Delirium in the Elderly

The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis

OBJECTIVE

The aim of our meta-analysis was to update evidence for the association between frailty and delirium in different types of hospitalized patients, given the large volume of new studies with inconsistent results.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

In this updated meta-analysis, we searched 3 databases (Embase, PubMed, and the Cochrane Library) for observational studies, exploring the association between frailty and delirium from database inception to September 21, 2020, among hospitalized patients. Relevant data were extracted from the studies that were included. A random effects model was conducted to synthesize and pool the effect size of frailty on delirium due to different frailty score instruments, different countries, and various delirium assessments that were used. The participants enrolled in this meta-analysis were hospitalized patients.

MEASURES

Delirium risk due to frailty.

RESULTS

A total of 30 independent studies from 9 countries, consisting of 217,623 patients, was identified, and the prevalence of frailty ranged from 16.20% to 78.00%. Frail patients exhibited an increased risk for delirium compared to those without frailty [odds ratio (OR) 2.96, 95% confidence interval (CI) 2.36-3.71]. In addition, different types of hospitalized patients had various OR values, which were 2.43 for selective surgical patients (95% CI 1.88-3.14), 3.61 for medical patients (95% CI 3.61-7.89), 3.76 for urgent surgical patients (95% CI 2.88-4.92), and 6.66 for emergency or critical illness patients (95% CI 1.41-31.47). Subgroup analysis based on the frailty score instrument showed the association still existed when using the Clinical Frailty Scale (OR 4.07, 95% CI 2.71-6.11), FRAIL Scale (OR 2.83, 95% CI 1.56-5.13), Frailty Index (OR 6.15, 95% CI 3.75-10.07), frailty phenotype (OR 2.30, 95%CI 1.35-5.66), or Erasmus Frailty Score (OR 2.79, 95% CI 1.63-4.77). However, an association between frailty and delirium was not observed when the Edmonton Frail Scale was used (OR 1.45, 95% CI 0.91-2.30).

CONCLUSIONS AND IMPLICATIONS

A 2.96-fold incremental risk of delirium in frail patients underscores the need for early screening of frailty and comprehensive delirium prevention. Appropriate interventions by clinicians should be performed to manage delirium, potentially reducing adverse clinical outcomes for hospitalized patients.

Reducing Perioperative Neurocognitive Disorders (PND) Through Depth of Anesthesia Monitoring: A Critical Review

General anesthesia has been administered for over 150 years, and in that time, has become progressively safer. Improvements in outcomes have been driven by multiple advances, including the use of non-invasive monitors to assess cardiovascular and respiratory status. More recent advances have included the development and use of monitors to measure neurologic status by means of “processed” electroencephalography (pEEG), wherein the frontal EEG signal is analyzed by proprietary algorithms to produce a dimensionless number (scaled from 0 to 100), wherein low values are associated with deepening levels of sedation that progresses to loss of consciousness. Such monitors have been shown to enable anesthetic titration so as to expedite emergence and early recovery, and their use is advocated for the prevention of intraoperative awareness in the setting of administration of total intravenous anesthesia and neuromuscular blockade. Whether their use can minimize, or prevent, longer term adverse events is a matter of debate. In this narrative review of the most recent literature, we provide an assessment on the use of pEEG monitors in the prevention of a notable, and important, postoperative adverse outcome – delirium – in elderly patients. As we will discuss, the existing data do not support its routine use for the prevention of postoperative delirium in this, or any other, patient population.

Delirium in older adults

This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.

Evaluating Pain, Opioids, and Delirium in Critically Ill Older Adults

Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined (n = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ²], 12.34, p = .0004), but not pain (χ², 3.31, p = .0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44-4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium.

Low Frontal Alpha Power Is Associated With the Propensity for Burst Suppression: An Electroencephalogram Phenotype for a "Vulnerable Brain"

BACKGROUND

A number of recent studies have reported an association between intraoperative burst suppression and postoperative delirium. These studies suggest that anesthesia-induced burst suppression may be an indicator of underlying brain vulnerability. A prominent feature of electroencephalogram (EEG) under propofol and sevoflurane anesthesia is the frontal alpha oscillation. This frontal alpha oscillation is known to decline significantly during aging and is generated by prefrontal brain regions that are particularly prone to age-related neurodegeneration. Given that burst suppression and frontal alpha oscillations are both associated with brain vulnerability, we hypothesized that anesthesia-induced frontal alpha power could also be associated with burst suppression.

