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Postoperative Delirium &
Cognitive Decline
Delirium & POCD
Wang et al., Am J Geriatr Psychiatry 2007;15:50 Incidence of Delirium J Am Geriatr Soc
Hip fracture
Berggren et al.
Edlund et al.
Morrison et al.
Schuurman et al.
Elective orthopedic
Fisher et al.
Rogers et al.
Elective Liver resection
Yoshimura et al.
Major elective surgery
9% (46% aortic
Marcantonio et al.
Elective vascular
36% (52% aortic)
Schneider et a.
Delirium Risk Factors
Delirium is a multifactorial syndrome influenced

Baseline patient risk factors (vulnerability)
Precipitating factors
Patients with more baseline risk factors and
exposed to more precipitating factors are much
more likely to develop delirium

Potential surgical risk factors
• Blood loss (Marcantonio, Am J Med 1998)• Type of surgery (Cardiac, orthopedic) Potential anesthetic factors
Anesthetic factors
Types (general vs. regional)
Williams-Russo, JAMA 1995
Rasmussen, Acta Anaesthesiol Scand 2003
Management (intra- &/or post-op)
Williams-Russo, Anesthesiology 1999
Specific anesthetic agent
Leung et al, Br J Anaesth, 2006
Pain & postoperative delirium
• Age > 70 years• Moderate to severe preop rest pain • Increase in pain at rest preop vs. POD #1 • Oral narcotics vs. PCA Vaurio L et al., Anesth & Analg 2006
Clinical trials in postoperative delirium
“proactive geriatric consultation” vs. standard care – Clinical trial of gabapentin vs. placebo• Postop delirium 5/12 in placebo vs. 0/9 in Sedation depth during spinal anesthesia for hip Postop delirium 19% in light sedation vs. 40% in JAGS. 2001;49:516-22Neurology 2006; 67:1-3Mayo Clin Proc. 2010;85:18-26 Clinical trials in postoperative delirium
Rivastigmine in elective cardiac surgery Postop delirium 3% in dexmedetomidine, vs. 50% each in propofol or midazolam groups, n=90 Crit Care Med. 2009;37:1762-8Psychosomatics. 2009;50:206-17 Risk factors for
early/intermediate POCD

Patient-related Risk Factor
Precipitating factors for
early/intermediate POCD

Perioperative Risk
Incidence of POCD
Risk of General anesthesia & cognitive decline
sectional study (Maastricht Aging Study, 946 patients with at least one operation Results: a history of an operation, # of operations, total duration of anesthesia complaints but did not predict cognitive Dijkstra et al., JAGS 1998;46:1258-1265 Surgery and long-term cognitive decline
Surgery and long-term cognitive decline
Avidan et al. Anesthesiology 2009;111:964-970 Surgery and long-term cognitive decline
Avidan et al. Anesthesiology 2009;111:964-970 Surgery and long-term cognitive decline
to a CDR > 0, but not more common after cognitive decline attributable to surgery or Avidan et al. Anesthesiology 2009;111:964-970 MCI and POCD
participating in aging studies at the NYU expected for a person’s age, without ADL Bekker et al. Am J Surg 2010;198:782-788 MCI and POCD
showed those with MCI had a significantly greater decline in performance on the DS- Bekker et al. Am J Surg 2010;198:782-788 POCD and long-term mortality/cognition
mortality at 1 yr & 3 months after surgery Monk et al. Anesthesiology 2008;108:18-30Steinmetz et al. Anesthesiology 2009;110:548-555Newman et al. New Eng J Med 2001;344:395-402



The following is a list of the most commonly prescribed maintenance drugs that are also on theExpress Scripts High Performance Formulary. Members who use these drugs will be targeted forSelect Home Delivery outreach. This is not an all-inclusive list of drugs that will be targeted, butrepresents the maintenance drugs that are on the High Performance Formulary. PLEASE NOTE: Not all of the drugs l

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