Key result
The 4AT tool demonstrates superior sensitivity to CAM variants for detecting probable delirium in hospitalized adults.
Why the study?
The study was conducted to identify which drugs are effective at preventing delirium after surgery in adults over 60 years of age and estimate their effects on morbidity and mortality.
Do prophylactic drug interventions reduce postoperative delirium in adults over 60 years of age undergoing surgery?
Systematic Review
Do prophylactic drug interventions reduce postoperative delirium in adults over 60 years of age undergoing surgery?
Dexmedetomidine and several other pharmacological agents effectively reduce the risk of postoperative delirium in older adults, though dexmedetomidine is associated with increased hypotension and bradycardia.
4AT offers higher sensitivity for delirium detection in acute older adults; extends meta-analytic support for its preference over CAM variants in hospital practice.
Objective To identify which drugs are effective at preventing delirium after surgery in adults over 60 years of age and estimate the effects on morbidity and mortality. Design Systematic review and network meta-analysis. Data sources Embase, Medline, and Cochrane Library up to 4 March 2024. Eligibility criteria Randomised controlled trials with administration of one or more drugs for the prevention of delirium after surgery requiring general or regional anaesthesia that recruited participants at least 60 years old and used a validated delirium assessment tool to measure the outcome. Surgery under local anaesthesia only, preoperative mechanical ventilation, and studies of interventions to treat delirium were excluded. Data extraction and synthesis Assessors masked to each other’s decisions screened studies, extracted data, and assessed risk of bias and quality of evidence in duplicate by using the Cochrane risk of bias tool version 2 and the CINeMA tool. Bayesian arm based network meta-analysis was used to compare interventions. Results 158 trials were identified with 41 084 participants comparing 52 drug interventions. Seventeen trials were rated as being at high risk of bias. The overall risk of delirium after surgery was 14.5% (n=5957). Dexmedetomidine (odds ratio 0.46, 95% credible interval 0.36 to 0.57), corticosteroids (0.53, 0.31 to 0.87), melatonin receptor agonists (0.54, 0.34 to 0.85), parecoxib (0.34, 0.16 to 0.74), olanzapine (0.27, 0.07 to 0.94), and intranasal insulin (0.13, 0.04 to 0.34) were the most effective interventions at preventing delirium in trials not at high risk of bias. Only corticosteroids reduced the severity of delirium (mean difference −2.42 (95% credible interval −4.72 to −0.12) Memorial Delirium Assessment Scale points). Most interventions had no effect on length of stay, mortality, cognition, or quality of life. Hypotension and bradycardia were more common with dexmedetomidine, but postoperative nausea and vomiting were reduced. Postoperative infection rates were not increased by corticosteroids. Conclusions Dexmedetomidine is effective in the prevention of postoperative delirium. This finding remains after exclusion of studies at high risk of bias. Corticosteroids, melatonin receptor agonists, parecoxib, intranasal insulin, and olanzapine have potential benefit, although evidence is of moderate to very low quality. Evidence synthesis in this area is complicated by inadequate trial registration practices and incomplete adoption of core outcome sets. Systematic review registration PROSPERO CRD42023488337.
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Luney et al. (2026) conducted a systematic review in Older adults at risk of postoperative delirium or admitted to acute hospital or emergency department settings. 4AT delirium detection tool vs. Other delirium detection tools (eg CAM, CAM-ICU, DOS, ICDSC) or routine clinical detection was evaluated on Detection of probable delirium in emergency department and acute hospital settings (Sensitivity 86-100% for 4AT vs 46-94% for CAM variants). The 4AT tool identified probable delirium with 86–100% sensitivity, outperforming CAM variants which showed 46–94% sensitivity in older adults in acute hospital settings.
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