101
|
Safavynia SA, Goldstein PA, Evered LA. Mitigation of perioperative neurocognitive disorders: A holistic approach. Front Aging Neurosci 2022; 14:949148. [PMID: 35966792 PMCID: PMC9363758 DOI: 10.3389/fnagi.2022.949148] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022] Open
Abstract
William Morton introduced the world to ether anesthesia for use during surgery in the Bullfinch Building of the Massachusetts General Hospital on October 16, 1846. For nearly two centuries, the prevailing wisdom had been that the effects of general anesthetics were rapidly and fully reversible, with no apparent long-term adverse sequelae. Despite occasional concerns of a possible association between surgery and anesthesia with dementia since 1887 (Savage, 1887), our initial belief was robustly punctured following the publication in 1998 of the International Study of Post-Operative Cognitive Dysfunction [ISPOCD 1] study by Moller et al. (1998) in The Lancet, in which they demonstrated in a prospective fashion that there were in fact persistent adverse effects on neurocognitive function up to 3 months following surgery and that these effects were common. Since the publication of that landmark study, significant strides have been made in redefining the terminology describing cognitive dysfunction, identifying those patients most at risk, and establishing the underlying etiology of the condition, particularly with respect to the relative contributions of anesthesia and surgery. In 2018, the International Nomenclature Consensus Working Group proposed new nomenclature to standardize identification of and classify perioperative cognitive changes under the umbrella of perioperative neurocognitive disorders (PND) (Evered et al., 2018a). Since then, the new nomenclature has tried to describe post-surgical cognitive derangements within a unifying framework and has brought to light the need to standardize methodology in clinical studies and motivate such studies with hypotheses of PND pathogenesis. In this narrative review, we highlight the relevant literature regarding recent key developments in PND identification and management throughout the perioperative period. We provide an overview of the new nomenclature and its implications for interpreting risk factors identified by clinical association studies. We then describe current hypotheses for PND development, using data from clinical association studies and neurophysiologic data where appropriate. Finally, we offer broad clinical guidelines for mitigating PND in the perioperative period, highlighting the role of Brain Enhanced Recovery After Surgery (Brain-ERAS) protocols.
Collapse
Affiliation(s)
- Seyed A. Safavynia
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
| | - Peter A. Goldstein
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain & Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Lisbeth A. Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain & Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Lisbeth A. Evered,
| |
Collapse
|
102
|
Li T, Dong T, Cui Y, Meng X, Dai Z. Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2022; 9:937293. [PMID: 35959124 PMCID: PMC9360531 DOI: 10.3389/fsurg.2022.937293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 12/21/2022] Open
Abstract
Objective Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD. Methods Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model. Results Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63). Conclusions There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.
Collapse
Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Tiantian Dong
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiangrui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
| |
Collapse
|
103
|
Mileski M, McClay R, Heinemann K, Dray G. Efficacy of the Use of the Calgary Family Intervention Model in Bedside Nursing Education: A Systematic Review. J Multidiscip Healthc 2022; 15:1323-1347. [PMID: 35734541 PMCID: PMC9208629 DOI: 10.2147/jmdh.s370053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/07/2022] [Indexed: 12/18/2022] Open
Abstract
Objective To objectively analyze the research for empirical evidence of the efficacy of the use of the Calgary Family Intervention Model (CFIM) in assisting bedside education by nurses and to identify facilitators and barriers to the use of the Model. Methods Four research databases (PubMed [MEDLINE], CINAHL, Web of Science, and Science Direct) were queried for studies commensurate with the objective statement from 1990 to 2021. In total, 169 articles were initially identified in the search, 135 were screened after duplicates and ineligible articles were removed, ultimately leaving the sample of 24 articles for the review. Results There is significant evidence to conclude that the CFIM is a very useful model to be used by nurses for bedside education and to improve overall patient and family outcomes. It enables communication, collaboration, and therapeutic conversations. The use of CFIM by nurses serves as a resource for both them and families and patients involved. There are some concerns to the use of CFIM as there are family dynamic issues, which result in problems providing care to patients. A lack of family sharing can result in inadequate care to the patient as well as unrealistic expectations from family members involved. Conclusion The CFIM is an excellent tool to enable nurses to provide education at the bedside and to enable improved patient and family outcomes. The use of the tool is suggested in situations where it would improve the level of care provided to patients and families.
