Association of Delirium With Cognitive Decline in Late Life: A Neuropathologic Study of 3 Population-Based Cohort Studies

Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System

OBJECTIVES

Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services.

DESIGN

Pragmatic prospective cohort study of consecutive admissions to a large health care system.

SETTING AND PARTICIPANTS

A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014.

METHODS

Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI).

RESULTS

Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001).

CONCLUSIONS AND IMPLICATIONS

This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.

Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson's Disease, Dementia, and Older Adults

BACKGROUND

Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal.

OBJECTIVE

To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson's disease (PD) and dementia.

METHODS

Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria.

RESULTS

On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS (AUC=0.90 and 0.84, respectively, p < 0.001 for both).

CONCLUSION

Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.

Population-Based Studies in Dementia and Ageing Research: A Local and National Experience in Cambridgeshire and the UK

Dementia has been recognised as a key challenge in many ageing societies across the world. Several population-based studies have been developed to investigate dementia and cognitive ageing from perspectives of biology, health, psychology and social sciences. However, there is a need to provide a better understanding of 'contexts', the circumstance where these ageing populations existed, and heterogeneity within and across the populations in different time and places. In this article, we summarise some examples of earlier population-based studies undertaken by our research groups in England and Wales and their contribution to the epidemiology of dementia, neuropathology, cognitive and mental health in older age. We also describe how these studies illustrated variation among ageing populations and changes in their health conditions across time and place. These findings highlight the contribution that population-based studies can make, along with the vital to incorporate contexts in ageing research. A lifecourse approach within social context is needed to integrate life experiences, social circumstances, and multiple dimensions of cognition, functioning, physical health and wellbeing over the ageing process. We also discuss how evidence from population-based studies can support various international initiatives on dementia, healthy ageing and Sustainable Development Goals and facilitate tailored approaches for diverse populations across global societies.

Cognitive Trajectories Following Acute Infection in Older Patients With and Without Cognitive Impairment: An 1-Year Follow-Up Study

Introduction: Dementia is a known risk factor for both delirium and acute systemic infections which may also play a significant role in promoting or accelerating neurodegenerative disease. Infections are both the main causes of hospitalization of dementia patients and can be a major precipitant of delirium but currently it is not possible to predict the risk of cognitive decline in older patients exposed to acute infection. Objectives: We aimed to determine the level of cognitive change at 1-year follow up in individuals with different patterns of cognitive function (dementia, delirium, delirium superimposed on dementia) at the time of their hospitalization due to a systemic infection and to correlate these cognitive patterns with clinical status variables. Methods: We recruited 53 hospitalized geriatric patients with a systemic infection, and we collected 12-months follow up data for 34 patients. These patients were classified in four groups: no cognitive impairment (controls-C), delirium only (D), dementia only (Dem), and delirium superimposed to dementia (DD). Cognitive performance was measured by change in score on the Montreal Cognitive Assessment (MoCA) and delirium was identified using Confusion Assessment Measure (CAM). We examined performance on the MoCA in the first year after hospitalization, controlling for demographic characteristics, coexisting medical conditions, and type of infection. Results: For the 34 patients to whom follow-up data was available, delirium presence in individuals with prior dementia (DD group) was associated with a negative mean change score of 3-point (p < 0.02) at 1 year follow up, whereas dementia patients without delirium had a mean change score of 1.5-point lower at 12-months (p = 0.04), when comparing follow-up and baseline MoCA scores. Cognitively healthy patients did not significantly decrease their MoCA score at follow-up (p = 0.15). MoCA and NPI scores during hospitalization were significantly correlated with the level of cognitive decline in the four groups (r = 0.658, p < 0.01 and r = 0.439, p = 0.02, respectively). Conclusions: Premorbid dementia and delirium superimposed on dementia during hospitalization in older patients with acute infections predict cognitive decline at 1 year following admission. Taken together, our findings suggest a pathophysiological interaction between neurodegenerative changes, acute infection, and delirium.

Characterizing the long-term cognitive impairment following delirium episodes: A call to action

The possible link between delirium and a long-term cognitive impairment is significant for patients, carers, and clinicians. To make progress, we need urgently novel advances in understanding the neural substrates underlying this cognitive impairment and any accompanying behavioral symptoms.

Management of Delirium in the Intensive Care Unit

In the intensive care unit, delirium is a major contributor to morbidity and mortality in adult patients. Patients with delirium have been shown to have increased length of stay, decreased functional outcomes, and increased risk for requiring placement at the time of discharge. In addition, decreased cognitive function and dementia have been shown to be long-term complications from delirium. The mainstay of treatment and prevention include therapy- and behavioral-based interventions, including frequent orientation, cognitive stimulation, mobilization, sleep restoration, and providing hearing and visual aids. Refractory delirium may require pharmacologic intervention with antipsychotics or alpha-2 agonists.

Delirium and Clusters of Older Patients Affected by Multimorbidity in Acute Hospitals

OBJECTIVES

Delirium is commonly seen in older adults with multimorbidity, during a hospitalization, resulting from the interplay between predisposing factors such as advanced age, frailty, and dementia, and a series of precipitating factors. The association between delirium and specific multimorbidity is largely unexplored so far although of potential key relevance for targeted interventions. The aim of the study was to check for a potential association of multimorbidity with delirium in a large cohort of older patients hospitalized for an acute medical or surgical condition.

DESIGN

This is a cross-sectional study nested in the 2017 Delirium Day project.

SETTING AND PARTICIPANTS

The study includes 1829 hospitalized patients (age: 81.8, SD: 5.5). Of them, 419 (22.9%) had delirium.

METHODS

Sociodemographic and medical history were collected. The 4AT was used to assess the presence of delirium. The Charlson Comorbidity index was used to assess multimorbidity.

RESULTS

The results identified neurosensorial multimorbidity as the most prevalent, including patients with dementia, cerebrovascular diseases, and sensory impairments. In light of the highest co-occurrence of 3 neurosensorial chronic conditions, we could hypothesize that a baseline altered brain functional and neural connectivity might determine the vulnerability signature for incipient overall system disruption in presence of acute insults.

CONCLUSIONS AND IMPLICATIONS

Eventually, our findings moved a step forward in supporting the key importance of routine screening for sensory impairments and cognitive status of older patients for the highest risk of in-hospital delirium. In fact, preventive interventions could be particularly relevant and effective in preventing delirium in such vulnerable populations and might help refining this early diagnosis.

