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Kobayashi K, Imagama S, Ando K, Ishiguro N, Yamashita M, Eguchi Y, Matsumoto M, Ishii K, Hikata T, Seki S, Terai H, Suzuki A, Tamai K, Aramomi M, Ishikawa T, Kimura A, Inoue H, Inoue G, Miyagi M, Saito W, Yamada K, Hongo M, Matsuoka Y, Suzuki H, Nakano A, Watanabe K, Chikuda H, Ohya J, Aoki Y, Shimizu M, Futatsugi T, Mukaiyama K, Hasegawa M, Kiyasu K, Iizuka H, Iizuka Y, Kobayashi R, Nishida K, Kakutani K, Nakajima H, Murakami H, Demura S, Kato S, Yoshioka K, Namikawa T, Watanabe K, Nakanishi K, Nakagawa Y, Yoshimoto M, Fujiwara H, Nishida N, Imajo Y, Yamazaki M, Sakane M, Abe T, Fujii K, Kaito T, Furuya T, Orita S, Ohtori S. Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study. Global Spine J 2017; 7:560-566. [PMID: 28894686 PMCID: PMC5582715 DOI: 10.1177/2192568217700115] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE Spine surgeries in elderly patients have increased in recent years due to aging of society and recent advances in surgical techniques, and postoperative complications have become more of a concern. Postoperative delirium is a common complication in elderly patients that impairs recovery and increases morbidity and mortality. The objective of the study was to analyze postoperative delirium associated with spine surgery in patients aged 80 years or older with cervical, thoracic, and lumbar lesions. METHODS A retrospective multicenter study was performed in 262 patients 80 years of age or older who underwent spine surgeries at 35 facilities. Postoperative complications, incidence of postoperative delirium, and hazard ratios of patient-specific and surgical risk factors were examined. RESULTS Postoperative complications occurred in 59 of the 262 spine surgeries (23%). Postoperative delirium was the most frequent complication, occurring in 15 of 262 patients (5.7%), and was significantly associated with hypertension, cerebrovascular disease, cervical lesion surgery, and greater estimated blood loss (P < .05). In multivariate logistic regression using perioperative factors, cervical lesion surgery (odds ratio = 4.27, P < .05) and estimated blood loss ≥300 mL (odds ratio = 4.52, P < .05) were significantly associated with postoperative delirium. CONCLUSIONS Cervical lesion surgery and greater blood loss were perioperative risk factors for delirium in extremely elderly patients after spine surgery. Hypertension and cerebrovascular disease were significant risk factors for postoperative delirium, and careful management is required for patients with such risk factors.
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Affiliation(s)
| | - Shiro Imagama
- Nagoya University, Nagoya, Aichi, Japan,Shiro Imagama, Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi 466-8550, Japan.
| | - Kei Ando
- Nagoya University, Nagoya, Aichi, Japan
| | | | | | - Yawara Eguchi
- Shimoshizu National Hospital, Yotsukaido-shi, Chiba, Japan
| | | | - Ken Ishii
- Keio University, Shinjuku-ku, Tokyo, Japan
| | | | - Shoji Seki
- University of Toyama, Toyama-shi, Toyama, Japan
| | | | | | - Koji Tamai
- Osaka City University, Abeno-ku, Osaka, Japan
| | | | | | - Atsushi Kimura
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Hirokazu Inoue
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Gen Inoue
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | | | - Wataru Saito
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | - Kei Yamada
- Kurume University, Kurume-shi, Fukuoka, Japan
| | | | | | | | | | | | | | - Junichi Ohya
- The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | | | | | | | | | | | - Haku Iizuka
- Gunma University, Maebashi-shi, Gunma, Japan
| | | | | | | | | | | | | | | | | | | | | | - Kei Watanabe
- Niigata University, Niigata-shi, Niigata, Japan,Sado General Hospital, Sado-shi, Niigata, Japan
| | | | | | | | | | | | | | | | | | - Tetsuya Abe
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kengo Fujii
- University of Tsukuba, Tsukuba, Ibaraki, Japan
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Neefjes ECW, van der Vorst MJDL, Verdegaal BATT, Beekman ATF, Berkhof J, Verheul HMW. Identification of patients with cancer with a high risk to develop delirium. Cancer Med 2017; 6:1861-1870. [PMID: 28688161 PMCID: PMC5548884 DOI: 10.1002/cam4.1106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 04/14/2017] [Accepted: 04/24/2017] [Indexed: 11/09/2022] Open
