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Benzodiazepine Treatment and Hospital Course of Medical Inpatients With Alcohol Withdrawal Syndrome in the Veterans Health Administration. Mayo Clin Proc Innov Qual Outcomes 2022; 6:126-136. [PMID: 35224452 PMCID: PMC8855212 DOI: 10.1016/j.mayocpiqo.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Vadagandla K, Sridhar Reddy P, Antony S, Prasanthy Reddy P. A Case of Refractory Delirium Managed by a Multimodal Approach Using Atypical Antipsychotics, Antidepressants, and Benzodiazepines in an ICU Setting. Cureus 2022; 14:e23354. [PMID: 35475066 PMCID: PMC9019854 DOI: 10.7759/cureus.23354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Delirium is an acute confusional state, most commonly observed in elderly patients admitted to the critical care unit. In most cases, early recognition, avoiding triggering factors and conservative measures are adequate for the management, but sometimes symptoms persist despite adequate medical care, which goes in the favor of refractory delirium. Refractory delirium has no clear-cut definition but it is discussed in some of the case reports and literature as the presence of symptoms despite adequate treatment without impairing consciousness. Management of such refractory symptoms requires careful evaluation to identify the cause and predominant symptoms, which further helps in choosing a better therapeutic regime. It is often difficult to manage such cases and require sedatives and anti-psychotics to reverse the condition. Atypical antipsychotics are now playing a prominent role in the management of refractory delirium, and the selection of a drug that is suitable for the patient profile with negligible side effects is of utmost importance. We are presenting one such case, with multiple causes for his delirium, with a predominant hyperactive state and the refractory symptoms managed by atypical antipsychotics, antidepressants, and benzodiazepines.
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Oliveira J. e Silva L, Stanich JA, Jeffery MM, Lindroth HL, Miller DM, Campbell RL, Rabinstein AA, Pignolo RJ, Bellolio F. Association between emergency department modifiable risk factors and subsequent delirium among hospitalized older adults. Am J Emerg Med 2022; 53:201-207. [DOI: 10.1016/j.ajem.2021.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022] Open
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Liu Y, Song F, Yang Y, Yang S, Jiang M, Zhang W, Ma Z, Gu X. Mitochondrial DNA methylation drift and postoperative delirium in mice. Eur J Anaesthesiol 2022; 39:133-144. [PMID: 34726198 DOI: 10.1097/eja.0000000000001620] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mitochondrial dysfunction is linked to the etiopathogenesis of postoperative delirium (POD), which severely affects the prognosis of elderly patients undergoing surgery. The methylation of mitochondrial DNA (mtDNA), a new and incompletely described phenomenon that regulates the structure and function of mitochondria, is associated with ageing. However, the relationship between mtDNA methylation and POD has not been established. OBJECTIVE To explore the potential roles of mitochondrial epigenetic regulation in POD. DESIGN A randomised animal study. PARTICIPANTS Eighty-eight 6-month-old and one hundred seventy-six 18-month-old male C57BL/6N mice. INTERVENTIONS POD was induced by abdominal surgery under 1.4% isoflurane for 2 h. Behavioural tests were performed at 24 h before surgery and at 6, 9 and 24 h after surgery. MAIN OUTCOME MEASURES 5-methylcytosine (5-mC) at five CpG sites of the displacement loop (D-loop) and at 60 CpG sites of coding gene loci in the mitochondrial genome after surgery of the hippocampus, prefrontal cortex, amygdala and anterior cingulate cortex in 6 and 18-month-old mice were detected using bisulfite pyrosequencing. Mitochondrial structure, mitochondrial gene expression and mtDNA copy number were also examined using Electron microscopy and real time PCR to find the association with mtDNA methylation. RESULTS The mtDNA methylation drift manifested as a decrease in the methylation levels at the D-loop and an increase or decrease in the methylation levels at several coding gene loci, ultimately resulting in reduced mtDNA copy numbers, altered mitochondrial gene expression and damaged mitochondrial structures in the hippocampus and prefrontal cortex after surgery. The activation of Silent information regulator-1 (SIRT1) ameliorated anaesthesia-induced and surgery-induced mitochondrial dysfunction and delirium-like behaviours by regulating mtDNA methyltransferase-mediated mtDNA methylation. CONCLUSION These data support the existence of epigenetic mtDNA regulation in POD; however, further studies are required to explore the specific mechanisms. TRIAL REGISTRATION No 20181204 Drum tower hospital.
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Affiliation(s)
- Yue Liu
- From the Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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Featherstone I, Sheldon T, Johnson M, Woodhouse R, Boland JW, Hosie A, Lawlor P, Russell G, Bush S, Siddiqi N. Risk factors for delirium in adult patients receiving specialist palliative care: A systematic review and meta-analysis. Palliat Med 2022; 36:254-267. [PMID: 34930056 DOI: 10.1177/02692163211065278] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions. AIM To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care. DESIGN Systematic review and meta-analysis (PROSPERO CRD42019157168). DATA SOURCES CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed. RESULTS Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty. POTENTIALLY MODIFIABLE RISK FACTORS Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence). NON-MODIFIABLE RISK FACTORS Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium. CONCLUSIONS Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.
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Affiliation(s)
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, England, UK
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, England, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Peter Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Gregor Russell
- Bradford District Care NHS Foundation Trust, Saltaire, England, UK
| | - Shirley Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
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Association of Nutritional Status with New-Onset Delirium in Elderly, Acute Care, Orthopaedic Trauma Patients: A Single-Center Observational Study. J Orthop Trauma 2022; 36:67-72. [PMID: 35061654 DOI: 10.1097/bot.0000000000002213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether nutritional status at hospital admission is independently associated with new-onset delirium (NOD) in elderly, orthopaedic trauma patients. DESIGN Single-center, retrospective, cross-sectional study. SETTING Data from patients at a large teaching hospital in Boston, MA, were analyzed. PATIENTS All patients were ≥65 years and hospitalized for acute surgical management of their major fractures after trauma. INTERVENTION None. MAIN OUTCOME MEASUREMENT Nutritional status was assessed at admission using the Mini Nutritional Assessment-Short Form (MNA-SF). Delirium was assessed using the Confusion Assessment Method within 24 hours of admission and daily throughout hospitalization. RESULTS The incidence of delirium was 20% (94/471). Each unit decrement in MNA-SF was associated with a 14% higher risk of NOD (adjusted OR 1.14; 95% CI 1.05-1.28). Moreover, malnourished patients (MNA-SF score 0-7) were twice as likely to develop NOD (adjusted OR 2.07; 95% CI 1.01-4.35) compared with patients who were not malnourished (MNA-SF score 8-14). CONCLUSIONS In hospitalized, elderly, orthopaedic trauma patients, poor nutritional status may be a modifiable risk factor for NOD. Future studies are needed to determine whether aggressive nutritional interventions can reduce the incidence of NOD and improve outcomes in this cohort of patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Heylen A, Vermeiren Y, De Rooij SE, Scholtens RM, Van Munster BC, Van Dam D, De Deyn PP. Plasma 5-HIAA activity indicative of serotonergic disturbances in cognitively impaired, elderly patients experiencing postoperative delirium. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5677. [PMID: 34985774 PMCID: PMC9303571 DOI: 10.1002/gps.5677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/21/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Delirium frequently arises in older demented and non-demented patients in postoperative, clinical settings. To date, the underlying pathophysiological mechanisms remain poorly understood. Monoamine neurotransmitter alterations have been linked to delirium and cognitive impairment. Our aim was to investigate if this holds true in cognitively normal and impaired patients experiencing delirium following hip surgery. METHODS Monoamines and metabolites were measured in plasma samples of 181 individuals by means of reversed-phase ultra-high-performance liquid chromatography with electrochemical detection. Delirium and delirium severity were scored with the Confusion Assessment Method and Delirium Rating Scale-Revised-1998. Cognitive function was assessed using the Informant Questionnaire on Cognitive Decline and the Mini-Mental State Examination, multimorbidity with the Charlson Comorbidity Index. RESULTS Plasma 5-hydroxyindoleacetic acid (5-HIAA), the major metabolite of serotonin (5-HT), was significantly higher in delirious and non-delirious cognitively impaired subjects as compared to control individuals without delirium and cognitive impairment (p < 0.001 and p = 0.007), which remained highly significant after excluding patients taking psychotropic medication (p < 0.0001 and p = 0.003). No significant differences were found for cognitively normal delirious patients, although serotonergic levels were numerically higher compared to control counterparts. CONCLUSIONS Our findings indicate a general serotonergic disturbance in delirious and non-delirious postoperative patients suffering from cognitive impairment. We observed a similar, but less pronounced difference in delirious patients, which suggests serotonergic disturbances may be further aggravated by the co-occurrence of delirium and cognitive impairment.
