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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Yoon BH, Yoo JI, Youn Y, Ha YC. Cholinergic enhancers for preventing postoperative delirium among elderly patients after hip fracture surgery: A meta-analysis. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Youn YC, Shin HW, Choi BS, Kim S, Lee JY, Ha YC. Rivastigmine patch reduces the incidence of postoperative delirium in older patients with cognitive impairment. Int J Geriatr Psychiatry 2017; 32:1079-1084. [PMID: 27561376 DOI: 10.1002/gps.4569] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To date, data regarding the efficacy of acetylcholinesterase inhibitors in preventing postoperative delirium (POD) are inconsistent and conflicting. Older individuals with cognitive dysfunction are thought to show POD more frequently. Our aim was to study the effectiveness of rivastigmine prophylaxis on the incidence, severity, and risk factors for POD in older patients with cognitive impairment undergoing hip fracture surgery. METHODS Of 62 older patients with cognitive impairment about to undergo surgery after a hip fracture, 31 were randomly assigned to receive a rivastigmine patch from 3 days before to 7 days after the operation (Group I), and the other 31 did not receive a rivastigmine patch (Group II). The two groups were compared with regard to incidence and severity of delirium on postoperative days 2 or 3 and 7. Multivariate logistic regression analysis was performed to assess factors associated with POD. RESULTS Postoperative delirium occurred in five Group I patients and 14 Group II patients (p = 0.013). The mean severity of delirium in the two groups as determined by the Delirium Rating Scale was 2.2 and 6.2 respectively (p = 0.033). The odds ratio for POD was 0.259 (95% CI: 0.074-0.905, p = 0.034) after adjusting for American Society of Anesthesiologists score (p = 0.058), age (p = 0.203), and gender (p = 0.560). There were no rivastigmine-related perioperative complications. CONCLUSION Perioperative rivastigmine patch application could reduce the occurrence of POD in older patients with low cognitive status. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Young Chul Youn
- Department of Neurology, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Hae-Won Shin
- Department of Neurology, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Byung-Sun Choi
- Department of Preventive Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - SangYun Kim
- Department of Neurology, Seoul National University College of Medicine & Seoul National University Bundang Hospital, Seoul, South Korea
| | - Jung-Yeop Lee
- Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
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Schwartz AC, Fisher TJ, Greenspan HN, Heinrich TW. Pharmacologic and nonpharmacologic approaches to the prevention and management of delirium. Int J Psychiatry Med 2017; 51:160-70. [PMID: 26941206 DOI: 10.1177/0091217416636578] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Delirium is a syndrome of neuropsychiatric signs and symptoms that can accompany virtually any serious medical condition. Delirium is characterized by a disturbance of attention and awareness, as well as variety of other aspects of cognition that develops over a short period of time in response to another medical condition. It is an independent risk factor for increased morbidity and mortality and is associated with increased lengths of stay and costs of care. Despite this, it frequently goes unrecognized, and debate continues about the best prevention and treatment strategies. This article will review the current best practices for the prevention and treatment of delirium and how collaborative care can aid in improving outcomes and minimizing adverse events for patients suffering from delirium.
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Affiliation(s)
- Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Travis J Fisher
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Heather N Greenspan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas W Heinrich
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Reddy SV, Irkal JN, Srinivasamurthy A. Postoperative delirium in elderly citizens and current practice. J Anaesthesiol Clin Pharmacol 2017; 33:291-299. [PMID: 29109625 PMCID: PMC5672535 DOI: 10.4103/joacp.joacp_180_16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Postoperative delirium (POD) represents an acute brain dysfunction in the postsurgical period. Perioperative physicians caring for the older adults are familiar with the care of dysfunction of organs such as lungs, heart, liver, or kidney in the perioperative setting, but they are less familiar with management of brain dysfunction. As early detection and prompt treatment of inciting factors are utmost important to prevent or minimize the deleterious outcomes of delirium. The purpose of this review is to prepare perioperative physicians with a set of current clinical practice recommendations to provide optimal perioperative care of older adults, with a special focus on specific perioperative interventions that have been shown to prevent POD. On literature search in EMBASE, CINAHL, and PUBMED between January 2000 and September 2015 using search words delirium, POD, acute postoperative confusion, and brain dysfunction resulted in 9710 articles. Among them, 73 articles were chosen for review, in addition, National Institute for Health and Clinical Excellence guidelines, American Geriatric Society guidelines, hospital elderly life program-confusion assessment method training manual, New York geriatric nursing protocols, World Health Organization's International Classification of Diseases, 10th Revision classification of mental disorders, Food and Drug Administration requests boxed warnings on older class of antipsychotic drugs 2008 and delirium in Miller's text book of anesthesia were reviewed and relevant information presented in this article.
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Affiliation(s)
- Siddareddygari Velayudha Reddy
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
| | - Jawaharlal Narayanasa Irkal
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
| | - Ananthapuram Srinivasamurthy
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
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Abstract
Older adults make up an ever-increasing number of patients presenting for surgery, and a significant percentage of these patients will be frail. Frailty is a geriatric syndrome that has been conceptualized as decreased reserve when confronted with stressors, although the precise definition of frailty has not been easy to standardize. The 2 most popular approaches to define frailty are the phenotypic approach and the deficit accumulation approach, although at least 20 tools have been developed, which has made comparison across studies difficult. In epidemiologic studies, baseline frailty has been associated with poor outcomes in both community cohorts and hospitalized patients. Specifically in cardiac surgery (including transcatheter aortic valve implantation procedures), frailty has been strongly associated with postoperative mortality and morbidity, and thus frailty likely improves the identification of high-risk patients beyond known risk scores. For perioperative physicians then, the question arises of how to incorporate this information into perioperative care. To date, 2 thrusts of research and clinical practice have emerged: (1) preoperative identification of high-risk patients to guide both patient expectations and surgical decision-making; and (2) perioperative optimization strategies for frail patients. However, despite the strong association of frailty and poor outcomes, there is a lack of well-designed trials that have examined perioperative interventions with a specific focus on frail patients undergoing cardiac surgery. Thus, in many cases, principles of geriatric care may need to be applied. Further research is needed to standardize and implement the feasible definitions of frailty and examine perioperative interventions for frail patients undergoing cardiac surgery.
