Postoperative delirium (POD) - NYSORA

Explore NYSORA knowledge base for free:

Postoperative delirium (POD)

Learning objectives

  • Recognize the signs of POD
  • Identify risk factors for POD
  • Reduce the risk of POD in susceptible patients
  • Manage POD occurrence


  • Postoperative delirium (POD) is defined as an acute onset fluctuating change in mental status characterized by reduced awareness of the environment and disturbance of attention
  • It is a temporary neurocognitive syndrome observed after surgery
  • Incidence in older surgical patients varies from 7% to 53%
  • POD prolongs postoperative ventilation, intensive care, length of stay, increases costs, and negatively impacts functional outcome and survival


3 subtypes:

  • Hyperactive: Restlessness, agitation, and hypervigilance, often hallucinations and delusions
  • Hypoactive: Lethargy and sedation, slow response to questioning, little spontaneous movement
  • Mixed: Both hyperactive and hypoactive features

Risk factors

Advanced ageICU admission
Male sexHigh-risk surgical procedure
Low body mass indexSleep deprivation
Sight/hearing lossPolypharmacy
Social isolationMedications
MultimorbiditySevere illness (e.g. infection, fracture, stroke)

Prior cognitive impairmentHyper- or hypothermia
MalnutritionSensory deprivation
Low serum albuminIncreasing duration of surgery
FrailtyUrgency of surgery
Alcohol/drug abusePerioperative complications
MalnutritionPhysical restraints
DehydrationProlonged use of catheters


  • Identify risk factors
  • Frailty assessment
  • Bispectral index (BIS) monitoring (Target BIS 40-60)
  • Avoid benzodiazepines
  • Multi-component interventions (visual and hearing aids, sleep promotion, minimalization of catheters/cannulae…)
  • Regional anesthesia instead of general
  • Treat pain (multimodal strategy)
  • Prehabilitation programs that improve physical and cognitive capacity

Preventative measures requiring further investigation:


Postoperative delirium, POD, management, substance abuse, cognitive impairment, risk factors, polypharmacy, benzodiazepines, dexmedetomidine, opioid-sparing, BIS monitoring, regional anesthesia, screening, 4AT, DSM, haloperidol, diazepam, assessment, CAM-ICU

Suggested reading

  • Hoogma, Danny Feike; Milisen, Koen; Rex, Steffen; Al tmimi, Layth. Postoperative delirium: identifying the patient at risk and altering the course: A narrative review. European Journal of Anaesthesiology and Intensive Care 2(3):p e0022, June 2023.
  • Mossie A, Regasa T, Neme D, Awoke Z, Zemedkun A, Hailu S. Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article. Int J Gen Med. 2022;15:4053-4065.
  • Swarbrick CJ, Partridge JSL. Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia. 2022;77 Suppl 1:92-101.
  • Subramaniam B, Shankar P, Shaefi S, et al. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial [published correction appears in JAMA. 2019 Jul 16;322(3):276]. JAMA. 2019;321(7):686-696.
  • Haque N, Naqvi RM, Dasgupta M. Efficacy of Ondansetron in the Prevention or Treatment of Post-operative Delirium-a Systematic Review. Can Geriatr J. 2019;22(1):1-6. Published 2019 Mar 30.
  • Khan BA, Perkins AJ, Gao S, et al. The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU. Crit Care Med. 2017;45(5):851-857.
  • Chan MT, Cheng BC, Lee TM, Gin T; CODA Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25(1):33-42.
  • Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220.
  • Robinson TN, Eiseman B. Postoperative delirium in the elderly: diagnosis and management. Clin Interv Aging. 2008;3(2):351-355.

We would love to hear from you. If you should detect any errors, email us at