Epidemiology and risk factors for delirium across hospital settings

Association between visitation restriction during the COVID-19 pandemic and delirium incidence among emergency admission patients: a single-center retrospective observational cohort study in Japan

Aim

This study aimed to identify the association between total visitation restriction because of the coronavirus 2019 (COVID-19) pandemic and the incidence of delirium for emergency inpatients.

Methods

This was a single-center, retrospective, observational cohort study conducted at a tertiary critical care center in urban Kyoto, Japan. Adult emergency patients hospitalized between January 1, 2019, and June 30, 2020, were recruited. In response to the COVID-19 pandemic, the authors' hospital began restricted visitation on March 28, 2020. This study defined before visitation restriction as January 1, 2019, through March 31, 2020, and after visitation restriction as April 1, 2020, through June 30, 2020. We did not restrict emergency services, and there were no changes in the hospital's routine, except for visitation restrictions. The primary outcome was the incidence of delirium. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for delirium incidence was calculated to compare the before and after visitation restriction periods, and the logistic model was used to adjust for seven variables: age, sex, ward type on admission, primary diagnosis, ventilator management, general anesthesia surgery, and dementia.

Results

Study participants were 6264 patients, median age 74 years (56-83), and 3303 men (52.7%). The total delirium incidence in entire research period was 2.5% (158 of 6264 patients), comprising 1.8% (95/5251) before visitation restriction and 6.2% (63/1013) after visitation restriction. The AOR for delirium incidence was 3.79 (95% CI, 2.70-5.31) after visitation restriction versus before visitation restriction. Subgroup analysis showed no apparent interaction for delirium incidence.

Conclusion

Visitation restriction was associated with an increased incidence of delirium in emergency inpatients.

Preoperative Acute Pain Is Associated with Postoperative Delirium

Background

Studies have provided some evidence that pain is a risk factor for postoperative delirium (POD). Therefore, we investigated the relationship between preoperative pain and POD after noncardiac surgery.

Methods

POD was assessed with the Montreal Cognitive Assessment, and preoperative cognition was assessed with the Mini-Mental State Examination. Plasma C-reactive protein (CRP) was detected by enzyme-linked immunosorbent assay before surgery. Preoperative pain was classified by its duration before surgery as chronic pain (lasting more than 1 month), acute pain (lasting less than 1 month), or no pain (no obvious pain). Multiple linear regression was used to adjust for confounding.

Results

From October 15, 2018, through August 12, 2019, a total of 67 patients were randomized; 7 were excluded because they were discharged before the seventh postoperative day. The prevalence of POD was significantly higher in the acute pain group (13 of 20; 65%) than in the chronic pain group (5 of 20; 25%) or the no pain group (6 of 20; 30%) (P = 0.019), indicating that delirium is associated with preoperative acute pain. The plasma level of preoperative CRP was also higher in the acute pain group than in the other two groups (mean [interquartile range]: 10.7 [3.3, 29.3] vs 1 [0.5, 3.8]mg/l; P < 0.001), suggesting that elevated preoperative plasma levels of CRP were associated with delirium.

Conclusions

Preoperative acute pain was associated with POD, and increased plasma levels of CRP provide a marker. In addition, we found that illiteracy and advanced age were risk factors for POD.

Derivation and validation of a novel comorbidity-based delirium risk index to predict postoperative delirium using national administrative healthcare database

OBJECTIVE

To derive and validate a comorbidity-based delirium risk index (DRI) to predict postoperative delirium.

DATA SOURCE/STUDY SETTING

Data of 506 438 hip fracture repair surgeries from 2006 to 2016 were collected to derive DRI and perform internal validation from the Premier Healthcare Database, which provided billing information on 20-25 percent of hospitalizations in the USA. Additionally, data of 1 130 569 knee arthroplasty surgeries were retrieved for external validation.

STUDY DESIGN

Thirty-six commonly seen comorbidities were evaluated by logistic regression with the outcome of postoperative delirium. The hip fracture repair surgery cohort was separated into a training dataset (60 percent) and an internal validation (40 percent) dataset. The least absolute shrinkage and selection operator (LASSO) procedure was applied for variable selection, and weights were assigned to selected comorbidities to quantify corresponding risks. The newly developed DRI was then compared to the Charlson-Deyo Index for goodness-of-fit and predictive ability, using the Akaike information criterion (AIC), Bayesian information criterion (BIC), area under the ROC curve (AUC) for goodness-of-fit, and odds ratios for predictive performance. Additional internal validation was performed by splitting the data by four regions and in 4 randomly selected hospitals. External validation was conducted in patients with knee arthroplasty surgeries.

DATA COLLECTION

Hip fracture repair surgeries, knee arthroplasty surgeries, and comorbidities were identified by using ICD-9 codes. Postoperative delirium was defined by using ICD-9 codes and analyzing billing information for antipsychotics (specifically haloperidol, olanzapine, and quetiapine) typically recommended to treat delirium.

PRINCIPAL FINDINGS

The derived DRI includes 14 comorbidities and assigns comorbidities weights ranging from 1 to 6. The DRI outperformed the Charlson-Deyo Comorbidity Index with better goodness-of-fit and predictive performance.

CONCLUSIONS

Delirium risk index is a valid comorbidity index for covariate adjustment and risk prediction in the context of postoperative delirium. Future work is needed to test its performance in different patient populations and varying definitions of delirium.

Surgery, Anesthesia and Intensive Care Environment Induce Delirium-Like Behaviors and Impairment of Synaptic Function-Related Gene Expression in Aged Mice

OBJECTIVE

To establish a clinically relevant mouse model of perioperative delirium.

METHODS

Aged C57BL/6J mice were tested at baseline in the Y-maze novel arm preference, buried food, simple discrimination task of the attentional set-shifting test, and open field tests. They were subsequently randomized to insult (anesthesia, surgery, and Intensive Care Unit environment) or control group. Insult-exposed mice received laparotomy under sevoflurane anesthesia, propofol sedation and exposure to intermittent lights, sounds and cage shaking. Controls did not receive anesthesia, surgery, or intensive care environment. All mice were tested in the Y-maze novel arm preference, buried food, attentional, and open field tests at the end of intensive care environment (0 h) and every 6 h up to 24 h. Mouse hippocampi were collected at 24 h for gene expression analyses.