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Affiliation(s)
- Annelies Heylen
- Laboratory of Neurochemistry and BehaviorUniversity of AntwerpAntwerpBelgium
| | - Yannick Vermeiren
- Laboratory of Neurochemistry and BehaviorUniversity of AntwerpAntwerpBelgium,Division of Human Nutrition and Health, Chair Group of Nutritional BiologyWageningen University and ResearchWageningenThe Netherlands
| | - Sophia E. De Rooij
- Department of Neurology and Alzheimer CenterUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands,Department of Internal Medicine, Geriatrics SectionAcademic Medical Center, University of AmsterdamAmsterdamThe Netherlands
| | - Rikie M. Scholtens
- Department of Neurology and Alzheimer CenterUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands,Department of Internal Medicine, Geriatrics SectionAcademic Medical Center, University of AmsterdamAmsterdamThe Netherlands
| | - Barbara C. Van Munster
- Department of Neurology and Alzheimer CenterUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Debby Van Dam
- Laboratory of Neurochemistry and BehaviorUniversity of AntwerpAntwerpBelgium,Department of Neurology and Alzheimer CenterUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Peter P. De Deyn
- Laboratory of Neurochemistry and BehaviorUniversity of AntwerpAntwerpBelgium,Department of Neurology and Alzheimer CenterUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
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Rengel KF, Boncyk CS, Hughes CG. Postoperative Delirium Prevention and Novel Cognitive Therapy Interventions. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00501-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lesko A, Kalafat N, Enoh K, Teltser WK. The Importance of Diagnosing Concomitant Delirium and Catatonia: A Case Report. Cureus 2022; 14:e21662. [PMID: 35233330 PMCID: PMC8881969 DOI: 10.7759/cureus.21662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 12/03/2022] Open
Abstract
Catatonia syndrome is characterized by motor, behavioral and affective abnormalities in association with psychiatric and medical illnesses and delirium syndrome is defined as acute brain dysfunction caused by an underlying medical condition or toxic exposure. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) contains a caveat that limits diagnosing catatonia in patients during delirium. However, the literature has shown that up to 31% of patients have co-occurring catatonia and delirium when using the Bush Francis Catatonia Rating Scale and 12.7% of patients with delirium meet DSM-5 criteria for catatonia. The authors present a case of a patient with concomitant delirium and catatonia. Diagnosing catatonia in this patient, even in the setting of delirium, was necessary for appropriate treatment and clinical improvement. Typical treatment for patients with delirium, antipsychotic medication, contributes to the worsening of catatonia while first-line treatment for catatonia, benzodiazepines, has been shown to exacerbate delirium. Delayed recognition of the patient’s catatonia resulted in inadequate treatment that worsened her catatonic symptoms and prolonged hospitalization. The potential contraindications to treatment interventions call for an appropriate diagnosis of catatonia when co-occurring with delirium despite the DSM-5 limitation. The World Health Organization (WHO) ICD-11 code for catatonia allows for less exclusivity in assessing for clinical catatonia in that the limitations to diagnosis only include harmful effects of drugs, medicaments or biological substance, not elsewhere classified - a more collaborative definition for catatonia criteria in the DSM-5 and the ICD-11 codes can provide a way forward with more flexibility in symptom interpretation and treatment.
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Pistacchi M, Gioulis M, Marsala SZ. Association between delirium and cognitive impairment: there is a link? Curr Alzheimer Res 2022; 19:47-55. [PMID: 35048808 DOI: 10.2174/1567205019666220120114552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delirium and dementia are both disorders involving global cognitive impairment that can occur separately or at the same time in the elderly. OBJECTIVE The aim of this study was to examine the frequency, correlation and relative risk between delirium and cognitive impairment in a prospective population study starting at basal line (onset of delirium) over a period of five years. The secondary aim was to determine any possible correlation between the kind of delirium and a specific type of dementia. MATERIAL AND METHODS We studied 325 patients, diagnosed according to the DSM-IV. The neuropsychological, moods and delirium disorders were evaluated with Hamilton Depression Rating Scale, Delirium Rating Scale-Revised-98, MMSE, Rey auditory-verbal learning test, Digit Span, Symbol Digit Modalities Test, Raven Progressive Matrices, ADL and IADL. RESULTS The prevalence of delirium in our population was 89 cases (27.4%): 78 patients (48 women and 30 men) showed evolution toward dementia (mean age was 67.9 ± 6.1 years for men and 68.4 ± 9.1 for women), and 11 patients (5 men and 6 women) presented only isolated delirium without evolution toward cognitive impairment (mean age of men was 68.1 ± 5.1 years and of women 66.4 ± 7.1). The neuropsychological study of the patients with delirium with dementia evolution revealed statistically significant differences over time with statistically significant intergroup difference and predisposition toward depression. CONCLUSION The association between delirium and cognitive impairment and the possible role of delirium as an early marker of neurodegenerative diseases need to be future investigated.
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Affiliation(s)
- Michele Pistacchi
- Neurology Service, San Giacomo Hospital, Via dei Carpani 16z, 31033 Castelfranco Veneto (TV), Italy
| | - Manuela Gioulis
- San Martino Hospital, Belluno, Neurology Service, viale europa 22 Belluno, Italy
| | - Sandro Zambito Marsala
- Department od Neurology, Ospedale San Martino, Neurology Service, viale europa 22 Belluno, Italy
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Kappenschneider T, Meyer M, Maderbacher G, Parik L, Leiss F, Quintana LP, Grifka J. [Delirium-an interdisciplinary challenge]. DER ORTHOPADE 2022; 51:106-115. [PMID: 35037987 DOI: 10.1007/s00132-021-04209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients. DIAGNOSTIC Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential. TREATMENT In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.
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Affiliation(s)
- Tobias Kappenschneider
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Matthias Meyer
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Günther Maderbacher
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Lukas Parik
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Franziska Leiss
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Loreto Pulido Quintana
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Shoulders BR, Elsabagh S, Tam DJ, Frantz AM, Alexander KM, Voils SA. Risk Factors for Delirium and Association of Antipsychotic Use with Delirium Progression in Critically Ill Trauma Patients. Am Surg 2022:31348211069792. [DOI: 10.1177/00031348211069792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Delirium occurs frequently in critically ill and injured patients and is associated with significant morbidity and mortality. Limited data exists on the risk factors for developing delirium in critically ill trauma patients and the effect of antipsychotic (AP) medications on delirium progression. Objective The objective of this study is to determine the incidence of delirium in critically ill trauma versus non-trauma surgical patients and determine if the presence of trauma was associated with intensive care unit (ICU) delirium. Secondary outcomes included identifying risk factors for delirium and determining the impact of AP medication use on delirium progression in critically ill trauma patients. Methods This retrospective review studies adult trauma/surgical ICU patients admitted between May 2017-July 2018 to a level I trauma and tertiary referral center. Regression modeling was used to determine the impact of AP use on delirium-free days. Results Delirium was more common in critically ill trauma patients versus non-trauma surgical ICU patients [54/157 (34.4%) vs 42/270 (15.6%), P < .001]. Of the 54 trauma patients with delirium, 28 (52%) received an AP medication for delirium treatment and in the multiple linear regression analysis, AP use was significantly associated with fewer delirium-free days ( P = .02). Discussion Higher admission sequential organ failure assessment scores and increased length of stay were significantly associated with delirium onset in critically ill trauma patients. Use of AP medications for delirium treatment in this population had a negative impact on delirium-free days.
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Affiliation(s)
- Bethany R. Shoulders
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Sarah Elsabagh
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Douglas J. Tam
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Amanda M. Frantz
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kaitlin M. Alexander
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Stacy A. Voils
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
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Alqadheeb N, Hashhoush M, Alharthy A, Mahmood N, Alfardan Z, Amin R, Maghrabi K, Almaani M, Alyamany M, Alenezi F, Alruwaili A, Alkhatib K, Rugaan A, Eltatar F, Algethamy H, Abudayah A, Ghabashi A, ElRakaiby G, Alkatheeri K, Alarifi M, Al Mubarak Y, Ismail N, Alnajdi I, Ahmed MI, Alansari M, Alenazi A, Almuslim O. Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter observational study. Int J Crit Illn Inj Sci 2022; 12:70-76. [PMID: 35845124 PMCID: PMC9285125 DOI: 10.4103/ijciis.ijciis_76_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Delirium in critically ill patients is independently associated with poor clinical outcomes. There is a scarcity of published data on the prevalence of delirium among critically ill patients in Saudi Arabia. Therefore, we sought to determine, in a multicenter fashion, the prevalence of delirium in critically ill patients in Saudi Arabia and explore associated risk factors. Methods: A cross-sectional point prevalence study was conducted on January 28, 2020, at 14 intensive care units (ICUs) across 3 universities and 11 other tertiary care hospitals in Saudi Arabia. Delirium was screened once using the Intensive Care Delirium Screening Checklist. We excluded patients who were unable to participate in a valid delirium assessment, patients admitted with traumatic brain injury, and patients with documented dementia in their medical charts. Results: Of the 407 screened ICU patients, 233 patients were enrolled and 45.9% were diagnosed with delirium. The prevalence was higher in mechanically ventilated patients compared to patients not mechanically ventilated (57.5% vs. 33.6%; P < 0.001). In a multivariate model, risk factors independently associated with delirium included age (adjusted odds ratio [AOR], 1.021; 95% confidence interval [CI], 1.01–1.04; P = 0.008), mechanical ventilation (AOR, 2.39; 95% CI, 1.34–4.28; P = 0.003), and higher severity of illness (AOR, 1.01; 95% CI, 1.001–1.021; P = 0.026). Conclusion: In our study, delirium remains a prevalent complication, with distinct risk factors. Further studies are necessary to investigate long-term outcomes of delirium in critically ill patients in Saudi Arabia.