Challenges in Predicting Cognitive Decline in Dementia with Lewy Bodies

Despite being the second most common form of neurodegenerative dementia, dementia with Lewy bodies (DLB) is under-recognized and carries a worse prognosis than other subtypes of the condition. Cognitive impairment is a cardinal feature of all types of dementia and DLB presents with a distinct profile with deficits in attention, executive function, and visuoperceptual abilities. This difference from Alzheimer's disease and the common presence of neuropsychiatric symptoms may lead to challenges in predicting cognitive decline in this patient population. Firstly, the diagnosis of DLB is often delayed in clinical practice leading to variability from which time point in the disease course cognitive decline is measured. Secondly, the most frequently used measurement tools for cognitive difficulties focus on memory and naming rather than the domains affected by DLB. While there is now largely a consensus which tools are useful in diagnosing DLB, their validity in assessing deteriorating cognition is less clear. Thirdly, the presence of fluctuating cognition, the propensity to develop delirium episodes, as well as difficulties in distinguishing the two entities in clinical practice make it difficult to predict the disease course. Sleep disturbances are likely to influence cognitive decline but require further study in patients within established DLB. Fourthly, as in most cases of dementia, neuropathological comorbidities are frequently present in DLB. While the influence of Alzheimer's pathology on cognitive decline in DLB is comparatively well understood, the impact of other pathologies remains unclear. The recent definition of research criteria for mild cognitive impairment in DLB could facilitate earlier diagnosis and more structured follow-up. Assessment tools measuring cognitive domains predominantly affected in DLB need to be more consistently used in longitudinal studies and clinical practice, as well as concurrent measures of fluctuations in cognition. Greater availability of biomarkers and digital healthcare solutions can play an important role in enabling more accurate monitoring and prediction of cognitive decline in DLB.

Gait Ability and Muscle Strength in Institutionalized Older Persons with and without Cognitive Decline and Association with Falls

Falls are a complex problem, given their multifactorial nature, the comorbidities involved, and due to the dependency of older persons living in nursing homes. Risk, fear of falling, falls themselves, and their recurrence are the main factors behind fragility fractures, lack of independence, and increases in pain prevalence, and other comorbidities in older populations. The objectives of the present quantitative and longitudinal study were: (a) to characterize the cognitive state and fall frequency of older persons living in nursing homes; (b) to analyze the relationship between cognitive status and some fall risk factors; and (c) to associate cognitive decline, gait ability, and muscle strength of the examined institutionalized older persons with fall occurrence and recurrence over 12 months. The participants were 204 older persons who lived in Portuguese nursing homes, and data were collected from January 2019 to February 2020 by consulting medical records and applying the following instruments: the Mini-Mental State Examination, Timed Up and Go Test, and Medical Research Council Manual Muscle Testing Scale. Fall prevalence, assessed in two periods, 12 months apart, was similar in both samples (with and without cognitive decline) and close to 42%, and the annual recurrence rate was 38.3%. Older persons with no cognitive decline showed an association between gait speed and occurrence of first fall and recurrent fall (p < 0.05). Muscle strength and use of gait aid devices were not related to falls and their recurrence, regardless of mental state.

Evaluation and Management of Delirium

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

Interventions to support recovery following an episode of delirium: A realist synthesis

OBJECTIVES

Persistent delirium is associated with poor outcomes in older adults but little is known about how to support longer-term recovery from delirium. The aim of this review was to identify and synthesise literature to understand mechanisms of recovery from delirium as a basis for designing an intervention that enables more effective recovery.

METHODS

A systematic search of literature relevant to the research question was conducted in two phases. Phase one focused on studies evaluating the efficacy of interventions to support recovery from delirium, and stage two used a wider search strategy to identify other relevant literature including similar patient groups and wider methodologies. Synthesis of the literature followed realist principles.

RESULTS

Phase one identified four relevant studies and stage two identified a further forty-six studies. Three interdependent recovery domains and four recovery facilitators were identified. Recovery domains were 1) support for physical recovery through structured exercise programmes; 2) support for cognitive recovery through reality orientation and cognitive stimulation; 3) support for emotional recovery through talking with skilled helpers. Recovery facilitators were 1) involvement and support of carers; 2) tailoring intervention to individual needs, preferences and abilities; 3) interpersonal connectivity and continuity in relationships and; 4) facilitating positive expressions of self.

CONCLUSIONS

Multicomponent interventions with elements that address all recovery domains and facilitators may have the most promise. Future research should build on this review and explore patients', carers', and professionals' tacit theories about the persistence of delirium or recovery from delirium in order to inform an effective intervention.

Hospitalisation without delirium is not associated with cognitive decline in a population-based sample of older people-results from a nested, longitudinal cohort study

BACKGROUND

Acute hospitalisation and delirium have individually been shown to adversely affect trajectories of cognitive decline but have not previously been considered together. This work aimed to explore the impact on cognition of hospital admission with and without delirium, compared to a control group with no hospital admissions.

METHODS

The Delirium and Cognitive Impact in Dementia (DECIDE) study was nested within the Cognitive Function and Ageing Study II (CFAS II)-Newcastle cohort. CFAS II participants completed two baseline interviews, including the Mini-Mental State Examination (MMSE). During 2016, surviving participants from CFAS II-Newcastle were recruited to DECIDE on admission to hospital. Participants were reviewed daily to determine delirium status.During 2017, all DECIDE participants and age, sex and years of education matched controls without hospital admissions during 2016 were invited to repeat the CFAS II interview. Delirium was excluded in the control group using the Informant Assessment of Geriatric Delirium Scale (i-AGeD). Linear mixed effects modelling determined predictors of cognitive decline.

RESULTS

During 2016, 82 of 205 (40%) DECIDE participants had at least one episode of delirium. At 1 year, 135 of 205 hospitalised participants completed an interview along with 100 controls. No controls experienced delirium (i-AGeD>4). Delirium was associated with a faster rate of cognitive decline compared to those without delirium (β = -2.2, P < 0.001), but number of hospital admissions was not (P = 0.447).

CONCLUSIONS

These results suggest that delirium during hospitalisation rather than hospitalisation per se is a risk factor for future cognitive decline, emphasising the need for dementia prevention studies that focus on delirium intervention.