RESULTS

Surgery, anesthesia and Intensive Care environment decreased the entries in the Y-maze novel arm at 0 h (P = 0.001), 6 h (P < 0.001), 18 h (P = 0.002), and 24 h (P = 0.029). Insult exposure increased the latency to find a buried cereal reward at 18 h (P = 0.035) and 24 h (P = 0.027), and increased the trials to criterion in the reverse compound discrimination (P = 0.013) and extradimensional shift (P < 0.001) tasks of the attentional test. The overall incidence of delirium was 72% in A/S/I mice. Messenger RNA levels of synuclein alpha (-3.785 fold change relative to controls), Neurotrophic Receptor Tyrosine Kinase1 (-2.267), and syntaxin1a (-1.498) were decreased in the hippocampus of mice 24 h after insult exposure. Protein levels of syntaxin 1a (P = 0.012), Neurotrophic Receptor Tyrosine Kinase1 (P = 0.039), synuclein alpha (P = 0.017), phosphorylated synuclein alpha (P = 0.008), synaptophysin (P = 0.002), postsynaptic density protein 95 (P = 0.003), and microtubule-associated protein 2 (P = 0.013) were also decreased, relative to controls.

CONCLUSION

Surgery, anesthesia and Intensive Care environment impaired mouse behaviors that depend on attention, memory, and thought organization. The changes were acute in onset and fluctuating in time. Mice with delirium exhibited decreased expression of key synaptic function-related genes. The behavioral changes induced by anesthesia, surgery, and Intensive Care environment in aged mice are consistent with the clinical features of human delirium, and support the use of this animal model for future mechanistic studies of perioperative delirium.

Pathomechanisms of Non-Traumatic Acute Brain Injury in Critically Ill Patients

Delirium, an acute alteration in mental status characterized by confusion, inattention and a fluctuating level of arousal, is a common problem in critically ill patients. Delirium prolongs hospital stay and is associated with higher mortality. The pathophysiology of delirium has not been fully elucidated. Neuroinflammation and neurotransmitter imbalance seem to be the most important factors for delirium development. In this review, we present the most important pathomechanisms of delirium in critically ill patients, such as neuroinflammation, neurotransmitter imbalance, hypoxia and hyperoxia, tryptophan pathway disorders, and gut microbiota imbalance. A thorough understanding of delirium pathomechanisms is essential for effective prevention and treatment of this underestimated pathology in critically ill patients.

The prevalence rates and adversities of delirium: Too common and disadvantageous

Objective

The prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled studies. Therefore, this study assesses the prevalence rates and outcome of and odds ratios for managing services for delirium.

Methods

In this prospective cohort study, based on the Diagnostic and Statistical Manual (DSM) 5, the Delirium Observation Screening (DOS) scale, and the Intensive Care Delirium Screening Checklist (ICDSC) construct, 28,118 patients from 35 managing services were included, and the prevalence rates and adverse outcomes were determined by simple logistic regressions and their corresponding odds ratios (ORs).

Results

Delirious patients were older, admitted from institutions (OR 3.44–5.2), admitted as emergencies (OR 1.87), hospitalized twice longer, and discharged, transferred to institutions (OR 5.47–6.6) rather than home (OR 0.1), or deceased (OR 43.88). The rate of undiagnosed delirium was 84.2%. The highest prevalence rates were recorded in the intensive care units (47.1–84.2%, pooled 67.9%); in the majority of medical services, rates ranged from 20% to 40% (pooled 26.2%), except, at both ends, palliative care (55.9%), endocrinology (8%), and rheumatology (4.4%). Conversely, in surgery and its related services, prevalence rates were lower (pooled 13.1%), except for cardio- and neurosurgical services (53.3% and 46.4%); the lowest prevalence rate was recorded in obstetrics (2%).

Significance of results

Delirium remains underdiagnosed, and novel screening approaches are required. Furthermore, this study identified the impact of delirium on patients, determined the prevalence rates for 32 services, and elucidated the association between individual services and delirium.

Risk factors for delirium among older adults in the emergency department: a systematic review protocol

INTRODUCTION

Delirium is commonly missed in older adults presenting to the emergency department (ED). Although current recommendations for active screening of delirium in the ED, this might not be feasible or practical. Identifying patients at high risk for prevalent and incident delirium in the ED will help to improve the screening process and to build interventions. There is currently scattered synthesis of evidence on risk factors associated with delirium in the ED. To address this gap, we are conducting a systematic review to describe the risk factors (patient vulnerability factors and precipitating factors) for delirium in the ED.

METHODS AND ANALYSIS

A literature search was performed from inception to March 2020 in Ovid EBM Reviews, Ovid EMBASE, Ovid MEDLINE, Scopus and Web of Science. We will include original research studies that report a quantitative relationship between at least one risk factor and delirium in the ED setting. Two investigators will use eligibility criteria from this protocol to independently screen titles and abstracts, and select studies based on full-text review of potentially eligible studies. After arriving at a final set of included studies, two investigators will extract data using a standardised data collection form. If appropriate, data regarding each risk factor will be pooled through a random-effect meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to evaluate the overall quality of evidence.

ETHICS AND DISSEMINATION

To our knowledge, this will be the first systematic review evaluating risk factors for prevalent and incident delirium specifically related to the ED setting. Results of this study will aid in the identification of older adults at risk for delirium in the ED. We aim to publish the results of this systematic review in a peer-reviewed journal with good visibility for the fields of emergency medicine and geriatrics.PROSPERO registration numberCDR42020175261.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.

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

Supplemental Digital Content is available in the text.

Objectives:

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

Design:

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

Setting:

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

Patients:

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

Interventions:

None.

Measurements and Main Results:

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

Conclusions:

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

Melatonin for delirium prevention in acute medically ill, and perioperative geriatric patients

Delirium is a challenging neuropsychiatric ailment that has a negative impact on morbidity and mortality and is difficult to treat once it has developed. The purpose of this review was to analyze the efficacy of melatonin in the prevention of delirium in hospitalized geriatric patients in the acute medically ill and perioperative wards. The databases searched included PubMed (1946 to February 12, 2020), CINAHL (1982 to February 12, 2020), EMBASE (1974 to February 12, 2020), and Web of Science (1900 to February 12, 2020) using search terms related to melatonin, delirium, and prevention. Meta-analyses, randomized controlled trials, and observational studies were included. We excluded publications pertaining to the intensive care unit or oncology, case reports/series, and those not in English. Seven full-text publications were included for qualitative analysis. Patient comorbidities, patient medications, melatonin dosing, dosing regimens, and duration of treatment varied between the studies, which yielded heterogeneous results. Overall, this literature review yielded four studies that showed positive results and three that showed negative results for delirium prevention. The current data for the use of melatonin in delirium is conflicting. This area requires further research of more homogeneous studies with larger sample sizes.

