The importance of the presence of chosen family in preventing peri-operative delirium

Introduction Postoperative delirium (POD) is an acute state of confusion characterised by inattention, altered cognition and fluctuating mental state. It remains a common yet underrecognised complication in older surgical patients, significantly influencing recovery, prolonging hospital stays and increasing healthcare costs and workload.1 Although traditionally peri-operative care has prioritised physical stabilisation, effectively addressing POD requires a holistic approach that also considers patients’ emotional and social well being.2 One well established strategy for managing delirium is the active involvement of family and caregivers. Research consistently shows that the presence of familiar individuals provides emotional support and orientation, which can alleviate stress and reduce disorientation,3,4 key factors contributing to the onset and severity of delirium.5 Allowing chosen family members or caregivers to accompany the patient during the peri-operative period has significant potential to mitigate the incidence and severity of delirium in geriatric patients. This approach is already a standard practice in paediatric care, wherein caregivers routinely accompany children peri-operatively to provide reassurance and emotional stability.6,7 Similarly, in obstetrics, partners are often present during procedures for analgesia and delivery, contributing to emotional well being and enhancing patient satisfaction.8 Adapting these models to older patients seems a natural evolution, as it can improve outcomes and ease the burden on overwhelmed nursing staff. The impact of delirium on quality of life in older patients POD is the most common complication in older surgical patients, affecting up to 25% of those undergoing major elective surgery and as much as 50% for emergency procedures among high-risk individuals.9 POD is associated with adverse outcomes, including longer hospital stays, in-hospital complications, higher rates of institutionalisation, increased mortality and long-term neurocognitive disorders, such as dementia.10 For some, POD can mark the transition from living independently to requiring full-time care. Many older individuals already contend with sensory impairments, chronic illnesses, reduced ability to cope and frailty. Delirium amplifies these challenges, often leading to loss of confidence, diminished mobility and increased dependence on caregivers. Moreover, the emotional toll of POD cannot be overstated. Patients often report feelings of fear, frustration and helplessness, as they attempt to reconcile the distorted perceptions and hallucinations they encountered during their POD episode.11 For family members and caregivers, witnessing a loved one in a state of confusion and agitation can be deeply distressing, evoking feelings of powerlessness and emotional exhaustion. POD is preventable in many cases. Nonpharmacological peri-operative care bundles are essential tools in POD prevention strategies.2 Among these, one of the most underutilised yet potentially effective is the peri-operative involvement of chosen caregivers. Lessons from paediatric care: the role of caregivers in the peri-operative setting In paediatric peri-operative care, the involvement of caregivers is widely recognised for its positive impact. Parents are often allowed to accompany their children until anaesthesia is administered. This practice reduces parental anxiety, calms the child, improves operating room efficiency and fosters better caregiver-clinician relationships, ultimately enhancing surgical outcomes.6,12 A systematic review and meta-analysis confirmed that parental presence significantly reduces postoperative agitation in children, highlighting the broader benefits of family involvement in peri-operative care.7 Caregivers also play a critical role in detecting early signs of complications, as they are often more attuned to subtle changes in their child's behaviour. Although young children and older adults are at different ends of the age spectrum, both have distinct needs and shared vulnerabilities such as anxiety, disorientation and fear of unfamiliar environments. The principles of paediatric peri-operative care, emphasising emotional support, family involvement and a patient-centred approach, can be effectively adapted to older patients to help reduce the incidence of POD. Older patients need emotional anchors in the peri-operative setting too Older adults, particularly those with pre-existing cognitive impairment, frailty or both, are at an increased risk for POD. The hospital environment, with its bright lights, unfamiliar routines and constant noise, can intensify confusion and disorientation, compounded by the effects of anaesthesia, pain and changes in medication. In this challenging context, the presence of chosen family members or caregivers,13 whether biological relatives, close friends or trusted individuals, play a vital role in maintaining emotional and cognitive stability of older patients. Their presence combats loneliness and provides a familiar reference point, helping to orient patients to time, place, situation and identity.14 Simple acts such as holding a hand, speaking reassuringly or offering reminders about daily events can have a powerful stabilising and orienting effect through familiar sensory inputs such as voice, touch and scent. Beyond emotional support, caregivers also assist with practical needs that significantly influence comfort and recovery. They ensure that sensory aids, such as