Fostering healthy aging: The interdependency of infections, immunity and frailty

Untangling the interdependency of infections, immunity and frailty may help to clarify their roles in the maintenance of health in aging individuals, and the recent COVID-19 pandemic has further highlighted such priority. In this scoping review we aimed to systematically collect the evidence on 1) the impact of common infections such as influenza, pneumonia and varicella zoster on frailty development, and 2) the role played by frailty in the response to immunization of older adults. Findings are discussed under a unifying framework to identify knowledge gaps and outline their clinical and public health implications to foster a healthier aging. Twenty-nine studies (113,863 participants) selected to answer the first question provided a moderately strong evidence of an association between infections and physical as well as cognitive decline - two essential dimensions of frailty. Thirteen studies (34,520 participants) investigating the second aim, showed that frailty was associated with an impaired immune response in older ages, likely due to immunosenescence. However, the paucity of studies, the absence of tools to predict vaccine efficacy, and the lack of studies investigating the efficacy of newer vaccines in presence of frailty, strongly limit the formulation of more personalized immunization strategies for older adults. The current evidence suggests that infections and frailty repeatedly cross each other pathophysiological paths and accelerate the aging process in a vicious circle. Such evidence opens to several considerations. First, the prevention of both conditions pass through a life course approach, which includes several individual and societal aspects. Second, the maintenance of a well-functioning immune system may be accomplished by preventing frailty, and vice versa. Third, increasing the adherence to immunization may delay the onset of frailty and maintain the immune system homeostasis, beyond preventing infections.

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers.

METHODS

Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence.

RESULTS

Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16).

CONCLUSION

In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.

LEVEL OF EVIDENCE

Therapeutic, level IV; Epidemiologic, level III.

Neurocognitive Impairment After Hematopoietic Stem Cell Transplant for Hematologic Malignancies: Phenotype and Mechanisms

Hematopoietic stem cell transplant (HSCT) plays a central role in the treatment of hematologic cancers. With the increasing survival of patients after HSCT, survivorship issues experienced by this population have become an important outcome. Cognitive impairment is an established sequela of HSCT, with studies to date establishing its presence, associated risk factors, and clinical phenotype. There are multiple potential contributors to cognitive impairment after HSCT. Efforts are ongoing to further characterize its clinical phenotype, associated biomarkers, and biologic underpinnings. A fundamental knowledge of post-HSCT cognitive impairment is of value for all clinicians who interface with this population, and further academic efforts are needed to more fully understand the impact of this cancer treatment on brain health. IMPLICATIONS FOR PRACTICE: As survival outcomes after hematopoietic stem cell transplant (HSCT) improve, an awareness of the post-treatment challenges faced by this population has become central to its care. HSCT can have a sustained and broad impact on brain health, causing cognitive dysfunction, fatigue, disturbed mood, and sleep. In affected patients, autonomy, return to work, relationships, and quality of life may all be affected. A fundamental fluency in this area is important for clinicians interfacing with HSCT survivors, facilitating the identification and management of cognitive dysfunction and concurrent symptom clusters, and stimulating interest in these sequelae as areas for future clinical research.

Association of Delirium With Long-term Cognitive Decline: A Meta-analysis

Importance

Delirium is associated with increased hospital costs, health care complications, and increased mortality. Long-term consequences of delirium on cognition have not been synthesized and quantified via meta-analysis.

Objective

To determine if an episode of delirium was an independent risk factor for long-term cognitive decline, and if it was, whether it was causative or an epiphenomenon in already compromised individuals.

Data Sources

A systematic search in PubMed, Cochrane, and Embase was conducted from January 1, 1965, to December 31, 2018. A systematic review guided by Preferred Reporting Items for Systematic Reviews and Meta-analyses was conducted. Search terms included delirium AND postoperative cognitive dysfunction; delirium and cognitive decline; delirium AND dementia; and delirium AND memory.

Study Selection

Inclusion criteria for studies included contrast between groups with delirium and without delirium; an objective continuous or binary measure of cognitive outcome; a final time point of 3 or more months after the delirium episode. The electronic search was conducted according to established methodologies and was executed on October 17, 2018.

Data Extraction and Synthesis

Three authors extracted data on individual characteristics, study design, and outcome, followed by a second independent check on outcome measures. Effect sizes were calculated as Hedges g. If necessary, binary outcomes were also converted to g. Only a single effect size was calculated for each study.

Main Outcomes and Measures

The planned main outcome was magnitude of cognitive decline in Hedges g effect size in delirium groups when contrasted with groups that did not experience delirium.

Results

Of 1583 articles, data subjected from the 24 studies (including 3562 patients who experienced delirium and 6987 controls who did not) were included in a random-effects meta-analysis for pooled effect estimates and random-effects meta-regressions to identify sources of study variance. One study was excluded as an outlier. There was a significant association between delirium and long-term cognitive decline, as the estimated effect size (Hedges g) for 23 studies was 0.45 (95% CI, 0.34-0.57; P < .001). In all studies, the group that experienced delirium had worse cognition at the final time point. The I2 measure of between-study variability in g was 0.81. A multivariable meta-regression suggested that duration of follow-up (longer with larger gs), number of covariates controlled (greater numbers were associated with smaller gs), and baseline cognitive matching (matching was associated with larger gs) were significant sources of variance. More specialized subgroup and meta-regressions were consistent with predictions that suggested that delirium may be a causative factor in cognitive decline.

Conclusions and Relevance

In this meta-analysis, delirium was significantly associated with long-term cognitive decline in both surgical and nonsurgical patients.

Clinical presentation and outcomes of COVID-19 in older hospitalised patients assessed by the record-based multidimensional prognostic index, a cross-sectional study

Aim

Confusion was more prevalent in frail than in non-frail older patients at hospital admission.

Finding

COVID-19 and accelerated functional decline were associated among frail older hospitalised patients when compared to non-frail.

Message

Ninety-day all-cause mortality was 70% among frail hospitalised patients with COVID-19 and 15% among non-frail.

Purpose

Older people are the most frequently hospital admitted patients with COVID-19. We aimed to describe the clinical presentation of COVID-19 among frail and nonfrail older hospitalised patients and to evaluate the potential association between frailty and clinical course, decision of treatment level with outcomes change in functional capacity and survival.

Methods

We performed a multi-center, retrospective cross-sectional cohort study examining data on clinical presentation and frailty-related domains for hospitalised people aged 75 + years with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test. Frailty was assessed at admission using record-based MPI (rMPI) and Clinical Frailty Scale (CFS). Decision on treatment level about invasive ventilation and cardiopulmonary resuscitation (CPR), change in CFS-score from admission to discharge, changed need of home care, and in-hospital, 30-day and 90-day mortality were registered.

Results

100 patients (median age 82 years (IQR 78–86), 56% female) with COVID-19 were included. 54 patients were assessed moderately or severely frail (rMPI-score = 2 or 3) and compared to non-frail (rMPI-score = 1). At admission, frail patients presented more frequently with confusion. At discharge, functional decline measured by change in CFS and increased home care was more prevalent among frail than the non-frail. Decisions about no invasive ventilation or CPR were more prevalent among frail older patients with COVID-19 than non-frail. Ninety-day mortality was 70% among frail patients versus 15% in non-frail.

