A new large-scale study spotlights postoperative delirium as a preventable and high-impact complication, which is driven by patient frailty and surgical stress—and one that can be addressed through low-cost, evidence-based interventions. The findings, which appear in JAMA Network Open, provide a call to action for clinicians, health systems, patients, and families to prioritize brain health throughout perioperative care.
"Postoperative delirium isn't a minor complication—it's analogous to acute brain failure, a medical emergency that should be recognized and addressed," said Laurent Glance, MD , a professor of Anesthesiology and Perioperative Medicine at the University of Rochester Medical Center (URMC) and senior author of the study. "Our analysis shows that postoperative delirium affects roughly one in 30 older adult patients, significantly increasing their risk for poor outcomes, and that simple, cost-effective strategies can curb the downstream costs and suffering associated with this condition."
Delirium's Impact and Opportunity for Prevention
Postoperative delirium is a sudden, often temporary, state of confusion that can occur after surgery. It typically involves disorganized thinking, inattention, and changes in alertness. This condition is especially common in older adults, with reported rates ranging from less than one percent to as high as 50 percent, depending on the type of surgery and hospital practices.
Once believed to be minor and self-resolving, delirium is now known to be associated with serious consequences, including long-term cognitive decline and the need for nursing home care. It also carries an estimated annual cost of $26–$42 billion in U.S. healthcare expenses.
Using Medicare claims data from 2017 to 2020, the researchers analyzed more than 5.5 million hospitalizations for adults aged 65 and older who underwent major non-cardiac surgery under general anesthesia. They identified postoperative delirium in 3.6 percent of cases. Compared to patients without delirium, those affected had:
- 3.5 times higher odds of death or major complications,
- 2.8 times higher odds of dying within 30 days,
- 4 times higher odds of being discharged to a facility rather than home.
Factors such as frailty, comorbidities, disease severity, and the complexity of the surgery were associated with higher incidences of postoperative delirium.
Low-Cost, High-Yield Interventions
"Postoperative delirium is a preventable—not inevitable—complication, " said Heather Lander, MD , an associate professor of Anesthesiology and Perioperative Medicine at URMC and first author of the study. "With proper resources, education, and systematic workflows, health institutions can improve quality of life and patient‐centered outcomes, while also reducing length of stay, complications, deaths, and financial burden."
Some of the measures identified by the authors include:
- Sleep hygiene: Cluster vitals/labs and meds to minimize nighttime disturbances during hospitalization.
- Sensory support: Ensure patients have and use glasses, hearing aids (with extra batteries) to maintain orientation.
- First-case scheduling for high-risk patients: Reduce prolonged fasting and circadian disruption by operating early in the day.
- Early geriatric or hospital-medicine co-management: Involve specialists to optimize medical and functional status before and after surgery.
The authors also emphasize the need to better educate patients and families about delirium risks and prevention tactics—such as maintaining familiar surroundings and preserving normal sleep patterns—to empower them to recognize warning signs and advocate for early intervention.
Additional co-authors include Karen Joynt Maddox, Mark Oldham, Stewart Lustik, Marjorie Gloff, Jacob Nadler, Isaac Wu, and Raymond Zollo with URMC, Andrew Dick with Washington University, Lee Fleisher with the University of Pennsylvania, Michael Mazzeffi with the University of Virginia, and Jingjing Shang and Patricia W. Stone with Columbia University. This study was supported by funding from the National Institute on Aging, the National Institute of Nursing Research, and the URMC Department of Anesthesiology and Perioperative Medicine.