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Affiliation(s)
- Antonio Graham
- From the *Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and †Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Tauber SC, Eiffert H, Brück W, Nau R. Septic encephalopathy and septic encephalitis. Expert Rev Anti Infect Ther 2016; 15:121-132. [DOI: 10.1080/14787210.2017.1265448] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Simone C. Tauber
- Department of Neurology, RWTH University Hospital, Aachen, Germany
| | - Helmut Eiffert
- Department of Medical Microbiology, Georg-August-University, Göttingen, Germany
| | - Wolfgang Brück
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
| | - Roland Nau
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
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Brown CH, LaFlam A, Max L, Wyrobek J, Neufeld KJ, Kebaish KM, Cohen DB, Walston JD, Hogue CW, Riley LH. Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes. J Am Geriatr Soc 2016; 64:2101-2108. [PMID: 27696373 DOI: 10.1111/jgs.14434] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery. DESIGN Prospective observational study. SETTING Academic medical center. PARTICIPANTS Individuals aged 70 and older undergoing spine surgery (N = 89). MEASUREMENTS Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state. RESULTS Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home. CONCLUSION Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Andrew LaFlam
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Julie Wyrobek
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David B Cohen
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy D Walston
- Department of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lee H Riley
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Souza-Dantas VC, Póvoa P, Bozza F, Soares M, Salluh J. Preventive strategies and potential therapeutic interventions for delirium in sepsis. Hosp Pract (1995) 2016; 44:190-202. [PMID: 27223862 DOI: 10.1080/21548331.2016.1192453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/18/2016] [Indexed: 06/05/2023]
Abstract
Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.
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Affiliation(s)
| | - Pedro Póvoa
- b Polyvalent Intensive Care Unit, Hospital S. Francisco Xavier , Centro Hospitalar de Lisboa Ocidental (CHLO) , Lisbon , Portugal
- c Nova Medical School , CEDOC, New University of Lisbon , Portugal
| | - Fernando Bozza
- d Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
| | - Marcio Soares
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
| | - Jorge Salluh
- e D'Or Institute for Research and Education , Rio de Janeiro , Brazil
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Tremblay P, Gold S. Prevention of Post-operative Delirium in the Elderly Using Pharmacological Agents. Can Geriatr J 2016; 19:113-126. [PMID: 27729950 PMCID: PMC5038927 DOI: 10.5770/cgj.19.226] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Post-operative delirium (POD) is a serious surgical complication that can cause significant morbidity and mortality. It is associated with prolonged hospital stay, delayed admission to rehabilitation programs, persistent cognitive deficits, marked health-care costs, and more. The pathophysiology is multi-factorial and not completely understood, which complicates the optimal management. Non-pharmacological measures have been the mainstay of treatment, but there has been an ongoing interest in the medical literature on the prevention of post-operative delirium using medications. The purpose of this review is to critically analyze the current evidence on pharmacological prevention of POD. Methods A literature review was conducted using PubMed and Embase databases, using the following search terms: delirium, anti-psychotics, cholinesterase inhibitors, and statins. Results A total of 1,152 articles were screened and 25 articles were reviewed. Fourteen articles found a reduced incidence of post-operative delirium using pharmacological agents: eight with antipsychotics, two with statins, one with melatonin, one with dexamethasone, one with gabapentin, and one with diazepam. However, study designs, methodological issues, or authors’ interpretations raise questions on these conclusions. Conclusions Further double-blinded randomized clinical trials should be conducted before administering pharmacological agents to reduce POD in a non-research setting.
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Affiliation(s)
- Patrice Tremblay
- Department of Family Medicine, St. Mary's Hospital Center, McGill University, Montreal, PQ
| | - Susan Gold
- Department of Geriatric Medicine, Jewish General Hospital, McGill University, Montreal, PQ
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Adamis D, Meagher D, O'Neill D, McCarthy G. The utility of the clock drawing test in detection of delirium in elderly hospitalised patients. Aging Ment Health 2016; 20:981-6. [PMID: 26032937 DOI: 10.1080/13607863.2015.1050996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Delirium is common neuropsychiatric condition among elderly inpatients. The clock drawing test (CDT) has been used widely as bedside screening tool in assessing cognitive impairment in elderly people. Previous studies which evaluate its usefulness in delirium reported conflicting results. The objective of this study was to evaluate the utility of CDT to detect delirium in elderly medical patients. METHOD Prospective, observational, longitudinal study. All acute medical admissions 70 years of age and above were approached within 72 hours of admission for recruitment. Patients eligible for inclusion were assessed four times, twice weekly during admission. Assessment included Confusion Assessment Method (CAM), Delirium Rating Scale (DRS-98R), Montreal Cognitive Assessment (MoCA), Acute Physiology and Chronic Health Evaluation II (APACHE) II, and CDT. Data was analysed using a linear mixed effect model. RESULTS Three hundred and twenty-three assessments with the CDT were performed on 200 subjects (50% male, mean age 81.13; standard deviation: 6.45). The overall rate of delirium (CAM+) during hospitalisation was 23%. There was a significant negative correlation between the CDT and DRS-R98 scores (Pearson correlation r = -0.618, p < 0.001), CDT and CAM (Spearman's rho = -0.402, p < 0.001) and CDT and total MoCA score (Pearson's r = 0.767, p < 0.001). However, when the data were analysed longitudinally controlling for all the factors, we found that cognitive function and age were significant factors associated with CDT scores (p < .0001): neither the presence nor the severity of delirium had an additional significant effect on the CDT. CONCLUSION CDT score reflects cognitive impairment, independently of the presence or severity of delirium. The CDT is not a suitable test for delirium in hospitalised elderly patients.