Conclusion

Frailty seems to be associated with confusion, more frequent decisions about treatment level, larger functional decline at discharge and a higher mortality rate among older patients with COVID-19.

Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.

Acute systemic inflammation exacerbates neuroinflammation in Alzheimer's disease: IL-1β drives amplified responses in primed astrocytes and neuronal network dysfunction

Neuroinflammation contributes to Alzheimer's disease (AD) progression. Secondary inflammatory insults trigger delirium and can accelerate cognitive decline. Individual cellular contributors to this vulnerability require elucidation. Using APP/PS1 mice and AD brain, we studied secondary inflammatory insults to investigate hypersensitive responses in microglia, astrocytes, neurons, and human brain tissue. The NLRP3 inflammasome was assembled surrounding amyloid beta, and microglia were primed, facilitating exaggerated interleukin-1β (IL-1β) responses to subsequent LPS stimulation. Astrocytes were primed to produce exaggerated chemokine responses to intrahippocampal IL-1β. Systemic LPS triggered microglial IL-1β, astrocytic chemokines, IL-6, and acute cognitive dysfunction, whereas IL-1β disrupted hippocampal gamma rhythm, all selectively in APP/PS1 mice. Brains from AD patients with infection showed elevated IL-1β and IL-6 levels. Therefore, amyloid leaves the brain vulnerable to secondary inflammation at microglial, astrocytic, neuronal, and cognitive levels, and infection amplifies neuroinflammatory cytokine synthesis in humans. Exacerbation of neuroinflammation to produce deleterious outcomes like delirium and accelerated disease progression merits careful investigation in humans.

Why is delirium more frequent in the elderly?

An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.

Diagnosing Urothelial Carcinoma from Delirium: A Near Miss

Urinary tract infection (UTI) is a common cause of delirium in the elderly. Although diagnosis of delirium secondary to UTI is relatively straightforward, a lack of thorough investigation could result in missing underlying factors and medical conditions that may require immediate clinical/surgical intervention. Case of a 77-year-old male with delirium diagnosis and multiple psychiatric hospital admissions is reported here. This patient with multiple medical disorders and anxiety was admitted to psychiatric facilities on three different occasions with multiple psychiatric diagnoses including delirium. After a month of hospital stay and thorough medical and radiological examinations, the cause of refractory delirium was identified as multifactorial including urothelial carcinoma. Although UTI and urinary retention are common in the elderly, this case shows the importance of multifactorial diagnoses in cases of prolonged or refractory delirium to avoid delays in appropriate treatment.

Interleukin-6 Inhibition Reduces Neuronal Injury In A Murine Model of Ventilator-Induced Lung Injury

Mechanical ventilation is a known risk factor for delirium, a cognitive impairment characterized by frontal cortex and hippocampal dysfunction. Although interleukin-6 (IL-6) is upregulated in mechanical ventilation-induced lung injury (VILI) and may contribute to delirium, it is not known whether inhibition of systemic IL-6 mitigates delirium-relevant neuropathology. To histologically define neuropathological effects of IL-6 inhibition in an experimental VILI model. VILI was simulated in anesthetized adult mice using a 35cc/kg tidal volume mechanical ventilation model. There were two controls groups: 1) spontaneously breathing, or 2) anesthetized and mechanically ventilated with 10cc/kg tidal volume to distinguish effects of anesthesia from VILI. Two hours prior to inducing VILI, mice were treated with either anti-IL-6 antibody, anti-IL-6 receptor antibody, or saline. Neuronal injury, stress, and inflammation were assessed using immunohistochemistry. Cleaved caspase-3 (CC3), a neuronal apoptosis marker, was significantly increased in the frontal (p<0.001) and hippocampal (p<0.0001) brain regions and accompanied by significant increases in c-Fos and heat shock protein-90 in the frontal cortices of VILI mice compared to controls (p<0.001). These findings were not related to cerebral hypoxia and there was no evidence of irreversible neuronal death. Frontal and hippocampal neuronal CC3 were significantly reduced with anti-IL-6 antibody (p<0.01 and p<0.0001, respectively), anti-IL-6 receptor antibody (p<0.05 and p<0.0001, respectively) compared to saline VILI mice. VILI induces potentially reversible neuronal injury and inflammation in the frontal cortex and hippocampus, which is mitigated with IL-6 inhibition. These data suggest a potentially novel neuroprotective role of systemic IL-6 inhibition that justifies further investigation.

Older Patients with Alzheimer's Disease-Related Cortical Atrophy Who Develop Post-Operative Delirium May Be at Increased Risk of Long-Term Cognitive Decline After Surgery

BACKGROUND

Older surgical patients with Alzheimer's disease (AD) dementia and delirium are at increased risk for accelerated long-term cognitive decline.

OBJECTIVE

Investigate associations between a probabilistic marker of preclinical AD, delirium, and long-term cognitive decline.

METHODS

The Successful Aging after Elective Surgery cohort includes older adults (≥70 years) without dementia who underwent elective surgery. 140 patients underwent preoperative magnetic resonance imaging and had≥6 months cognitive follow-up. Cortical thickness was measured in 'AD-Signature' regions. Delirium was evaluated each postoperative day by the Confusion Assessment Method. Cognitive performance was assessed using a detailed neuropsychological battery at baseline; months 1, 2, and 6; and every 6 months thereafter until 36 months. Using either a General Cognitive Performance composite (GCP) or individual test scores as outcomes, we performed linear mixed effects models to examine main effects of AD-signature atrophy and the interaction of AD-signature atrophy and delirium on slopes of cognitive change from post-operative months 2-36.

RESULTS

Reduced baseline AD-signature cortical thickness was associated with greater 36-month cognitive decline in GCP (standardized beta coefficient, β = -0.030, 95% confidence interval [-0.060, -0.001]). Patients who developed delirium who also had thinner AD signature cortex showed greater decline on a verbal learning test (β = -0.100 [-0.192, -0.007]).

CONCLUSION

Patients with the greatest baseline AD-related cortical atrophy who develop delirium after elective surgery appear to experience the greatest long-term cognitive decline. Thus, atrophy suggestive of preclinical AD and the development of delirium may be high-risk indicators for long-term cognitive decline following surgery.

The Clinician's Interview-Based Impression of Change (Plus caregiver input) and goal attainment in two dementia drug trials: Clinical meaningfulness and the initial treatment response

INTRODUCTION

The Clinician's Interview-Based Impression of Change Plus caregiver input (CIBIC-Plus) has been widely used in dementia drug trials to evaluate cognition, behavior, and function. New trials of symptomatic drugs forecast renewed interest in this measure.