METHODS

We analyzed EEG data from a previously reported cohort in which 155 patients received propofol (n = 60) or sevoflurane (n = 95) as the primary anesthetic. We computed the EEG spectrum during stable anesthetic maintenance and identified whether or not burst suppression occurred during the anesthetic. We characterized the relationship between burst suppression and alpha power using logistic regression. We proposed 5 different models consisting of different combinations of potential contributing factors associated with burst suppression: (1) a Base Model consisting of alpha power; (2) an Extended Mechanistic Model consisting of alpha power, age, and drug dosing information; (3) a Clinical Confounding Factors Model consisting of alpha power, hypotension, and other confounds; (4) a Simplified Model consisting only of alpha power and propofol bolus administration; and (5) a Full Model consisting of all of these variables to control for as much confounding as possible.

RESULTS

All models show a consistent significant association between alpha power and burst suppression while adjusting for different sets of covariates, all with consistent effect size estimates. Using the Simplified Model, we found that for each decibel decrease in alpha power, the odds of experiencing burst suppression increased by 1.33-fold.

CONCLUSIONS

In this study, we show how a decrease in anesthesia-induced frontal alpha power is associated with an increased propensity for burst suppression, in a manner that captures individualized information above and beyond a patient's chronological age. Lower frontal alpha band power is strongly associated with higher propensity for burst suppression and, therefore, potentially higher risk of postoperative neurocognitive disorders. We hypothesize that low frontal alpha power and increased propensity for burst suppression together characterize a "vulnerable brain" phenotype under anesthesia that could be mechanistically linked to brain metabolism, cognition, and brain aging.

Rehabilitation Concerns in the Geriatric Critically Ill and Injured - Part 1

Elderly patients who are critically ill have unique challenges that must be considered when attempting to prognosticate survival and determine expectations for physical rehabilitation and meaningful recovery. Furthermore, frail elderly patients present unique rehabilitation and clinical challenges when suffering from critical illness. There are multiple symptoms and syndromes that affect morbidity and mortality of elderly patients who require intensive care unit management including delirium, dementia, pain, and constipation. Rehabilitation goals should be based on patient values, clinical course, and functional status. Patients and families need accurate prognostic information to choose the appropriate level of care needed after critical illness.

Systems Level Analysis and Identification of Pathways and Key Genes Associated with Delirium

Delirium is a complex pathophysiological process, and multiple contributing mechanisms have been identified. However, it is largely unclear how the genes associated with delirium contribute and which of them play key roles. In this study, the genes associated with delirium were retrieved from the Comparative Toxicogenomics Database (CTD) and integrated through a protein-protein interaction (PPI) network. Delirium-associated genes formed a highly interconnected PPI subnetwork, indicating a high tendency to interact and agglomerate. Using the Molecular Complex Detection (MCODE) algorithm, we identified the top two delirium-relevant network modules, M1 and M5, that have the most significant enrichments for the delirium-related gene sets. Functional enrichment analysis showed that genes related to neurotransmitter receptor activity were enriched in both modules. Moreover, analyses with genes located in human accelerated regions (HARs) provided evidence that HAR-Brain genes were overrepresented in the delirium-relevant network modules. We found that four of the HAR-Brain genes, namely APP, PLCB1, NPY, and HTR2A, in the M1 module were highly connected and appeared to exhibit hub properties, which might play vital roles in delirium development. Further understanding of the function of the identified modules and member genes could help to identify therapeutic intervention targets and diagnostic biomarkers for delirium.

