Postoperative delirium: non-drug management first

Delirium is an acute, fluctuating disturbance of attention and cognition with an underlying medical cause. It affects up to half of older patients after major abdominal surgery. This man has the typical features: sudden onset, fluctuation, inattention and disorientation, in a setting full of precipitants: surgery, sepsis, opioid withdrawal after stopping the PCA, a mildly low sodium, an anticholinergic-type drug (metoclopramide) and an unfamiliar environment.

The Australian Commission on Safety and Quality in Health Care's Delirium Clinical Care Standard (2021) sets the approach. First, identify and treat the causes: review medications, check for pain, urinary retention, constipation, infection, hypoxia and electrolyte disturbance. Second, deliver non-pharmacological care, which is the only intervention proven to reduce delirium: frequent reorientation, a clock and calendar in view, family at the bedside, glasses and hearing aids in place, good lighting by day and quiet by night, early mobilisation, adequate hydration and nutrition, and avoiding restraints and unnecessary lines.

Antipsychotics do not shorten delirium or improve outcomes, and they carry risks of falls, QT prolongation, aspiration and stroke in older people. The standard reserves them for severe distress or danger to the patient or others that has not responded to non-drug measures, at the lowest dose for the shortest time. Pulling at lines is a concern, but the first response is one-to-one nursing and family presence, not sedation.

Brain imaging is indicated when there are focal signs, a head injury, anticoagulation, or a presentation that does not fit. None applies here.

Pain is a real trigger and should be assessed with a validated tool, but adding an opioid without assessment risks worsening the delirium.