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Brain Prehabilitation for Oncologic Surgery. Curr Oncol Rep 2022; 24:1513-1520. [PMID: 35900715 PMCID: PMC9606060 DOI: 10.1007/s11912-022-01312-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the current research on postoperative cognitive complications, such as delirium and cognitive dysfunction. This includes discussion on preoperative preventive strategies, such as physical and nutritional prehabilitation as well as up-to-date information on neuroprehabilitation. RECENT FINDINGS Current recommendations for prevention of postoperative delirium have focused on multicomponent interventions. The optimal composition of surgical prehabilitation programs targeting exercise and nutrition has not yet been established. The Neurobics Trial shows that cognitive prehabilitation improves cognitive reserve and may be a useful addition to multimodal surgical prehabilitation. Perioperative management of oncologic patients is often associated with a myriad of challenges, such as the management of tumor-related pathologies, adverse events from neoadjuvant therapy, and chronic metabolic and immunological changes associated with malignancy. In addition, oncologic patients are at increased risk of developing frailty, which adversely affects postoperative recovery and further cancer treatment. As a result, oncologic patients are at considerable risk of developing postoperative cognitive complications, such as delirium and cognitive dysfunction. In this review, we discuss the effect of prehabilitation on postoperative cognitive outcomes.
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Malik J. Animal-Assisted Interventions in Intensive Care Delirium: A Literature Review. AACN Adv Crit Care 2021; 32:391-397. [PMID: 34879136 DOI: 10.4037/aacnacc2021708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Critical illness has lasting consequences on the mind and the body. Acute sequelae include a decline in cognitive function known as delirium. Increased interest in improving outcomes for intensive care unit survivors without a high incidence of delirium has initiated a focus on an array of nonpharmacologic interventions in many countries. One such intervention is animalassisted intervention. As the role of animals in human healing is being recognized by clinicians, need is increasing for formal and professionally directed therapies. This review ascertains the effect of interaction with animals on critically ill patients. Emerging evidence indicates that animal-assisted intervention improves the efficacy of critical care regarding primary symptoms and secondary factors of delirium.
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Affiliation(s)
- Jahanzeb Malik
- Jahanzeb Malik is the Senior Registrar, Emergency and Critical Care, Rawalpindi Institute of Cardiology, Rawal Road, Rawalpindi, 46000, Pakistan
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Jäckel M, Zotzmann V, Wengenmayer T, Duerschmied D, Biever PM, Spieler D, von Zur Mühlen C, Stachon P, Bode C, Staudacher DL. Incidence and predictors of delirium on the intensive care unit after acute myocardial infarction, insight from a retrospective registry. Catheter Cardiovasc Interv 2021; 98:1072-1081. [PMID: 32926556 DOI: 10.1002/ccd.29275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study aimed to identify the incidence and potential risk factors for delirium after myocardial infarction (MI). BACKGROUND Delirium is a common complication on intensive care units. Data on incidence and especially on predictors of delirium in patients after acute MI are rare. METHODS In this retrospective study, all patients hospitalized for MI treated with coronary angiography in an university hospital in 2018 were included and analyzed. Onset of delirium within the first 5 days after MI was attributed to the MI and was defined by a Nursing Delirium screening scale (NuDesc) ≥2. This score is taken as part of daily care in every patient on intensive care unit three times a day by especially trained nurses. RESULTS A total of 624 patients with MI (age 68.5 ± 13.2 years, ST-elevation MI 41.6%, hospital mortality 3.2%) were included in the study. Delirium was detected in 10.9% of all patients. In the subgroup of patients with a stay on the intensive care unit (ICU) for more than 24 hr (n = 229), delirium was detected in 29.7%. Hospital and ICU stay were significantly longer in patients with delirium (p < .001). Delirium was an independent predictor of prolonged ICU-stay. Independent predictors of delirium were age, dementia, alcohol abuse, cardiac arrest, hypotension, and leucocytosis. Infarct size or presentation with ST-elevation were not associated with incidence of delirium. CONCLUSION Development of delirium is frequent after acute MI and prolongs hospitalization. Incidence of delirium is associated with clinical instability, preexisting comorbidity, and age rather than MI type or size.
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Affiliation(s)
- Markus Jäckel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M Biever
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Derek Spieler
- Department of Psychosomatic Medicine and Psychotherapy, Center for Mental Health, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Wang D, Li R, Li S, Wang J, Zeng M, Dong J, Liu X, Lin N, Peng Y. Effect of dexmedetomidine on postoperative delirium in patients undergoing brain tumour resections: study protocol of a randomised controlled trial. BMJ Open 2021; 11:e051584. [PMID: 34758995 PMCID: PMC8587577 DOI: 10.1136/bmjopen-2021-051584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication. The incidence of POD is about 25% in non-cardiac surgery and ranges from 10% to 30% in neurological procedures. A lot of trials show that dexmedetomidine might help to reduce the incidence of delirium in patients undergoing non-cardiac surgery. However, the impact of dexmedetomidine on POD for patients undergoing craniotomy and tumour resections remains unclear. METHODS AND ANALYSIS The study is a prospective, single-centre, randomised, double-blinded, paralleled-group controlled trial. Patients undergoing elective frontotemporal tumour resections will be randomly assigned to the dexmedetomidine group and the control group. After endotracheal intubation, patients in the dexmedetomidine group will be administered with a loading dose of dexmedetomidine 0.6 µg/kg in 10 min followed by continuous infusion at a rate of 0.4 µg/kg/hour until the start of dural closure. In the control group, patients will receive the identical volume of normal saline in the same setting. The primary outcome will be the cumulative incidence of POD within 5 days. The delirium assessment will be performed by using the confusion assessment method in the first 5 consecutive days after surgery. Secondary outcomes include the pain severity assessed by Numerical Rating Scale pain score, quality of postoperative sleep assessed by the Richards Campbell sleep questionnaire and postoperative quality of recovery from anaesthesia by the Postoperative Quality Recovery Scale. ETHICS AND DISSEMINATION The protocol (V.1.0, 10 November 2020) has been approved by the Ethics Review Committee of the Chinese Clinical Trial Registry (number ChiECRCT-20200436). The findings of the study will be disseminated in a peer-reviewed journal and at a scientific conference. TRIAL REGISTRATION NUMBER NCT04674241.
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Affiliation(s)
- Dexiang Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Ruowen Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Nan Lin
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
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68
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Seiler A, Meyer R, Boettger S. [Delirium Management in Palliative Care]. PRAXIS 2021; 110:872-878. [PMID: 34814715 DOI: 10.1024/1661-8157/a003782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Delirium Management in Palliative Care Abstract. Delirium is one of the most common neuropsychiatric complications in patients with advanced incurable disease. End-of-life delirium is common but is often overlooked, undiagnosed or incorrectly diagnosed/untreated. Delirium should also be treated in a palliative situation - as far as possible - because persistent delirious states increase the patient's fragility, limit physical functionality and shorten the lifespan. In addition, acute states of confusion trigger high levels of distress in affected patients and their relatives, impair the quality of life and a dignified dying process. While hallucinations and visions at the end of life are interpreted as delirium in medicine and treated as such, this phenomenon is interpreted by philosophical and theological hermeneutics as a resource that can help patients and their relatives to reconcile with past life events and to deal with the process of dying. However, the occurrence of end-of-life visions as opposed to delirium has not yet been studied very much and requires more detailed exploration.