METHODS

To test its clinical meaningfulness, we examined how CIBIC-Plus performed in two cholinesterase inhibitor trials compared to goal attainment scaling Scale (GAS) scores, a patient-reported outcome measure.

RESULTS

Net goal attainment was seen for all but one GAS domains in subjects who improved on the CIBIC-Plus. Subjects who improved initially on CIBIC-Plus scores were likely to remain improved across all other outcomes for each trial's duration, except for Disability Assessment for Dementia scores.

DISCUSSION

The initial response to treatment, as assessed by CIBIC-Plus, remained stable for most outcome measures. Even small CIBIC-Plus improvement changes are associated with clinically meaningful change as assessed by GAS. Other tests detect decline better than improvement.

Health-related quality of life, functional decline, and long-term mortality in older patients following hospitalisation due to COVID-19

Background

Older people are particularly vulnerable to severe COVID-19. Little is known about long-term consequences of COVID-19 on health-related quality of life (HR-QoL) and functional status in older people, and the impact of age in this context. We aimed to study age-related change in health-related quality of life, functional decline and mortality among older patients 6 months following hospitalisation due to COVID-19.

Methods

This was a cohort study including patients aged 60 years and older admitted to four general hospitals in South-Eastern Norway due to COVID-19, from March 1 up until July 1, 2020. Patients who were still alive were invited to attend a six-month follow-up. Change in HR-QoL and functional status compared to before the COVID-19 hospitalisation were assessed using the EuroQol 5-dimensional-5 levels questionnaire (EQ. 5D-5L). A change in visual analogue scale (VAS) score of 7 or more was considered clinically relevant.

Results

Out of 216 patients aged 60 years and older that were admitted to hospital due to COVID-19 during the study period, 171 were still alive 180 days after hospital admission, and 106 patients (62%) attended the six-month follow-up. Mean age was 74.3 years, 27 patients (26%) had experienced severe COVID-19. Fifty-seven participants (54%) reported a decrease in the EQ. 5D-5L VAS score after 6 months, with no significant difference between persons aged 75 years and older compared to younger. Seventy participants (66%) reported a negative change in any of the dimensions of the EQ. 5D-5L, with impaired ability to perform activities of daily life (35%), reduced mobility (33%) and having more pain or discomfort (33%) being the most commonly reported changes. Forty-six participants (43%) reported a negative change in cognitive function compared to before the COVID-19 hospitalisation. Six-month mortality was 21%, and increased with increasing age.

Conclusions

More than half of the patients reported a negative change in HR-QoL 6 months following hospitalisation due to COVID-19, and one out of three experienced a persistently impaired mobility and ability to carry out activities of daily living. The results suggest awareness of long-term functional decline in older COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02140-x.

Anticholinergic load and delirium in end-of-life patients

BACKGROUND

Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated.

OBJECTIVE

To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium.

METHODS

This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale.

RESULTS

Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model.

CONCLUSIONS

Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.

Do specific delirium aetiologies have different associations with death? A longitudinal cohort of hospitalised patients

Aim

To investigate aetiology-specific associations with mortality among older patients with delirium.

Findings

Delirium predicted mortality, as did inflammatory and metabolic disorders. However, there was no evidence for any interactions between these factors.

Message

Mortality from delirium is consistent regardless of underlying aetiology, suggesting that no aetiology carries better or worse prognosis than another.

Purpose

To describe aetiology-specific associations with mortality among older hospital patients with delirium.

Methods

Over 21 months, a cohort of 1702 patients with 2471 acute hospital admissions (median age 85, IQR 80–90, 56% women) were assessed for delirium, categorised with inflammatory and metabolic aetiologies based on available laboratory results, and followed up for all-cause mortality. Interactions between aetiology and delirium were tested.

Results

The total mortality for the cohort was 35.2%. While inflammation, metabolic disturbance, and delirium at time of admission all demonstrated independent associations with mortality, there was no evidence for any interactions between delirium and these laboratory-measured aetiologies.

Conclusions

Delirium remains an important predictor of death in older hospital patients, irrespective of underlying aetiology.

Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program

OBJECTIVE

To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium.

METHODS

A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method.

RESULTS

Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99).

CONCLUSIONS

Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.

Machine Learning to Develop and Internally Validate a Predictive Model for Post-operative Delirium in a Prospective, Observational Clinical Cohort Study of Older Surgical Patients

BACKGROUND

Our objective was to assess the performance of machine learning methods to predict post-operative delirium using a prospective clinical cohort.

METHODS

We analyzed data from an observational cohort study of 560 older adults (≥ 70 years) without dementia undergoing major elective non-cardiac surgery. Post-operative delirium was determined by the Confusion Assessment Method supplemented by a medical chart review (N = 134, 24%). Five machine learning algorithms and a standard stepwise logistic regression model were developed in a training sample (80% of participants) and evaluated in the remaining hold-out testing sample. We evaluated three overlapping feature sets, restricted to variables that are readily available or minimally burdensome to collect in clinical settings, including interview and medical record data. A large feature set included 71 potential predictors. A smaller set of 18 features was selected by an expert panel using a consensus process, and this smaller feature set was considered with and without a measure of pre-operative mental status.

RESULTS

The area under the receiver operating characteristic curve (AUC) was higher in the large feature set conditions (range of AUC, 0.62-0.71 across algorithms) versus the selected feature set conditions (AUC range, 0.53-0.57). The restricted feature set with mental status had intermediate AUC values (range, 0.53-0.68). In the full feature set condition, algorithms such as gradient boosting, cross-validated logistic regression, and neural network (AUC = 0.71, 95% CI 0.58-0.83) were comparable with a model developed using traditional stepwise logistic regression (AUC = 0.69, 95% CI 0.57-0.82). Calibration for all models and feature sets was poor.

CONCLUSIONS

We developed machine learning prediction models for post-operative delirium that performed better than chance and are comparable with traditional stepwise logistic regression. Delirium proved to be a phenotype that was difficult to predict with appreciable accuracy.

The economic cost of delirium: A systematic review and quality assessment

INTRODUCTION

This review aims to systematically identify and appraise the methodological quality of claims on the cost of delirium; and discuss challenges and opportunities for improvements in the precision of the estimates.

METHODS

Searches of scientific papers and gray literature were performed up until June 2020. The Larg and Moss checklist was used to assess the methodological quality of the included studies.