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Affiliation(s)
- Dimitrios Adamis
- a Sligo Mental Health Services , Sligo , Ireland.,b Research and Academic Institute of Athens , Athens , Greece
| | - David Meagher
- c Cognitive Impairment Research Group (CIRG) , Graduate-Entry Medical School University of Limerick , Limerick , Ireland
| | | | - Geraldine McCarthy
- a Sligo Mental Health Services , Sligo , Ireland.,d Sligo Medical Academy , NUI Galway and Sligo Mental Health Services , Sligo , Ireland
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Tampi RR, Tampi DJ, Ghori AK. Acetylcholinesterase Inhibitors for Delirium in Older Adults. Am J Alzheimers Dis Other Demen 2016; 31:305-10. [PMID: 26646113 PMCID: PMC10852606 DOI: 10.1177/1533317515619034] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this systematic review is to identify published randomized controlled trials (RCTs) that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). METHODS A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO, and Cochrane collaboration databases for RCTs in any language that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). Also, bibliographic databases of the published articles were searched for additional studies. RESULTS A total of 7 RCTs that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years) were identified. In 5 of the 7 studies, there was no benefit for the acetylcholinesterase inhibitor in either the prevention or the management of delirium. In one study, there was a trend toward benefit for the active drug group on the incidence of delirium and the length of hospital stay, but both outcomes did not attain statistical significance. One study found a longer duration of delirium and a longer length of hospital stay in the active drug group when compared to the placebo group. The acetylcholinesterase inhibitors were well tolerated in 4 of the 7 studies. In 1 study, the mortality rate was found to be almost 3 times higher in the group receiving haloperidol and rivastigmine when compared to the group receiving haloperidol and placebo. CONCLUSION Current evidence does not suggest efficacy of acetylcholinesterase inhibitors for the prevention or management of delirium in older adults.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, MetroHealth, Cleveland, OH, USA
| | - Deena J Tampi
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
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Olfactory dysfunction is related to postoperative delirium in Parkinson’s disease. J Neural Transm (Vienna) 2016; 123:589-94. [DOI: 10.1007/s00702-016-1555-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/11/2016] [Indexed: 11/28/2022]
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Evans AS, Weiner MM, Arora RC, Chung I, Deshpande R, Varghese R, Augoustides J, Ramakrishna H. Current approach to diagnosis and treatment of delirium after cardiac surgery. Ann Card Anaesth 2016; 19:328-37. [PMID: 27052077 PMCID: PMC4900348 DOI: 10.4103/0971-9784.179634] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/09/2016] [Indexed: 01/12/2023] Open
Abstract
Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.
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Affiliation(s)
- Adam S. Evans
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Menachem M. Weiner
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Insung Chung
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Robin Varghese
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Augoustides
- Department of Anesthesiology, University of Pennsylvania, PA, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, United States
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Brown CH, Laflam A, Max L, Lymar D, Neufeld KJ, Tian J, Shah AS, Whitman GJ, Hogue CW. The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. Ann Thorac Surg 2016; 101:1663-9. [PMID: 27041454 DOI: 10.1016/j.athoracsur.2015.12.074] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/07/2015] [Accepted: 12/22/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Delirium is a common complication after cardiac surgical procedures and is associated with increased morbidity and mortality. However, whether rigorously assessed postoperative delirium is associated with an increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. METHODS Patients (n = 66) undergoing coronary artery bypass or valve operations, or both, were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record, and hospital charges were obtained from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. RESULTS Patients who developed delirium (56%) versus no delirium (43%) had increased median LOS-ICU (75.6 hours [interquartile range (IQR): 43.6 to 136.8] vs. 29.7 hours [IQR: 21.7 to 46.0]; p = 0.002), increased median LOS (9 days [IQR: 6 to 16] vs. 7 days [IQR: 5 to 8]; p = 0.006), and increased median hospital charges ($51,805 [IQR: $44,041 to $80,238] vs. $41,576 [IQR: $35,748 to $43,660]; p = 0.002). In propensity score models adjusted for patient-related and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated on the basis of the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and increased charges in a dose-response manner. CONCLUSIONS Delirium after cardiac surgical procedures is independently associated with both increased LOS-ICU and higher hospital charges. Because delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore.