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Affiliation(s)
- Annina Seiler
- Kompetenzzentrum Palliative Care, Klinik für Radio-Onkologie, Universitätsspital Zürich, Universität Zürich, Zürich
| | - Rafael Meyer
- Klinik für Konsiliar-, Alters- und Neuropsychiatrie, Zentrum für Konsiliar- und Liaisonpsychiatrie und Psychosomatik, Psychiatrische Dienste Aargau AG, Windisch
| | - Soenke Boettger
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Universität Zürich, Zürich
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Zipser CM, Hildenbrand FF, Haubner B, Deuel J, Ernst J, Petry H, Schubert M, Jordan KD, von Känel R, Boettger S. Predisposing and Precipitating Risk Factors for Delirium in Elderly Patients Admitted to a Cardiology Ward: An Observational Cohort Study in 1,042 Patients. Front Cardiovasc Med 2021; 8:686665. [PMID: 34660708 PMCID: PMC8513394 DOI: 10.3389/fcvm.2021.686665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: Although the risk factors for delirium in general medicine are well-established, their significance in cardiac diseases remains to be determined. Therefore, we evaluated the predisposing and precipitating risk factors in patients hospitalized with acute and chronic heart disease. Methods and Results: In this observational cohort study, 1,042 elderly patients (≥65 years) admitted to cardiology wards, 167 with and 875 without delirium, were included. The relevant sociodemographic and cardiac- and medical-related clusters were assessed by simple and multiple regression analyses and prediction models evaluating their association with delirium. The prevalence of delirium was 16.0%. The delirious patients were older (mean 80 vs. 76 years; p < 0.001) and more often institutionalized prior to admission (3.6 vs. 1.4%, p = 0.05), hospitalized twice as long (12 ± 10 days vs. 7 ± 7 days; p < 0.001), and discharged more often to nursing homes (4.8 vs. 0.6%, p < 0.001) or deceased (OR, 2.99; 95% CI, 1.53–5.85; p = 0.003). The most relevant risk factor was dementia (OR, 18.11; 95% CI, 5.77–56.83; p < 0.001), followed by history of stroke (OR, 6.61; 95% CI 1.35–32.44; p = 0.020), and pressure ulcers (OR, 3.62; 95% CI, 1.06–12.35; p = 0.040). The predicted probability for developing delirium was highest in patients with reduced mobility and institutionalization prior to admission (PP = 31.2%, p = 0.001). Of the cardiac diseases, only valvular heart disease (OR, 1.57; 95% CI, 1.01–2.44; p = 0.044) significantly predicted delirium. The patients undergoing cardiac interventions did not have higher rates of delirium (OR, 1.39; 95% CI 0.91–2.12; p = 0.124). Conclusion: In patients admitted to a cardiology ward, age-related functional and cognitive impairment, history of stroke, and pressure ulcers were the most relevant risk factors for delirium. With regards to specific cardiological factors, only valvular heart disease was associated with risk for delirium. Knowing these factors can help cardiologists to facilitate the early detection and management of delirium.
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Affiliation(s)
- Carl Moritz Zipser
- Consultation-Liaison Psychiatry and Psychosomatic Medicine, University of Zurich, University Hospital Zurich, Zurich, Switzerland.,Department of Neurology and Neurophysiology, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | | | - Bernhard Haubner
- Department of Cardiology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Jeremy Deuel
- Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom.,Department of Hematology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center for Clinical Nursing Science, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Heidi Petry
- Center for Clinical Nursing Science, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Maria Schubert
- Zurich University of Applied Science, School of Health Professions, Winterthur, Switzerland
| | - Katja-Daniela Jordan
- Consultation-Liaison Psychiatry and Psychosomatic Medicine, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Roland von Känel
- Consultation-Liaison Psychiatry and Psychosomatic Medicine, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Soenke Boettger
- Consultation-Liaison Psychiatry and Psychosomatic Medicine, University of Zurich, University Hospital Zurich, Zurich, Switzerland
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Son CS, Kang WS, Lee JH, Moon KJ. Machine Learning to Identify Psychomotor Behaviors of Delirium for Patients in Long-Term Care Facility. IEEE J Biomed Health Inform 2021; 26:1802-1814. [PMID: 34596563 DOI: 10.1109/jbhi.2021.3116967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study aimed to develop accurate and explainable machine learning models for three psychomotor behaviors of delirium for hospitalized adult patients. A prospective pilot study was conducted with 33 participants admitted to a long-term care facility between August 10 and 25, 2020. During the pilot study, we collected 560 cases that included 33 clinical variables and the survey items from the short confusion assessment method (S-CAM), and developed a mobile-based application. Multiple machine learning algorithms, including four rule-mining algorithms (C4.5, CBA, MCAR, and LEM2) and four other statistical learning algorithms (LR, ANNs, SVMs with three kernel functions, and random forest), were validated by paired Wilcoxon signed-rank tests on both macro-averaged F1 and weighted average F1-measures during the 10-times stratified 2-fold cross-validation. The LEM2 algorithm achieved the best prediction performance (macro-averaged F1-measure of 49.35%; weighted average F1-measure of 96.55%), correctly identifying adult patients at delirium risk. In the pairwise comparison between predictive powers observed from independent models, the LEM2 model showed a medium or large effect size between 0.4925 and 0.8766 when compared with LR, ANN, SVM with RBF, and MCAR models. We have confirmed that acute consciousness in S-CAM assessment is closely associated with different predictors for screening three psychomotor behaviors of delirium: 1) education level, dementia type or its level, sleep disorder, dehydration, and infection in mixed-type delirium; 2) gender, education level, dementia type, dehydration, bedsores, and foley catheter in hyperactive delirium; and 3) pain, sleep disorder, and haloperidol use in hypoactive delirium.
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71
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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Hariyanto TI, Putri C, Hananto JE, Arisa J, Fransisca V Situmeang R, Kurniawan A. Delirium is a good predictor for poor outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A systematic review, meta-analysis, and meta-regression. J Psychiatr Res 2021; 142:361-368. [PMID: 34425488 PMCID: PMC8376475 DOI: 10.1016/j.jpsychires.2021.08.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
AIM Delirium is a common presenting symptom among older patients. Patients who presented with delirium may have a higher morbidity and mortality rate due to older age, other comorbidities, and atypical COVID-19 presentation. Currently, the evidence supporting delirium as one of the predictors of poor outcome of COVID-19 is still insufficient. This study aims to explore the potential association between delirium and poor outcomes from COVID-19. METHODS We systematically searched the PubMed and Google Scholar databases using specific keywords related to our aims until January 30th, 2021. All articles published on COVID-19 and delirium were retrieved. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies and Joanna Briggs Institute (JBI) Critical Appraisal Tools for case-series studies. Statistical analysis was done using Review Manager 5.4 software. RESULTS Our meta-analysis of 20 studies showed that delirium symptoms on admission was associated with poor outcomes from COVID-19 [OR 2.36 (95% CI 1.80-3.09), p < 0.00001, I2 = 76%, random-effect models] and its subgroup which consist of severe COVID-19 [OR 3.89 (95% CI 1.72-8.75), p = 0.001, I2 = 91%, random-effect models], and mortality from COVID-19 [OR 1.90 (95% CI 1.55-2.33), p < 0.00001, I2 = 36%, random-effect models]. Meta-regression showed that the association was influenced by age (p = 0.005). CONCLUSIONS Our study suggests delirium as an important marker to identify patients at higher risk for developing poor COVID-19 outcomes. The physicians should add delirium as one of the common presenting symptoms of COVID-19 in older populations.
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Affiliation(s)
- Timotius Ivan Hariyanto
- Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia
| | - Cynthia Putri
- Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia
| | - Joshua Edward Hananto
- Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia
| | - Jessie Arisa
- Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia
| | - Rocksy Fransisca V Situmeang
- Department of Neurology, Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia
| | - Andree Kurniawan
- Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman Street, Karawaci, Tangerang, 15811, Indonesia.
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Delirium risk of histamine-2 receptor antagonists and proton pump inhibitors: A study based on the adverse drug event reporting database in Japan. Gen Hosp Psychiatry 2021; 72:88-91. [PMID: 34352509 DOI: 10.1016/j.genhosppsych.2021.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Although histamine-2 receptor antagonists (H2RAs) have been shown to be more likely to cause delirium than proton pump inhibitors (PPIs), these results were not adjusted for potential confounding factors. Accordingly, we investigated whether H2RAs and PPIs are risk factors for delirium, even when adjusting for other risk factors by analyzing adverse drug event reports compiled in the post-marketing stages of drugs provided by the Japanese regulatory authorities. METHOD We analyzed 577,431 reports in the Japanese Adverse Drug Event Report database from April 2004 to July 2020. RESULTS Of all reports analyzed, 2532 described delirium, and 574,899 described other adverse events. Delirium was associated with H2RAs (crude reporting odds ratio, ROR, 4.17; 95% CI, 3.34-5.22) but not PPIs (crude ROR 0.62; 95% CI 0.43-0.90). Even with adjustment for age, sex, history of dementia or depression, and concomitant drugs reported as risk factors for delirium, the use of H2RAs showed a significantly higher adjusted ROR than that of PPIs (H2RAs: adjusted ROR 3.99; 95% CI 3.18-5.01 and PPIs: adjusted ROR 0.58; 95%CI 0.40-0.84). CONCLUSIONS These results suggest that, from a cognitive perspective, PPIs may be preferable to H2RAs for patients with or at risk for delirium.