Prevention of Delirium in Older Adults With Dementia: A Systematic Literature Review

Although dementia is the largest independent risk factor for delirium and leads to poor health outcomes, we know little about how to prevent delirium in persons with dementia (PWD). The purpose of the current systematic literature review was to identify interventions designed to prevent delirium in older PWD. Seven studies meeting inclusion criteria were extracted. Five studies were in the acute care setting and two were community settings. One study used a randomized controlled trial design. Five of the seven interventions comprised multiple components addressing delirium risk factors, including education. Two studies addressed delirium by administration of medication or vitamin supplementation. Using the GRADE framework for the evaluation of study quality, we scored three studies as moderate and four studies as low. Thus, high-quality research studies to guide how best to prevent delirium in PWD are lacking. Although more research is required, the current review suggests that multicomponent approaches addressing delirium risk factors should be considered by health care professionals when supporting older PWD. [Journal of Gerontological Nursing, 46(10), 43-54.].

An advanced practice nurse-led delirium consultation service reduces delirium severity and length of stay in orthopedic patients: A nonrandomized posttest only evaluation study

PURPOSE

Delirium is an acute neuropsychiatric disorder and is a common and serious complication during hospitalization for older people. This study evaluated the value of an advanced practice nurse (APN)-led delirium consultation service on patient outcomes DESIGN AND METHODS: This was a retrospective chart review of 137 patients over 65 years, hospitalized between 2012 and 2015 in a tertiary care setting in Switzerland, who underwent orthopedic surgery and experienced delirium.

FINDINGS

Of the 137 eligible patients, 53 received the delirium consultation service and 84 received the standard care. The group receiving "early" delirium consultation experienced significantly reduced delirium severity over the course of time and the shortest length of stay.

PRACTICE IMPLICATIONS

The APN-led delirium consultation service had a positive effect on patient outcomes.

The efficacy of acupuncture in postoperative sleep quality: a literature review

PURPOSE

General anesthesia may affect the quality of postoperative sleep, especially after surgery on elderly patients. The decline of postoperative sleep quality may produce harmful effects on the postoperative recovery of patients. In this review, we summarized the efficacy and potential mechanism of acupuncture on postoperative sleep quality.

METHODS

We review the effect of general anesthesia on circadian sleep rhythm. In addition, to provide evidence about the impairment of decreased postoperative sleep quality, we also emphasize the mechanism of acupuncture alleviates factors that affect sleep quality after general anesthesia.

RESULTS

The application of acupuncture technology has been helpful to improve sleep quality and alleviate postoperative complications affecting postoperative sleep quality after general anesthesia.

CONCLUSION

Acupuncture at different acupoints could effectively improve body's neurotransmitter levels and regulate biological clock genes through various mechanisms, and then improve postoperative sleep quality. Large-scale multi-center trials are needed to verify these findings.

Different Cognitive and Functional Outcomes in Attenuated and Full Delirium Syndromes Among Recent Stroke Survivors

BACKGROUND

Very little is known about the outcomes of poststroke delirium in relation to its symptom spectrum. We investigated the 3-months cognitive and functional outcomes of attenuated (ADS) and full delirium syndromes in Nigerian survivors of first ever stroke.

METHODS

A prospective observational study with repeated assessments conducted in the first week of stroke using the confusion assessment method. Full delirium was diagnosed according to criteria in the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-V). ADS was characterised in survivors who were free of full, but had ≥two core features of, delirium. Baseline and follow-up assessments were conducted using the Mini-Mental state examination (MMSE), 10-words list learning and delayed recall test, Animal naming test and Barthel index.

RESULTS

Among 150 participants, ADS was present in 32 (21.3%), full delirium in 29 (19.3%). In linear regression analyses adjusting for age, economic status and systemic hypertension, ADS [(Mean difference (MD) = -3.8, 95% C.I = -7.0, -0.7)] and full delirium (MD = -5.6, 95% C.I = -9.0, -2.1) independently predicted poorer global cognitive functioning at follow-up. Significant declines in memory (MD = -1.9, 95% C.I = -2.8, 0.9), executive (MD = -2.2, 95% C.I = -4.1, -0.3) and physical functioning (MD = -2.8, 95% C.I = -5.5, -0.2), as well as a 4-fold increase in the independent odds (O.R) for dementia (O.R = 4.1, 95% C.I = 1.0,16.1) were also recorded in full, but not attenuated, delirium.

CONCLUSION

Attenuated and full delirium are associated with graded risk of poststroke cognitive decline. Reconsideration of poststroke delirium as a spectrum, rather than threshold-based categorical diagnosis will improve detection and prioritization of stroke survivors at increased risk of cognitive decline.