Collapse
Affiliation(s)
- Michael Mileski
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Rebecca McClay
- School of Science, Technology, Engineering, and Math, American Public University System, Charles Town, WV, USA
| | - Katharine Heinemann
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Gevin Dray
- School of Health Administration, Texas State University, San Marcos, TX, USA
| |
Collapse
|
104
|
Saunders R, Crookes K, Seaman K, Ang SGM, Bulsara C, Bulsara MK, Ewens B, Gallagher O, Graham RM, Gullick K, Haydon S, Hughes J, Atee M, Nguyen KH, O'Connell B, Scaini D, Etherton-Beer C. Effectiveness of nurse-led volunteer support and technology-driven pain assessment in improving the outcomes of hospitalised older adults: protocol for a cluster randomised controlled trial. BMJ Open 2022; 12:e059388. [PMID: 35725261 PMCID: PMC9214388 DOI: 10.1136/bmjopen-2021-059388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Hospitalised older adults are prone to functional deterioration, which is more evident in frail older patients and can be further exacerbated by pain. Two interventions that have the potential to prevent progression of frailty and improve patient outcomes in hospitalised older adults but have yet to be subject to clinical trials are nurse-led volunteer support and technology-driven assessment of pain. METHODS AND ANALYSIS This single-centre, prospective, non-blinded, cluster randomised controlled trial will compare the efficacy of nurse-led volunteer support, technology-driven pain assessment and the combination of the two interventions to usual care for hospitalised older adults. Prior to commencing recruitment, the intervention and control conditions will be randomised across four wards. Recruitment will continue for 12 months. Data will be collected on admission, at discharge and at 30 days post discharge, with additional data collected during hospitalisation comprising records of pain assessment and volunteer support activity. The primary outcome of this study will be the change in frailty between both admission and discharge, and admission and 30 days, and secondary outcomes include length of stay, adverse events, discharge destination, quality of life, depression, cognitive function, functional independence, pain scores, pain management intervention (type and frequency) and unplanned 30-day readmissions. Stakeholder evaluation and an economic analysis of the interventions will also be conducted. ETHICS AND DISSEMINATION Ethical approval has been granted by Human Research Ethics Committees at Ramsay Health Care WA|SA (number: 2057) and Edith Cowan University (number: 2021-02210-SAUNDERS). The findings will be disseminated through conference presentations, peer-reviewed publications and social media. TRIAL REGISTRATION NUMBER ACTRN12620001173987.
Collapse
Affiliation(s)
- Rosemary Saunders
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Kate Crookes
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Karla Seaman
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Seng Giap Marcus Ang
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Caroline Bulsara
- School of Nursing and Midwifery, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Beverley Ewens
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Olivia Gallagher
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Renee M Graham
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Karen Gullick
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- Clinical Services, Hollywood Private Hospital, Perth, Western Australia, Australia
| | - Sue Haydon
- Clinical Services, Hollywood Private Hospital, Perth, Western Australia, Australia
| | - Jeff Hughes
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- PainChek, Sydney, New South Wales, Australia
| | - Mustafa Atee
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- The Dementia Centre, HammondCare, Wembley, Western Australia, Australia
| | - Kim-Huong Nguyen
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Bev O'Connell
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Debra Scaini
- Clinical Services, Hollywood Private Hospital, Perth, Western Australia, Australia
| | - Christopher Etherton-Beer
- Western Australian Centre for Health and Ageing, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
105
|
Costa MLM, Mafra ACCN, Cendoroglo MS, Rodrigues PS, Ferreira MS, Studenski SA, Franco FGDM. Development and validation of predictive model for long-term hospitalization, readmission, and in-hospital death of patients over 60 years old. EINSTEIN-SAO PAULO 2022; 20:eAO8012. [PMID: 35730807 PMCID: PMC9239538 DOI: 10.31744/einstein_journal/2022ao8012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To develop and validate a high-risk predictive model that identifies, at least, one common adverse event in older population: early readmission (up to 30 days after discharge), long hospital stays (10 days or more) or in-hospital deaths. Methods This was a retrospective cohort study including patients aged 60 years or older (n=340) admitted at a 630-beds tertiary hospital, located in the city of São Paulo, Brazil. A predictive model of high-risk indication was developed by analyzing logistical regression models. This model prognostic capacity was assessed by measuring accuracy, sensitivity, specificity, and positive and negative predictive values. Areas under the receiver operating characteristic curve with 95% confidence intervals were also obtained to assess the discriminatory power of the model. Internal validation of the prognostic model was performed in a separate sample (n=168). Results Statistically significant predictors were identified, such as current Barthel Index, number of medications in use, presence of diabetes mellitus, difficulty chewing or swallowing, extensive surgery, and dementia. The study observed discrimination model acceptance in the construction sample 0.77 (95% confidence interval: 0.71-0.83) and good calibration. The characteristics of the validation samples were similar, and the receiver operating characteristic curve area was 0.687 (95% confidence interval: 0.598-0.776). We could assess an older patient’s adverse health events during hospitalization after admission. Conclusion A predictive model with acceptable discrimination was obtained, with satisfactory results for early readmission (30 days), long hospital stays (10 days), or in-hospital death.