A Tunisian version of the confusion assessment method for the intensive care unit (CAM-ICU): translation and validation

BACKGROUND

Delirium is common in critically ill patients and it is associated with poor outcomes. In Tunisia, however, it is still underdiagnosed as there is no validated screening tool. The aim of this study was to translate and to validate a Tunisian version of the CAM-ICU.

METHODS

For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in the patients admitted to the ICU between October 2017 and June 2018. All the patients consecutively admitted to the ICU for more than 24 h and having a Richmond Agitation-Sedation Scale greater than or equal to "-3" were assessed for delirium excluding those with stroke, dementia, psychosis or persistent coma. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. The inter-rater reliability was calculated using the kappa (κ) statistic. The CAM-ICU concurrent validity was assessed using Cronbach's α coefficient, sensitivity, specificity as well as positive and negative predictive values (PPV and NPV, respectively) for the two Tunisian CAM-ICU raters.

RESULTS

The study involved 137 patients [median (IQR) age: 60 [49-68] years, male sex (n = 102), invasive mechanical ventilation (n = 49)]. Using the DSM-V criteria evaluations, 46 patients were diagnosed with delirium. When applying the Tunisian version of the CAM-ICU, 38(27.7%) patients were diagnosed with delirium for the first rater and 45(32.6%) patients for the second one. The Tunisian CAM-ICU showed a very-high inter-rater reliability for both intensivists (κ = 0.844, p < 0.001). Using the DSM-V rater as the reference standard, the sensitivity of the two intensivists' evaluations was 80.4 vs. 95.7%. Specificity was 98.9% for both. The Cronbach's α of the first and second raters' evaluations using the Tunisian version of the CAM-ICU were 0.886 and 0.887, respectively.

CONCLUSIONS

The Tunisian version of the CAM-ICU showed almost perfect validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training.

TRIAL REGISTRATION

Not applicable.

Melatonin and its analogues for the prevention of postoperative delirium: A systematic review and meta-analysis

It remains unclear whether melatonin and its analogues prevent postoperative delirium (POD). Therefore, we conducted a systematic review and meta-analysis to evaluate the effect of melatonin and its analogues on POD prevention. PubMed, Cochrane Library, Web of Science, Embase and CINAHL databases were searched. Primary outcome was the incidence of POD. Six randomized controlled trials, 2 cohort studies and 1 case-control study were included in this meta-analysis. Results showed that melatonin and its analogue ramelteon decreased the incidence of POD in the entire adult surgical population (odds ratio [OR] = 0.45, 95% confidence interval [CI] 0.24-0.84, P = .01). When administered at a higher dose (5 mg), melatonin was effective in reducing the POD incidence (OR = 0.32, 95% CI 0.20-0.52, P < .00001). Melatonin administered less than 5 elimination half-lives before the surgery significantly reduced the POD incidence (OR = 0.31, 95% CI 0.19-0.49, P < .00001). Current literature supports the effectiveness of melatonin and its analogue ramelteon in POD prevention. However, the present study was limited by the significant heterogeneity of the included studies. More studies are needed to ascertain the preventive effect of melatonin and its analogues on the incidence of delirium after cardiac and noncardiac surgeries.

Development and validation of the delirium risk assessment score (DRAS)

PURPOSE

Development and validation of a delirium risk assessment score. Predisposing risk factors for delirium were used, which are easily assessed at hospital admission without additional clinical or laboratory testing.

METHODS

A systematic literature search identified ten risk factors: acute admission, alcohol use > 4 units/day, cognitive impairment, ADL impairment, age > 75 years, earlier delirium, hearing/vision problems, number of medication ≥ 5, number of morbidities > 2 and male. The DRAS was developed in a mixed patient population (N = 842) by the use of univariate and multivariate analyses and -2 log-likelihood calculation to weigh the risk factors. Based on the sensitivity and specificity, a cutoff score was calculated. The validation was performed in 3 cohorts (N = 408, N = 186, N = 365). In cohort 3, the DRAS was compared (AUC, sensitivity and specificity) to 3 instruments (Inouye, Kalisvaart, VMS rules).

RESULTS

The delirium incidence was 31.8%, 20.3%, 15.6% and 15.1%. All risk factors were independently predictive for delirium, except male. The multivariate analyses excluded morbidities. The final DRAS consists of 8 items; acute admission, cognitive impairment, alcohol use (3 points), ADLimpairment/mobilityproblems (2 points), higher age, earlier delirium, hearing/vision problems, and medication (1 point). The total score is 15 points and at a cut-of score of 5 or higher the patient is at risk of developing a delirium. The cutoff was at 5 or more points, AUC: 0.76 (95% CI 0.72-0.79), sensitivity 0.77, specificity 0.60. Validation cohorts AUC was 0.75 (95% CI 0.96-0.81), 0.76 (95% CI 0.70-0.83) and 0.78 (95% CI 0.70-0.87), sensitivity 0.71, 0.67 and 0.89 and specificity 0.70, 0.72 and 0.60. The comparison revealed the highest AUC for the DRAS.

CONCLUSION

Based on an admission interview, the delirium risk can be easily evaluated using the DRAS shortlist score of predisposing risk factors for delirium in older inpatients.

Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor

Background

Catheter-related bladder discomfort occurs because of involuntary contractions of the bladder smooth muscle after urinary catheterization. Magnesium is associated with smooth muscle relaxation. This study hypothesized that among patients having transurethral resection of bladder tumor, magnesium will reduce the incidence of postoperative moderate-to-severe catheter-related bladder discomfort.

Methods

In this double-blind, randomized study, patients were randomly allocated to the magnesium group (n = 60) or the control group (n = 60). In magnesium group, a 50 mg/kg loading dose of intravenous magnesium sulfate was administered for 15 min, followed by an intravenous infusion of 15 mg · kg−1 · h−1 during the intraoperative period. Patients in the control group similarly received normal saline. The primary outcome was the incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively. None, mild, moderate, and severe catheter-related bladder discomfort at 1, 2, and 6 h postoperatively, patient satisfaction, and magnesium-related adverse effects were also assessed.