Managing insomnia in older adults

Nurses frequently care for patients with complaints of insomnia in the hospital and community settings. Because older adults with insomnia present unique challenges for successful patient management, nurses should understand the latest assessment and treatment options.

Relationship Between Intensive Care Unit Delirium Severity and 2-Year Mortality and Health Care Utilization

BACKGROUND

Critical care patients with delirium are at an increased risk of functional decline and mortality long term.

OBJECTIVE

To determine the relationship between delirium severity in the intensive care unit and mortality and acute health care utilization within 2 years after hospital discharge.

METHODS

A secondary data analysis of the Pharmacological Management of Delirium and Deprescribe randomized controlled trials. Patients were assessed twice daily for delirium or coma using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Delirium severity was measured using the CAM-ICU-7. Mean delirium severity (from time of randomization to discharge) was categorized as rapidly resolving, mild to moderate, or severe. Cox proportional hazards regression was used to model time to death, first emergency department visit, and rehospitalization. Analyses were adjusted for age, sex, race, Charlson Comorbidity Index, Acute Physiology and Chronic Health Evaluation II score, discharge location, diagnosis, and intensive care unit type.

RESULTS

Of 434 patients, those with severe delirium had higher mortality risk than those with rapidly resolving delirium (hazard ratio 2.21; 95% CI, 1.35-3.61). Those with 5 or more days of delirium or coma had higher mortality risk than those with less than 5 days (hazard ratio 1.52; 95% CI, 1.07-2.17). Delirium severity and number of days of delirium or coma were not associated with time to emergency department visits and rehospitalizations.

CONCLUSION

Increased delirium severity and days of delirium or coma are associated with higher mortality risk 2 years after discharge.

Evaluating delirium outcomes among older adults in the surgical intensive care unit

BACKGROUND

Delirium is prevalent in hospitalized older adults. Little is known about delirium among older adults admitted to the surgical intensive care unit (SICU).

OBJECTIVES

The purpose of this study was to describe the incidence of delirium, length of stay, 30-day readmission and mortality rates experienced by older adults in the SICU before and after a nurse-driven protocol for delirium-informed care.

METHODS

This study employed a retrospective observational cohort design. Consecutive patients 65 years or older admitted to the SICU over six-month periods were compared before (n = 101) and following (n = 172) a nurse-driven protocol for delirium-informed care. Patient-level outcomes included incidence delirium, SICU and hospital length of stay, 30-day readmission and mortality rates. All measures were collected using medical record review.

RESULTS

In the pre- and post-intervention cohorts, 37% (37/101) and 33% (56/172) of patients screened positive for delirium, respectively. Following implementation of the delirium-informed care intervention, the number of days where no CAM-ICU assessment was performed significantly decreased (Pre 1.1 ± 1.4; Post 0.45 ± 0.65; p <0.001) and the number of negative assessments significantly increased (Pre 2.45 ± 1.66; Post 2.94 ± 1.69; p < 0.0178), indicating that nurses post-intervention were more consistently assessing for delirium.

CONCLUSIONS

This study failed to show improvements in patient outcomes (SICU and hospital length of stay, 30-day readmission and mortality rates), before and following a delirium-informed care intervention. However, positive trends in the data suggest that delirium-informed care has the potential to increase rates of assessment and delirium identification, thereby providing the foundation for reducing the consequences of delirium and improve patient-level outcomes. Further better controlled prospective work is needed to validate this intervention.

Cancer and older adult patient care

Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.

[Mortality of gerontopsychiatric inpatients in Graz, Austria-a retrospective case-control study]

BACKGROUND

Despite the demographic development and the increasing number of psychiatric diseases in older people, there are only few scientific investigations on the characteristics of patients in gerontopsychiatry and their mortality. In this retrospective case control study patient data were examined in order to establish which features of patients who died in a department of gerontopsychiatry show differences to those of patients who were discharged.

METHOD

A total of 284 patient files from the department of gerontopsychiatry and geriatric psychotherapy of the State Hospital Graz II were evaluated. Between 1 January 2015 and 31 December 2017, a total of 51 women and 91 men died (= cases) in hospital. These patients were compared with 142 sex-matched patients (control group) who were discharged during the same period of time. The evaluation was carried out using logistic regression models.