hearing devices or spectacles, are functional, reducing the risk of sensory-related confusion. Caregivers also provide support for feeding, hydration and monitoring bowel movements, preventing discomfort and secondary complications. They serve as advocates, ensuring patient preferences and concerns are conveyed to healthcare providers. They help maintain routines or cultural practices important to the patient, such as specific dietary preferences or rituals, fostering continuity in an otherwise unfamiliar setting. By addressing emotional and practical needs, caregivers reduce the patient's vulnerability, enhance their sense of security and improve their overall care experience. Integrating caregivers into the peri-operative setting is not just a compassionate choice, it is a clinically effective strategy for supporting older patients through surgery and recovery. The ripple effect on nursing staff The benefits of allowing chosen family members in the peri-operative setting extend beyond patient outcomes; there is also the potential to alleviate the workload of nursing staff. Although nurses are pivotal in preventing and managing delirium, they often face time constraints and competing priorities, especially in settings with insufficient nurse-to-patient ratios to provide individualised care for high-risk patients. Chosen caregivers can step in to assist with nonclinical tasks and provide companionship, reducing loneliness and anxiety that may otherwise demand nurses’ attention. This collaboration allows nurses to concentrate on their clinical responsibilities without neglecting patients’ emotional and social needs. Furthermore, caregivers bring unique insights into the patient's baseline cognitive and functional status, which can be invaluable for healthcare providers. They are often the first to notice subtle changes in a patient's speech, behaviour or emotional state, signs that might otherwise go undetected during routine clinical assessments. These observations can enable early intervention, preventing complications and improving overall care outcomes. Overcoming barriers to implementation Despite the clear benefits, logistical and cultural barriers hinder the integration of chosen family members into the peri-operative care of older adults. Concerns about infection control, space limitation and potential disruption to clinical workflow are often cited as reasons for restricting family presence. However, these challenges are not insurmountable. Flexible visiting policies can balance infection control with the advantages of family involvement. Providing them with personal protective equipment (PPE) and clear hygiene instructions can help minimise the risk of infections. Designating family-friendly spaces within peri-operative units can address concerns about overcrowding. Equally important is the training of healthcare staff to recognise the value of family involvement. Although some providers may initially perceive family members as disruptive, proper guidance and transparent communication can help transform them into valuable partners in care. A recent feasibility study exploring the presence of family members in the operating room with older adults highlighted both benefits and challenges.4 Although most patients and caregivers supported repeating the process, operating room personnel were less receptive to adopting it as routine practice, in stark contrast to its acceptance in paediatric care. This hesitation suggests an ageist bias and underscores the importance of educating medical teams about preventing POD and the critical role of family presence. Another recent study identified a higher incidence of falls during hospitalisation among childless older surgical patients.15 This finding underscores the essential role of social support in healthcare settings and highlights loneliness as a significant risk factor for adverse outcomes. It reinforces the importance of integrating chosen caregivers into peri-operative care to enhance emotional well being and improve patient safety, reduce complications and support overall recovery. A call to action Preventing POD in geriatric patients is a multifaceted challenge that requires innovative yet practical solutions. One such intervention – allowing chosen caregivers to be present during the peri-operative period – is a simple yet profoundly effective intervention. Family members or trusted companions can provide emotional support, ensure continuity of care and act as advocates for the patient's needs, ultimately helping to reduce the incidence and severity of delirium, improve patient outcomes and ease the workload of nursing staff. The success of this approach in paediatric care serves as a compelling precedent. Just as children benefit from the comforting presence of a parent or guardian, older adults can gain security and reassurance from having a trusted companion during a vulnerable time. Healthcare systems must recognise the value of family involvement in peri-operative care and implement policies that prioritise the presence of the caregiver. This includes addressing logistical barriers, training clinical staff and fostering a cultural shift towards inclusivity. In doing so, we honour not only the dignity and humanity of our elderly patients but also the deep interdependence that lies at the heart of all caregiving relationships. By fostering a culture of inclusivity and compassion, we can ensure that no patient faces the challenges of surgery alone (Fig. 1).Fig. 1: The importance of the presence of chosen family in prevention of peri-operative delirium.