Postoperative Delirium:

Challenges and Opportunities

Phillip Vlisides, MD

Executive Director, Neuroscience Research

Associate Professor of Anesthesiology

Department of Anesthesiology

Michigan Medicine

Ann Arbor, MI USA

Funding and Disclosures

• Funding: NIH/NIGMS K23GM126317; NIH/NCATS

NIH/NCATS UL1TR002240; NIH/NIA AG024824;

PCORI DE-2022C1-25666

• Other Disclosures: Blue Cross Blue Shield of

Michigan (ASPIRE CQI)

Koster S et al. Ann Thorac Surg. 2012

• Common (10-70%)

• Increased mortality

• Cognitive decline

• Functional decline

• Healthcare costs (>$140 billion annually)

Delirium

Gottesman RF et al. Ann Neurol. 2010

Saczynski JS et al. N Engl J Med. 2012

Gou RY et al. JAMA Surg 2021

Leslie DL et al., J Am Geriatr Soc 2011

Prevention

Identification

Ragheb J. et al. BMC Health Services Research (2023)

Phase I

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“When it came to our CAM tool…I don’t

necessarily know that someone sat down

with me and went through each step of it,

but it was just more of an expectation that

I knew I need to chart [it] every night”

(Participant 7).

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“I think that a lot of the CAM scoring is dependent

on the person who is doing the scoring. It can be

very…individualized based on the perception of

the individual” (Participant 3).

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“Once someone screens positive for delirium,

nothing happens after that. [With sepsis], the

charge nurse gets a page, the nurse gets a page,

[the] doctor…that’s with the sepsis screening.

There’s nothing like that that exists with the

delirium.” (Participant 5).

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“If you don’t show me the added value, I’m not

doing it. I’ve got enough stuff that I’ve got to

do…And so, you may tell me you’ve got to

document this, but if I know it’s not going to

make a difference in the care that’s being

provided to my patient, I don’t see the added

value.” (Participant 11).

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“I feel like there’s less of an investment from…

executive leadership…because it’s not directly

tied to a quality measure. You know, it is not a

[hospital acquired infection], but really it is

affecting length of stay. So, I think as much as we

can get buy-in from executive leadership…”

(Participant 3).

Theme

1. Delirium Screening Challenges and Perceptions

2. Organizational Culture Towards Delirium

3. Competing Clinical Priorities

4. Desired Improvements

“What if [an alert] could just serve as an initial

reminder, like, ‘you’re CAM positive, here’s your

reminder - check with your physician about

initiating delirium protocols?’” (Participant 16).

“Yeah, if [a positive delirium screen] triggered,

‘initiate delirium bundle,’ and we sort of knew

what that meant and what to do about it, that

would be really helpful” (Participant 6).

• Objective: Test a multicomponent program for

delirium screening, charting, and management in

older, hospitalized adults

– Comparison of different delirium screening tools (4AT,

NuDesc, CAM)

Michigan Recommendations and Alerting for

Delirium Alleviation in Real-Time (M-RADAR)

(Submitted; under review)

Phase II

• Objective: Test a multicomponent program for

delirium screening, charting, and management in

older, hospitalized adults

– Comparison of different delirium screening tools

(4AT, NuDesc, CAM)

– Recurrent delirium education and training

– Pager/MiChart alerts sent to primary teams upon

positive delirium screen

– Delirium order sets

Michigan Recommendations and Alerting for

Delirium Alleviation in Real-Time (M-RADAR)

(Submitted; under review)

Phase II

Prevention

https://help.agscocare.org/

• Reduced delirium incidence (OR 0.47, 95% CI 0.37 – 0.59)

• Fall rate reduced by 42% (OR 0.58, 95% CI 0.35 – 0.95)

• Saved $1600-$3800/patient in hospital costs, $16,000 per

person-year in terms of long-term costs

HELP Volunteer Protocols

Intervention

Description

Orientation

•

Daily orientation

•

Orientation board

Cognitively

Stimulating

Activities

•

Cognitive stimulation activities twice daily

Early mobilization

•

Ambulation and range of motion activities

Sleep

enhancement

•

Sleep and bedtime procedures

•

Noise reduction procedures

Vision protocol

•

Visual aids (e.g., glasses, magnifying lenses), adaptive

equipment, large print books

•

Daily reinforcement of use

Hearing protocol

•

Portable amplifying devices and special communication

techniques, with daily reinforcement; Ear wax clearing as

needed

Fluid repletion

•

Encourage fluids twice daily

Feeding assistance

•

Feeding assistance and encouragement during meals

https://help.agscocare.org/

Alerting System Fidelity

By postoperative day one:

• 13/24 (54%) participants enrolled in alerting

arms

• 0/26 (0%) in non-alerting arms (p<0.001)

By postoperative day three:

• 22/24 (92%) enrolled in alerting arms

• 2/26 (8%) in non-alerting arms (P <0.001).

39 [5-75] minutes per participant vs. 0 [0 to 0] min; P<0.001

Family Care Partner Fidelity

Median 18 [ 11 – 25] bedside hours through postop day three

Family Care Partner Fidelity

Median 18 [ 11 – 25] bedside hours through postop day three

https://enhancetrial.org/

Group

Proportion (%) of Positive

Delirium Cases

Placebo Caffeine

p=0.04

Caffeine: 4/33, 12% vs. Placebo: 10/30, 33%; p=0.04

Vlisides et al., Anesth Analg 2021

Vlisides et al., BMJ Open 2023

Summary

• Delirium screening – need to identify site-level

challenges

• Role for alerting systems

• Testing different delirium assessment tools

• Family care partner support may mitigate

postoperative delirium risk

• Caffeine (CAPACHINOS-2 – 2027)

Acknowledgements

PCORI DE-2022C1-25666

“If the human brain

were so simple that

we could understand

it, we would be so

simple that we

couldn’t.”

– Emerson M. Pugh