Abstract
Delirium deteriorates the quality of life in patients with cancer, but is frequently underdiagnosed and not adequately treated. In this study, we evaluated the occurrence of delirium and its risk factors in patients admitted to the hospital for treatment or palliative care in order to develop a prediction model to identify patients at high risk for delirium. In a period of 1.5 years, we evaluated the risk of developing delirium in 574 consecutively admitted patients with cancer to our academic oncology department with the Delirium Observation Screening Scale. Risk factors for delirium were extracted from the patient's chart. A delirium prediction algorithm was constructed using tree analysis, and validated with fivefold cross‐validation. A total of 574 patients with cancer were acutely (42%) or electively (58%) admitted 1733 times. The incidence rate of delirium was 3.5 per 100 admittances. Tree analysis revealed that the predisposing factors of an unscheduled admittance and a metabolic imbalance accurately predicted the development of delirium. In this group the incidence rate of delirium was 33 per 100 patients (1:3). The AUC of the model was 0.81, and 0.65 after fivefold cross‐validation. We identified that especially patients undergoing an unscheduled admittance with a metabolic imbalance do have a clinically relevant high risk to develop a delirium. Based on these factors, we propose to evaluate preventive treatment of these patients when admitted to the hospital in order to improve their quality of life.
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Affiliation(s)
- Elisabeth C W Neefjes
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Maurice J D L van der Vorst
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, Amsterdam, the Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Bertha A T T Verdegaal
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Aartjan T F Beekman
- Department of Psychiatry and EMGO, Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Biostatistics, VU University medical center, Amsterdam, the Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, Amsterdam, the Netherlands
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Pallaria TJ, Panebianco C, Kamienski MC. Perioperative Delirium Protocol for the Older Patient. J Perianesth Nurs 2017; 33:275-280. [PMID: 29784256 DOI: 10.1016/j.jopan.2016.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/06/2016] [Accepted: 08/13/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Delirium is an acute change in cognition and attention. It may affect any age group. It is most common in older patients and is associated with a significant increase in mortality. The purpose of this project was to implement an assessment protocol to identify patients at risk for postoperative delirium. DESIGN A case study approach was used. METHODS The Confusion Assessment Method (CAM) tool for screening and diagnostic purposes was used to train surgeons, anesthesia providers, and nurses. A standardized delirium assessment and management protocol was developed and implemented. FINDINGS The CAM and geriatric preoperative assessment was used with the patient discussed in the case study. The patient did not experience postoperative delirium and was discharged from perioperative services on the same day. CONCLUSION Evidence informs us that early recognition and multifaceted interventions can prevent postoperative delirium in the elderly.
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Delirium is a severe and common yet under-diagnosed disorder in the clinical routine. Multiple factors may contribute to the development of delirium, which is associated with increased mortality and high healthcare costs. Treatment of delirium is often provided with delay and limited to pharmacological interventions. This article summarizes the key symptoms for delirium as well as risk factors and highlights the pharmacological and non-pharmacological options for treatment and prevention.