Collapse
|
106
|
Lee S, Chen H, Hibino S, Miller D, Healy H, Lee JS, Arendts G, Han JH, Kennedy M, Carpenter CR. Can we improve delirium prevention and treatment in the emergency department? A systematic review. J Am Geriatr Soc 2022; 70:1838-1849. [PMID: 35274738 PMCID: PMC9314609 DOI: 10.1111/jgs.17740] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults presenting to the emergency department (ED). METHODS Health sciences librarian designed electronic searches were conducted from database inception through September 2021. Two authors reviewed studies, and included studies that evaluated interventions for the prevention and/or treatment of delirium and excluded non-ED studies. The risk of bias (ROB) was evaluated by the Cochrane ROB tool or the Newcastle-Ottawa (NOS) scale. Meta-analysis was conducted to estimate a pooled effect of multifactorial programs on delirium prevention. RESULTS Our search strategy yielded 11,900 studies of which 10 met study inclusion criteria. Two RCTs evaluated pharmacologic interventions for delirium prevention; three non-RCTs employed a multi-factorial delirium prevention program; three non-RCTs evaluated regional anesthesia for hip fractures; and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium. Only four studies demonstrated a significant impact on delirium incidence or duration of delirium-one RCT of melatonin reduced the incidence of delirium (OR 0.19, 95% CI 0.06 to 0.62), one non-RCT study on a multi-factorial program decreased inpatient delirium prevalence (41% to 19%) and the other reduced incident delirium (RR 0.37, 95% CI 0.22 to 0.61). One case-control study on the use of ED Foley catheters in the ED increased the duration of delirium (proportional OR 3.1, 95% CI 1.3 to 7.4). A pooled odds ratio for three multifactorial programs on delirium prevention was 0.46 (95% CI 0.31-0.68, I2 = 0). CONCLUSION Few interventions initiated in the ED were found to consistently reduce the incidence or duration of delirium. Delirium prevention and treatment trials in the ED are still rare and should be prioritized for future research.
Collapse
Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Hao Chen
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Seikei Hibino
- Department of Emergency MedicineUniversity of Minnesota Medical CenterMinneapolisMinnesotaUSA
| | - Daniel Miller
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Heather Healy
- Hardin Library for the Health SciencesUniversity of IowaIowa CityIowaUSA
| | - Jacques S. Lee
- Schwartz/Reisman Emergency Medicine InstituteSinai HealthTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Glenn Arendts
- Emergency MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Jin Ho Han
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical CenterTennessee Valley Healthcare SystemNashvilleTennesseeUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | | |
Collapse
|
107
|
Validation of Screening Tools for Predicting the Risk of Functional Decline in Hospitalized Elderly Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116685. [PMID: 35682269 PMCID: PMC9180656 DOI: 10.3390/ijerph19116685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Functional decline and increased dependence on others are common health issues among hospitalized elderly patients. However, a well-validated screening tool for predicting functional decline in elderly patients is still lacking. The current study therefore aimed to evaluate and compare the diagnostic accuracy of the Identification of Seniors at Risk-Hospitalized Patients (ISAR-HP), Variable Indicative of Placement Risk (VIP), and Score Hospitalier d' Evaluation du Risque de Perte d'Autonomie (SHERPA) in predicting functional decline 30 days after discharge in older patients admitted to an acute hospital ward. METHODS A prospective, longitudinal study was conducted in 197 elderly inpatients at the internal medicine ward of a teaching hospital in central Taiwan. Data were collected twice, first within 48 h after hospitalization and second via a telephone interview 30 days after hospital discharge. Variables included demographic data, Barthel Index of activities of daily living (ADL), and screening instruments. The Barthel Index was used to measure functional disability. Functional decline was defined as a decline of at least five points on the Barthel Index 30 days after discharge compared to that at pre-admission. RESULTS Patients had a mean age of 77.7 years, with 55.7% being female. Functional decline was observed in 39.1% of all patients. The best cutoff point, sensitivity, specificity, and area under the receiver operating characteristic curve were 2.5, 96.1%, 52.5%, and 0.751 for ISAR-HP; 1.5, 83.1%, 62.5%, and 0.761 for VIP; and 4.75, 89.6%, 54.2%, and 0.758 for SHERPA, respectively. CONCLUSIONS All three instruments showed moderate diagnostic accuracy as indicated by their best cutoff points. Therefore, the results presented herein can guide health care professionals in selecting the appropriate assessment tool for predicting functional decline among hospitalized elderly patients in a clinical setting.