| | - Andrew Laflam
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Daria Lymar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ashish S Shah
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Glenn J Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
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Tsuruta R, Oda Y. A clinical perspective of sepsis-associated delirium. J Intensive Care 2016; 4:18. [PMID: 27011789 PMCID: PMC4804610 DOI: 10.1186/s40560-016-0145-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 03/04/2016] [Indexed: 12/29/2022] Open
Abstract
The term sepsis-associated encephalopathy (SAE) has been applied to animal models, postmortem studies in patients, and severe cases of sepsis. SAE is considered to include all types of brain dysfunction, including delirium, coma, seizure, and focal neurological signs. Clinical data for sepsis-associated delirium (SAD) have been accumulating since the establishment of definitions of coma or delirium and the introduction of validated screening tools. Some preliminary studies have examined the etiology of SAD. Neuroinflammation, abnormal cerebral perfusion, and neurotransmitter imbalances are the main mechanisms underlying the development of SAD. However, there are still no specific diagnostic blood, electrophysiological, or imaging tests or treatments specific for SAD. The duration of delirium in intensive care patients is associated with long-term functional disability and cognitive impairment, although this syndrome usually reverses after the successful treatment of sepsis. Once the respiratory and hemodynamic states are stabilized, patients with severe sepsis or septic shock should receive rehabilitation as soon as possible because early initiation of rehabilitation can reduce the duration of delirium. We expect to see further pathophysiological data and the development of novel treatments for SAD now that reliable and consistent definitions of SAD have been established.
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Affiliation(s)
- Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Yasutaka Oda
- Acute and General Medicine, Yamaguchi Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Restrepo Bernal D, Niño García JA, Ortiz Estévez DE. [Delirium Prevention]. REVISTA COLOMBIANA DE PSIQUIATRIA 2016; 45:37-45. [PMID: 26896403 DOI: 10.1016/j.rcp.2015.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/06/2015] [Accepted: 06/30/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Delirium is the most prevalent neuropsychiatric syndrome in the general hospital. Its presence is a marker of poor prognosis for patients. Its prevention could be the most effective strategy for reducing its frequency and its complications. OBJECTIVE To review recent findings and strategies for the prevention of delirium. METHODOLOGY A non-systematic review of scientific articles published in the last ten years in Spanish and English. A search was made in databases such as MEDLINE, Cochrane, EMBASE, Ovid, and ScienceDirect, for articles that included the terms, delirium and prevention. RESULTS Identification of predisposing and precipitating factors for delirium and a better understanding of the pathophysiological mechanisms underlying the onset of delirium have enabled the implementation of various pharmacological and non-pharmacological strategies in patients at high risk to develop hospital delirium. The studies to prevent delirium have focused on surgical patients. The current evidence supports the daily implementation of non-pharmacological measures to prevent delirium, as they are easy and cost effective. The available evidence is still limited to recommend the daily use of pharmacological strategies in delirium prophylaxis, and there is a consensus against the modest use of antipsychotic drugs in surgical patients and dexmedetomidine in patients in intensive care. CONCLUSIONS New high-quality clinical trials and studies involving non-surgical patients are needed to provide more evidence about this subject.
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Mohammadi M, Ahmadi M, Khalili H, Cheraghchi H, Arbabi M. Cyproheptadine for the Prevention of Postoperative Delirium: A Pilot Study. Ann Pharmacother 2015; 50:180-7. [PMID: 26706862 DOI: 10.1177/1060028015624938] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postoperative delirium is a common neurobehavioral complication after major surgeries. There is no conclusive approach for prevention of delirium in these patients. OBJECTIVE In this study, efficacy of cyproheptadine for prevention of postoperative delirium was evaluated. METHODS Delirium status of surgical patients was evaluated postoperatively at the time of admission to the intensive care unit (ICU) using the Confusion Assessment Method (CAM-ICU) scale. Patients without delirium were assigned to the cyproheptadine or placebo group based on the simple randomization method. Patients received cyproheptadine or placebo tablet at a dose of 4 mg 3 times per day for 7 days. Patients were monitored daily for incidence of delirium. RESULTS Changes in the incidence rates of delirium over time during the study phase (P = 0.04) and between the groups showed statistically significant differences (P = 0.029). However, severity of delirium was not significantly different between the cyproheptadine and placebo groups during the study period. CONCLUSION It seems that cyproheptadine with its diverse effects can be a potential option for prevention of postoperative delirium. In this pilot study, cyproheptadine significantly decreased the incidence but not severity of postoperative delirium.
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Hollinger A, Siegemund M, Goettel N, Steiner LA. Postoperative Delirium in Cardiac Surgery: An Unavoidable Menace? J Cardiothorac Vasc Anesth 2015; 29:1677-87. [DOI: 10.1053/j.jvca.2014.08.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Indexed: 01/20/2023]
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Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc19. [PMID: 26609286 PMCID: PMC4645746 DOI: 10.3205/000223] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 02/08/2023]
Abstract
In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
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Affiliation(s)
| | | | | | | | - Stephan Braune
- German Society of Internal Medicine Intensive Care (DGIIN)
| | - Hartmut Buerkle
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Peter Dall
- German Society of Gynecology & Obstetrics (DGGG)
| | - Sueha Demirakca
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Verena Eggers
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ingolf Eichler
- German Society for Thoracic and Cardiovascular Surgery (DGTHG)
| | | | | | | | - Lars Garten
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Irene Harth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | - Johannes Horter
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ralf Huth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Uwe Janssens
- German Society of Internal Medicine Intensive Care (DGIIN)
| | | | | | - Paul Kessler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Matthias Kumpf
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Andreas Meiser
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Anika Mueller
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Bernd Roth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | | | - Monika Schindler
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Reinhard Schmitt
- German Society for Specialised Nursing and Allied Health Professions (DGF)
| | - Jens Scholz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Stefan Schroeder
- German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)
| | | | - Claudia Spies
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | - Peter Tonner
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Uwe Trieschmann
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Michael Tryba
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Frank Wappler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Christian Waydhas
- German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
| | - Bjoern Weiss
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Guido Weisshaar
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
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Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:346. [PMID: 26395253 PMCID: PMC4579578 DOI: 10.1186/s13054-015-1060-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Abstract
Introduction As evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations. Method A prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies. Results In total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors. Conclusion Of many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Nc Gosselt
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Pascal Rq Boere
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Irene J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, Pierini V, Dessì Fulgheri P, Lattanzio F, O’Mahony D, Cherubini A. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One 2015; 10:e0123090. [PMID: 26062023 PMCID: PMC4465742 DOI: 10.1371/journal.pone.0123090] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/27/2015] [Indexed: 01/08/2023] Open
Abstract
Background Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making. Methods and Findings We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I2=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I2=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium. Conclusions In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.