RESULTS

After deduplication, the search identified 317 potentially relevant articles, of which 17 articles were eligible for inclusion. After adjusting for inflation and common currency, the cost of delirium ranged between $806 and $24,509 (in 2019 US$).

DISCUSSION

This review found significant variation among the cost estimates and methodological quality. There has been limited focus on dementia as a sequela of delirium in terms of economic implications, but recent evidence suggests cost implications of delirium may be 52% higher when dementia is considered.

Investigating how electroencephalogram measures associate with delirium: A systematic review

Delirium is a common neurocognitive disorder in hospital settings, characterised by fluctuating impairments in attention and arousal following an acute precipitant. Electroencephalography (EEG) is a useful method to understand delirium pathophysiology. We performed a systematic review to investigate associations between delirium and EEG measures recorded prior, during, and after delirium. A total of 1,655 articles were identified using PsycINFO, Embase and MEDLINE, 31 of which satisfied inclusion criteria. Methodological quality assessment was undertaken, resulting in a mean quality score of 4 out of a maximum of 5. Qualitative synthesis revealed EEG slowing and reduced functional connectivity discriminated between those with and without delirium (i.e. EEG during delirium); the opposite pattern was apparent in children, with cortical hyperexcitability. EEG appears to have utility in differentiating those with and without delirium, but delirium vulnerability and the long-term effects on brain function require further investigation. Findings provide empirical support for the theory that delirium is a disorder of reduced functional brain integration.

EVALUATION OF FALL RISK FACTORS PRESENT DURING INSTITUTIONALIZATION OF ELDERLY PEOPLE

ABSTRACT Objectives: to describe the development and validation of the Scale of Practices of Evaluation of Fall Risk Factors during Institutionalization of Elderly People and to describe the practices of evaluation of communication of fall risks to institutionalized elderly people. Methods: methodological study, which allowed construction and determination of the psychometric properties of the Scale of Practices of Evaluation of Fall Risk Factors during Institutionalization of Elderly People, which was carried out in six long-term care institutions for elderly people, in 2018. Results: the scale showed satisfactory internal consistency, with a Cronbach’s alpha of 0.949. It was designed to have three dimensions: practices of evaluation of biophysiological risk factors; practices of communication and training; and practices of evaluation of risks related to elderly people’s putting on clothing and footwear. Conclusions: the risk factors that had their value recognized were related to mobility. There is not proper recognition of the importance of information about fall risk factors and communication between elderly people and health teams during institutionalization.

Time course of dementia following sepsis in German health claims data

Objective

We evaluated the short-, medium-, and long-term effects of sepsis on dementia incidence using German health claims data.

Methods

A total of 161,567 patients (65 years or older) were followed from 2004 to 2015 at quarterly intervals. Time since sepsis was categorized into 0 (the effective quarter of sepsis diagnosis), 1–8, and ≥9 quarters since the latest diagnosis of sepsis, taking into account admission to intensive care unit and controlling for delirium, surgery, age, sex, and comorbidities. Incident dementia was defined for all persons who did not have a validated dementia diagnosis in 2004 and 2005 and who received a first-time, valid diagnosis between 2006 and 2015.

Results

During the quarter of sepsis diagnosis, patients not admitted to intensive care had a 3.14-fold (95% CI 2.83–3.49) increased risk, and those with intensive care stay had a 2.22-fold (95% CI: 1.83–2.70) increased risk of receiving an incident dementia diagnosis compared with patients without sepsis. The impact of sepsis on incident dementia remained in the following 2 years, remitting only thereafter.

Conclusions

For sepsis survivors, medium-term dementia risk remains elevated, whereas long-term risk may reach the level of those without sepsis, even after controlling for delirium. These findings encourage identifying modifiable components of hospital and rehabilitation care.

Brain MRI after critical care admission: A longitudinal imaging study

PURPOSE

To investigate the association between episodes of critical care hospitalizations and delirium with structural brain changes in older adults.

MATERIALS AND METHODS

We included Mayo Clinic Study of Aging participants ≥60 years old at the time of study enrollment (October 29, 2004, through September 11, 2017) with available brain MRI and 'amyloid' positron emission tomography (PET) scans. We tested the hypothesis that a) intensive care unit (ICU) admission is associated with greater cortical thinning and atrophy in entorhinal cortex, inferior temporal cortex, middle temporal cortex, and fusiform cortex (Alzheimer''s disease-signature regions); b) atrophy in hippocampus and corpus callosum; c) delirium accelerates these changes; and d) ICU admission is not associated with increased deposition of cortical amyloid.

RESULTS

ICU admission was associated with cortical thinning in temporal, frontal, and parietal cortices, and decreases in hippocampal/corpus callosum volumes, but not Alzheimer''s disease-signature regions. For hippocampal volume, and 10 of 14 cortical thickness measurements, the change following ICU admission was significantly more pronounced for those who experienced delirium. ICU admission was not associated with an increased amyloid burden.

CONCLUSIONS

Critical care hospitalization is associated with accelerated brain atrophy in selected brain regions, without increases in amyloid deposition, suggesting a pathogenesis based on neurodegeneration unrelated to Alzheimer''s pathway.

Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study

OBJECTIVE

Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium.

DESIGN

Cross-sectional study nested in the 2017 "Delirium Day" project.

SETTING AND PARTICIPANTS

Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy.

METHODS

Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters).

RESULTS

A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63).

CONCLUSIONS AND IMPLICATIONS

Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.

Neuroinflammation after surgery: from mechanisms to therapeutic targets

Injury is a key driver of inflammation, a critical yet necessary response involving several mediators that is aimed at restoring tissue homeostasis. Inflammation in the central nervous system can be triggered by a variety of stimuli, some intrinsic to the brain and others arising from peripheral signals. Fine-tuned regulation of this response is crucial in a system that is vulnerable due to, for example, aging and ongoing neurodegeneration. In this context, seemingly harmless interventions like a common surgery to repair a broken limb can overwhelm the immune system and become the driver of further complications such as delirium and other perioperative neurocognitive disorders. Here, we discuss potential mechanisms by which the immune system affects the central nervous system after surgical trauma. Together, these neuroimmune interactions are becoming hallmarks of and potential therapeutic targets for multiple neurologic conditions, including those affecting the perioperative space.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

A Systematic Review of Delirium Biomarkers and Their Alignment with the NIA-AA Research Framework

OBJECTIVES

To identify whether delirium biomarkers aligned with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework, a conceptual model that describes the use of diagnostic biomarkers for Alzheimer's disease and other related dementias (ADRD).

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

SETTING

Acute care and outpatient settings.

PARTICIPANTS

Adults diagnosed with delirium.