Collapse
|
108
|
Kinchin I, Edwards L, Hosie A, Agar M, Mitchell E, Trepel D. Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations. Acta Psychiatr Scand 2022; 147:430-459. [PMID: 35596552 DOI: 10.1111/acps.13457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium. METHODS Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%). CONCLUSION Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.
Collapse
Affiliation(s)
- Irina Kinchin
- Centre for Health Policy and Management, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Layla Edwards
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Eileen Mitchell
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Dominic Trepel
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| |
Collapse
|
109
|
Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
Collapse
Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| |
Collapse
|
110
|
Effects of non-pharmacological interventions for preventing delirium in general ward inpatients: A systematic review & meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0268024. [PMID: 35522654 PMCID: PMC9075647 DOI: 10.1371/journal.pone.0268024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
Abstract
The purpose of this study was to identify the types and contents of non-pharmacological delirium prevention interventions applied to inpatients in general wards, and to verified the effectiveness of the interventions on the incidence of delirium. We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform, PubMed and Google Scholar, and Korean DB such as RISS, DBpia, KISS, NDSL and KCI) using terms to identify delirium, prevention, and non-pharmacological. We searched all databases from their inception to January 2021 and imposed restriction on language of publication in English and Korean. We included studies if they were conducted as all types of randomized controlled trials (RCT), involving adult patients aged 19 years or more who were admitted to a general ward. We included trials comparing non-pharmacological intervention versus usual care. The entire process of data selection and extraction, assessment of risk of bias with ROB2.O was independently performed by three researchers. The estimated effect size was an odds ratio (OR) and 95% confidence interval. The fixed effects model and general inverse variance estimation method were adopted. The type of non-pharmacological delirium prevention interventions for inpatients in general ward was mainly multi-component intervention to correct delirium risk factors. The content and intensity of non-pharmacological interventions varied greatly depending on the characteristics of the patient and the clinical situation. As a result of the meta-analysis, non-pharmacological multi-component intervention was effective in reducing the incidence of delirium, and it was confirmed that it was effective in reducing the incidence of delirium in both the internal and surgical wards. It was confirmed by quantitative evidence that non-pharmacological interventions, especially multi-component interventions, were effective in preventing delirium in general ward inpatients.