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Affiliation(s)
- Iosief Abraha
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
- * E-mail:
| | - Fabiana Trotta
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Joseph M. Rimland
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | | | | | - Roy L. Soiza
- Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, United Kingdom
| | - Valentina Pierini
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Paolo Dessì Fulgheri
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Denis O’Mahony
- Department of Medicine, University College Cork, Cork, Ireland
| | - Antonio Cherubini
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
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Pharmacological interventions for preventing delirium in the elderly. Maturitas 2015; 81:287-92. [DOI: 10.1016/j.maturitas.2015.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/30/2015] [Indexed: 01/26/2023]
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Pharmacologic agents for the prevention and treatment of delirium in patients undergoing cardiac surgery: systematic review and metaanalysis. Crit Care Med 2015; 43:194-204. [PMID: 25289932 DOI: 10.1097/ccm.0000000000000673] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Postcardiac surgery delirium is associated with increased risks of morbidity, cognitive decline, poor health-related quality of life and mortality, and higher healthcare costs. We performed a systematic review of randomized controlled trials to examine the effect of pharmacologic agents for the prevention and the treatment of delirium after cardiac surgery. DATA SOURCES Electronic search on PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, and CINAHL up to December 2013. STUDY SELECTION Randomized controlled trials of pharmacologic agents used for the prevention and the treatment of delirium after emergency or elective cardiac surgery in adults. DATA EXTRACTION We extracted data on patient population, pharmacologic agents, delirium characteristics, rescue treatment, length of stays in the ICU and hospital, and mortality. For each trial, we assessed the risk of bias domains and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS Of the 13 studies (10 prevention and three treatment) involving 5,848 patients, one multicentered randomized controlled trial on prophylactic dexamethasone made up 77% of the total sample size. The use of pharmacologic agents (dexamethasone, rivastigmine, risperidone, ketamine, dexmedetomidine, propofol, and clonidine) reduced the risk of delirium (relative risk, 0.57; 95% CI, 0.40-0.80) with quality of evidence rated as moderate. There was high quality of evidence for no increased risk of mortality (relative risk, 0.89; 95% CI, 0.57-1.38) associated with the use of prophylactic pharmacologic agents. Metaanalysis of treatment trials was not undertaken because of high heterogeneity. In two small trials (total number of patients = 133), haloperidol did not appear to be effective in treating delirium. CONCLUSIONS Moderate to high-quality evidence supports the use of pharmacologic agents for the prevention of delirium, but results are based largely on one randomized controlled trial. The evidence for treating postcardiac surgery delirium with pharmacologic agents is inconclusive.
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Serafim RB, Bozza FA, Soares M, do Brasil PEAA, Tura BR, Ely EW, Salluh JIF. Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review. J Crit Care 2015; 30:799-807. [PMID: 25957498 DOI: 10.1016/j.jcrc.2015.04.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of the study is to determine if pharmacologic approaches are effective in prevention and treatment of delirium in critically ill patients. MATERIALS AND METHODS We performed a systematic search to identify publications (from January 1980 to September 2014) that evaluated the pharmacologic interventions to treat or prevent delirium in intensive care unit (ICU) patients. RESULTS From 2646 citations, 15 studies on prevention (6729 patients) and 7 studies on treatment (1784 patients) were selected and analyzed. Among studies that evaluated surgical patients, the pharmacologic interventions were associated with a reduction in delirium prevalence, ICU length of stay, and duration of mechanical ventilation, but with high heterogeneity (respectively, I(2) = 81%, P = .0013; I(2) = 97%, P < .001; and I(2) = 97%). Considering treatment studies, only 1 demonstrated a significant decrease in ICU length of stay using dexmedetomidine compared to haloperidol (Relative Risk, 0.62 [1.29-0.06]; I(2) = 97%), and only 1 found a shorter time to resolution of delirium using quetiapine (1.0 [confidence interval, 0.5-3.0] vs 4.5 [confidence interval, 2.0-7.0] days; P = .001). CONCLUSION The use of antipsychotics for surgical ICU patients and dexmedetomidine for mechanically ventilated patients as a preventive strategy may reduce the prevalence of delirium in the ICU. None of the studied agents that were used for delirium treatment improved major clinical outcome, including mortality.
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Affiliation(s)
- Rodrigo B Serafim
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Hospital Copa D'Or, Rio de Janeiro, Brazil; Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Instituto de Pesquisa Clínica Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
| | | | - Bernardo R Tura
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
| | - E Wesley Ely
- Vanderbilt University School of Medicine, Nashville, TN, USA; Veteran Affairs Tennessee Valley Geriatric Research Education Clinical Center (VA-GRECC), Nashville, TN, USA.
