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Summary
- Dr. Elizabeth Mahanna-Gabrielli is investigating methods for reducing delirium among frail, older patients after surgery.
- Delirium often occurs in the days following surgery and results agitation and disorganized thinking.
- Dr. Mahanna-Gabrielli and Dr. Richard Epstein will investigate the effect of assigning a team of geriatric specialists to assess patients deemed at risk of delirium.
After surgery, patients, especially elderly ones, can enter a confused state called delirium. These disturbing episodes pass, but they do not bode well for patients’ health.
“It’s an important thing to try to prevent, because delirium is associated with a lot of other serious complications,” said Elizabeth Mahanna-Gabrielli, M.D., an associate professor of clinical anesthesiology at the University of Miami Miller School of Medicine. These include an increased risk of cognitive decline and dementia down the road.
She and Richard Epstein, M.D., a professor of clinical anesthesiology at the Miller School, have received a two-year, $150,000 grant from the Anesthesia Patient Safety Foundation to investigate methods for reducing delirium among the frail, older patients most at risk of experiencing it. They anticipate beginning to recruit participants from the University of Miami Health System starting in March.
A Cause or a Harbinger of Dementia?
Formally known as postoperative delirium, this state most often occurs two to five days after surgery. Patients’ thinking becomes disorganized and they may become extremely agitated or withdrawn. Inability to pay attention, hallucinations and paranoid delusions are common. Even though their thinking is no longer coherent, patients’ emotions at the time are real. Some can develop post-traumatic stress disorder as a result, Dr. Mahanna-Gabrielli said.
Delirium can occur in patients young and old, and after many types of surgery. But it is most common among the elderly and after certain procedures, such as those involving the heart or orthopedic injuries, like hip fractures, she said. Research indicates that the anesthesia given during surgery contributes to these episodes.
In the short term, delirium is associated with issues that include longer hospital stays, increased infections and poorer recovery from surgery. Studies have also linked it to an increase in the risk of dementia and greater cognitive decline in the years that follow.
Researchers don’t yet understand this relationship.
“We don’t know if delirium is just a marker of a vulnerable brain,” she said, “or if there’s something about that whole experience that causes changes that lead to cognitive impairment later on.”
Age Versus Frailty
In the study, Dr. Mahanna-Gabrielli and Dr. Epstein will investigate the effect of assigning a team of geriatric specialists to assess patients deemed at risk of delirium. This team will take steps — often small measures that would otherwise easily fall through the cracks — to help prevent it. Team members may, for example, make sure a patient has their hearing aids and glasses handy, that they aren’t given unnecessary sedatives and that they get out of bed and move around once they are ready.
Previous research on such geriatric care has produced mixed results. Dr. Mahanna-Gabrielli suspects that these studies don’t reflect its full effect on delirium because some include older patients based on their age, not their vulnerability.
“There are 65-year-olds who run marathons and have much less risk of delirium than a 65-year-old who has multiple medical conditions. The same can be true for an 80-year-old,” she said.
Those patients most at risk of delirium are not just advanced in years. They are also frail. They lack resilience to physical stress, such as that imposed on the body by surgery. For the study, Dr. Mahanna-Gabrielli and Dr. Epstein plan to recruit patients 60 years old and older who are deemed frail based on a short, formal assessment. Its five questions consider medical conditions, such as diabetes and heart failure, and patients’ ability to perform everyday activities.
Study participants’ frail status will be noted in their medical records. Some of these patients will receive routine care. Others will also receive daily assessment by the geriatric team to ensure precautions accounting for their frailty are followed. The researchers plan to follow both groups to see if the addition of the specialized care better reduces delirium.
If it does, Dr. Mahanna-Gabrielli plans to partner with investigators at other institutions to conduct larger studies. But if simply highlighting a patients’ frailty in the medical record appears to prevent these episodes, “that’s great news, too, because that’s easier for health care institutions to implement,” she said.
Tags: anesthesiology, cognitive decline, delirium, dementia, Department of Anesthesiology, Dr. Elizabeth Mahanna-Gabrielli, Dr. Richard Epstein, frailty, patient frailty
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