Collapse
|
111
|
Falling for It: Of Falls, Families, and Delirium. Crit Care Med 2022; 50:889-891. [PMID: 35485590 DOI: 10.1097/ccm.0000000000005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
112
|
Nonpharmacological interventions for agitation in the adult intensive care unit: A systematic review. Aust Crit Care 2022; 36:385-400. [PMID: 35513998 DOI: 10.1016/j.aucc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Person-centred nonpharmacological strategies should be used whenever possible to reduce agitation in the intensive care unit due to issues related to an overreliance on physical restraints and psychoactive drugs. However, the effect of nonpharmacological interventions to reduce agitation is unclear. OBJECTIVES The objectives of this study were to systematically review studies that evaluate the effectiveness of nonpharmacological interventions designed to prevent and minimise or manage patient agitation in the adult intensive care unit. METHODS This systematic review was conducted following the Joanna Briggs Institute's Systematic Review of Effectiveness method and a priori PROSPERO protocol. Quantitative studies were identified from seven databases, including MEDLINE, EmCare, CINAHL, Web of Science, PsycINFO, Scopus, and Cochrane Library. In addition, grey literature from several repositories and trial registers was searched. The primary outcome of interest was the effect on prevention, minimisation, and management of agitation. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RESULTS Eleven studies were included (n = 882). Meta-analyses of two studies demonstrated significantly lower levels of agitation (measured with the Richmond Agitation Sedation Scale) in the group receiving a multicomponent nonpharmacological intervention than in those receiving usual care. Individual studies showed a significant effect of nature-based sounds, music, foot reflexology, healing touch, and aromatherapy. The type of the endotracheal suction system did not affect levels of agitation. Overall, the certainty of the findings was rated very low. Harms and adverse effects were not reported in any studies. CONCLUSIONS Nonpharmacological interventions have the potential to reduce levels of agitation in the intensive care unit. However, inconsistencies in reporting, low quality of methodological designs, and small sample sizes impact the certainty of the results. Future trials must include larger sample sizes, use rigorous methods to improve knowledge in this field, and consider a range of other outcomes.
Collapse
|
113
|
Mickelson Weldingh N, Kirkevold M. What older people and their relatives say is important during acute hospitalisation: a qualitative study. BMC Health Serv Res 2022; 22:578. [PMID: 35488250 PMCID: PMC9052562 DOI: 10.1186/s12913-022-07981-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to the growing population of older people across the world, providing safe and effective care is an increasing concern. Older persons in need for hospitalisation often have, or are susceptible to develop, cognitive impairment. Hospitals need to adapt to ensure high-quality care for this vulnerable patient group. Several age-friendly frameworks and models aiming at reducing risks and complications have been promoted. However, care for older people must be based on the persons' reported needs, and relatives are often an important part of older persons' social support. The primary aim of this study was to explore older peoples' and their relatives' experiences of acute hospitalisation and determine what is important for them to experience a good hospital stay. The study was not limited to patients with cognitive impairment; but included a wider group of older individuals vulnerable to developing delirium, with or without an underlying chronic cognitive impairment. METHODS This study had a qualitative research design in which people aged 75 years or older and their relatives were interviewed during an acute hospitalisation. The study was conducted at two medical wards at a large university hospital in Norway, and included a total of 60 participants. All interviews were informed by a semi-structured interview guide and were thematically analysed. RESULTS Four major themes were identified in the older people's and the relatives' descriptions of how they experienced the hospital stay and what was important for them during the hospital stay: being seen and valued as a person, individualised care, patient-adapted communication and information, and collaboration with relatives. The themes span both positive and negative experiences, reflecting great variability in the experiences described. The presence of these four characteristics promoted positive experiences among patients and relatives, whereas the absence or negative valuation of them promoted negative experiences. CONCLUSIONS The findings underscore the interrelatedness of older people and their relatives and that patients and relatives are quite consistent in their experiences and opinions. This suggests that listening to the concerns of relatives is important, as they can voice the older patient's needs and concerns in situations where older people might find it difficult to do so. Furthermore, the results underscore how 'small things' matter in relation to how health professionals capture the patient's individual values, need for care, information and involvement of relatives and that these are essential to ensure predictability and security and a good stay for older people and their relatives.
Collapse
Affiliation(s)
- Nina Mickelson Weldingh
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway
| | - Marit Kirkevold
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| |
Collapse
|
114
|
Applicability of the interventions recommended for patients at risk or with delirium in medical and post-acute settings: a systematic review and a Nominal Group Technique study. Aging Clin Exp Res 2022; 34:1781-1791. [PMID: 35451735 DOI: 10.1007/s40520-022-02127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is a common condition during hospitalisation that should be prevented and treated. Several recommendations have been established to date, whereas few studies have investigated their applicability in daily practice for medical and post-acute settings. AIM The aim of this research exercise was to emerge the applicability of the interventions recommended by studies in the daily care of patients at risk or with delirium cared in medical and post-acute settings. METHODS The study was organised in three phases. A systematic literature review according to Centre for Reviews and Dissemination was conducted (January-February 2021). Cochrane Library, Pubmed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Psychological Information Database, and the Joanna Briggs Institute databases were searched. Primary and secondary studies were evaluated in their methodological quality with the Standard Quality Assessment Criteria, the Critical Appraisal Skills Programme, and the Appraisal of Guidelines for Research & Evaluation. Then, the interventions identified were assessed in their applicability using the Nominal Group Technique who ranked their judgement on a four-point Likert scale from 1 (totally inapplicable) to 4 (totally applicable). Qualitative feedbacks were also considered, and a validation of the final list was performed by the Nominal Group. RESULTS A total of 12 studies were included producing a list of 96 interventions categorised into four macro-areas (prevention, non-pharmacological, communication and pharmacological management). The Nominal Group identified 51 interventions (average score > 3.5) as applicable in medical and post-acute settings. Then, through a process of re-reading, and revising according to the comments provided by the Nominal Group, a list of 35 interventions out of the initial 96 were judged as applicable. CONCLUSION Applicability should be assessed with experts in the field to understand the involved factors. One-third of interventions have been judged as applicable in the Italian context; the nurses' expertise, the work environment features, and the time required for each intervention in a high workload setting may prevent the full applicability of the interventions recommended by the literature.
