Do the delirium risk assessment in the pre-assessment clinic, not on the ward

Postoperative delirium is predicted mostly by things that are knowable weeks before the operation: age, pre-existing cognitive impairment, sensory impairment, frailty, polypharmacy with anticholinergic burden, alcohol use, and previous delirium. All of it can be collected at pre-assessment, and almost none of it can be collected usefully the night before.

So put a brief cognitive screen into the pre-assessment clinic for patients over 65, and record the baseline. Without a documented baseline, postoperative confusion cannot be distinguished from pre-existing impairment, and the family's account becomes the only evidence. Then act on what the screen finds: reconcile anticholinergics and benzodiazepines in advance, make sure hearing aids and glasses travel with the patient to theatre and come back with them, and flag the patient to the ward so orientation, sleep and early mobilisation are planned rather than improvised.

The interventions that work for delirium are unglamorous and organisational, and they all need to be arranged before the patient is confused.

• Screen cognition at pre-assessment in patients over 65 and record the baseline score
• Reconcile anticholinergic and benzodiazepine burden at pre-assessment, not on admission
• Send hearing aids and glasses to theatre with the patient and ensure their return
• Ask about previous postoperative delirium - it is the strongest single predictor in the history
• Flag high-risk patients to the ward so orientation and sleep protocols start on day zero

Why it matters

Without a baseline recorded before surgery, postoperative delirium cannot be diagnosed with any confidence, only suspected.

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