METHODS AND MEASUREMENTS

MEDLINE, PsycInfo, Embase, and the Cochrane Library were searched for English-language studies published from January 2010 to February 2020. Studies included adults older than 18 years, identified delirium with a standardized assessment tool, and measured an ADRD biomarker. Independent reviewers determined whether an association between delirium and ADRD biomarker was found, the quality of biomarker data based on the REMARK (REporting recommendations for tumor MARKer prognostic studies) checklist, and the study bias based on the Newcastle-Ottawa Scale.

RESULTS

A total of 61,256 citations were identified; 113 studies were included. Most studies did not examine amyloid, tau, or neurodegeneration biomarkers. Delirium may be associated with neurodegeneration biomarkers, but few to no studies found an association with amyloid and tau biomarkers. Delirium was not consistently associated with inflammatory biomarkers. The quality of biomarker data was moderate, and the risk of bias was moderate to high. Studies often did not collect prehospital and posthospital cognitive data.

CONCLUSION

Most delirium diagnostic biomarker studies did not measure amyloid, tau, and/or neurodegenerative biomarkers, making characterization of the relationship between delirium and ADRD difficult. Future delirium biomarker diagnostic studies could improve the understanding of pathophysiologic links between delirium with other conditions affecting cognition.

Risk factors associated with postoperative intensive care unit delirium in patients undergoing invasive mechanical ventilation following acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

This study was performed to determine the risk factors associated with intensive care unit delirium (ICUD) in patients undergoing invasive mechanical ventilation (IMV) secondary to acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Data involving 620 patients undergoing IMV secondary to acute exacerbation of COPD from 2009 to 2019 at the First Hospital of Hebei Medical University were retrospectively analysed. The primary endpoint was the risk factors associated with developing ICUD. Univariable and multivariable logistic regression analyses were used to identify these risk factors.

RESULTS

Of 620 patients, 93 (15.0%) developed ICUD. In the multivariable analysis, risk factors that were significantly associated with ICUD were increased age, male sex, alcoholism with active abstinence, current smoking, stage 3 acute kidney injury (AKI), and an American Society of Anesthesiologists (ASA) physical status of III.

CONCLUSION

This study showed that increasing age, male sex, alcoholism with active abstinence, current smoking, stage 3 AKI, and an ASA physical status of III might be associated with a risk of developing ICUD. Even if these risk factors are unaltered, they provide a target population for quality improvement initiatives.

Association Between Common Infections and Incident Post-Stroke Dementia: A Cohort Study Using the Clinical Practice Research Datalink

PURPOSE

To investigate the association between common infections and post-stroke dementia in a UK population-based cohort.

MATERIALS AND METHODS

A total of 60,392 stroke survivors (51.2% male, median age 74.3 years, IQR 63.9-82.4 years) were identified using primary care records from the Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics (HES) with no history of dementia. Primary exposure was any GP-recorded infection (lower respiratory tract infection (LRTI), urinary tract infection (UTI) requiring antibiotics, skin and soft tissue infection requiring antibiotics) occurring after stroke. The primary outcome was incident all-cause dementia recorded in primary care records. In sensitivity analyses, we restricted to individuals with linked hospital records and expanded definitions to include ICD-10 coded hospital admissions. We used multivariable Cox regression to investigate the association between common infections and dementia occurring from 3 months to 5 years after stroke.

RESULTS

Of 60,392 stroke survivors, 20,969 (34.7%) experienced at least one infection and overall 4512 (7.5%) developed dementia during follow-up. Early dementia (3 months to 1-year post-stroke) risk was increased in those with at least one GP-recorded infection (HR 1.44, 95% CI 1.21-1.71), with stronger associations when hospitalised infections were included (HR 1.84, 95% CI 1.58-2.14). Late dementia (1-5 years) was only associated with hospitalised, but not with GP-recorded, infections.

CONCLUSION

There was evidence of an association between common infections and post-stroke dementia, strongest in the 3-12 months following stroke. Better understanding of this relationship could help inform knowledge of pathways to dementia post-stroke and targeting of preventive interventions.

A two-year multicenter point prevalence study of older patients with hip fractures admitted to rehabilitation units in Italy

PURPOSE

To date in Italy we do not have sufficient information on the rehabilitation process of older patients with hip fractures especially in the context of dementia. The main aims of the study were to gather information on the characteristics of older patients with hip fracture admitted to rehabilitation units with a specific focus on geriatric syndromes and the rehabilitation process.

METHODS

A national multi-center "point prevalence study" was conducted in Italy over two index days in 2017 and 2018. All patients aged 70 years and older hospitalized on the index day in Rehabilitation Units after a hip fracture were eligible.

RESULTS

A total of 615 patients were included. Most of the hospitals involved were from northern Italy, to a lesser extent from central and from southern Italy. The mean age was 83.08 ± 7.9 years. Almost half of the patients lived alone before the hip fracture. Most of the falls happened at home and while walking. The prevalence of delirium, dementia and malnutrition was 9.1%, 36.6%, and 19.3%, respectively. Antidepressants were prescribed in 27% of the population. The multidisciplinary team was activated as follows: occupational therapist in 18.9% of the cases, psychologists in 14.5%, social workers in 15.3%, and speech therapists in 6.5%.

CONCLUSION

The study allowed the collection of data on a relatively large sample of older patients with hip fracture showing the possible current limitations in the correct management of geriatric syndromes in this frail population. Future multicenter longitudinal studies are required to further study this population.

Functional and cognitive outcomes after COVID-19 delirium

Aim

To investigate functional and cognitive outcomes among patients with delirium in COVID-19.

Findings

Delirium in COVID-19 was prevalent (42%), but only a minority had been recognised by the clinical team. At 4-week follow-up, delirium was significantly associated with worse functional outcomes, independent of pre-morbid frailty. Cognitive outcomes were not appreciably worse.

Message

The presence of delirium is a significant factor in predicting worse functional outcomes in patients with COVID-19.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00353-8) contains supplementary material, which is available to authorized users.

Purpose

To ascertain delirium prevalence and outcomes in COVID-19.

Methods

We conducted a point-prevalence study in a cohort of COVID-19 inpatients at University College Hospital. Delirium was defined by DSM-IV criteria. The primary outcome was all-cause mortality at 4 weeks; secondary outcomes were physical and cognitive function.

Results

In 71 patients (mean age 61, 75% men), 31 (42%) had delirium, of which only 12 (39%) had been recognised by the clinical team. At 4 weeks, 20 (28%) had died, 26 (36%) were interviewed by telephone and 21 (30%) remained as inpatients. Physical function was substantially worse in people after delirium − 50 out of 166 points (95% CI − 83 to − 17, p = 0.01). Mean cognitive scores at follow-up were similar and delirium was not associated with mortality in this sample.