Collapse
|
115
|
Meulenbroek AL, van Mil SR, Faes MC, Mattace-Raso FUS, Fourneau I, van der Laan L. A systematic review of strategies for preventing delirium in patients undergoing vascular surgery. Ann Vasc Surg 2022; 85:433-443. [PMID: 35460860 DOI: 10.1016/j.avsg.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Elderly patients undergoing vascular surgery are at risk of developing postoperative delirium, which is associated with a high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery', 'prevention' and 'delirium', and was last run on October 21st, 2021 in the electronic databases Pubmed, MEDLINE, Embase, Web of Science, the Cochrane library and Emcare. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group versus 11% in the intervention group, p = 0.018), and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group versus 8.2% in the intervention group, p = 0.043, OR = 0.56). A non-significant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group versus 14.6% in the intervention group, p = 0.17). The study concerning the impact of the type of anaesthesia on delirium in eleven older vascular surgical patients, of which three developed delirium, did not differentiate between the different types of anaesthesia the patients received. CONCLUSION Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.
Collapse
Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, the Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Inge Fourneau
- Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands; Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
| |
Collapse
|
116
|
Weldingh NM, Mellingsæter MR, Hegna BW, Benth JS, Einvik G, Juliebø V, Thommessen B, Kirkevold M. Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a controlled clinical trial design. BMC Geriatr 2022; 22:266. [PMID: 35361136 PMCID: PMC8974092 DOI: 10.1186/s12877-022-02949-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards. Methods This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 ‘A’s Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR). Results Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote “dementia-friendly” care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality. Conclusions A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention. Trial registration The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021.
Collapse
Affiliation(s)
- N M Weldingh
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B W Hegna
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway
| | - J Saltyte Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - G Einvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pulmonary Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - V Juliebø
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - M Kirkevold
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.,Faculty of Medicine, Department of Nursing Science, University of Oslo, Institute of Health and Society, Oslo, Norway
| |
Collapse
|
117
|
Krüger L, Bolte C, Fröhlich M, Heide K, Schumacher J, Oldag A, Wolter B, Lauenroth H, Wefer F. [Delirium prevention and management: Development and implementation of a non-pharmacological catalog of measures in the acute setting]. Pflege 2022; 35:302-311. [PMID: 35333108 DOI: 10.1024/1012-5302/a000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Delirium prevention and management: Development and implementation of a non-pharmacological catalog of measures in the acute setting Abstract. Background: In October 2018, a new delirium management concept was developed in a university hospital for cardiovascular diseases. As part of a multi-professional approach, the previously established "Evidence-based Nursing working group (AK EBN)", consisting of academically qualified nurses from the hospital, was involved in the implementation process. Aim: The AK EBN aimed to identify effective non-pharmacological interventions to prevent and treat delirium and to establish how these interventions could influence delirium rates in hospital patients. Methods: The EbN method was employed to address the study question applying the PICO framework (Behrens & Langer, 2016) as the bases for systematic searches in different databases. Relevant studies were identified, data were extracted, displayed in tables and discussed within the AK using established critical appraisal tools for quality assessment. Results: Despite a heterogeneous study sample, results showed that there is meaningful evidence for the effectiveness of intervention bundles on the reduction of delirium rates. Bundles include for example, aspects of orientation and noise reduction. As a result, a catalogue of non-pharmacological interventions, communication aids, and a guide for involving caregivers in the prevention and treatment of delirium were developed. Additionally, continuing training events held by the participants of AK EBN were organized. Conclusions: To promote the successful implementation of projects in practice, the involvement of all stakeholders is important. As part of a skill-grade-mix, nurses made an important contribution in this multi-professional project.