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Incidence and predictors of delirium on the intensive care unit in patients with acute kidney injury, insight from a retrospective registry. Sci Rep 2021; 11:17260. [PMID: 34446816 PMCID: PMC8390667 DOI: 10.1038/s41598-021-96839-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/17/2021] [Indexed: 11/12/2022] Open
Abstract
Acute kidney injury (AKI) and delirium are common complications on the intensive care unit (ICU). Few is known about the association of AKI and delirium, as well as about incidence and predictors of delirium in patients with AKI. In this retrospective study, all patients with AKI, as defined by the KDIGO (kidney disease improving global outcome) guideline, treated for more than 24 h on the ICU in an university hospital in 2019 were included and analyzed. Delirium was defined by a NuDesc (Nursing Delirium screening scale) ≥ 2, which is evaluated three times a day in every patient on our ICU as part of daily routine. A total of 383/919 (41.7%) patients developed an AKI during the ICU stay. Delirium was detected in 230/383 (60.1%) patients with AKI. Independent predictors of delirium were: age, psychiatric disease, alcohol abuse, mechanical ventilation, severe shock, and AKI stage II/III (all p < 0.05). The primary cause of illness had no influence on the onset of delirium. Among patients with AKI, the duration of the ICU stay correlated with higher stages of AKI and the presence of delirium (stage I/no delirium: median 1.9 (interquartile range (25th–75th) 1.3–2.9) days; stage II/III/no delirium: 2.6 (1.6–5.5) days; stage I/delirium: 4.1 (2.5–14.3) days; stage II/III/delirium: 6.8 (3.5–11.9) days; all p < 0.01). Delirium, defined as NuDesc ≥ 2 is frequent in patients with AKI on an ICU and independently predicted by higher stages of AKI.
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Reducing Delirium in Hospitalized Adults Through a Structured Sleep Promotion Program. J Nurs Care Qual 2021; 36:149-154. [PMID: 32568963 DOI: 10.1097/ncq.0000000000000499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delirium affects approximately 1 in 4 patients during their hospitalization and is associated with numerous complications. Sleep deprivation is a significant risk factor for developing delirium and is a patient dissatisfier. PROBLEM An internal assessment revealed that up to 25% of all patients on medical-surgical units had a diagnosis of delirium while in the hospital. APPROACH An evidence-based practice project was implemented to reduce the development of delirium through sleep promotion on 2 inpatient units. A dedicated time was selected, and key strategies were identified to promote sleep with minimal interruptions. OUTCOMES Delirium decreased by 33% and 45% on the 2 units over 1 year. Overall, patient satisfaction for quietness at night survey responses also increased (P = .0005; CI, 0.05 to 0.67) with ongoing sustainment. CONCLUSIONS Implementation of a dedicated period to sleep was associated with a reduction in delirium and increased patient satisfaction for quietness at night.
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Kappen PR, Kakar E, Dirven CMF, van der Jagt M, Klimek M, Osse RJ, Vincent APJE. Delirium in neurosurgery: a systematic review and meta-analysis. Neurosurg Rev 2021; 45:329-341. [PMID: 34396454 PMCID: PMC8827408 DOI: 10.1007/s10143-021-01619-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/08/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022]
Abstract
Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.
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Affiliation(s)
- P R Kappen
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.
| | - E Kakar
- Department of Neuroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - C M F Dirven
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - R J Osse
- Department of Psychiatry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A P J E Vincent
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Mart MF, Pun BT, Pandharipande P, Jackson JC, Ely EW. ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness. Crit Care Med 2021; 49:1227-1240. [PMID: 34115639 PMCID: PMC8282752 DOI: 10.1097/ccm.0000000000005125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Brenda T Pun
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
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Ouchi K, Liu S, Tonellato D, Keschner YG, Kennedy M, Levine DM. Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities. J Am Coll Emerg Physicians Open 2021; 2:e12517. [PMID: 34322684 PMCID: PMC8295243 DOI: 10.1002/emp2.12517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Shan Liu
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Daniel Tonellato
- Department of Emergency MedicineMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
- Department of Emergency MedicineGeorgetown University School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Yonatan G. Keschner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Maura Kennedy
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - David M. Levine
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
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Pal S, Sharma N, Singh SM, Kumar S, Pannu AK. A prospective cohort study on predictors of mortality of delirium in an emergency observational unit. QJM 2021; 114:246-251. [PMID: 32483589 DOI: 10.1093/qjmed/hcaa183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delirium is often an underdiagnosed and underestimated neuropsychiatric syndrome, especially in low- and middle-income countries. AIM To document the prevalence and clinical profile of delirium and to detect the baseline parameters associated with in-hospital mortality. DESIGN A prospective cohort study conducted between January 2016 to December 2016 at an adult medical emergency observational unit of an academic hospital in north India. METHODS Confusion Assessment Method for the intensive care unit was used for screening and diagnosis of delirium. Subtypes of delirium and severity were defined with the Richmond agitation-sedation scale and Delirium Rating Scale-Revised-98 (DRS-R-98). RESULTS Out of 939 screened patients, 312 (33.2%) had delirium, including 73.7% unrecognized cases. The mean age was 49.1 ± 17.3 years (range 17-90), and only 33.3% of the patients were above 60 years. The prevalence of hypoactive, mixed and hyperactive delirium was 39.1, 33.7 and 27.2%, respectively. Usual predisposing factors were alcohol use disorder (57.4%) and hypertension (51.0%), and infections remain the most common precipitating factors (42.0%). In total, 96.1% of patients received midazolam before delirium onset, and physical restraints were used in 73.4%. Mortality was higher in delirium (19.9% vs. 6.4%). The independent predictors of death in delirium were low diastolic blood pressure (P-value = 0.000), Glasgow coma scale score <15 (P = 0.026), high Acute Physiology and Chronic Health Evaluation II score (P = 0.007), high DRS-R-98 severity score (P = 0.000) and hyperactive delirium (P = 0.024). CONCLUSION Rapid screening with Confusion Assessment Method for the intensive care unit detected a high prevalence of delirium (even in young patients), and it associated with high mortality.
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Affiliation(s)
- S Pal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S M Singh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, 3rd Floor, Cobalt Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
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Li X, Wang Y, Liu J, Xiong Y, Chen S, Han J, Xie W, Wu Q. Effects of perioperative interventions for preventing postoperative delirium: A protocol for systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26662. [PMID: 34398027 PMCID: PMC8294881 DOI: 10.1097/md.0000000000026662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) not only increases the medical burden but also adversely affects patient prognosis. Although some cases of delirium can be avoided by early intervention, there is no clear evidence indicating whether any of these measures can effectively prevent POD in specific patient groups. OBJECTIVE The aim of this meta-analysis was to compare the efficacy and safety of the existing preventive measures for managing POD. METHODS The PubMed, OVID (Embase and MEDLINE), Web of Science, and the Cochrane Library databases were searched for articles published before January 2020. The relevant randomized controlled trials (RCTs) were selected based on the inclusion and exclusion criteria. Data extraction and methodological quality assessment were performed according to a predesigned data extraction form and scoring system, respectively. The interventions were compared on the basis of the primary outcome like incidence of POD, and secondary outcomes like duration of delirium and the length of intensive care unit and hospital stay. RESULTS Sixty-three RCTs were included in the study, covering interventions like surgery, anesthesia, analgesics, intraoperative blood glucose control, cholinesterase inhibitors, anticonvulsant drugs, antipsychotic drugs, sleep rhythmic regulation, and multi-modal nursing. The occurrence of POD was low in 4 trials that monitored the depth of anesthesia with bispectral index during the operation (P < .0001). Two studies showed that supplementary analgesia was useful for delirium prevention (P = .002). Seventeen studies showed that perioperative sedation with α2-adrenergic receptor agonists prevented POD (P = .0006). Six studies showed that both typical and atypical antipsychotic drugs can reduce the incidence of POD (P = .002). Multimodal nursing during the perioperative period effectively reduced POD in 6 studies (P < .00001). Furthermore, these preventive measures can reduce the duration of delirium, as well as the total and postoperative length of hospitalized stay for non-cardiac surgery patients. For patients undergoing cardiac surgery, effective prevention can only reduce the length of intensive care unit stay. CONCLUSION Measures including intraoperative monitoring of bispectral index, supplemental analgesia, α2-adrenergic receptor agonists, antipsychotic drugs, and multimodal care are helpful to prevent POD effectively. However, larger, high-quality RCTs are needed to verify these findings and develop more interventions and drugs for preventing postoperative delirium.
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Kracht F, Boekholt M, Schumacher-Schönert F, Nikelski A, Chikhradze N, Lücker P, Vollmar HC, Hoffmann W, Kreisel SH, Thyrian JR. Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital - cross-sectional results of the intersec-CM study. BMC Geriatr 2021; 21:425. [PMID: 34253180 PMCID: PMC8276375 DOI: 10.1186/s12877-021-02298-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care. METHODS The analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs. RESULTS The sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment. CONCLUSIONS Descriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care. TRIAL REGISTRATION The intersec-CM trial is registered at ClinicalTrials.gov ( NCT03359408 ).
