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Clinical Crossroads | Conferences With Patients and Doctors| Clinician's Corner

Postoperative Delirium:  A 76-Year-Old Woman With Delirium Following Surgery

Edward R. Marcantonio, MD, SM
JAMA. 2012;308(1):73-81. doi:10.1001/jama.2012.6857.
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Delirium (acute confusion) complicates 15% to 50% of major operations in older adults and is associated with other major postoperative complications, prolonged length of stay, poor functional recovery, institutionalization, dementia, and death. Importantly, delirium may be predictable and preventable through proactive intervention. Yet clinicians fail to recognize and address postoperative delirium in up to 80% of cases. Using the case of Ms R, a 76-year-old woman who developed delirium first after colectomy with complications and again after routine surgery, the diagnosis, prevention, and treatment of delirium in the postoperative setting is reviewed. The risk of postoperative delirium can be quantified by the sum of predisposing and precipitating factors. Successful strategies for prevention and treatment of delirium include proactive multifactorial intervention targeted to reversible risk factors, limiting use of sedating medications (especially benzodiazepines), effective management of postoperative pain, and, perhaps, judicious use of antipsychotics.

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Figure. Inflammatory Model of the Pathophysiology of Postoperative Delirium
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This figure depicts a theoretical inflammatory model for the pathophysiology of delirium that has direct relevance for Ms R and is gaining acceptance in the literature.34,36,102
aThe extent and magnitude of the systemic inflammatory response varies widely among individuals, possibly related to chronic activity of stress response systems.34
bIt is unknown which specific cytokines or mediators cross the blood-brain barrier.
cLikely risk factors for the long-term consequences of neuroinflammation include preexisting cognitive impairment, cerebrovascular disease, and severe illness.

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