RESULTS

Patients who died on the geriatric psychiatry ward were clearly older and were in a clearly poorer physical state of health than the discharged patients. The deceased patients had a 2.7-fold higher chance of an ischemic cardiac disease as well as a 2.5-fold and 3.5-fold higher chance of being referred from a nursing home or hospital, respectively. They also had a threefold higher chance for a lower functional status, a fourfold increased chance of higher C‑reactive protein (CRP) values and a diagnosis of delirium compared to discharged patients.

CONCLUSION

The deceased patients had a substantially poorer state of health and tended to suffer more from delirium compared to the discharged patients. Structural health policy precautions must be undertaken so that unnecessary transfers to gerontopsychiatry departments do not become necessary.

Analysis of Risk Factors for Postoperative Delirium After Liver Transplantation

PURPOSE

The study aimed to analyze the incidence of postoperative delirium (POD) and associated risk factors after liver transplantation (LT).

PATIENTS AND METHODS

We identified and enrolled patients undergoing LT at the Second Xiangya Hospital, Central South University between August 2018 and May 2019. We abstracted their relevant clinical information and assigned the patients into a POD group and non-POD group to compare differences in clinical information. Risk factors of POD were analyzed using logistic regression.

RESULTS

A total of 159 LT patients were enrolled. Forty-two patients exhibited delirium (26.4%). Of the 42 with delirium, 33 (78.6%) had delirium within 3 days postoperatively and a median duration of 5 days (quartile 3-7 days). The results of binary logistic regression are as follows: preoperative ammonia (≥46 vs <46 μmol/L; OR 3.51, 95% CI [1.31-9.46], P<0.05), Model for End-Stage Liver Disease (MELD) score (≥15 vs.<15; OR 3.33, 95% CI [1.27-8.79], P<0.05), presence of hepatic encephalopathy (OR 3.30, 95% CI [1.20-9.07], P<0.05), aspartate aminotransferase (AST) on day 1 postoperatively (OR 1.33, 95% CI [1.06 -1.68], P<0.05), anhepatic period (OR 1.04, 95% CI [1.02 -1.06], P<0.01). The POD group had a longer intubation time (2925.0 vs 1410.0 min, P<0.01), ICU length of stay (6 vs 4 d, P<0.01) and increased medical costs (43.96 vs 33.74 ten thousand yuan, P<0.01).

CONCLUSION

The incidence of POD in LT patients is a significant clinical feature. Ammonia ≥46 μmol/l, MELD score ≥15, hepatic encephalopathy, anhepatic period, and AST at 1 day postoperatively were independent risk factors for POD.

Delirium Superimposed on Dementia: Challenges and Opportunities

Delirium superimposed on dementia is an acute medical illness that is difficult to diagnose because of the similarities of the symptoms to dementia. Delirium can contribute to the suffering of the patient as well as the family and caregiver. An initial holistic assessment of the patient is critical in establishing the cognitive baseline symptoms of delirium. Prevention of delirium can be assisted by ongoing reassessment of the patient for symptoms of delirium. The goal of treatment is to treat the underlying cause of the delirium.

Antipsychotics for Preventing Delirium in Hospitalized Adults: A Systematic Review

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

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

CONCLUSION

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

PRIMARY FUNDING SOURCE

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

Managing insomnia in older adults

NPs frequently care for patients with complaints of insomnia in the hospital and community settings. Because older adults with insomnia present unique challenges for successful management, NPs should understand the latest assessment and treatment options.

Development of a Tool for the Assessment of Nurses' Attitudes Toward Delirium

BACKGROUND AND PURPOSE

The prevalence of delirium during hospitalization is high in older patients and there is evidence of staff regarding them as unpopular or a burden. This study aims to develop an instrument examining nurses' attitudes toward patients with delirium.

METHODS

Stages included (a) content identification, (b) content development, (c) content critique, (e) pilot study with a test-retest reliability, (f) field study consisting of psychometric testing of the internal consistency and construct validity.

RESULTS

The Cronbach's alpha was 0.89 and the stability reliability was acceptable. The factor analysis resulted in three factors explaining a total of 56.5% of the variance. hese factors are "beliefs," "behavior," and "emotions," explaining 37.025%, 12.792%, and 5.652% of variance.