Results

The incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively was significantly lower in the magnesium group than in the control group (13 [22%] vs. 46 [77%]; P &lt; 0.001; relative risk = 0.283; 95% CI, 0.171 to 0.467; absolute risk reduction = 0.55; number needed to treat = 2); similar results were observed for catheter-related bladder discomfort above a moderate grade at 1 and 2 h postoperatively (5 [8%] vs. 17 [28%]; P = 0.005; relative risk = 0.294; 95% CI, 0.116 to 0.746; and 1 [2%] vs. 14 [23%]; P &lt; 0.001; relative risk = 0.071; 95% CI, 0.010 to 0.526, respectively). Patient satisfaction on a scale from 1 to 7 was significantly higher in the magnesium group than in the control group (5.1 ± 0.8 vs. 3.5 ± 1.0; P &lt; 0.001; 95% CI, 1.281 to 1.919). Magnesium-related adverse effects were not significantly different between groups.

Conclusions

Magnesium reduced the incidence of catheter-related bladder discomfort above a moderate grade and increased patient satisfaction among patients having transurethral resection of bladder tumor.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study

BACKGROUND

Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment.

METHODS

This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events.

RESULTS

Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay.

CONCLUSION

The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.

Association Between Level of Arousal and 30-Day Survival in Acutely Ill Older Adults

OBJECTIVE

To investigate the association between impaired arousal on admission and 30-day mortality in acutely ill older adults.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients age +65 years admitted to the geriatric ward of a tertiary university hospital from 2010 to 2018 in Sao Paulo, Brazil.

METHODS

Participants were evaluated on admission according to a standardized comprehensive geriatric assessment model. Delirium was detected using the short version of the Confusion Assessment Method (Short-CAM). We used 2 alternative criteria to define impaired arousal: lethargy, stupor, or coma according to the Short-CAM; and a Glasgow Coma Scale (GCS) score of ≤13. Our primary outcome was time-to-death in 30 days, and we used Cox proportional hazards models to explore the association between impaired arousal and decreased survival.

RESULTS

We included 1554 admissions with a mean age of 81 years and of whom 61% were women. Overall, prevalent delirium was observed in 28% of the cases. We found that in 33% of admissions, patients were lethargic, stuporous, or comatose, and that in 23%, they had GCS scores of ≤13. General 30-day mortality was 19% but reached 32% in patients with GCS scores of ≤13. Impaired arousal was independently associated with lower survival in 30 days, both when defined using Short-CAM criteria [lethargy + stupor + coma: hazard ratio (HR) 2.33, 95% confidence interval (CI) 1.66‒3.27] and GCS scores (GCS 12‒13: HR 1.62, 95% CI 1.13‒2.33; GCS ≤ 11: HR 2.53, 95% CI 1.68‒3.80). In interaction analyses, we confirmed our results in patients who had impaired arousal but were neither delirious (lethargy + stupor + coma: HR 2.16, 95% CI 1.44‒3.24; GCS ≤ 11: HR 3.07; 95% CI 1.50‒6.29) nor demented (lethargy + stupor + coma: HR 1.95, 95% CI 1.15‒3.28).

CONCLUSIONS AND IMPLICATIONS

Level of arousal on admission was an independent predictor of 30-day survival in acutely ill older adults, regardless of delirium or baseline dementia. Clinicians should be aware that even if unsure of whether a patient has delirium, arousal assessment can provide crucial clinical and prognostic insight.

Analysis of Risk Factors for Postoperative Delirium After Liver Transplantation

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Delirium post-cardiac surgery: Incidence and associated factors

BACKGROUND

Post-operative delirium among cardiac surgery patients is a prevalent complication that associated with multiple negative outcomes.

AIM

This study aimed to assess delirium incidence, associated factors, and outcomes for adult patients who underwent elective cardiac surgery.

DESIGN

An exploratory prospective cohort design was used for this study.

METHODS

Delirium was diagnosed by the Confusion Assessment Method for the Intensive Care Unit. Incidence, preoperative, intraoperative, and post-operative variables for 245 patients during 3-month period were collected and analysed.

RESULTS

Delirium developed in 9% (n = 22) of the sample. Patients with delirium were significantly older (mean age = 65.7, SD = 8.1), t (243) = -3.66, P < .05); had longer surgery time (mean time = 286.3, SD = 82.2), t (243) = -2.25, P < .05); received more blood post-surgery (t (243) = -3.86, P < .05); spent more time on mechanical ventilation (t [21.6] = -2.2, P < .05); had longer critical care unit stay (t [21.7] = -4.0, P < 0.05); and had longer hospitalization than patients without delirium.

CONCLUSIONS

The risk factors associated with development of delirium were advanced age and increased duration of surgery. Negative outcomes associated with delirium were increased duration of mechanical ventilation, increased volume of post-operative infused colloids and blood/products, increased critical care unit stay, and increased hospitalization. A multifactorial model for delirium risk factors should be considered to detect and work on potentially preventable delirium factors.

RELEVANCE TO CLINICAL PRACTICE

Post-cardiac surgery delirium leads to longer mechanical ventilation time, increased ICU stay, and prolonged hospitalization. Delirium post-cardiac surgery is potentially preventable with appropriate identification of risk factors by nurses.

Distress in delirium: causes, assessment and management

Purpose

Delirium is a common clinical syndrome associated with increased physical and psychological morbidity, mortality, inpatient stay and healthcare costs. There is growing interest in understanding the delirium experience and its psychological impact, including distress, for patients and their relatives, carers and healthcare providers.

Methods

This narrative review focuses on distress in delirium (DID) with an emphasis on its effect on older patients. It draws on qualitative and quantitative research to describe patient and environmental risk factors and variations in DID across a number of clinical settings, including medical and surgical inpatient wards and end of life care. The article provides an overview of the available distress assessment tools, both for clinical and research practice, and outlines their use in the context of delirium. This review also outlines established and emerging management strategies, focusing primarily on prevention and limitation of distress in delirium.

Results

Both significant illness and delirium cause distress. Patients who recall the episode of delirium describe common experiential features of delirium and distress. Relatives who witness delirium also experience distress, at levels suggested to be greater than that experienced by patients themselves. DID results in long-term psychological sequelae that can last months and years. Preventative actions, such pre-episode educational information for patients and their families in those at risk may reduce distress and psychological morbidity.

Conclusions

Improving clinicians’ understanding of the experience and long term psychological harm of delirium will enable the development of targeted support and information to patients at risk of delirium, and their families or carers.

Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review

BACKGROUND

Delirium is common in hospitalized patients and is associated with worse outcomes. Antipsychotics are commonly used; however, the associated benefits and harms are unclear.

PURPOSE

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

DATA SOURCES

PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions.

STUDY SELECTION

Randomized controlled trials (RCTs) of antipsychotic versus placebo or another antipsychotic, and prospective observational studies reporting harms.