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
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Khan BA, Gutteridge D, Campbell NL. Update on Pharmacotherapy for Prevention and Treatment of Post-operative Delirium: A Systematic Evidence Review. CURRENT ANESTHESIOLOGY REPORTS 2015; 5:57-64. [PMID: 25729334 PMCID: PMC4339069 DOI: 10.1007/s40140-014-0090-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Delirium is highly prevalent among elderly post-operative patients with no pharmacological intervention approved by the Food and Drug Administration for prevention or treatment. We conducted a systematic evidence review to critically appraise literature related to the pharmacotherapy of post-operative delirium. Ten studies fulfilled our inclusion criteria with two interventions for delirium treatment and eight interventions for delirium prevention in post-operative patients. The quality of evidence of delirium treatment studies was poor, whereas the quality of evidence in delirium prevention studies ranges from moderate to high. Delirium treatment studies find similar delirium duration and length-of-stay outcomes between haloperidol and either morphine or ondansetron. Risperidone was found to reduce the conversion of sub-syndromal delirium to delirium in one study compared to placebo. Haloperidol, olanzapine, and ketamine were each found to reduce delirium incidence, whereas rivastigmine had no impact on delirium incidence or duration. Lighter anesthesia as monitored by bi-spectral index led to a decreased delirium incidence. Considering results from studies conducted prior to the dates of this review, the current evidence suggests that certain pharmacologic classes and lighter sedation using BIS monitoring may prevent post-operative delirium, although a conclusive recommendation for clinical practice must await further research.
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Affiliation(s)
- Babar A. Khan
- Indiana University School of Medicine, Indianapolis, IN, USA. Indiana University Center for Aging Research, Indianapolis, IN, USA. Regenstrief Institute, Inc., Indianapolis, IN, USA
| | | | - Noll L. Campbell
- Indiana University Center for Aging Research, Indianapolis, IN, USA. Regenstrief Institute, Inc., Indianapolis, IN, USA. Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA
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Hassani S, Alipour A, Darvishi Khezri H, Firouzian A, Emami Zeydi A, Gholipour Baradari A, Ghafari R, Habibi WA, Tahmasebi H, Alipour F, Ebrahim Zadeh P. Can Valeriana officinalis root extract prevent early postoperative cognitive dysfunction after CABG surgery? A randomized, double-blind, placebo-controlled trial. Psychopharmacology (Berl) 2015; 232:843-50. [PMID: 25173770 DOI: 10.1007/s00213-014-3716-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 08/08/2014] [Indexed: 11/24/2022]
Abstract
RATIONALE We hypothesized that valerian root might prevent cognitive dysfunction in coronary artery bypass graft (CABG) surgery patients through stimulating serotonin receptors and anti-inflammatory activity. OBJECTIVES The aim of this study was to evaluate the effect of Valeriana officinalis root extract on prevention of early postoperative cognitive dysfunction after on-pump CABG surgery. METHODS In a randomized, double-blind, placebo-controlled trial, 61 patients, aged between 30 and 70 years, scheduled for elective CABG surgery using cardiopulmonary bypass (CPB), were recruited into the study. Patients were randomly divided into two groups who received either one valerian capsule containing 530 mg of valerian root extract (1,060 mg/daily) or placebo capsule each 12 h for 8 weeks, respectively. For all patients, cognitive brain function was evaluated before the surgery and at 10-day and 2-month follow-up by Mini Mental State Examination (MMSE) test. RESULTS Mean MMSE score decreased from 27.03 ± 2.02 in the preoperative period to 26.52 ± 1.82 at the 10th day and then increased to 27.45 ± 1.36 at the 60th day in the valerian group. Conversely, its variation was reduced significantly after 60 days in the placebo group, 27.37 ± 1.87 at the baseline to 24 ± 1.91 at the 10th day, and consequently slightly increased to 24.83 ± 1.66 at the 60th day. Valerian prophylaxis reduced odds of cognitive dysfunction compared to placebo group (OR = 0.108, 95 % CI 0.022-0.545). CONCLUSION We concluded that, based on this study, the cognitive state of patients in the valerian group was better than that in the placebo group after CABG; therefore, it seems that the use of V. officinalis root extract may prevent early postoperative cognitive dysfunction after on-pump CABG surgery.
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Affiliation(s)
- Soghra Hassani
- Department of Nursing, Faculty of Medicine, Islamic Azad University, 7th km of Sea Road (Farah Abaad), Firoozkande, Sari, Iran
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Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, Deiner S, Fick D, Hutchison L, Johanning J, Katlic M, Kempton J, Kennedy M, Kimchi E, Ko C, Leung J, Mattison M, Mohanty S, Nana A, Needham D, Neufeld K, Richter H. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Coll Surg 2015; 220:136-48.e1. [DOI: 10.1016/j.jamcollsurg.2014.10.019] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 12/17/2022]
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Liao B, Han Q, Le YG, Fan JC, Jiang C, Xie XF, Zeng F. Recent progress in research of postoperative delirium after abdominal surgery. Shijie Huaren Xiaohua Zazhi 2015; 23:236-242. [DOI: 10.11569/wcjd.v23.i2.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Postoperative delirium (POD) is a common acute cerebral syndrome after abdominal surgery, with disturbance of consciousness, cognition and attention as the main clinical manifestations, found mostly in elderly male patients. POD often increases mortality dramatically and prolongs the length of hospital stay. There are many factors responsible for the occurrence of POD, such as age, underlying diseases and antipsychotic drugs. Due to the complex onset of the disease, multicomponent intervention strategies have been recommended and proved effective. In contrast, there has been no evidence that pharmacological prevention or therapy could reduce the incidence or shorten the duration of POD. This paper reviews the recent progress in research of postoperative delirium after abdominal surgery with regards to its mechanism, risk factors, prevention and treatment.