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Affiliation(s)
- F Kracht
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
| | - M Boekholt
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
| | - F Schumacher-Schönert
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany
| | - A Nikelski
- Evangelisches Klinikum Bethel, Campus Bielefeld-Bethel, Division of Geriatric Psychiatry, Universitätsklinikum OWL der Universität Bielefeld, Bielefeld, Germany
| | - N Chikhradze
- Institute of General Practice and Family Medicine (AM RUB), Faculty of Medicine, Ruhr University Bochum (RUB), Bochum, Germany
| | - P Lücker
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany
| | - H C Vollmar
- Institute of General Practice and Family Medicine (AM RUB), Faculty of Medicine, Ruhr University Bochum (RUB), Bochum, Germany
| | - W Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany
| | - S H Kreisel
- Evangelisches Klinikum Bethel, Campus Bielefeld-Bethel, Division of Geriatric Psychiatry, Universitätsklinikum OWL der Universität Bielefeld, Bielefeld, Germany
| | - J R Thyrian
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany.
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82
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Nakamura ZM, Deal AM, Park EM, Quillen LJ, Chien SA, Stanton KE, McCabe SD, Heiling HM, Wood WA, Shea TC, Rosenstein DL. A randomized double-blind placebo-controlled trial of intravenous thiamine for prevention of delirium following allogeneic hematopoietic stem cell transplantation. J Psychosom Res 2021; 146:110503. [PMID: 33945982 PMCID: PMC8172461 DOI: 10.1016/j.jpsychores.2021.110503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if high dose intravenous (IV) thiamine can prevent delirium during hospitalization following allogeneic HSCT. Secondarily, we evaluated the effects of high dose IV thiamine on thiamine levels and explored risk factors for delirium. METHODS Randomized, double-blind, placebo-controlled trial in patients undergoing allogeneic HSCT at a U.S. academic medical center between October 2017 and March 2020. 64 participants were randomized 1:1 to thiamine 200 mg IV three times daily for 7 days or placebo. We used the Delirium Rating Scale to assess for delirium. Delirium incidence was compared between groups using the chi-square test. Group differences in time to onset and duration of delirium were compared using the Kaplan-Meier method. Fisher's Exact and Wilcoxon Rank Sum tests were used to examine associations between pre-transplantation variables and delirium. RESULTS 61 participants were analyzed. Delirium incidence (25% vs. 21%, Chi-square (df = 1) = 0.12, p = 0.73), time to onset, duration, and severity were not different between study arms. Immediately following the intervention, thiamine levels were higher in the thiamine arm (275 vs. 73 nmol/L, t-test (df = 57) = 13.63, p < 0.0001), but not predictive of delirium. Variables associated with delirium in our sample included disease severity, corticosteroid exposure, infection, and pre-transplantation markers of nutrition. CONCLUSION High dose IV thiamine did not prevent delirium in patients receiving allogeneic HSCT. Given the multiple contributors to delirium in this population, further research regarding the efficacy of multicomponent interventions may be needed. TRIAL REGISTRATION Clinical Trials NCT03263442. FUNDING Rising Tide Foundation for Clinical Cancer Research.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate E Stanton
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean D McCabe
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hillary M Heiling
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Oliveira J E Silva L, Berning MJ, Stanich JA, Gerberi DJ, Murad MH, Han JH, Bellolio F. Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2021; 78:549-565. [PMID: 34127307 DOI: 10.1016/j.annemergmed.2021.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
| | - Michelle J Berning
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; University of Minnesota Medical School, Minneapolis, MN
| | | | | | - Mohammad Hassan Murad
- Department of Internal Medicine, Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
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Wang A, Park A, Albert R, Barriga A, Goodrich L, Nguyen BN, Knox E, Preda A. Iatrogenic Delirium in Patients on Symptom-Triggered Alcohol Withdrawal Protocol: A Case Series. Cureus 2021; 13:e15373. [PMID: 34249526 PMCID: PMC8248506 DOI: 10.7759/cureus.15373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/15/2022] Open
Abstract
In this report, we present a case series involving four patients placed on the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) protocol for alcohol or sedative-hypnotic withdrawal syndromes, who developed delirium on sustained or increasing symptom-triggered benzodiazepine dosages. In each of the four cases, delirium was not present on admission and resolved in the hospital itself with fixed benzodiazepine tapers. Cases were selected from an electronic medical record database of patients admitted to a United States-based university hospital and placed on CIWA-Ar between 2017 and 2018. This case series illustrates the major limitations of CIWA-Ar including its subjective nature, its susceptibility to inappropriate patient selection, and its requirement for providers to consider alternative etiologies to alcohol and benzodiazepine withdrawal syndromes. These cases demonstrate the necessity of considering other assessment and treatment options such as objective alcohol withdrawal scales, fixed benzodiazepine tapers, and even antiepileptics. An effective systems-based approach to overcoming these challenges may include setting time limits on CIWA-Ar orders within the electronic health record (EHR) system.
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Affiliation(s)
- Alex Wang
- Psychiatry and Neurology, University of California Irvine School of Medicine, Irvine, USA
| | - Andrew Park
- Psychiatry and Neurology, University of California Irvine Medical Center, Orange, USA
| | - Ralph Albert
- Psychiatry and Neurology, University of California Irvine School of Medicine, Irvine, USA
| | - Alyssa Barriga
- Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, USA
| | - Leigh Goodrich
- Psychiatry and Neurology, University of California Irvine Medical Center, Orange, USA
| | - Bao-Nhan Nguyen
- Psychiatry and Neurology, University of California Irvine Medical Center, Orange, USA
| | - Erin Knox
- Psychiatry and Neurology, University of California Irvine Health Sciences, Orange, USA
| | - Adrian Preda
- Psychiatry and Neurology, University of California Irvine Medical Center, Orange, USA
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Arsenault-Lapierre G, Henein M, Gaid D, Le Berre M, Gore G, Vedel I. Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2111568. [PMID: 34100939 PMCID: PMC8188269 DOI: 10.1001/jamanetworkopen.2021.11568] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Importance Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high. Objective To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician. Data Sources Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Study Selection Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician. Data Extraction and Synthesis Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes. Main Outcomes and Measures Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits. Results Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results. Conclusions and Relevance The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.
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Affiliation(s)
| | - Mary Henein
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Dina Gaid
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada
| | - Mélanie Le Berre
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Université de Montréal, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Genevieve Gore
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montréal, Québec, Canada
| | - Isabelle Vedel
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
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Ince I, Chiu A, Sagir A, Chahar P, Lin J, Douglas A, Adi A, Fang J, Mao G, Turan A. Association of Pain With Atrial Fibrillation and Delirium After Cardiac Surgery: A DECADE Sub-Study. J Cardiothorac Vasc Anesth 2021; 35:3021-3026. [PMID: 34148803 DOI: 10.1053/j.jvca.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to evaluate the effects of postoperative pain on the incidence of atrial fibrillation and delirium in patients having surgery with cardiopulmonary bypass (CPB). DESIGN Post hoc analysis of the (An investigator-initiated, multicentre, double-blind trial (ClinicalTrials NCT02004613) (DECADE)), a randomized, placebo-controlled trial. SETTING Tertiary, academic hospital. PARTICIPANTS Six hundred five adults from the DECADE enrolled at Cleveland Clinic Main Campus, who had had surgery with CPB. INTERVENTIONS Dexmedetomidine versus placebo started before surgical incision and postoperatively was maintained until 24 hours. MEASUREMENTS Primary outcomes were atrial fibrillation, diagnosed by clinicians in the intensive care unit (ICU), presence of delirium assessed with the Confusion Assessment Method for the ICU, data on pain scores, and opioid consumption, occurring between ICU admission and the earlier of postoperative day five or hospital discharge. RESULTS Postoperative pain levels were similar among patients with or without atrial fibrillation. Two hundred six (34%) patients had atrial fibrillation and ninety-two (15%) had delirium before hospital discharge within the first five postoperative days. The risk of atrial fibrillation was not significantly different between groups (hazard ratio: 1.09; 97.5% confidence interval [CI]: 0.99, 1.20, p = 0.039); there were no associations between postoperative pain and the risk of postoperative delirium (hazard ratio: 0.96; 97.5% CI: 0.84-1.11; p = 0.57). Postoperative opioid consumption was neither significantly associated with postoperative atrial fibrillation nor delirium. CONCLUSIONS Atrial fibrillation and delirium was not associated with pain after cardiac surgery. Opioid use was not associated with atrial fibrillation and delirium. Because both atrial fibrillation and delirium have a multifactorial nature, further studies should be focused on other plausible mechanisms.
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Affiliation(s)
- Ilker Ince
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Afrin Sagir
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Praveen Chahar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jia Lin
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Aaron Douglas
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Ahmad Adi
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jonathan Fang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Guangmei Mao
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH.