DATA EXTRACTION

One reviewer extracted data and assessed strength of evidence (SOE) for critical outcomes, with confirmation by another reviewer. Risk of bias was assessed independently by 2 reviewers.

DATA SYNTHESIS

Across 16 RCTs and 10 observational studies of hospitalized adults, there was no difference in sedation status (low and moderate SOE), delirium duration, hospital length of stay (moderate SOE), or mortality between haloperidol and second-generation antipsychotics versus placebo. There was no difference in delirium severity (moderate SOE) and cognitive functioning (low SOE) for haloperidol versus second-generation antipsychotics, with insufficient or no evidence for antipsychotics versus placebo. For direct comparisons of different second-generation antipsychotics, there was no difference in mortality and insufficient or no evidence for multiple other outcomes. There was little evidence demonstrating neurologic harms associated with short-term use of antipsychotics for treating delirium in adult inpatients, but potentially harmful cardiac effects tended to occur more frequently.

LIMITATIONS

Heterogeneity was present in terms of dose and administration route of antipsychotics, outcomes, and measurement instruments. There was insufficient or no evidence regarding multiple clinically important outcomes.

CONCLUSION

Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.

PRIMARY FUNDING SOURCE

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

Implementation of the Confusion Assessment Method for Noncritically Ill Adult Patients

Several hospital interventions increase patient risk for developing delirium, including mechanical ventilation, monitoring devices, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to increased length of hospital stay, likelihood of requiring long-term care services after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensorimotor functioning. Routine screening and early recognition prevent or reduce the long-term health and financial effects of delirium. The Confusion Assessment Method is a useable tool for screening noncritically ill adult patients for delirium.

Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients

INTRODUCTION

Predisposing and precipitating factors for delirium are well known; however, their interaction and impact on delirium in neurological patients remains largely unknown. Therefore, those factors were evaluated in hospitalized patients with neurological disorders.

METHODS

In this prospective cohort study, 1487 neurological patients were included, 356 patients with delirium and 1131 without delirium. Relevant neurological- and medical-related clusters were assessed with multiple regression analyses, prediction models, and cluster analysis evaluating their association with delirium.

RESULTS

The 1-year incidence of delirium in this cohort was 23.9%. Delirium developed in 31% of patients with stroke, in 39.5% with epilepsy, and in 58.4% with ICH. The most relevant predisposing factors were substance-use disorders (OR 4.24, 2.28-7.78, p < 0.001), advanced age (OR 3.44, CI 2.40-4.92, p < 0.001), and neurodegenerative disorders (OR 2.58, CI 1.47-4.54, p = 0.001). The most relevant precipitating factors were meningitis (OR 21.52, CI 1.22-379.83, p = 0.036), acute renal failure (OR 10.01, CI 1.13-88.73, p = 0.039), and intracranial hemorrhage (OR 3.62, CI 2.08-6.30, p < 0.001). Delirious patients were hospitalized 6 days longer, had higher in-hospital mortality, and were discharged more often to nursing homes and rehabilitation. Best predictor for delirium was the coexistence of advanced age with epilepsy (58.3%, p < 0.001), while patients aged < 65 years without epilepsy and stroke rarely developed delirium (5.1%, p < 0.001).

CONCLUSIONS

Delirium is common in elder neurological patients and associated with worse outcome. Primary cerebral conditions most frequently precipitate delirium in neurology. Neurologists are advised to monitor symptoms of delirium in the presence of risk factors to enable both timely diagnostic work-up and management of delirium.

Acute Fasting Does Not Induce Cognitive Impairment in Mice

Preoperative baseline cognitive impairment is associated with postoperative neurocognitive disorder (PND). Fasting, and more generally, calorie restriction has been shown to exert controversial effects in clinical settings and various animal models of neurological disorders. Every patient needs acute fasting before anesthesia and surgery. However, the impact of acute fasting on cognitive function remain largely unknown. We, therefore, set out to determine whether acute fasting can induce neurotoxicity and neurobehavioral deficits in rodents. In the present system establishment study, a mouse model of acute fasting was established. The effects of the acute fasting on natural and learned behavior were evaluated in the buried food test, open field test and the Y maze test. The expression of c-Fos, the marker of neuronal activation, and caspase-3 activation, the marker of cellular apoptosis, were measured with immunohistochemistry. We found that the 9 h acute fasting increased the latency to eat food in the buried food test. The acute fasting also selectively increased the total distance and decreased the freezing time in open field test, and increased the duration in the novel arm in the Y maze test. Besides, the immunohistochemical study showed that the fasting significantly increased the c-Fos level in the hippocampus and various sub-cortical areas, including paraventricular thalamus (PVT), dorsomedial hypothalamus (DMH), lateral hypothalamus (LH), and basal amygdala (BMA). However, the acute fasting did not induce apoptosis, demonstrating by no appearance of caspase-3 activation in the corresponding brain areas. These data showed that acute fasting did not cause cellular apoptosis and cognitive impairment in the mice. Instead, the acute fasting increased the neuronal activity, enhanced the ambulatory activity and improved the spatial recognition memory in the mice. These findings will promote more research in the established system to further determine the effects of perioperative factors on the postoperative neurocognitive function and the underlying mechanisms.

Characteristics of Hospitalized Patients Screening Positive for Delirium

BACKGROUND

Delirium in the hospitals leads to worse outcomes for patients. There were no previous studies that characterize patients with delirium from multiple hospital locations.

OBJECTIVE

To describe patient characteristics screening positive for delirium and identify any correlations with hospital location and medication use.

DESIGN, SETTINGS, PATIENTS

Retrospective chart review of 227 hospitalized patients from a large, academic, tertiary referral, 2-campus health system. Patients were ≥18 years old and had delirium for at least ≥24 hours. Validated delirium screening tools were utilized.

MEASUREMENTS

Patients' demographics, inpatient stay information, delirium episodes characteristics, drugs, and palliative and psychiatry teams' involvement.

RESULTS

Most patients were older with a mean age of 64.1 years. The most common primary diagnoses were infection, cardiac, and pulmonary. Average length of delirium was 7.2 days (standard deviation [SD] = 8.2), and average length of stay (LOS) was 18.7 days (median = 10.5, SD = 35.1, 95% confidence interval = 14.1-23). Thirty-day readmission rate was 24.8% (65/262 hospitalizations); 12.8% of patients died in the hospital (29/227). Around one-third of hospitalizations had involvement of palliative care, palliative psychiatry, or general psychiatry team. There was a decrease in the number of medications administered 24 hours after the first recording of delirium compared to the immediate preceding 48 hours. Those hospitalizations where delirium first occurred in the intensive care unit (ICU) did have a longer LOS (average = 22.9, SD = 45.7) than those where delirium first occurred outside the ICU (average = 14.8, SD = 20.5). Patients were likely to have received an opioid within 48 hours in 51% of hospitalizations and to have received benzodiazepines in 16% of hospitalizations.