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Firouzian A, Darvishi Khezri H. Can Glycyrrhiza glabra L. reduce delirium after coronary artery bypass graft surgery? FORSCHENDE KOMPLEMENTARMEDIZIN (2006) 2015; 21:418-9. [PMID: 25592953 DOI: 10.1159/000370035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Abolfazl Firouzian
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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85
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Messinger-Rapport BJ, Gammack JK, Little MO, Morley JE. Clinical Update on Nursing Home Medicine: 2014. J Am Med Dir Assoc 2014; 15:786-801. [DOI: 10.1016/j.jamda.2014.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 12/18/2022]
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Korc-Grodzicki B, Root JC, Alici Y. Prevention of post-operative delirium in older patients with cancer undergoing surgery. J Geriatr Oncol 2014; 6:60-9. [PMID: 25454768 DOI: 10.1016/j.jgo.2014.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/05/2014] [Accepted: 10/07/2014] [Indexed: 12/21/2022]
Abstract
Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box 205, New York, NY 10065, United States.
| | - James C Root
- Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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Trabold B, Metterlein T. Postoperative Delirium: Risk Factors, Prevention, and Treatment. J Cardiothorac Vasc Anesth 2014; 28:1352-60. [DOI: 10.1053/j.jvca.2014.03.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Indexed: 01/07/2023]
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Perioperative education in geriatrics. Int Anesthesiol Clin 2014; 52:1-13. [PMID: 25268860 DOI: 10.1097/aia.0000000000000036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Can intensive care unit delirium be prevented and reduced? Lessons learned and future directions. Ann Am Thorac Soc 2014; 10:648-56. [PMID: 24364769 DOI: 10.1513/annalsats.201307-232fr] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.
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de Jonghe A, van Munster BC, Goslings JC, Kloen P, van Rees C, Wolvius R, van Velde R, Levi M, de Haan RJ, de Rooij SE. Effect of melatonin on incidence of delirium among patients with hip fracture: a multicentre, double-blind randomized controlled trial. CMAJ 2014; 186:E547-56. [PMID: 25183726 DOI: 10.1503/cmaj.140495] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Disturbance of the sleep-wake cycle is a characteristic of delirium. In addition, changes in melatonin rhythm influence the circadian rhythm and are associated with delirium. We compared the effect of melatonin and placebo on the incidence and duration of delirium. METHODS We performed this multicentre, double-blind, randomized controlled trial between November 2008 and May 2012 in 1 academic and 2 nonacademic hospitals. Patients aged 65 years or older who were scheduled for acute hip surgery were eligible for inclusion. Patients received melatonin 3 mg or placebo in the evening for 5 consecutive days, starting within 24 hours after admission. The primary outcome was incidence of delirium within 8 days of admission. We also monitored the duration of delirium. RESULTS A total of 452 patients were randomly assigned to the 2 study groups. We subsequently excluded 74 patients for whom the primary end point could not be measured or who had delirium before the second day of the study. After these postrandomization exclusions, data for 378 patients were included in the main analysis. The overall mean age was 84 years, 238 (63.0%) of the patients lived at home before admission, and 210 (55.6%) had cognitive impairment. We observed no effect of melatonin on the incidence of delirium: 55/186 (29.6%) in the melatonin group v. 49/192 (25.5%) in the placebo group; difference 4.1 (95% confidence interval -0.05 to 13.1) percentage points. There were no between-group differences in mortality or in cognitive or functional outcomes at 3-month follow-up. INTERPRETATION In this older population with hip fracture, treatment with melatonin did not reduce the incidence of delirium. TRIAL REGISTRATION Netherlands Trial Registry, NTR1576: MAPLE (Melatonin Against PLacebo in Elderly patients) study; www.trialregister.nl/trialreg/admin/rctview.asp?TC=1576.
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Affiliation(s)
- Annemarieke de Jonghe
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands.
| | - Barbara C van Munster
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - J Carel Goslings
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Peter Kloen
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Carolien van Rees
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Reinder Wolvius
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Romuald van Velde
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Marcel Levi
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Rob J de Haan
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
| | - Sophia E de Rooij
- Department of Internal Medicine, Geriatrics Section (de Jonghe, van Munster, de Rooij), Department of Surgery, Trauma Unit (Goslings), Department of Orthopedic Surgery (Kloen), Department of Internal Medicine (Levi) and Clinical Research Unit (de Haan), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Geriatrics (van Munster), Gelre Hospitals, Apeldoorn, The Netherlands; Department of Geriatrics (van Rees), Department of Orthopaedic Surgery (Wolvius) and Department of Surgery (van Velde), Tergooi Hospitals, Hilversum, The Netherlands
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Randomized ICU trials do not demonstrate an association between interventions that reduce delirium duration and short-term mortality: a systematic review and meta-analysis. Crit Care Med 2014; 42:1442-54. [PMID: 24557420 DOI: 10.1097/ccm.0000000000000224] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We reviewed randomized trials of adult ICU patients of interventions hypothesized to reduce delirium burden to determine whether interventions that are more effective at reducing delirium duration are associated with a reduction in short-term mortality. DATA SOURCES We searched CINHAHL, EMBASE, MEDLINE, and the Cochrane databases from 2001 to 2012. STUDY SELECTION Citations were screened for randomized trials that enrolled critically ill adults, evaluated delirium at least daily, compared a drug or nondrug intervention hypothesized to reduce delirium burden with standard care (or control), and reported delirium duration and/or short-term mortality (≤ 45 d). DATA EXTRACTION In duplicate, we abstracted trial characteristics and results and evaluated quality using the Cochrane risk of bias tool. We performed random effects model meta-analyses and meta-regressions. DATA SYNTHESIS We included 17 trials enrolling 2,849 patients which evaluated a pharmacologic intervention (n = 13) (dexmedetomidine [n = 6], an antipsychotic [n = 4], rivastigmine [n = 2], and clonidine [n = 1]), a multimodal intervention (n = 2) (spontaneous awakening [n = 2]), or a nonpharmacologic intervention (n = 2) (early mobilization [n = 1] and increased perfusion [n = 1]). Overall, average delirium duration was lower in the intervention groups (difference = -0.64 d; 95% CI, -1.15 to -0.13; p = 0.01) being reduced by more than or equal to 3 days in three studies, 0.1 to less than 3 days in six studies, 0 day in seven studies, and less than 0 day in one study. Across interventions, for 13 studies where short-term mortality was reported, short-term mortality was not reduced (risk ratio = 0.90; 95% CI, 0.76-1.06; p = 0.19). Across 13 studies that reported mortality, meta-regression revealed that delirium duration was not associated with reduced short-term mortality (p = 0.11). CONCLUSIONS A review of current evidence fails to support that ICU interventions that reduce delirium duration reduce short-term mortality. Larger controlled studies are needed to establish this relationship.