CONCLUSIONS

The Attitude Tool of Delirium (ATOD) is a reliable and valid instrument for the assessment of attitudes toward delirium.

Delirium induced by levofloxacin

Delirium is the most frequent complication of hospitalization for elders and a potentially devastating problem. It is accompanied by high morbidity and mortality rate, and despite sensitive methods for its detection, delirium often is unrecognized and is missed by clinicians in up to 70% of delirious patients. Medications are considered one of the most common causes of delirium with sedatives, narcotics, dihydroperidines, antihistamines, and anticholinergics are most often implicated in its causation. Antibiotic-induced delirium has been infrequently reported where cephalosporins and macrolides are implicated in the majority of cases published. Delirium associated with fluoroquinolones has rarely been reported, and to the best of our knowledge only eight cases of levofloxacin-induced delirium have been described until yet in the medical literature, two of which from our medical ward. We describe another case of delirium associated with levofloxacin treatment in an elderly patient who was hospitalized in our medical ward for acute bronchitis. Description of three cases of levofloxacin-induced delirium from one medical ward (ours) and the other six from the rest of the world reflects the extreme under-recognition and under-diagnosis of drug-induced delirium generally, and levofloxacin-induced delirium specifically by physicians world-wide. It also seems likely that this severe and potentially fetal adverse effect of levofloxacin is much more common than previously reported. The present case and the other previously reported emphasize the urgent need of much more awareness by physicians to the occurrence of this serious but preventable and potentially reversible CNS complication of levofloxacin.

Structural Brain Changes in Delirium: An Integrative Review

Delirium is a serious complication of acute illness. Little is known, however, regarding the neurobiology of delirium, largely due to challenges in studying the complex inpatient population. Neuroimaging is one noninvasive method that can be used to study structural and functional brain abnormalities associated with delirium. The purpose of this integrative literature review was to examine the content and quality of current structural neuroimaging evidence in delirium. After meeting inclusion criteria, 11 articles were included in the review. Commonly noted structural abnormalities were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures. Limitations of the studies in this review included small sample sizes, inappropriate or questionable delirium measurements, and failure to consider confounding variables. This review provides insight into possible structural changes responsible for the signs and symptoms seen in patients with delirium, but more high-quality studies are needed.

Postoperative cognitive decline: the nurse's role in identifying this underestimated and misinterpreted condition

BACKGROUND

postoperative cognitive changes can increase morbidity and mortality, demand for postoperative care and social and health costs, and can lead to dementia.

AIM

this article discusses perioperative variables that can be used to identify patients who are more vulnerable to experiencing cognitive decline after surgery. It also highlights some screening tools that could be useful for early detection and for planning nursing care.

METHOD

a literature search was conducted using the Medline, CINAHL, PsychINFO and Cochrane Library databases from 2010 to 2018. Google Scholar was also consulted. The reference lists of relevant articles covering postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) were reviewed for further relevant papers.

CONCLUSION

assessment and evaluation of a patient's cognitive resources before and after surgery can lead to clinical interventions to support the person's coping mechanisms; health professionals can reduce the short- and long-term effects of cognitive decline. Screening tools could be used as part of a strategy to minimise postoperative cognitive changes.

Behavioral, Psychiatric, and Cognitive Adverse Events in Older Persons Treated with Glucocorticoids

Background: Since the introduction of glucocorticoids (GCs) in the physician's pharmacological arsenal, it has been known that they are a cause of behavioral or psychiatric adverse events (BPAE), as well as of cognitive problems. To the best of our knowledge, the relationship between these adverse events and GCs in older persons has never been evaluated, except through case-reports or series with few cases. In this paper, a review of the literature regarding BPAEs and cognitive disorders in older people treated with CSs is undertaken. Methods: A comprehensive literature search for BPAEs was carried out on the three main bibliographic databases: EMBASE, MEDLINE and PsycINFO (NICE HDAS interface). Emtree terms were: Steroid, steroid therapy, mental disease, mania, delirium, agitation, depression, behavior change, dementia, major cognitive impairment, elderly. The search was restricted to all clinical studies and case reports with focus on the aged (65+ years) published in any language since 1998. Results: Data on the prevalence of the various BPAEs in older patients treated with GCs were very scarse, consisting mainly of case reports and of series with small numbers of patients. It was hence not possible to perform any statistical evaluation of the data (including meta-analysis). Amongst BPAEs, he possibility that delirium can be induced by GCs has been recently been questioned. Co-morbidities and polypharmacy were additional risk factors for BPAEs in older persons. Conclusions: Data on BPAEs in older persons treated with GCs, have several unmet needs that need to be further evaluated with appropriately designed studies.