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Cole MG, McCusker J, Wilchesky M, Voyer P, Monette J, Champoux N, Vu M, Ciampi A, Belzile E. Use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults: a nested case-control study. Int J Geriatr Psychiatry 2017; 32:208-213. [PMID: 27001903 DOI: 10.1002/gps.4468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 02/23/2016] [Accepted: 02/23/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults. METHODS A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium. RESULTS Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant. CONCLUSION The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Martin G Cole
- Department of Psychiatry, St. Mary's Hospital Center and McGill University, Montreal, Quebec.,St. Mary's Research Centre, St Mary's Hospital Center, Montreal, Quebec
| | - Jane McCusker
- St. Mary's Research Centre, St Mary's Hospital Center, Montreal, Quebec.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
| | - Machelle Wilchesky
- Division of Geriatric Medicine, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec.,Donald Berman Maimonides Geriatric Center, Montreal, Quebec
| | - Philippe Voyer
- Faculty of Nursing Sciences, Laval University, Montreal, Quebec
| | - Johanne Monette
- Division of Geriatric Medicine, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec.,Donald Berman Maimonides Geriatric Center, Montreal, Quebec
| | - Nathalie Champoux
- Institut Universitaire de Gériatrie de Montréal; Département de médecine familiale, Université de Montréal, Montreal, Quebec
| | - Minh Vu
- Division of Geriatric Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec.,Department of Medicine, Université de Montréal, Montreal, Quebec
| | - Antonio Ciampi
- St. Mary's Research Centre, St Mary's Hospital Center, Montreal, Quebec.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
| | - Eric Belzile
- St. Mary's Research Centre, St Mary's Hospital Center, Montreal, Quebec
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Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Reply to "Limitations of Conclusions of Systematic Review & Meta-analysis Due to Exclusion of Groups Most at Risk". J Am Geriatr Soc 2017; 65:661-663. [PMID: 28140455 DOI: 10.1111/jgs.14727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Sichuan Province, China
| | - Thomas N Robinson
- Department of Surgery, University of Colorado, School of Medicine, Aurora, Colorado
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts.,Institute for Aging Research Hebrew Senior Life, Boston, Massachusetts
| | - Dale M Needham
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University, 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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Sheth KN, Nourollahzadeh E. Neurologic complications of cardiac and vascular surgery. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:573-592. [PMID: 28190436 DOI: 10.1016/b978-0-444-63599-0.00031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.
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Affiliation(s)
- K N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.
| | - E Nourollahzadeh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
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Fukata S, Kawabata Y, Fujishiro K, Kitagawa Y, Kuroiwa K, Akiyama H, Takemura M, Ando M, Hattori H. Haloperidol prophylaxis for preventing aggravation of postoperative delirium in elderly patients: a randomized, open-label prospective trial. Surg Today 2016; 47:815-826. [DOI: 10.1007/s00595-016-1441-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022]
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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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Preventing ICU Subsyndromal Delirium Conversion to Delirium With Low-Dose IV Haloperidol: A Double-Blind, Placebo-Controlled Pilot Study. Crit Care Med 2016; 44:583-91. [PMID: 26540397 DOI: 10.1097/ccm.0000000000001411] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of scheduled low-dose haloperidol versus placebo for the prevention of delirium (Intensive Care Delirium Screening Checklist ≥ 4) administered to critically ill adults with subsyndromal delirium (Intensive Care Delirium Screening Checklist = 1-3). DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Three 10-bed ICUs (two medical and one surgical) at an academic medical center in the United States. PATIENTS Sixty-eight mechanically ventilated patients with subsyndromal delirium without complicating neurologic conditions, cardiac surgery, or requiring deep sedation. INTERVENTIONS Patients were randomly assigned to receive IV haloperidol 1 mg or placebo every 6 hours until delirium occurred (Intensive Care Delirium Screening Checklist ≥ 4 with psychiatric confirmation), 10 days of therapy had elapsed, or ICU discharge. MEASUREMENTS AND MAIN RESULTS Baseline characteristics were similar between the haloperidol (n = 34) and placebo (n = 34) groups. A similar number of patients given haloperidol (12/34 [35%]) and placebo (8/34 [23%]) developed delirium (p = 0.29). Haloperidol use reduced the hours per study day spent agitated (Sedation Agitation Scale ≥ 5) (p = 0.008), but it did not influence the proportion of 12-hour ICU shifts patients spent alive without coma (Sedation Agitation Scale ≤ 2) or delirium (p = 0.36), the time to first delirium occurrence (p = 0.22), nor delirium duration (p = 0.26). Days of mechanical ventilation (p = 0.80), ICU mortality (p = 0.55), and ICU patient disposition (p = 0.22) were similar in the two groups. The proportion of patients who developed corrected QT-interval prolongation (p = 0.16), extrapyramidal symptoms (p = 0.31), excessive sedation (p = 0.31), or new-onset hypotension (p = 1.0) that resulted in study drug discontinuation was comparable between the two groups. CONCLUSIONS Low-dose scheduled haloperidol, initiated early in the ICU stay, does not prevent delirium and has little therapeutic advantage in mechanically ventilated, critically ill adults with subsyndromal delirium.
