Preventive Effect of Preoperative Intranasal Dexmedetomidine for Postoperative Delirium in Elderly Patients with Sleep Disorders Undergoing Major Noncardiac Surgery: A Randomized, Triple-Blind, Placebo-Controlled Trial.

Summary

In a triple-blind RCT of 348 older adults with sleep disorders, preoperative intranasal dexmedetomidine given the night before major noncardiac surgery reduced postoperative delirium versus placebo and improved preoperative sleep. Bradycardia occurred more frequently, necessitating monitoring.

Key Findings

• Preoperative intranasal dexmedetomidine reduced POD incidence versus placebo (18.4% vs 32.8%; RR 0.56, 95% CI 0.38–0.82).
• Preoperative sleep quality improved with dexmedetomidine.
• Bradycardia was more frequent in the dexmedetomidine group, highlighting a safety consideration.

Clinical Implications

Consider intranasal dexmedetomidine the night before surgery for older patients with sleep disorders at high delirium risk, embedded in delirium prevention bundles, with vigilant bradycardia monitoring and contraindication screening.

Limitations

• Adverse event signal of bradycardia requires careful monitoring and may limit generalizability.
• Population restricted to older adults with sleep disorders; applicability to broader surgical populations is uncertain.

Future Directions

Validate findings across diverse surgeries and risk profiles, define optimal dosing/timing, and integrate with multimodal delirium prevention (e.g., sleep hygiene, nonpharmacologic measures).