Hard Look at Clinician Prescribing Habits
The most striking finding involved medication use even before delirium began, including benzodiazepines, prokinetics, analgesic and antipyretic opiate agonists, antidepressants, and others.
Hospital records also revealed:
- More than 320 opioid doses were administered before onset of delirium.
- More than 50 benzodiazepine orders were documented.
- Hydromorphone was prescribed frequently, often every 1–3 hours.
- Lorazepam was the most commonly used benzodiazepine, sometimes at high doses.
Opioids and benzodiazepines are standard agents that are prescribed in postoperative care, especially for pain and agitation. But in older adults, these medications carry well-established risks. Both drug classes can cause sedation, disrupt sleep–wake cycles, and interfere with the brain’s delicate neurotransmitter systems—creating the perfect environment for delirium to develop.
Typically, healthcare providers are aware of these risks, however in smaller hospitals like CGMH, the default approach is to treat the pain with the necessary medications as it presents.
Ramifications of Postoperative Delirium
While most patients recovered from postoperative delirium, the consequences were often serious. Ten patients died or were transitioned to end-of-life care during the same admission. In nine out of 10 of those patients, there was an existing history of dementia or history of alcohol misuse, two proven predictors of poor delirium outcomes.
Delirium is not simply a transient problem while the patient is in the hospital. This condition may reduce cognitive baseline for these patients even after discharge.
Lessons Learned from Rural Hospitals
Among rural communities, including Collingwood, Meaford, and Owen Sound (in southern Ontario, Canada), surgical patients undergoing significant operations, including hip replacements and emergency surgeries, often require careful selection and monitoring.
While larger tertiary centers often have geriatric teams, including dedicated delirium specialists and sophisticated monitoring tools, smaller hospitals rarely have access to these resources. Instead, in these settings, delirium prevention is predicated on simple but resource-intensive strategies:
- Monitoring hydration, pain, and sensory needs
- Frequent mobilization
- Avoiding unnecessary psychoactive medications
- Minimizing night-time disturbances
- Preoperative screening for cognitive impairment
“Preventing delirium in our patients requires a collaborative effort with health staff at every level,” said Dr. Lisi.
Shifting Culture from Sedation to Prevention
The audit at CGMH has inspired conversations about improving prescribing habits among clinicians. The findings support what major geriatric guidelines have long recommended: opioids and benzodiazepines should be used cautiously in consideration of a patient’s age, frailty, and comorbidities to help avoid placing them at higher risk of delirium.
CGMH administrators are now exploring the following options:
- Reviewing policies for opioid and benzodiazepines medications
- Improving documentation and early recognition of delirium postoperatively
- Developing pain control protocols that minimize the reliance on benzodiazepines
- Offering preoperative cognitive screening for all older adults
- Standardized delirium prevention checklists for nursing staff
There is a new culture shift at CGMH, one that is proactive and driven by data to reduce delirium rates and hospital length of stay.
“This is not just an academic exercise,” said Dr. Lisi. “These are real patients whose lives are disrupted by a preventable condition. If we can reduce delirium, even by a small percentage, that is a win for families, staff, and the health system.”
The patient mentioned earlier in this article eventually recovered and was safely discharged home, but her daughter said the experience has changed the family’s perspective about surgery.
With an aging patient population and challenges related to resource availability in rural and regional health centers, CGMH’s medication audit suggests that postoperative delirium is preventable and can be mitigated with collaboration between families, healthcare providers, and supportive healthcare system policy.
