöllner-Kojnov, Bernhard Heimbach, Jonas Hoch, Markus Hören, Nicole Zimmermann, Alfred Königsrainer, Peter Rosenberger, Christian Schlensak, Nikolaus Wülker, Thomas Hupp, Christian Knop, Jörg Köninger, Andreas Walther, Andreas Liebold, Heiko Reichel, Stephan Kirschner, Uwe Mehlhorn, Hagen Schmal, Stefan Fichtner-Feigl
Journal: JAMA Surgery (2021)

<h3>Importance</h3> Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored. <h3>Objective</h3> To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures. <h3>Design, Setting, and Participants</h3> This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021. <h3>Interventions</h3> First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion. <h3>Main Outcomes and Measures</h3> Postoperative delirium incidence and duration. <h3>Results</h3> Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98;<i>P</i> = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%;<i>P</i> = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99;<i>P</i> = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99;<i>P</i> = .54). <h3>Conclusions and Relevance</h3> This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.