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Bannon L, McGaughey J, Clarke M, McAuley DF, Blackwood B. Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research. Syst Rev 2016; 5:75. [PMID: 27146132 PMCID: PMC4855765 DOI: 10.1186/s13643-016-0254-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 04/25/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Critically ill patients have an increased risk of developing delirium during their intensive care stay. To date, pharmacological interventions have not been shown to be effective for delirium management but non-pharmacological interventions have shown some promise. The aim of this systematic review is to identify effective non-pharmacological interventions for reducing the incidence or the duration of delirium in critically ill patients. METHODS We will search MEDLINE, EMBASE, CINAHL, Web of Science, AMED, psycINFO and the Cochrane Library. We will include studies of critically ill adults and children. We will include randomised trials and controlled trials which measure the effectiveness of one or more non-pharmacological interventions in reducing incidence or duration of delirium in critically ill patients. We will also include qualitative studies that provide an insight into patients and their families' experiences of delirium and non-pharmacological interventions. Two independent reviewers will assess studies for eligibility, extract data and appraise quality. We will conduct meta-analyses if possible or present results narratively. Qualitative studies will also be reviewed by two independent reviewers, and a specially designed quality assessment tool incorporating the CASP framework and the POPAY framework will be used to assess quality. DISCUSSION Although non-pharmacological interventions have been studied in populations outside of intensive care units and multicomponent interventions have successfully reduced incidence and duration of delirium, no systematic review of non-pharmacological interventions specifically targeting delirium in critically ill patients have been undertaken to date. This systematic review will provide evidence for the development of a multicomponent intervention for delirium management of critically ill patients that can be tested in a subsequent multicentre randomised trial. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015016625.
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Affiliation(s)
- Leona Bannon
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland.
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, BT12 6BJ, Northern Ireland
| | - Daniel Francis McAuley
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Bronagh Blackwood
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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O'Neal JB, Shaw AD. Predicting, preventing, and identifying delirium after cardiac surgery. Perioper Med (Lond) 2016; 5:7. [PMID: 27119013 PMCID: PMC4845390 DOI: 10.1186/s13741-016-0032-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/29/2016] [Indexed: 02/07/2023] Open
Abstract
Delirium after cardiac surgery is a major problem. The exact mechanisms behind delirium are not understood. Potential pathways of delirium include neurotransmitter interference, global cognitive disorder, and neuroinflammation. Several predisposing and precipitating risk factors have been identified for postoperative delirium. The development of delirium following cardiac surgery is associated with worse outcomes in the perioperative period. Multiple interventions are being explored for the prevention and treatment of delirium. Studies investigating the potential roles of biomarkers in delirium as well as pharmacological interventions to reduce the incidence and duration of delirium are necessary to mitigate this negative outcome.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
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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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69
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Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2016; 64:705-14. [PMID: 27004732 DOI: 10.1111/jgs.14076] [Citation(s) in RCA: 248] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of antipsychotic medications in preventing and treating delirium. DESIGN Systematic review and meta-analysis. SETTING PubMed, EMBASE, CINAHL, and ClinicalTrials.gov databases were searched from January 1, 1988, to November 26, 2013. PARTICIPANTS Adult surgical and medical inpatients. INTERVENTION Antipsychotic administration for delirium prevention or treatment in randomized controlled trials or cohort studies. MEASUREMENTS Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. Heterogeneity was considered as chi-square P < .1 or I(2) > 50%. Using a random-effects model (I(2) > 50%) or a fixed-effects model (I(2) < 50%), odds ratios (ORs) were calculated for dichotomous outcomes (delirium incidence and mortality), and mean or standardized mean difference for continuous outcomes (delirium duration, severity, hospital and intensive care unit (ICU) length of stay (LOS)). Sensitivity analyses included postoperative prevention studies only, exclusion of studies with high risk of bias, and typical versus atypical antipsychotics. RESULTS Screening of 10,877 eligible records identified 19 studies. In seven studies comparing antipsychotics with placebo or no treatment for delirium prevention after surgery, there was no significant effect on delirium incidence (OR = 0.56, 95% confidence interval (CI) = 0.23-1.34, I(2) = 93%). Using data reported from all 19 studies, antipsychotic use was not associated with change in delirium duration, severity, or hospital or ICU LOS, with high heterogeneity among studies. No association with mortality was detected (OR = 0.90, 95% CI = 0.62-1.29, I(2) = 0%). CONCLUSION Current evidence does not support the use of antipsychotics for prevention or treatment of delirium. Additional methodologically rigorous studies using standardized outcome measures are needed.