Acute Delirium Associated With Levofloxacin

Delirium is considered as the most common complication afflicting hospitalized elderly patients, accompanied by high morbidity and mortality rate; and despite its high prevalence, it often remains unrecognized. Drug-induced delirium is a well-known entity with sedatives, narcotics and anticholinergics most often implicated in its causation. Delirium attributed to antibiotics, mainly cephalosporins and macrolids, has been infrequently reported, and until yet only seven cases of levofloxacin-induced delirium have been described in the medical literature. We describe another case of delirium associated with levofloxacin in an elderly patient who was hospitalized in our medical ward for pneumonia. The present case and the other cases previously reported should raise the awareness of physicians to this serious, underestimated, and underdiagnosed adverse effect of a commonly used antibiotic, levofloxacin.

Cholinesterase inhibitors for the treatment of delirium in non-ICU settings

BACKGROUND

Delirium is a common clinical syndrome defined as alterations in attention with an additional disturbance in cognition or perception, which develop over a short period of time and tend to fluctuate during the course of the episode. Delirium is commonly treated in hospitals or community settings and is often associated with multiple adverse outcomes such as increased cost, morbidity, and even mortality. The first-line intervention involves a multicomponent non-pharmacological approach that includes ensuring effective communication and reorientation in addition to providing reassurance or a suitable care environment. There are currently no drugs approved specifically for the treatment of delirium. Clinically, however, various medications are employed to provide symptomatic relief, such as antipsychotic medications and cholinesterase inhibitors, among others.

OBJECTIVES

To evaluate the effectiveness and safety of cholinesterase inhibitors for treating people with established delirium in a non-intensive care unit (ICU) setting.

SEARCH METHODS

We searched ALOIS, which is the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 26 October 2017. We also cross-checked the reference lists of included studies to identify any potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials, published or unpublished, reported in English or Chinese, which compared cholinesterase inhibitors to placebo or other drugs intended to treat people with established delirium in a non-ICU setting.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were duration of delirium, severity of delirium, and adverse events. The secondary outcomes were use of rescue medications, persistent cognitive impairment, length of hospitalisation, institutionalisation, mortality, cost of intervention, leaving the study early, and quality of life. For dichotomous outcomes, we calculated the risk ratio (RR) with 95% confidence intervals (CIs); for continuous outcomes we calculated the mean difference (MD) with 95% CIs. We assessed the quality of evidence using GRADE to generate a 'Summary of findings' table.

MAIN RESULTS

We included one study involving 15 participants from the UK. The included participants were diagnosed with delirium based on the Confusion Assessment Method (CAM) criteria. Eight males and seven females were included, with a mean age of 82.5 years. Seven of the 15 participants had comorbid dementia at baseline. The risk of bias was low in all domains.The study compared rivastigmine with placebo. We did not find any clear differences between the two groups in terms of duration of delirium (MD -3.6, 95% CI -15.6 to 8.4), adverse events (nausea, RR 0.30, 95% CI 0.01 to 6.29), use of rescue medications (RR 0.13, 95% CI 0.01 to 2.1), mortality (RR 0.10, 95% CI 0.01 to 1.56), and leaving the study early (RR 0.88, 95% CI 0.07 to 11.54). Evidence was not available regarding the severity of delirium, persistent cognitive impairment, length of hospitalisation, cost of intervention, or other predefined secondary outcomes.The quality of evidence is low due to the very small sample size.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the use of cholinesterase inhibitors for the treatment of delirium in non-ICU settings. No clear benefits or harms associated with cholinesterase inhibitors were observed when compared with placebo due to the lack of data. More trials are required.