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McDonagh DL, Berger M, Mathew JP, Graffagnino C, Milano CA, Newman MF. Neurological complications of cardiac surgery. Lancet Neurol 2014; 13:490-502. [PMID: 24703207 PMCID: PMC5928518 DOI: 10.1016/s1474-4422(14)70004-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.
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Affiliation(s)
- David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - Carmelo A Milano
- Department of Surgery (Division of Cardiovascular and Thoracic Surgery), Duke University Medical Center, Durham, NC, USA
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Abstract
PURPOSE OF REVIEW Evidence is emerging that delirium is associated with both short-term and long-term morbidity and mortality. This review highlights the epidemiology, outcomes, prevention and treatment strategies associated with delirium after cardiac surgery. RECENT FINDINGS The incidence of delirium after cardiac surgery is estimated to be 26-52%, with a significant percentage being hypoactive delirium. It is clear that without an appropriate structured test for delirium, the incidence of delirium will be underrecognized clinically. Delirium after cardiac surgery is associated with poor outcomes, including increased long-term mortality, increased risk of stroke, poor functional status, increased hospital readmissions and substantial cognitive dysfunction for 1 year following surgery. The effectiveness of prophylactic antipsychotics to reduce the risk of delirium is controversial, with data from recent small studies in noncardiac surgery potentially showing a benefit. Although antipsychotic medications are often used to treat delirium, the evidence that antipsychotics in cardiac surgery patients reduce duration of delirium or improve long-term outcomes following delirium is poor. SUMMARY Clinicians in the ICU must recognize the impact of delirium in predicting long-term outcomes for patients. Further research is needed in determining interventions that will be effective in preventing and treating delirium in cardiac surgical setting.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, The John Hopkins School of Medicine, Baltimore, Maryland, USA
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Theuerkauf N, Guenther U. Delir auf der Intensivstation. Med Klin Intensivmed Notfmed 2014; 109:129-36. [DOI: 10.1007/s00063-014-0354-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 11/24/2022]
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95
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Underrepresentation of patients with pre-existing cognitive impairment in pharmaceutical trials on prophylactic or therapeutic treatments for delirium: a systematic review. J Psychosom Res 2014; 76:193-9. [PMID: 24529037 DOI: 10.1016/j.jpsychores.2013.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Representation of hospitalized patients with pre-existing cognitive impairment in pharmaceutical delirium trials is important because these patients are at high risk for developing delirium. The aim of this systematic review is to investigate whether patients with cognitive impairment were included in studies on pharmacological prophylaxis or treatment of delirium and to explore the motivations for their exclusion (if they were excluded). STUDY DESIGN This study was a systematic review. A MEDLINE search was performed for publications dated from 1 January 1985 to 15 November 2012. Randomized and non-randomized controlled trials that investigated medication to prevent or treat delirium were included. The number of patients with cognitive impairment was counted, and if they were excluded, motivations were noted. RESULTS The search yielded 4293 hits, ultimately resulting in 31 studies that met the inclusion criteria. Of these, five studies explicitly mentioned the percentage of patients with cognitive impairment that were included. These patients comprised a total of 8% (n = 279 patients) of the 3476 patients included in all 31 studies. Ten studies might have included cognitively impaired patients but did not mention the exact percentage, and sixteen studies excluded all patients with cognitive impairment. The motivations for exclusion varied, but most were related to the influence of dementia on delirium. CONCLUSION The exclusion of patients with pre-existing cognitive impairment hampers the generalizability of the results of these trials and leaves clinicians with limited evidence about the pharmacological treatment of this group of vulnerable patients who have an increased risk of side effects.
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Affiliation(s)
- Michael C Reade
- From the Burns, Trauma and Critical Care Research Centre, University of Queensland, and Joint Health Command, Australian Defence Force, Brisbane (M.C.R.); and the George Institute for Global Health, and Royal North Shore Hospital, University of Sydney, Sydney (S.F.) - all in Australia
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99
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Japanese guidelines for the management of Pain, Agitation, and Delirium in intensive care unit (J-PAD). ACTA ACUST UNITED AC 2014. [DOI: 10.3918/jsicm.21.539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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100
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Baranyi A, Rothenhäusler HB. The Impact of Soluble Interleukin-2 Receptor as a Biomarker of Delirium. PSYCHOSOMATICS 2014; 55:51-60. [DOI: 10.1016/j.psym.2013.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 06/04/2013] [Accepted: 06/04/2013] [Indexed: 01/04/2023]
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