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Affiliation(s)
- Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Thomas N Robinson
- Department of Surgery, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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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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Lo J, Hill C. Intensive care unit management of transcatheter aortic valve recipients. Semin Cardiothorac Vasc Anesth 2016; 19:95-105. [PMID: 25975594 DOI: 10.1177/1089253215575183] [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] [Indexed: 11/16/2022]
Abstract
Severe aortic stenosis is an increasingly prevalent disease that continues to be associated with significant mortality. Transcatheter aortic valve replacements have been used as an alternative to surgical aortic valve replacement in high-risk patients with multiple comorbidities. In this review, we discuss postoperative considerations pertinent to the successful management of these complicated patients in the intensive care unit.
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Affiliation(s)
- Joyce Lo
- Stanford University, Stanford, CA, USA
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Kersten A, Reith S. [Delirium and delirium management in critically ill patients]. Med Klin Intensivmed Notfmed 2016; 111:14-21. [PMID: 26795215 DOI: 10.1007/s00063-015-0130-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
Abstract
Delirium in critically ill patients is a common entity in the intensive care unit (ICU) and is an expression of the cerebral organ dysfunction of the patient. The hallmark signs are disturbed consciousness and cognition in combination with inattentiveness and alterations in perception, which are manifested within a time interval of hours to days during treatment on the ICU. Delirium has been shown to have negative effects on patient short-term and long-term outcome parameters and increases morbidity and mortality. Despite its significance in many cases delirium remains inadequately diagnosed during routine treatment by ICU personnel. There are two validated and easily applicable scales for the standardized diagnosis of delirium: the confusion assessment method for the ICU (CAM-ICU) and the intensive care delirium screening checklist (ICDSC). These are simple to apply by medical as well as non-medical personnel. The therapy of delirium is mostly determined by non-pharmacological measures aiming at early identification, reorientation and mobilization of the patient, improving cerebral activity and establishing adequate wake-sleep cycles. There is only sparse evidence for pharmacological treatment of delirium; however, the choice of sedative agent has a proven effect on the incidence and duration of delirium in the ICU.
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Affiliation(s)
- A Kersten
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - S Reith
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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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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Cropsey C, Kennedy J, Han J, Pandharipande P. Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 2015; 19:309-17. [DOI: 10.1177/1089253215570062] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Neurologic injury in the form of cognitive decline, delirium, and stroke are common phenomena in patients undergoing cardiac surgery and continues to be one of the most common complication after cardiac surgery, in spite of improvements in mortality and and improved surgical and anesthetic techniques. These complications lead to a significant increase in length of stay in the intensive care unit, increased length of hospital admission, and functional impairment, resulting in not only profound negative effects on patients who experience these complications, but also to increased costs of medical care and delivery. We discuss each of these complications in regard to their risks factors, incidence, potential therapeutic modalities, and relevant intraoperative and postoperative considerations.
