Article

Geriatric Initiative Engages Families to Identify, Intervene Before Delirium Presents

Presurgical education part of a broad-based effort to improve seniors’ surgical outcomes

Counseling a patient

An effort to improve the engagement of family members in identifying and preventing delirium among senior patients before surgery is being implemented by Duke geriatricians.

Developed in conjunction with a surgical preparation program known as Perioperative Optimization of Senior Health (POSH), the effort leverages family communication skills to identify early signals of delirium and to better understand patients’ needs during hospital stays before and after surgery. Developed by Duke geriatricians and colleagues in anesthesiology and surgery, POSH was launched in 2011. Through interprofessional pre-operative evaluation, assessment, and education, the goal of POSH is to reduce negative outcomes after elective surgical procedures.

“Surgery related delirium often leads to increased morbidity and mortality rates, longer hospital stays, and more postoperative complications,” says Serena Wong, DO, a Duke geriatrician and specialist in delirium education, identification, and management. Delirium tends to be underreported, Wong adds, but the incidence rate stands between 30% and 40% of all patients over age 65 following surgery.

Physicians have identified an association between the development of delirium in hospital settings and future dementia among senior patients, she notes. “The combination is really worrisome. We work to lower the risk at every opportunity.”

As part of the initiative, geriatricians provide information about delirium to families and work closely with them to take advantage of their familiarity with the patient. Wong says the geriatricians encourage family members to work on specific tasks:

  • Maintain an advocacy role; stay with the patient as much as possible.
  • Remind the patient regularly of current activities; reorient them as needed.
  • Encourage a regular sleep/wake cycle.
  • Promote daily walking and movement.
  • Discourage all-day napping to prevent sleepless evenings.
  • Ensure the patient drinks fluids and eats regularly to avoid dehydration and maintain baseline nutrition.
  • Interpret the patient’s requests regarding pain medication when necessary, particularly if the patient is unable to communicate because of confusion or dementia.

“The most important task for the families, particularly involving a patient with some evidence of dementia, is helping nurses and doctors understand what was normal for this individual before surgery,” Wong says. “If we know the normal state, we are more effective in monitoring for delirium. The baseline information is critical.”

Wong meets with patients before surgery in the pre-operative POSH clinic, as well as after surgery while they are recovering in the hospital. For the initial meeting, typically scheduled two weeks before surgery, Wong and her colleagues encourage patients to bring at least one family member to help with interpretation and communication throughout the surgical and recovery process.

To assess the value of the engagement effort, Wong asked families to complete a questionnaire at the end of the hospital stay. Knowledge about delirium signs as well as management of the condition improved from about 66% to more than 80% following the education process, Wong says. “Family members who recognize the risks are very grateful that we offer this targeted education effort. But we also encounter families who have never personally experienced delirium until surgery and believe it will happen to someone else, not them.”