Collapse
Affiliation(s)
- Lars Krüger
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Christina Bolte
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Mandy Fröhlich
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Kristina Heide
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Jana Schumacher
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Anne Oldag
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Björn Wolter
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Hanni Lauenroth
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| | - Franziska Wefer
- Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen
| |
Collapse
|
118
|
He S, Rolls K, Stott K, Shekhar R, Vueti V, Flowers K, Moseley M, Shepherd B, Mayahi-Neysi M, Chasle B, Warner B, Ni Chroinin D, Frost SA. Does delirium prevention reduce risk of in-patient falls among older adults? A systematic review and trial sequential meta-analysis. Australas J Ageing 2022; 41:396-406. [PMID: 35257469 DOI: 10.1111/ajag.13051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine whether delirium prevention interventions reduce the risk of falls among older hospitalised patients. METHODS A systematic search of health-care databases was undertaken. Given the frequency of small sample sized trials, a trial sequential meta-analysis was conducted to present estimate summary effects to date. A Bayesian approach was used to estimate the posterior probability of the delirium prevention interventions reducing falls risk by various clinically relevant levels. RESULTS Five randomised controlled trials were included in our final meta-analysis. There was a 43% reduction in the risk of falls among participants in the delirium prevention intervention arm, compared to the control; however, confidence intervals were wide (RE RR = 0.57, 95% CI 0.32; 1.00, p = 0.05). This result was found to be statistically significant, according to traditional significance levels (z > 1.96) and the more conservative trial sequential analysis monitoring boundaries. The posterior probabilities of the delirium prevention intervention reducing the risk of falls by 10%, 20% and 30% were 0.86, 0.63 and 0.29 respectively. CONCLUSIONS The results of this systematic review and trial sequential meta-analysis suggest that delirium prevention trials may reduce the risk of in-hospital falls among older patients by 43%. However, despite significant risk reduction found upon meta-analysis, the variation among study populations and intervention components raised questions around its application in clinical practice. Further research is required to investigate what the necessary components of a multifactorial intervention are to reduce both delirium and fall incidence among older adult in-patients.
Collapse
Affiliation(s)
- Steven He
- South Western Sydney Nursing and Midwifery Research Alliance, Western Sydney University and Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Kaye Rolls
- South Western Sydney Nursing and Midwifery Research Alliance, Western Sydney University and Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Katrina Stott
- Bankstown Lidcombe Hospital, New South Wales, Australia
| | - Rozina Shekhar
- South Western Sydney Local Health District, Liverpool, New South Wales, Australia.,Fairfield Hospital, Fairfield, New South Wales, Australia
| | - Vaulina Vueti
- Fairfield Hospital, Fairfield, New South Wales, Australia
| | - Kelli Flowers
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | | | | | - Briony Chasle
- South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Bradley Warner
- South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Danielle Ni Chroinin
- Liverpool Hospital, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Steven A Frost
- South Western Sydney Nursing and Midwifery Research Alliance, Western Sydney University and Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| |
Collapse
|
119
|
Associations Between Stroke Localization and Delirium: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106270. [PMID: 34954599 PMCID: PMC8837688 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106270] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Delirium is common among patients with acute stroke and associated with worse outcomes. However, it is unclear which stroke locations or types are most associated with delirium. MATERIALS AND METHODS We systematically reviewed studies of patients with acute stroke that reported stroke locations and types by delirium status. We included papers in any language, through a combined search from January 2010 to June 2021. Case studies with less than 20 patients, case-control studies, and randomized controlled trials were excluded. MEDLINE, EMBASE, PsycINFO, CINAHL, and Alois databases were searched. Pooled relative risks were calculated using bivariate random effects models or network meta-analysis. Methodological quality was assessed across 8 factors. RESULTS 31 patient samples representing 8329 patients were included. Delirium was more common in patients with supratentorial lesions than infratentorial (RR [Relative Risk] 2.01, CI [Confidence Interval] 1.49-2.72); anterior circulation lesions than posterior (RR 1.41, CI 1.13-1.78); and cortical lesions than subcortical (RR 1.54, CI 1.25-1.89). Stroke side was not associated with delirium (right vs. left: RR 0.99, CI 0.77-1.28). Delirium was more common in patients with hemorrhagic strokes than ischemic (RR 1.74, CI 1.42-2.11) and patients with preexisting qualitative atrophy (RR 1.66, CI 1.21-2.27). CONCLUSION Several brain localizations and types of strokes were associated with delirium. Conclusions were in part limited by the heterogeneity of studies and broad or qualitative lesion descriptions. These results may assist in anticipating the risk of delirium in acute stroke and highlight brain networks and pathologies that may be involved in the pathophysiology of delirium.