CONCLUSION

In our study, we found that delirium significantly impacted length of delirium episode, number of episodes of delirium, length of hospital admission, and mortality. The population most sensitive to the impacts of delirium were elderly patients.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Achieving Milestones as a Prerequisite for Proceeding With a Clinical Trial

BACKGROUND

Although the National Institutes of Health (NIH) invests $30 billion in research annually, many funded studies fail to generate results that can inform practice. The National Institutes of Health introduced a phased funding mechanism as one potential solution. Study-specific milestones are established for an initial pilot phase. We assess the utility of this phased approach through the ongoing Electroencephalography (EEG) Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) pragmatic clinical trial. The hypothesis of the trial is that EEG guidance of general anesthesia, through prevention of EEG suppression, can decrease postoperative delirium and its downstream negative sequelae.

METHODS

In collaboration with study stakeholders, we identified critical milestones for the ENGAGES study, with themes common to many clinical trials. These themes include: regulatory tasks; enrollment targets; feasibility and impact of study intervention; primary outcome incidence; measurement reliability of primary outcome; and follow-up. Progress in achieving the milestones was assessed at regular intervals during the pilot phase by ENGAGES investigators, a National Institute on Aging program officer, and a nonpartisan research organization (Westat).

RESULTS

Regulatory tasks, including institutional review board approval, infrastructure establishment, and trial registration, were completed on schedule. A total of 117 patients were randomized, exceeding the target by 51. The EEG-guided protocol was successfully implemented, and a relevant effect on anesthetic practice was demonstrated (decrease in median age-adjusted minimum alveolar anesthetic concentration from 0.93 to 0.78 [P < .001] and increase in median proportion of zero EEG suppression time from 87% to 94% [P < .01]). Nearly all patients (115 of 117, 98.3%) were assessed for delirium using the Confusion Assessment Method, and the delirium incidence was similar (28.1%; 95% CI, 20%-37%) to the estimate (25%) used for the sample size calculation. Good interrater reliability of delirium assessment was demonstrated (κ = 0.94 [95% CI, 0.86-1]). Finally, 1-month follow-up vital status data were obtained for 96.9% of patients, with 85.7% of patients completing at least 1 survey.

CONCLUSIONS

With the ENGAGES trial, we demonstrated that key milestones can be identified and progressively assessed during a pilot phase. Success in attaining appropriate milestones hypothetically predicts meaningful completion of a study, and can provide justification for proceeding beyond a pilot phase. The impact of this phased approach on return on investment and scientific yield requires additional study.

The predisposing and precipitating risk factors for delirium in neurosurgery: a prospective cohort study of 949 patients

BACKGROUND

Delirium is the most common neuropsychiatric presentation during hospitalization. In neurosurgery, studies on predisposing and precipitating risk factors for the development of delirium are rare but required for the individual risk estimation.

METHODS

Prospective cohort study in a tertiary university center. In total, 949 neurosurgical patients, 307 with and 642 without delirium, were included. Demographic factors, neurosurgery-related, neurological, and medical clusters were tested as predictors of delirium in multiple logistic regression analyses.

RESULTS

The incidence of delirium in this cohort of neurosurgical patients was 32.4%. Compared to patients without delirium, those with delirium were significantly older, more cognitively and neurologically impaired, transferred from hospitals and nursing homes, admitted as emergencies, longer hospitalized (16.2 vs. 9.5 days; p < 0.001), in greater need of intensive care management, and more frequently transferred to rehabilitation. Predisposing factors of delirium were stroke (OR 5.45, CI 2.12-14.0, p < 0.001), cardiac insufficiency (OR 4.59, CI 1.09-19.26, p = 0.038), cerebral neoplasm (OR 1.53, CI 0.92-2.54, p = 0.019), and age ≥ 65 years (OR 1.47, CI 1.03-2.09, p = 0.030). Precipitating factors of delirium were acute cerebral injury (OR 3.91, CI 2.24-6.83, p < 0.001), hydrocephalus (OR 3.10, CI 1.98-4.87, p < 0.001), and intracranial hemorrhage (OR 1.90, CI 1.23-2.94, p = 0.004).

CONCLUSIONS

Delirium in acute neurosurgical patients was associated with longer hospitalization. Whereas common etiologies of delirium like infections and dementia, did not predict delirium, pre-existing neurovascular and traumatic diseases, as well as surgery-related events seem important risk factors contributing to delirium in neurosurgery.

Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction

Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.

SF-36 scores predict postoperative delirium after surgery for cervical spondylotic myelopathy

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord dysfunction. Surgery for CSM is generally effective, but postoperative delirium is a potential complication. Although there have been some studies that investigated postoperative delirium after spine surgery, no useful tool for identifying high-risk patients has been established, and it is unknown if 36-Item Short Form Health Survey (SF-36) scores can predict postoperative delirium. The objective of this study was to evaluate the correlation between preoperative SF-36 scores and postoperative delirium after surgery for CSM.

METHODS

Sixty-seven patients who underwent surgery for CSM at the authors' institution were enrolled in this study. Medical records of these patients were retrospectively reviewed. Patient background, preoperative laboratory data, preoperative SF-36 scores, the preoperative Japanese Orthopaedic Association (JOA) score for the evaluation of cervical myelopathy, and perioperative factors were selected as potential risk factors for postoperative delirium. These factors were evaluated using univariable and multivariable logistic regression analysis.

RESULTS

Ten patients were diagnosed with postoperative delirium. Univariable analysis revealed that the physical functioning score (p = 0.01), general health perception score (p < 0.01), and vitality score (p < 0.01) of the SF-36 were significantly lower in patients with postoperative delirium than in those without. The total number of medications was significantly higher in the delirium group compared with the no-delirium group (p = 0.02). In contrast, there were no significant differences between the delirium group and the no-delirium group in cervical JOA scores (p = 0.20). Multivariable analysis revealed that a low general health perception score was an independent risk factor for postoperative delirium (p = 0.02; odds ratio 0.810, 95% confidence interval 0.684-0.960).

CONCLUSIONS

Some of the SF-36 scores were significantly lower in patients with postoperative delirium than in those without. In particular, the general health perception score was independently correlated with postoperative delirium. SF-36 scores could help identify patients at high risk for postoperative delirium and aid in the development of prevention strategies.

