Patients With Postoperative Delirium May Benefit From a Holistic Management Approach

Patients With Postoperative Delirium May Benefit From a Holistic Management Approach

Postoperative delirium in patients with head and neck cancer may be managed by several strategies including communication techniques, pain management, nutritional support, environmental optimization, and psychological services, especially due to its multifaceted nature, according to an article published in the Clinical Journal of Oncology Nursing.

“By prioritizing individualized care plans and patient education, nurses have a pivotal role in enhancing outcomes and promoting a supportive recovery environment for patients receiving oncology care undergoing head and neck surgery,” the authors wrote.

Postoperative delirium in adults receiving head and neck surgery can potentially affect morbidity, mortality, and healthcare costs, as it impacts between 12% and 15% of adults older than 75 to 80 years of age. Of note, in the United States, head and neck malignancies account for about 4% of all cancers.

Delirium is prevalent among older adults, with an incident rate of up to 50% in geriatric emergency departments after major surgery. While postoperative delirium occurs in between 2.5% and 3% of patients in the general surgical population, adults older than 60 to 70 years have increased risk of between 10% and 20%.

Pharmacologic approaches such as antipsychotics may be necessary in managing postoperative delirium but pose inconsistent efficacy and potential adverse effects, according to the paper. Nonpharmacologic strategies include reorientation protocols, physical training, early mobilization, nutrition and hydration management, and maintenance of regular sleep-wake rhythm. Providing familiar items, minimizing noise and light disruptions, and encouraging family presence reduces sensory overload while enhancing orientation.

Peripheral C-reactive protein and interleukin-6 are inflammatory mediators that may increase in adults experiencing postoperative delirium. Peripheral inflammation has been shown to disrupt the blood-brain barrier, which may lead to these mediators penetrating the central nervous system. Reduced plasticity, neuroapoptosis, and impaired neurogenesis are potential results from the accumulation of these mediators in the central nervous system, according to the paper.

Postoperative delirium development may also be linked to acetylcholine, a neurotransmitter associated with attention and memory. During the development of postoperative delirium, acetylcholine levels have been shown to decrease. Other associations linked with its development include dopamine receptors and genetic polymorphisms in dopamine-related genes.

Attention and cognition disturbances manifests with delirium including fluctuating symptoms up to 5 days after surgery. Agitation, hypervigilance, and hallucinations present itself with hyperactive delirium, while psychomotor slowing and lethargy presents itself with hypoactive delirium.

Currently no biomarkers have been clinically validated for diagnosis or monitoring, although primary diagnostic characteristics exist. Symptoms include inattention, cognitive disruption that suggests disorganized thinking, and altered consciousness. Conditions may mimic delirium such as depression and psychosis; however, a strong key indicator includes changes in consciousness, less commonly seen in depression and psychosis.

Cognitive impairment screening is now a standard of preoperative evaluation aiming to establish a baseline mental health status for adults. The Mini-Cog, an cognitive screening test, may be able to identify cognitive impairment in older adults with minimal bias, according to the paper. Healthcare professionals will be able to assess and score adults within 2 to 5 minutes using the Mini-Cog with appropriate training. A score of 3 or lower indicates risks for postoperative delirium in adults. Other widely used tools include The Confusion Assessment Method and the Richmond Agitation-Sedation Scale, which is used to measure levels of sedation or agitation.

Reference

Babu S, Kurian Sajith B. Managing Postoperative Delirium in Patients Receiving Head and Neck Surgery: An Educational Overview. Clin J Oncol Nurs. 2024;28(4):E1-E8. doi:10.1188/24.CJON.E1-E8