Conclusions

Our findings indicate that delirium is common, yet under-recognised. Delirium is associated with functional impairments in the medium term.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00353-8) contains supplementary material, which is available to authorized users.

Delirium Post-Stroke-Influence on Post-Stroke Dementia (Research Study-Part of the PROPOLIS Study)

BACKGROUND

Previous research confirmed association between delirium and subsequent dementia in different clinical settings, but the impact of post-stroke delirium on cognitive functioning is still under-investigated. Therefore, we aimed to assess the risk of dementia among patients with stroke and in-hospital delirium.

METHODS

A total of 750 consecutive patients admitted to the stroke unit with acute stroke or transient ischemic attacks were screened for delirium, during the first seven days after admission. At the three- and twelve-month follow-up, patients underwent cognitive evaluation. The DSM-5 definition for dementia was used. Cases with pre-stroke dementia were excluded from the analysis.

RESULTS

Out of 691 included cases, 423 (61.22%) and 451 (65.27%) underwent cognitive evaluation, three and twelve months after stroke; 121 (28.61%) and 151 (33.48%) patients were diagnosed with dementia, respectively. Six (4.96%) patients with dementia, three months post-stroke did not meet the diagnostic criteria for dementia nine months later. After twelve months, 37 (24.50%) patients were diagnosed with dementia, first time after stroke. Delirium in hospital was an independent risk factor for dementia after three months (OR = 7.267, 95%CI 2.182-24.207, p = 0.001) but not twelve months after the stroke.

CONCLUSIONS

Patients with stroke complicated by in-hospital delirium are at a higher risk for dementia at three but not twelve months post-stroke.

Long-Term Cognitive Impairment Associated With Delirium in Acute Neurological Injury

Supplemental Digital Content is available in the text.

Objectives:

To characterize the risk of long-term cognitive impairment associated with delirium in acute neurologic injury patients.

Design:

We analyzed a 10-year cohort of adult acute neurologic injury patients (stroke and traumatic brain injury) without preexisting mild cognitive impairment or dementia, utilizing administrative databases. Patients were followed for in-hospital delirium and mild cognitive impairment or dementia. We report incidence and adjusted hazard ratios for mild cognitive impairment or dementia associated with delirium. Subgroups analyzed include acute neurologic injury categories, dementia subtypes, repeated delirium exposure, and age strata.

Setting:

We used state emergency department and state inpatient databases for New York, Florida, and California. All visits are included in the databases regardless of payer status.

Patients:

We included adult patients with diagnosis of stroke and traumatic brain injury as acute neurologic injury. Patients with preexisting mild cognitive impairment or dementia were excluded.

Interventions:

None.

Measurements and Main Results:

Among 911,380 acute neurologic injury patients, 5.2% were diagnosed with delirium. Mild cognitive impairment or dementia incidence among delirium patients was approximately twice that of nondelirium patients. In adjusted models, risk of mild cognitive impairment or dementia was higher among patients with delirium (adjusted hazard ratio, 1.58). Increased risk was observed across all subgroups including patients less than or equal to 55 years old.

Conclusions:

Identification, management, and prevention of in-hospital delirium could potentially improve long-term cognitive outcomes in acute neurologic injury patients.

Delirium disorder

Objective

As the US population ages and with no definitive delirium treatments on the horizon, the delirium epidemic is on course to expand over the coming decades. Recognizing the import of this condition, a recent position statement from 10 medical societies—among whom the American Academy of Neurology was represented—issued recommendations on preferred nomenclature of delirium and acute encephalopathy: it concluded by preferring both terms. Urgently needed is an integrated model that addresses the near-total segregation of these separate bodies of literature, ideally one that offers an interdisciplinary framework to bring these 2 terms and those who use them together.

Methods

We review the historical forces that have led these terms to diverge and consider the unique benefits of each approach as well as their liabilities when considered in isolation. We then explore the potential implications of integrating these concepts and propose a hybrid model to capitalize on the strengths of both the model of delirium and that of acute encephalopathy.

Results

The model we propose—delirium disorder—builds on the recommendations of this recent position statement and provides a unifying framework designed to have clinical utility and interdisciplinary appeal. It also broadens the translational landscape by identifying 4 distinct treatment targets: underlying causes, procognitive factors, delirium (phenotype alone), and neurophysiologic targets.

Conclusions

This person-centered model aims to integrate delirium and acute encephalopathy within a single framework and shared nomenclature. It is hoped that this model aids in harmonizing research efforts and advancing clinical practice.

Association Between Sepsis and Microvascular Brain Injury

OBJECTIVES

Many survivors of sepsis suffer long-term cognitive impairment, but the mechanisms of this association remain unknown. The objective of this study was to determine whether sepsis is associated with cerebral microinfarcts on brain autopsy.

DESIGN

Retrospective cohort study.

SETTING AND SUBJECTS

Five-hundred twenty-nine participants of the Adult Changes in Thought, a population-based prospective cohort study of older adults carried out in Kaiser Permanente Washington greater than or equal to 65 years old without dementia at study entry and who underwent brain autopsy.

MEASUREMENTS AND MAIN RESULTS

Late-life sepsis hospitalization was identified using administrative data. We identified 89 individuals with greater than or equal to 1 sepsis hospitalization during study participation, 80 of whom survived hospitalization and died a median of 169 days after discharge. Thirty percent of participants with one or more sepsis hospitalization had greater than two microinfarcts, compared with 19% participants without (χ p = 0.02); 20% of those with sepsis hospitalization had greater than two microinfarcts in the cerebral cortex, compared with 10% of those without (χ p = 0.01). The adjusted relative risk of greater than two microinfarcts was 1.61 (95% CI, 1.01-2.57; p = 0.04); the relative risk for having greater than two microinfarcts in the cerebral cortex was 2.12 (95% CI, 1.12-4.02; p = 0.02). There was no difference in Braak stage for neurofibrillary tangles or consortium to establish a registry for Alzheimer's disease score for neuritic plaques between, but Lewy bodies were less significantly common in those with sepsis.

CONCLUSIONS

Sepsis was specifically associated with moderate to severe vascular brain injury as assessed by microvascular infarcts. This association was stronger for microinfarcts within the cerebral cortex, with those who experienced severe sepsis hospitalization being more than twice as likely to have evidence of moderate to severe cerebral cortical injury in adjusted analyses. Further study to identify mechanisms for the association of sepsis and microinfarcts is needed.