Postoperative Delirium in the Elderly after Major Orthopaedic Procedures: Report of Two Cases of the Hyper-active Motor Subtype

Abstract

Introduction: Postoperative delirium is a common complication of major surgery in the elderly, and has strong association to poor outcome. In  particular, the hypoactive motor subtype of delirium which is predominant in elderly patients is mostly unrecognized yet has the worst prognosis.  Recent interest in postoperative delirium is derived from increasing demand for surgery by older adults resulting from the global increase in life  expectancy and greater access to safe anaesthesia. This report aims to highlight the presentation, risk factors, gaps and opportunities in the clinical management of postoperative delirium.
Case presentation: The presentation is on two cases of hyperactive motor subtype of postoperative delirium in elderly female patients that  underwent major orthopaedic procedures. The cases typify the multiple risk factors inherent in such patient population with yearning opportunities  for targeted interventions to address the modifiable risk factors in individual patients. These interventions, pharmacological and non-pharmacological, may be implemented at the preoperative, intraoperative and postoperative phases of care; even in anaemic Jehovah's Witness faithfuls who may require major surgery as in one of the index patients.
Conclusion: Elderly patients with postoperative delirium are frequently managed poorly with respect to recognising and targeting the risk factors in  the individual patient and instituting appropriate therapy. As postoperative delirium occurs in all surgical specialties, with better understanding  of the risk factors and routine use of validated tools for the detection and diagnosis of postoperative delirium, management can be appropriately  instituted based on each patient's clinical profile.