The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient

RATIONALE

Intensive care unit (ICU) delirium is highly prevalent and a potentially avoidable hospital complication. The current cost of ICU delirium is unknown.

OBJECTIVES

To specify the association between the daily occurrence of delirium in the ICU with costs of ICU care accounting for time-varying illness severity and death.

RESEARCH DESIGN

We performed a prospective cohort study within medical and surgical ICUs in a large academic medical center.

SUBJECTS

We analyzed critically ill patients (N=479) with respiratory failure and/or shock.

MEASURES

Covariates included baseline factors (age, insurance, cognitive impairment, comorbidities, Acute Physiology and Chronic Health Evaluation II Score) and time-varying factors (sequential organ failure assessment score, mechanical ventilation, and severe sepsis). The primary analysis used a novel 3-stage regression method: first, estimation of the cumulative cost of delirium over 30 ICU days and then costs separated into those attributable to increased resource utilization among survivors and those that were avoided on the account of delirium's association with early mortality in the ICU.

RESULTS

The patient-level 30-day cumulative cost of ICU delirium attributable to increased resource utilization was $17,838 (95% confidence interval, $11,132-$23,497). A combination of professional, dialysis, and bed costs accounted for the largest percentage of the incremental costs associated with ICU delirium. The 30-day cumulative incremental costs of ICU delirium that were avoided due to delirium-associated early mortality was $4654 (95% confidence interval, $2056-7869).

CONCLUSIONS

Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.

Delirium Assessment in Older People in Emergency Departments. A Literature Review

Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.

Delirium Incidence and Risk Factors in Adult Critically Ill Patients in Saudi Arabia

BACKGROUND

Delirium in intensive care units (ICUs) is associated with long ICU stay, long hospital stay and increased costs of treatment. Unfortunately, delirium in ICU is significantly underestimated and overlooked by healthcare providers.

AIMS

The aim of this tudy is to determine the incidence and associated risk factors of delirium among critically ill patients in Saudi Arabia.

METHODS

This is a prospective study. Patients were assessed for delirium using the confusion assessment method for the ICU. Delirium was the independent variable in this study.

RESULTS

Fifty-nine patients (17.3%) showed positive delirium at least once compared to 283 patients (82.7%) who did not show positive delirium. Certain factors for delirium found to be significantly correlated with delirium (P < 0.005); including receiving sedation, mode of sedation, receiving mechanical ventilation, resistance to mechanical ventilator, and baseline Glasgow Coma Scale.

CONCLUSION

Delirium occurred in >17% of our ICU patients. More efforts should be directed to consider ICU delirium and to minimize its triggering factors.

The relationship between serum cobalamin, folic acid, and homocysteine and the risk of post-cardiac surgery delirium

Purpose: It has been reported that cobalamin and folate deficiency is related to delirium in persons with dementia. We evaluated the association of admission serum levels of cobalamin, folic acid, and homocysteine with the occurrence of acute delirium after coronary artery bypass surgery. Methods: In this prospective cohort study, serum levels of cobalamin, folic acid, and homocysteine were measured for 296 patients upon admission. Delirium was defined by the confusion assessment method for the intensive care unit. Results: Postoperative delirium was detected in 23% (n=68) of patients. Cobalamin deficiency, folate deficiency, and hyperhomocysteinemia were observed in 29% (n=86), 6% (n=18), and 68% (n=200) of patients, respectively. The mean ± SD serum levels of folic acid were 10.77±5.39 ng/mL and 12.86±6.51 ng/mL in delirium and non-delirium patients, respectively (P=0.008). The median (interquartile range [IQR]) serum levels of cobalamin were 280 (216-351) and 247 (195.5-336) in delirium and non-delirium patients, respectively (P=0.09). The median (IQR) serum levels of homocysteine were 18.5 (14.5-22.1) µmol/L and 17.33 (14.2-23.2) µmol/L in delirium and non-delirium patients, respectively (P=0.94). Multivariate regression analysis adjusted by other risk factors indicated that serum homocysteine, folate, and cobalamin levels had no association with the occurrence of delirium. Conclusion: There was no relationship between the preoperative levels of cobalamin, folate, and homocysteine, and acute occurrence of delirium observed after cardiac surgery.

Delirium in medical intensive care units: Incidence, subtypes, risk factors, and outcome

BACKGROUND

Delirium is a frequent yet underdiagnosed neuropsychiatric condition encountered in intensive care units (ICUs). Being both a preventable and potentially reversible process associated with significant morbidity and mortality, understanding risk factors that predispose and precipitate delirium in any given patient are critical in ICUs.

AIMS AND OBJECTIVES

The aim of this study is to evaluate the incidence, motor subtypes, risk factors, and clinical outcome of delirium in the medical ICU.

MATERIALS AND METHODS

We used a prospective study design on a cohort of consecutive medical ICU admissions of a tertiary care teaching hospital. The Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale were used to diagnose and motor subtype delirium, respectively, along with a checklist to assess risk factors.

RESULTS

Of the 280 ICU admissions, 88 (31.4%) developed delirium. Hypoactive delirium was the most common motor subtype (55.7%). The detection rate of delirium was 12.5% (lowest for hypoactive delirium at 2.04%). Age, gender, and years of education did not significantly predict delirium (all P > 0.05). Tobacco use, chronic liver disease, and past episodes of delirium significantly predisposed, while mechanical ventilation, hypoxia, fever, raised levels of bilirubin and creatinine, and benzodiazepine administration significantly precipitated ICU delirium. Delirium was significantly associated with longer ICU stay (t = 4.23, P = 0.000) and 1-month postdischarge mortality (χ ² = 6.867, P = 0.009).

CONCLUSION

Detection of delirium is challenging, especially in ICU patients on mechanical ventilation and hypoactive delirium. Screening and monitoring for predisposing and precipitating risk factors can greatly improve the odds of detection and intervention as ICU delirium is associated with significant morbidity and mortality.