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Affiliation(s)
| | | | - Jin Han
- Vanderbilt University, Nashville, TN, USA
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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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81
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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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82
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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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84
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Affiliation(s)
- Mary E Britton
- Aged Care Services; Heidelberg Repatriation Hospital; Heidelberg West Victoria
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85
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Fok MC, Sepehry AA, Frisch L, Sztramko R, Borger van der Burg BLS, Vochteloo AJH, Chan P. Do antipsychotics prevent postoperative delirium? A systematic review and meta-analysis. Int J Geriatr Psychiatry 2015; 30:333-44. [PMID: 25639958 DOI: 10.1002/gps.4240] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 10/30/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To summarize the effect of antipsychotics for preventing postoperative delirium. DESIGN We conducted a literature search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and clinicaltrials.gov. We included randomized controlled trials of adults undergoing surgery who were given antipsychotics to prevent postoperative delirium. Quality was assessed via the Cochrane risk of bias tool. Random-effects meta-analysis and meta-regression were conducted. Q-statistics and I(2) were used for assessment of heterogeneity. The main outcome was delirium incidence using validated definitions. RESULTS A total of 1710 subjects were included, with a mean age ranging from 60.7 to 86.4 years. Antipsychotics reduced the incidence of postoperative delirium with the global effect-size estimate (weighted odds ratio) using the random effects model of 0.44 (95% confidence interval: 0.28-0.70; N = 6; Q-value: 16, p-value 0.0005; I(2) = 69%). Significant heterogeneity existed with the pooled global effect of delirium incidence; however, meta-regression allowed us to test both treatment-level and patient-level explanations for significant between-study variance. Baseline risk for delirium was found to be a significant contributor to study heterogeneity, and meta-regression suggested that antipsychotic type and dosage were two of the several treatment-level factors that also may have led to heterogeneity. Our analysis implied the presence of a breakeven baseline level of delirium risk below which preventive treatment with antipsychotics might prove ineffective. CONCLUSIONS Within the limits of few randomized controlled trials, antipsychotics appeared to reduce the incidence of postoperative delirium in several surgical settings, predominantly orthopedic and for those at higher risk for delirium.
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Affiliation(s)
- Mark C Fok
- Department of Medicine, Division of Geriatrics, University of British Columbia, Vancouver, British Columbia, Canada
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86
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Norman BC, Hughes CG. Sedative Agents and Prophylaxis in ICU Delirium. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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87
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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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88
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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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90
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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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91
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Brooks P, Spillane JJ, Dick K, Stuart-Shor E. Developing a strategy to identify and treat older patients with postoperative delirium. AORN J 2014; 99:257-73; quiz 274-6. [PMID: 24472589 DOI: 10.1016/j.aorn.2013.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 07/16/2013] [Accepted: 12/17/2013] [Indexed: 12/27/2022]
Abstract
Postoperative delirium is one of the most common adverse outcomes in elderly patients undergoing surgery and is associated with increased morbidity, length of stay, and patient care costs. The purpose of this quality improvement project was to evaluate the effectiveness of a multicomponent strategy to identify and treat general surgical patients 65 years of age or older at risk for and who develop postoperative delirium at Cape Cod Hospital, a community hospital in southern New England. We evaluated 96 patients using the Mini-Cog assessment tool preoperatively and the Confusion Assessment Method (CAM) delirium screening tool or CAM-Intensive Care Unit (CAM-ICU) assessment tool postoperatively. Patients who tested positive during preoperative assessment underwent a postoperative delirium management protocol. We summarized data using descriptive statistics. The results showed an association between compliance and outcomes. High compliance with implementation of CAM and CAM-ICU assessment tools resulted in increased identification of postoperative delirium in the older surgical population. The use of screening tools helped facilitate early identification of postoperative delirium in elderly surgical patients.
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92
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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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93
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Inouye SK, Marcantonio ER, Metzger ED. Doing Damage in Delirium: The Hazards of Antipsychotic Treatment in Elderly Persons. Lancet Psychiatry 2014; 1:312-315. [PMID: 25285270 PMCID: PMC4180215 DOI: 10.1016/s2215-0366(14)70263-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA ; Aging Brain Center, Institute for Aging Research,, Hebrew SeniorLife, Boston, MA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA ; Aging Brain Center, Institute for Aging Research,, Hebrew SeniorLife, Boston, MA
| | - Eran D Metzger
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA ; Division of Psychiatry, Hebrew SeniorLife, Boston, MA
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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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98
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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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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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