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van Loveren K, Singla A, Sinvani L, Calandrella C, Perera T, Brave M, Becker L, Li T. Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium. West J Emerg Med 2021; 22:726-735. [PMID: 34125053 PMCID: PMC8202999 DOI: 10.5811/westjem.2021.1.49320] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development. Methods This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway. Results A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83). Conclusion Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.
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Affiliation(s)
- Kate van Loveren
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Arnav Singla
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Liron Sinvani
- Center for Health Innovations and Outcomes Research, Feinstein Institutes of Medical Research, Northwell Health, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Division of Hospital Medicine, Manhasset, New York
| | - Christopher Calandrella
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Thomas Perera
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Martina Brave
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Lance Becker
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Timmy Li
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
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Risk factors for delirium among hospitalized patients in Zambia. PLoS One 2021; 16:e0249097. [PMID: 33831010 PMCID: PMC8031188 DOI: 10.1371/journal.pone.0249097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To identify risk factors for delirium among hospitalized patients in Zambia. Methods We conducted a prospective cohort study at the University Teaching Hospital in Lusaka, Zambia, from October 2017 to April 2018. We report associations of exposures including sociodemographic and clinical factors with delirium over the first three days of hospital admission, assessed using a modified Brief Confusion Assessment Method (bCAM). Findings 749 patients were included for analysis (mean age, 42.9 years; 64.8% men; 47.3% with HIV). In individual regression analyses of potential delirium risk factors adjusted for age, sex and education, factors significantly associated with delirium included being divorced/widowed (OR 1.64, 95% CI 1.09–2.47), lowest tercile income (OR 1.58, 95% CI 1.04–2.40), informal employment (OR 1.97, 95% CI 1.25–3.15), untreated HIV infection (OR 2.18, 95% CI 1.21–4.06), unknown HIV status (OR 2.90, 95% CI 1.47–6.16), history of stroke (OR 2.70, 95% CI 1.15–7.19), depression/anxiety (OR 1.52, 95% CI 1.08–2.14), alcohol overuse (OR 1.96, 95% CI 1.39–2.79), sedatives ordered on admission (OR 3.77, 95% CI 1.70–9.54), severity of illness (OR 2.00, 95% CI 1.82–2.22), neurological (OR 7.66, 95% CI 4.90–12.24) and pulmonary-system admission diagnoses (OR 1.91, 95% CI 1.29–2.85), and sepsis (OR 2.44, 95% CI 1.51–4.08). After combining significant risk factors into a multivariable regression analysis, severity of illness, history of stroke, and being divorced/widowed remained predictive of delirium (p<0.05). Conclusion Among hospitalized adults at a national referral hospital in Zambia, severity of illness, history of stroke, and being divorced/widowed were independently predictive of delirium. Extension of this work will inform future efforts to prevent, detect, and manage delirium in low- and middle-income countries.
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Kennedy M, Webb M, Gartaganis S, Hwang U, Biese K, Stuck A, Lesser A, Hshieh T, Inouye SK. ED-DEL: Development of a change package and toolkit for delirium in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12421. [PMID: 33969341 PMCID: PMC8082702 DOI: 10.1002/emp2.12421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
Delirium is a common and deadly problem in the emergency department affecting up to 30% of older adult patients. The 2013 Geriatric Emergency Department guidelines were developed to address the unique needs of the growing older population and identified delirium as a high priority area. The emergency department (ED) environment presents unique challenges for the identification and management of delirium, including patient crowding, time pressures, competing priorities, variable patient acuity, and limitations in available patient information. Accordingly, protocols developed for inpatient units may not be appropriate for use in the ED setting. We created a Delirium Change Package and Toolkit in the Emergency Department (ED-DEL) to provide protocols and guidance for implementing a delirium program in the ED setting. This article describes the multistep process by which the ED-DEL program was created and the key components of the program. Our ultimate goal is to create a resource that can be disseminated widely and used to improve delirium identification, prevention, and management in older adults in the ED.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Margaret Webb
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
| | - Sarah Gartaganis
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
| | - Ula Hwang
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Geriatric Research, Education and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA
| | - Kevin Biese
- Department of Emergency MedicineDivision of Geriatric Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Amy Stuck
- Strategy DepartmentWest Health InstituteSan DiegoCaliforniaUSA
| | - Adriane Lesser
- Clinical Research DepartmentWest Health InstituteSan DiegoCaliforniaUSA
| | - Tammy Hshieh
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineDivision of AgingBrigham and Women's HospitalBostonMassachusettsUSA
| | - Sharon K. Inouye
- Aging Brain CenterMarcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineDivision of Gerontology, Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Dexmedetomidine with sufentanil in intravenous patient-controlled analgesia for relief from postoperative pain, inflammation and delirium after esophageal cancer surgery. Biosci Rep 2021; 40:222794. [PMID: 32343308 PMCID: PMC7214400 DOI: 10.1042/bsr20193410] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIMS Postoperative pain can cause serious adverse reactions that severely affect postoperative outcome. The present study evaluated the effect of dexmedetomidine (DEX) added to sufentanil in intravenous patient-controlled analgesia (PCA) on the relief of pain and inflammatory responses during postoperative recovery of patients undergoing a combined thoracoscopic-laparoscopic esophagectomy (TLE). METHODS Sixty patients undergoing TLE were randomly allocated to receive 1 μg/ml of sufentanil alone (Group S) or 1 μg/ml of sufentanil plus 2.5 μg/ml of DEX (Group D) for postoperative intravenous (IV) PCA. Postoperative pain relief, cumulative PCA requirements, inflammatory marker levels, delirium and recovery were assessed. RESULTS A joint DEX and sufentanil regimen significantly reduced the area under the curve of numerical rating scores for pain at rest (NRSR) and coughing (NRSC) at 1-48 h postoperatively (P = 0.000) that were associated with lower PCA-delivered cumulative sufentanil consumption and less PCA frequency until 48 h postoperatively (P < 0.05 and P < 0.0001, respectively). The simultaneous administration of DEX and sufentanil significantly reduced plasma IL-6 and TNF-α concentrations and increased IL-10 level (P < 0.0001, P = 0.0003 and P = 0.0345, respectively), accompanied by better postoperative delirium categories and health statuses of patients (P = 0.024 and P < 0.05, respectively). There was no hypotension, bradycardia, respiratory depression or oversedation in Group D. CONCLUSION Patients receiving DEX in addition to IV PCA sufentanil for TLE exhibited better postoperative analgesia, fewer inflammatory responses and lower postoperative delirium categories and better health statuses.
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Shayan S, DE Wolf AM. Delirious after liver transplantation: are we oblivious? Minerva Anestesiol 2021; 87:630-633. [PMID: 33688702 DOI: 10.23736/s0375-9393.21.15623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Shahriar Shayan
- Feinberg School of Medicine, Department of Anesthesiology, Northwestern University, Chicago, IL, USA
| | - Andre M DE Wolf
- Feinberg School of Medicine, Department of Anesthesiology, Northwestern University, Chicago, IL, USA -
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Susano MJ, Dias M, Seixas FS, Vide S, Grasfield R, Abelha FJ, Crosby G, Culley DJ, Amorim P. Association Among Preoperative Cognitive Performance, Regional Cerebral Oxygen Saturation, and Postoperative Delirium in Older Portuguese Patients. Anesth Analg 2021; 132:846-855. [PMID: 33002925 DOI: 10.1213/ane.0000000000005159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium is common among older patients and preoperative identification of high-risk patients is widely recommended. The aim of this study was to assess whether preoperative cognitive performance using brief screening tools or regional cerebral oxygen saturation (Scto2) was associated with the development of postoperative delirium in older Portuguese patients undergoing elective surgery. METHODS Prospective observational cohort study where preoperative cognitive screening tools (Mini-Cog, Mini-Mental State Examination, verbal fluency) and Scto2 (INVOS 5100C; Medtronic, Ireland) were assessed in 238 patients ≥65 years old undergoing elective surgery between July 2017 and May 2019 at a tertiary academic center in Portugal. The primary outcome was postoperative delirium detected by the 3D-Confusion Assessment Method. Data were analyzed by univariate analysis and multivariable logistic regression. RESULTS Delirium was identified in 53 patients (22%); 162 patients (68%) had completed only 4 years of education. On multivariable analysis, probable cognitive impairment tested by the Mini-Cog (odds ratio [OR] = 1.57; 95% confidence interval [CI], 0.70-3.53; corrected P value >.999), by the Mini-Mental State Examination (OR = 2.75; 95% CI, 1.23-6.13; corrected P value = .052), and by the animal verbal fluency test (OR = 1.24; 95% CI, 0.49-3.16; corrected P value >.999) were not significantly associated with the development of postoperative delirium. In contrast, lower preoperative Scto2 (OR = 1.08; 95% CI, 1.02-1.14; corrected P value = .024 for each point decrease in Scto2) was associated with postoperative delirium. CONCLUSIONS We did not find enough evidence to suggest that poor preoperative cognitive performance was significantly associated with the development of postoperative delirium in an older Portuguese surgical population with an overall low level of formal education, but rather that preoperative Scto2 may be helpful in identifying patients at risk for delirium.