Meta-analysis of Prevalence and Risk Factors for Delirium After Transcatheter Aortic Valve Implantation

Delirium is a severe and common complication following transcatheter aortic valve implantation (TAVI). We sought to identify the prevalence and risk factors associated with the development of postprocedural delirium in patients aged over 60 years who underwent elective TAVI for aortic stenosis. Overall, 1,051 articles were searched, from which 9 studies were included. The prevalence of delirium following TAVI was higher in studies that assessed delirium for a minimum of 3 consecutive days (24.9%) compared with the studies that did not (2%). There were large effect sizes (d > 0.8) for 3 risk factors: acute kidney injury (odds ratio [OR] 5, p < 0.001), transapical approach (OR 4, p < 0.001) and carotid artery disease (OR 4, p < 0.001), whilst small effect sizes were found for a history of atrial fibrillation, prior stroke/transient ischemic attack, peripheral artery disease, hypertension, and prior cognitive impairment. In conclusion, 23% of patients 60 years and over who underwent TAVI experience delirium, a preventative cause of cognitive impairment and dementia. Recognition of risk factors for delirium after TAVI, such as a history of carotid artery disease, development of acute kidney injury, or use of a transapical approach, provides an opportunity to implement proven delirium preventative measures.

Angiotensin II Brings More Questions Than Answers

The approval of synthetic human angiotensin II (Giapreza, LaJolla Pharmaceuticals) by the FDA in December 2017 provides clinicians with a new tool in the treatment of distributive shock. Angiotensin II (ATII) was approved based on the results of the ATHOS-3 trial. In this trial, patients who received angiotensin II were more likely to achieve a mean arterial pressure of 75 mmHg or an increase in mean arterial pressure of 10 mmHg above that seen in patients who received a placebo. However, the results of ATHOS-3 also highlighted important concerns about thrombotic and infectious complications associated with ATII. Given that the cost of medication acquisition is approximately $1,500 per vial, practitioners must also decide how to implement ATII into practice in the most cost-effective manner. This commentary examines the current controversies surrounding both the safety and efficacy of ATII.

Validity of a screening method for delirium risk in older patients admitted to a general hospital in the Netherlands

OBJECTIVE

Delirium is an impactful, frequently occurring complication in older hospital patients. Consequently, risk stratification of delirium was included in a set of mandatory safety measures in general hospitals in the Netherlands. This risk stratification contains three consensus-based questions that have not been validated. Therefore, we evaluated their predictive performance and examined whether other routinely collected patient data can improve the prediction of delirium.

METHOD

Using data from a continuous data registry from a general hospital, the prediction of the three questions was compared with the occurrence of delirium in 3786 older patients. Regression models were fitted that included other patient-related delirium risk factors. The performance was expressed by discrimination and calibration.

RESULTS

Delirium occurrence was 16.8%. The three questions, a regression model with the three questions, a full model and a reduced model - including the three questions, age, use of glasses, number of medications and Katz-ADL - showed sensitivities of 0.88, 0.88, 0.92 and 0.91 and specificities of 0.52, 0.52, 0.53 and 0.54, when treated as dichotomous models respectively. The three risk models had C-statistics of 0.81, 0.86 and 0.86, with excellent p-values of the U-statistics.

CONCLUSION

The three risk-stratification questions show promising results but substantial overprediction (49% predicting positive). Further validation should be done outside the Netherlands, given the potential bias as a result of clinical activities following the risk stratification. The reduced model shows excellent calibration performance, indicating good prediction in each individual patient. In clinical practice, this advantage adds to clinical reasoning.

Can delirium research activity impact on routine delirium recognition? A prospective cohort study

OBJECTIVE

To assess if ongoing delirium research activity within an acute admissions unit impacts on prevalent delirium recognition.

DESIGN

Prospective cohort study.

SETTING

Single-site tertiary university teaching hospital.

PARTICIPANTS

125 patients with delirium, as diagnosed by an expert using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition reference criteria, were recruited to a prospective cohort study investigating use of informant tools to detect unrecognised dementia. This study evaluated recognition of delirium and documentation of delirium by medical staff.

INTERVENTIONS

The main study followed an observational design; the intervention discussed was the implementation of this study itself.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was recognition of delirium by the admitting medical team prior to study diagnosis. Secondary outcomes included recording of or description of delirium in discharge summaries, and factors which may be associated with unrecognised delirium.

RESULTS

Delirium recognition improved between the first half (48%) and second half (71%) of recruitment (p=0.01). There was no difference in recording of delirium or description of delirium in the text of discharge summaries.

CONCLUSION

Delirium research activity can improve recognition of delirium. This has the potential to improve patient outcomes.

Postoperative cognitive disorders: an update

BACKGROUND

Cognitive dysfunction is a common complication after surgery. It is a major cause for increased, sometimes long-term, morbidity and mortality.

METHODS

In this narrative review we performed a literature search regarding postoperative cognitive decline regarding risk factors, the type of surgical intervention, potential neuroprotective effects of anesthetic drugs, and associated quality of life and healthcare costs.

RESULTS

Several risk factors are implicated in postoperative cognitive impairment. Cardiac surgery and specific orthopedic interventions are associated with a higher incidence of postoperative cognitive disorders. Results regarding the neuroprotective effects of anesthetics agents are still controversial but promising. Postoperative cognitive alterations are a major public healthcare issue as they impair the everyday quality of life, and expand the yearlong expenses.

CONCLUSIONS

Postoperative cognitive disorders are devastating, potentially life-threatening complications. High-suspicion, especially in high-risk patients and operations, and adoption of available neuroprotective strategies may prove lifesaving. HIPPOKRATIA 2018, 22(4): 147-154.

Whole-Genome mRNA Gene Expression Differs Between Patients With and Without Delirium

OBJECTIVE

To identify differences in gene expression between patients with in-hospital delirium from a known etiology (urinary tract infection [UTI]) and patients with delirium from an unknown etiology, as well as from nondelirious patients.

METHODS

Thirty patients with delirium (8 with UTI) and 21 nondelirious patients (11 with UTI) were included in this prospective case-control study. Transcriptomic profiles from messenger RNA sequencing of peripheral blood were analyzed for gene expression and disease-specific pathway enrichment patterns, correcting for systemic inflammatory response syndrome. Genes and pathways with significant differential activity based on Fisher exact test ( P < .05, |Z score| >2) are reported.

RESULTS

Patients with delirium with UTI, compared to patients with delirium without UTI, exhibited significant activation of interferon signaling, upstream cytokines, and transcription regulators, as well as significant inhibition of actin cytoskeleton, integrin, paxillin, glioma invasiveness signaling, and upstream growth factors. All patients with delirium, compared to nondelirious patients, had significant complement system activation. Among patients with delirium without UTI, compared to nondelirious patients without UTI, there was significant activation of elF4 and p7056 K signaling.

CONCLUSIONS

Differences exist in gene expression between delirious patients due to UTI presence, as well as due to the presence of delirium alone. Transcriptional profiling may help develop etiology-specific biomarkers for patients with delirium.