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Postoperative delirium
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of postoperative delirium are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2025), the European Society of Intensive Care Medicine (ESICM 2024), the American Academy of Family Physicians (AAFP 2023), the Global Alliance for Infection in Surgery (GAIS/WSES/AAST/SIAARTI 2022), the The Scottish Intercollegiate Guidelines Network ...
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Classification and risk stratification
Preoperative risk assessment: as per ESICM 2024 guidelines, assess the following preoperative risk factors for postoperative delirium:
older age
ASA physical status > 2
Charlson Comorbidity Index > 2
mini Mental State Examination score < 25.
B
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American Society of Anesthesiologists score (ASA score)
Description
Absence of systemic disease
Mild systemic disease without functional limitations
Moderate systemic disease with functional limitations
Severe systemic disease that is a constant threat to life
A moribund patient who is not expected to survive without the operation
Brain-dead patient whose organs are being removed for donor purposes
Emergency surgery
No
Yes
Please make a selection
Diagnostic investigations
Initial assessment: as per APA 2025 guidelines, obtain regular structured assessments for the presence or persistence of delirium in patients with delirium or at risk for delirium using valid and reliable measures.
B
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Diagnostic imaging
EEG
Medical management
General principles
As per APA 2025 guidelines:
Develop a documented, comprehensive treatment plan for patients with delirium.
B
Provide multicomponent nonpharmacological interventions to manage and prevent delirium in patients with delirium or at risk for delirium.
B
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Antipsychotics
Benzodiazepines
Dexmedetomidine
Melatonin
Nonpharmacologic interventions
Physical restraints: as per APA 2025 guidelines, do not use physical restraints in patients with delirium, except when there is an imminent risk of injury to self or others, and only after reviewing factors that may contribute to racial, ethnic, and other biases in decisions about restraint, with frequent monitoring, and with repeated reassessment of the ongoing risks and benefits of restraint use compared to less restrictive interventions.
D
Perioperative care
Monitoring depth of anesthesia
As per ESICM 2024 guidelines:
Consider obtaining index-based EEG monitoring for guiding the depth of anesthesia to reduce the risk of postoperative delirium.
C
Consider obtaining multiparameter intraoperative EEG monitoring (burst suppression, density spectral array, density spectral array) during anesthesia to reduce the risk of postoperative delirium.
C
Preventative measures
Nonpharmacological prevention program
As per ESICM 2024 guidelines:
Implement multicomponent nonpharmacological interventions for all patients at risk of postoperative delirium.
B
Insufficient evidence to suggest a specific type of surgery or anesthesia to reduce the incidence of postoperative delirium in patients undergoing surgery.
I
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Pharmacological prophylaxis