Postoperative delirium is one of the most common and devastating complications of older patients. Kratz and Diefenbacher rightly emphasize that delirium can also be present preoperatively. Patients with preoperative delirium present with conspicuous findings in cognitive testing, which is recommended as part of the preoperative assessment. In this case, considering the possibility of preoperative delirium and then carrying out delirium screening is a sensible additional step. It should be taken into account that the aspects of “fluctuation” and “acute onset” according to ICD-10 may be difficult to assess here. Similar to Kratz and Diefenbacher, Thomas also emphasizes the high relevance of postoperative cognitive dysfunction (POCD), which can develop from delirium. In our article, we address the serious consequences of delirium, without however calling POCD by its name. Nonetheless, this clinical picture is explicitly included here, as are all cognitive changes that negatively affect quality of life and daily functioning of patients but that do not meet criteria for POCD. In general, diagnosis of POCD is based solely on psychometric test results, and patient-relevant factors such as impact on independence and daily life activities are often not included. Furthermore, outside the specialties of anesthesiology and surgery, there is a continuing demand for redefinition of the concept of POCD (1).
We (the authors) are eagerly following the promising PAWEL study by Thomas et al.. Prevention of delirium is an essential therapeutic goal of perioperative geriatric medicine. Implementation of appropriate measures often fails in practice due to time and personnel resources. The health economic evaluation of later costs of delirium—which are difficult to capture in monetary terms—gives this study an outstanding importance. Hopefully, this will show that delirium prevention leads to an extra financial burden only in the short term, and that it can save on costs to health care as well as to society over the long term.
Finally, it should be emphasized that our demands for perioperative geriatric medicine by no means represents a disregard of the geriatric expertise, as feared by Burkhardt. The expertise of geriatric departments is indispensable for perioperative care of older patients. However, given the number of affected patients and the numerous hospitals with no geriatric departments, presenting and assisting every older patient at risk is not possible. Gerontological “basic knowledge” is too often lacking in our clinical daily practice. Therefore, our demands were aimed primarily at sensitizing the non-geriatrician care provider to the special features of older patients—so that perioperative geriatric medicine can be practiced even when no geriatrician is present.
On behalf of the authors
Dr. med. Cynthia Olotu
Klinik und Poliklinik für Anästhesiologie
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Evered L, Silbert B, Knopman DS, et al.: Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth 2018; 121: 1005–12 CrossRef MEDLINE|
|2.||Olotu C, Weimann A, Bahrs C, Schwenk W, Scherer M, Kiefmann R: The perioperative care of older patients—time for a new, interdisciplinary approach. Dtsch Arztebl Int 2019; 116: 63–9 VOLLTEXT|