gms | German Medical Science

Background and status of (inter)national research: Postoperative delirium (POD) is a frequent complication after surgery in older adults. POD can be associated with a range of adverse short- and longterm consequences such as higher institutionalization rates, development and more rapid progress of dementia, and increased health care costs. Incidence rates of POD vary widely between patient groups, with higher incidence rates in patients undergoing cardiac surgery. Age and preexisting cognitive deficits are established risk factors for the development of POD. In many cases delirium is a preventable condition. Meta-analyses have shown that multimodal, non-pharmacological interventions are a promising approach in the prevention of POD, but randomized trials, especially in elective surgery are rare. Consequently, delirium is a healthcare quality indicator in older adults and the prevention of delirium is an essential parameter for patients´ safety.

Question and objective: Is a multimodal non-pharmacological delirium prevention intervention effective in elderly patients undergoing elective surgery?

Method or hypothesis: The PAWEL study is a stepped wedge cluster randomized trial conducted in five medical centres in Baden-Württemberg, southwest Germany. Patients recruited for the study were 70 years old or older and were undergoing an elective surgery with a planned duration of at least 60 minutes. Data, was collected preadmission, preoperative, and postoperative, at discharge as well as 2, 6, and 12 months after surgery. Primary outcomes were delirium incidence and delirium duration.

The PAWEL-intervention comprises an all-encompassing delirium prevention and management approach including:

1.

training of medical, therapeutic, and support staff involved in the care of the study patients,

2.

the adaption of the hospital environment regarding the special needs of the patients,

3.

seven manualized “best practice” procedures including various cognitive and physical activations.

The PAWEL study is funded by the Innovationsfond (Gemeinsamer Bundesausschuss, Grant No. VF1_2016-201).

Results: 1,470 patients could be included in the study between November 2017 and April 2019, with 730 patients assigned to the control group and 740 patients to the intervention group. On average patients were 78 years old and had 12 years of education. 51.9% of the patients were male. Orthopedic/spine surgery and cardio-vascular surgery were the most frequent operations in the study group. Depending on the type of surgery, the intervention showed promising results and could contribute to a reduction of postoperative delirium.

Discussion: A manualized non-pharmacological delirium prevention program can effectively prevent and shorten delirium occurrence. However, differences in effectiveness were influenced by type of surgery.

Practical implications: The findings of the PAWEL study suggest a broad implementation of multimodal non-pharmacological delirium prevention programs taking the type of operation into account.

Appeal for practice (science and/or care) in one sentence: Multimodal non-pharmacological delirium prevention programs are a promising and safe approach for the reduction of postoperative delirium in older patients.