Which first-line conventional drug is commonly used in the treatment of delirium?

Selective Serotonin Reuptake Inhibitors (SSRIs)

In postoperative intensive care unit, five patients developed postoperative wound infection on the same day. The best method to prevent cross infection occurring in other patients in the same ward is to:

Disinfect the ward with sodium hypochlorite

Give antibiotics to all other patients in the ward

A hospital is implementing a protocol to reduce perioperative pulmonary complications in high-risk patients undergoing major abdominal surgery. Based on current evidence, which combination of interventions would provide the greatest benefit?

Smoking cessation >8 weeks prior, lung expansion maneuvers, epidural analgesia

Preoperative spirometry, postoperative incentive spirometry, early mobilization

Prophylactic bronchodilators, routine chest physiotherapy, supplemental oxygen

Preoperative antibiotics, deep breathing exercises, prolonged mechanical ventilation

A 62-year-old man with drug-eluting stent placed 4 months ago requires urgent colonoscopy with polypectomy for a bleeding polyp. He is on dual antiplatelet therapy (aspirin and clopidogrel). Analysis of risks shows continued bleeding risk versus stent thrombosis risk. What is the most evidence-based management strategy?

Continue aspirin, discontinue clopidogrel 5 days before procedure

Discontinue clopidogrel only, add prophylactic heparin bridging

Discontinue both aspirin and clopidogrel 7 days before procedure

Continue both aspirin and clopidogrel throughout procedure

A 72-year-old man develops postoperative delirium on day 2 after hip replacement. His vitals are stable, and examination is unremarkable except for confusion. Laboratory workup including CBC, electrolytes, and arterial blood gas is normal. What is the most likely precipitating factor?

Multifactorial including surgery, medications, and environmental factors

Undiagnosed dementia with acute decompensation

Hypoxia from subclinical pulmonary embolism

Occult infection not yet manifested

Postoperative Delirium Prevention for INI-CET: High-Yield Internal Medicine Lessons

Postoperative Delirium Prevention - Brain Fog Alert

Acute, fluctuating neurocognitive disorder. Common post-op; linked to ↑morbidity, mortality, LOS.
Key Risks: Age >65, dementia/cognitive impairment, polypharmacy, sensory impairment, major surgery (cardiac, hip).
Prevention:
- Pre-op: Risk stratification, review meds (avoid benzodiazepines, anticholinergics).
- Intra-op: Optimize anesthesia depth, maintain cerebral oxygenation.
- Post-op: Non-pharmacological (reorientation, sleep, mobilization, hydration, nutrition), pain management.

⭐ The Hospital Elder Life Program (HELP) is a multicomponent strategy effective in preventing delirium in older adults hospitalised for acute illness or surgery, reducing incidence by up to 40%.

Postoperative Delirium Prevention - Danger Zones

Pre-operative Factors	Intra-operative Factors	Post-operative Factors
* Age > 65 years	* Major surgery (cardiac, ortho)	* Uncontrolled pain
* Cognitive impairment (dementia, MCI)	* Emergency surgery	* Infection (UTI, pneumonia)
* Functional dependence (ADLs ↓)	* Prolonged anesthesia (>2 hrs)	* Metabolic imbalance (Na⁺, glucose, Ca²⁺)
* Sensory impairment (vision, hearing)	* Intraoperative hypotension/hypoxia	* Psychoactive meds (BZD, opioids)
* Polypharmacy (≥5 meds)	* Benzodiazepines, anticholinergics	* Sleep deprivation, immobility
* History of delirium/alcohol abuse	* Significant blood loss / anemia	* Catheters, physical restraints
* Malnutrition (Albumin <3.5 g/dL)	* Hypothermia (<36°C)	* ICU environment

Postoperative Delirium Prevention - Shield Up!

Identify High-Risk Patients: Age >65 yrs, cognitive impairment (dementia, MCI), prior delirium, severe illness, sensory impairment (vision/hearing), polypharmacy, major surgery (e.g., cardiac, orthopedic).
Multicomponent Non-Pharmacological (📌 HELP Model): Cornerstone & most effective!
- Consistent reorientation & therapeutic activities.
- Early mobilization & ambulation.
- Sleep hygiene protocols (minimize disruptions, non-pharma aids).
- Ensure use of vision & hearing aids.
- Optimize hydration & nutrition.
- Effective multimodal pain control (opioid-sparing).
Pharmacological Cautions:
- Avoid/Minimize: Benzodiazepines, anticholinergics, certain antihistamines.
- Prophylactic antipsychotics: Generally not routine. Consider for select, very high-risk patients (e.g., post-cardiac surgery) after careful evaluation.

Multicomponent intervention for delirium prevention

⭐ The Hospital Elder Life Program (HELP), a multicomponent non-pharmacological strategy, is proven to reduce delirium incidence by approximately 30-40% in hospitalized older adults.

Postoperative Delirium Prevention - Cautious Use

Pharmacological prevention is generally NOT routine; prioritize non-pharmacological strategies.
Consider for select, very high-risk patients if other measures are insufficient or contraindicated.
Antipsychotics (e.g., Haloperidol 0.5-1 mg, Olanzapine 2.5-5 mg):
- Limited evidence for routine prevention; weigh risk/benefit carefully.
- Potential adverse effects: QTc prolongation, extrapyramidal symptoms (EPS).
Dexmedetomidine:
- May reduce delirium incidence in ICU/post-cardiac surgery patients.
- Requires careful monitoring (hypotension, bradycardia).
Cholinesterase inhibitors: Generally NOT effective for prevention.

⭐ Avoid routine benzodiazepine use for delirium prevention as they can precipitate or worsen delirium, especially in older adults.

High‑Yield Points - ⚡ Biggest Takeaways

Postoperative delirium is a frequent complication, particularly in elderly and cognitively impaired patients.

Preoperative risk assessment and multifactorial interventions are crucial for prevention.

Emphasize non-pharmacological strategies: early mobilization, reorientation, sleep enhancement, and sensory aids.

Avoid high-risk medications such as benzodiazepines and anticholinergics.

Optimize pain management with multimodal analgesia to reduce opioid exposure.

Routine prophylactic antipsychotics are not recommended; consider only for very high-risk cases after evaluating risks and benefits.

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