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Affiliation(s)
- Maria J Susano
- From the Centre for Clinical Research in Anesthesia, Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Surgical Centre, Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Mariana Dias
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Francisco S Seixas
- Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Sérgio Vide
- Surgical Centre, Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Department of Anaesthesia, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Rachel Grasfield
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Fernando J Abelha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Anesthesiology, Surgery and Physiology, Centro Hospitalar de São João, Porto, Portugal
| | - Gregory Crosby
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro Amorim
- From the Centre for Clinical Research in Anesthesia, Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Banerdt JK, Mateyo K, Wang L, Lindsell CJ, Riviello ED, Saylor D, Heimburger DC, Ely EW. Delirium as a predictor of mortality and disability among hospitalized patients in Zambia. PLoS One 2021; 16:e0246330. [PMID: 33571227 PMCID: PMC7877643 DOI: 10.1371/journal.pone.0246330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/18/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the epidemiology and outcomes of delirium among hospitalized patients in Zambia. METHODS We conducted a prospective cohort study at the University Teaching Hospital in Lusaka, Zambia, from October 2017 to April 2018. The primary exposure was delirium duration over the initial 3 days of hospitalization, assessed daily using the Brief Confusion Assessment Method. The primary outcome was 6-month mortality. Secondary outcomes included 6-month disability, evaluated using the World Health Organization Disability Assessment Schedule 2.0. FINDINGS 711 adults were included (median age, 39 years; 461 men; 459 medical, 252 surgical; 323 with HIV). Delirium prevalence was 48.5% (95% CI, 44.8%-52.3%). 6-month mortality was higher for delirious participants (44.6% [39.3%-50.1%]) versus non-delirious participants (20.0% [15.4%-25.2%]; P < .001). After adjusting for covariates, delirium duration independently predicted 6-month mortality and disability with a significant dose-response association between number of days with delirium and odds of worse clinical outcome. Compared to no delirium, presence of 1, 2 or 3 days of delirium resulted in odds ratios for 6-month mortality of 1.43 (95% CI, 0.73-2.80), 2.20 (1.07-4.51), and 3.92 (2.24-6.87), respectively (P < .001). Odds of 6-month disability were 1.20 (0.70-2.05), 1.73 (0.95-3.17), and 2.80 (1.78-4.43), respectively (P < .001). CONCLUSION Among hospitalized medical and surgical patients in Zambia, delirium prevalence was high and delirium duration independently predicted mortality and disability at 6 months. This work lays the foundation for prevention, detection, and management of delirium in low-income countries. Long-term follow up of outcomes of critical illness in resource-limited settings appears feasible using the WHO Disability Assessment Schedule.
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Affiliation(s)
- Justin K. Banerdt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Kondwelani Mateyo
- University of Zambia School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Lusaka, Zambia
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Elisabeth D. Riviello
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Deanna Saylor
- University of Zambia School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Lusaka, Zambia
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Douglas C. Heimburger
- University of Zambia School of Medicine, Lusaka, Zambia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, United States of America
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Incidence and Risk Factors of Delirium in the Intensive Care Unit: A Prospective Cohort. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6219678. [PMID: 33506019 PMCID: PMC7810554 DOI: 10.1155/2021/6219678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/01/2020] [Accepted: 12/28/2020] [Indexed: 12/03/2022]
Abstract
Purpose The purpose of this study was to determine the incidence, risk factors, and impact of delirium on outcomes in ICU patients. In addition, the scoring systems were measured consecutively to characterize how these scores changed with time in patients with and without delirium. Material and Methods. A prospective cohort study enrolling 400 consecutive patients admitted to the ICU between 2018 and 2019 due to trauma or surgery. Patients were followed up for the development of delirium over ICU days using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC). Cox model logistic regression analysis was used to explore delirium risk factors. Results Delirium occurred in 108 (27%) patients during their ICU stay, and the median onset of delirium was 4 (IQR 3–4) days after admission. According to multivariate cox regression, the expected hazard for delirium was 1.523 times higher in patients who used mechanical ventilator as compared to those who did not (HR: 1.523, 95% CI: 1.197-2.388, P < 0.001). Conclusion Our findings suggest that an important opportunity for improving the care of critically ill patients may be the determination of modifiable risk factors for delirium in the ICU. In addition, the scoring systems (APACHE IV, SOFA, and RASS) are useful for the prediction of delirium in critically ill patients.
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FitzGerald JM, Price A. Delirium in the acute hospital setting: the role of psychiatry. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2020.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
SUMMARYIn this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.
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Omichi C, Ayani N, Oya N, Matsumoto Y, Tanaka M, Morimoto T, Kadotani H, Narumoto J. Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study. Compr Psychiatry 2021; 104:152216. [PMID: 33227543 DOI: 10.1016/j.comppsych.2020.152216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Several studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium. METHODS This retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission. RESULTS Among 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008). CONCLUSIONS Abrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.
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Affiliation(s)
- Chie Omichi
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Nobutaka Ayani
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; Department of Psychiatry, National Hospital Organization, Maizuru Medical Center, 2410 Yukinaga, Maizuru, Kyoto 625-8502, Japan.
| | - Nozomu Oya
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yoshihiro Matsumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Maki Tanaka
- Department of Medical Safety Management, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo 663-8501, Japan
| | - Hiroshi Kadotani
- Department of Sleep and Behavioral Sciences, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga 520-2192, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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McCoy TH, Castro VM, Hart KL, Perlis RH. Stratified delirium risk using prescription medication data in a state-wide cohort. Gen Hosp Psychiatry 2021; 71:114-120. [PMID: 34091195 PMCID: PMC8249339 DOI: 10.1016/j.genhosppsych.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list. METHOD Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort. RESULTS The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender. CONCLUSION Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.
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Affiliation(s)
- Thomas H McCoy
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Victor M Castro
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Kamber L Hart
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Roy H Perlis
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
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Abstract
Supplemental Digital Content is available in the text. Objective: Summarize performance and development of ICU delirium-prediction models published within the past 5 years. Data Sources: Systematic electronic searches were conducted in April 2019 using PubMed, Embase, Cochrane Central, Web of Science, and Cumulative Index to Nursing and Allied Health Literature to identify peer-reviewed studies. Study Selection: Eligible studies were published in English during the past 5 years that specifically addressed the development, validation, or recalibration of delirium-prediction models in adult ICU populations. Data Extraction: Screened citations were extracted independently by three investigators with a 42% overlap to verify consistency using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. Data Synthesis: Eighteen studies featuring 23 distinct prediction models were included. Model performance varied greatly, as assessed by area under the receiver operating characteristic curve (0.62–0.94), specificity (0.50–0.97), and sensitivity (0.45–0.96). Most models used data collected from a single time point or window to predict the occurrence of delirium at any point during hospital or ICU admission, and lacked mechanisms for providing pragmatic, actionable predictions to clinicians. Conclusions: Although most ICU delirium-prediction models have relatively good performance, they have limited applicability to clinical practice. Most models were static, making predictions based on data collected at a single time-point, failing to account for fluctuating conditions during ICU admission. Further research is needed to create clinically relevant dynamic delirium-prediction models that can adapt to changes in individual patient physiology over time and deliver actionable predictions to clinicians.
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Abstract
OBJECTIVE Although age and pre-existent dementia are robust risk factors for developing delirium, evidence for patients older than 90 years is lacking. Therefore, this study assesses the delirium prevalence rates and sequelae in this age group. METHOD Based on a Diagnostic and Statistical Manual (DSM)-5, Delirium Observation screening scale (DOS), and Intensive Care Delirium Screening Checklist (ICDSC) construct, in this prospective cohort study, the prevalence rates and sequelae of delirium were determined in 428 patients older than 90 years by simple logistic regressions and corresponding odds ratios (ORs). RESULTS The overall prevalence delirium rate was 45.2%, with a wide range depending upon specialty: intermediate and intensive care services (83.1%), plastic surgery and palliative care (75%), neurology (72%), internal medicine (69%) vs. dermatology (26.5%), and angiology (14.5%). Delirium occurred irrespective of age and gender; however, pre-existent dementia was the strongest delirium predictor (OR 36.05). Delirious patients were less commonly admitted from home (OR 0.47) than from assisted living (OR 2.24), indicating functional impairment. These patients were more severely ill, as indicated by emergency (OR 3.25) vs. elective admission (OR 0.3), requirement for intensive care management (OR 2.12) and ventilation (OR 5.56-8.33). At discharge, one-third did not return home (OR 0.22) and almost half were transferred to assisted living (OR 2.63), or deceased (OR 47.76). SIGNIFICANCE OF RESULTS At age older than 90 years, the prevalence and sequelae of delirium are substantial. In particular, functional impairment and pre-existent dementia predicted delirium and subsequently, the loss of independence and death were imminent.
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