Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review

Death due to delirium: a case of a self-cut hemodialysis dialysis catheter - a case report

Background

Neuropsychiatric conditions such as depression, delirium and cognitive impairment are common in patients with end-stage kidney disease (ESKD) and individuals suffering from ESKD are more likely to commit suicide than members of the general population. Self-harm gestures are not infrequent for ESKD patients suffering from depression, but not well described in other conditions.

Case presentation

We present a case of self-harm in a patient with ESKD suffering from acute delirium. A man in his mid-seventies was admitted with fungal peritoneal dialysis (PD) associated peritonitis. On the first day post operatively, he was found with absent vital signs due to exsanguination from newly inserted central catheter which he which had self-severed. He died a few days later as a result of the self-harm gesture.

Conclusion

This case highlights that delirium may lead to self-harm events in ESKD and identifies a few strategies to help reduce the risk of self-harm events.

Antipsychotics for Preventing Delirium in Hospitalized Adults: A Systematic Review

BACKGROUND

Delirium is an acute disorder marked by impairments in attention and cognition, caused by an underlying medical problem. Antipsychotics are used to prevent delirium, but their benefits and harms are unclear.

PURPOSE

To conduct a systematic review evaluating the benefits and harms of antipsychotics for prevention of delirium in adults.

DATA SOURCES

PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception through July 2019, without restrictions based on study setting, language of publication, or length of follow-up.

STUDY SELECTION

Randomized, controlled trials (RCTs) that compared an antipsychotic with placebo or another antipsychotic, and prospective observational studies with a comparison group.

DATA EXTRACTION

One reviewer extracted data and graded the strength of the evidence, and a second reviewer confirmed the data. Two reviewers independently assessed the risk of bias.

DATA SYNTHESIS

A total of 14 RCTs were included. There were no differences in delirium incidence or duration, hospital length of stay (high strength of evidence [SOE]), and mortality between haloperidol and placebo used for delirium prevention. Little to no evidence was found to determine the effect of haloperidol on cognitive function, delirium severity (insufficient SOE), inappropriate continuation, and sedation (insufficient SOE). There is limited evidence that second-generation antipsychotics may lower delirium incidence in the postoperative setting. There is little evidence that short-term use of antipsychotics was associated with neurologic harms. In some of the trials, potentially harmful cardiac effects occurred more frequently with antipsychotic use.

LIMITATIONS

There was significant heterogeneity in antipsychotic dosing, route of antipsychotic administration, assessment of outcomes, and adverse events. There were insufficient or no data available to draw conclusions for many of the outcomes.

CONCLUSION

Current evidence does not support routine use of haloperidol or second-generation antipsychotics for prevention of delirium. There is limited evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but more research is needed. Future trials should use standardized outcome measures.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109552).

Use of an expert panel to identify domains and indicators of delirium severity

PURPOSE

Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity.

METHODS

We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better ASsessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one-month period, experts participated in two rounds of review.

RESULTS

Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of consciousness, Inattention, Psychiatric-Behavioral, Emotional dysregulation, Psychomotor features, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations.

CONCLUSIONS

We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

Delirium Assessment in Older People in Emergency Departments. A Literature Review

Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.