Collapse
|
120
|
Deeken F, Sánchez A, Rapp MA, Denkinger M, Brefka S, Spank J, Bruns C, von Arnim CAF, Küster OC, Conzelmann LO, Metz BR, Maurer C, Skrobik Y, Forkavets O, Eschweiler GW, Thomas C. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg 2022; 157:e216370. [PMID: 34910080 PMCID: PMC8674802 DOI: 10.1001/jamasurg.2021.6370] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
Importance Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored. Objective To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures. Design, Setting, and Participants This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021. Interventions First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion. Main Outcomes and Measures Postoperative delirium incidence and duration. Results Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54). Conclusions and Relevance This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.
Collapse
Affiliation(s)
- Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Michael A. Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
- Social and Preventive Medicine, Department of Sports and Health Sciences, Intrafaculty Unit of Cognitive Sciences, Faculty of Human Science, and Faculty of Health Sciences Brandenburg, Research Area Services Research and e-Health, University of Potsdam, Potsdam, Germany
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Simone Brefka
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Juliane Spank
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Carola Bruns
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Christine A. F. von Arnim
- Division of Geriatrics, University Medical Center Goettingen, Göttingen, Germany
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | | | | | - Brigitte R. Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Christoph Maurer
- Center for Geriatrics and Gerontology, Medical Center University of Freiburg, Freiburg, Germany
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Oksana Forkavets
- Department of Neurology, University Hospital Ulm, Ulm, Germany
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
| | - Gerhard W. Eschweiler
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Christine Thomas
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| |
Collapse
|
121
|
Swarbrick CJ, Partridge JSL. Evidence‐based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia 2022; 77 Suppl 1:92-101. [DOI: 10.1111/anae.15607] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 12/18/2022]
Affiliation(s)
- C. J. Swarbrick
- Department of Anaesthesia Royal Devon and Exeter Hospital Exeter UK
| | - J. S. L. Partridge
- Peri‐operative medicine for Older People undergoing Surgery Department of Ageing and Health Guy's and St Thomas' NHS Foundation Trust London UK
| |
Collapse
|
122
|
Postoperative delirium prediction using machine learning models and preoperative electronic health record data. BMC Anesthesiol 2022; 22:8. [PMID: 34979919 PMCID: PMC8722098 DOI: 10.1186/s12871-021-01543-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 12/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Accurate, pragmatic risk stratification for postoperative delirium (POD) is necessary to target preventative resources toward high-risk patients. Machine learning (ML) offers a novel approach to leveraging electronic health record (EHR) data for POD prediction. We sought to develop and internally validate a ML-derived POD risk prediction model using preoperative risk features, and to compare its performance to models developed with traditional logistic regression. Methods This was a retrospective analysis of preoperative EHR data from 24,885 adults undergoing a procedure requiring anesthesia care, recovering in the main post-anesthesia care unit, and staying in the hospital at least overnight between December 2016 and December 2019 at either of two hospitals in a tertiary care health system. One hundred fifteen preoperative risk features including demographics, comorbidities, nursing assessments, surgery type, and other preoperative EHR data were used to predict postoperative delirium (POD), defined as any instance of Nursing Delirium Screening Scale ≥2 or positive Confusion Assessment Method for the Intensive Care Unit within the first 7 postoperative days. Two ML models (Neural Network and XGBoost), two traditional logistic regression models (“clinician-guided” and “ML hybrid”), and a previously described delirium risk stratification tool (AWOL-S) were evaluated using the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, positive likelihood ratio, and positive predictive value. Model calibration was assessed with a calibration curve. Patients with no POD assessments charted or at least 20% of input variables missing were excluded. Results POD incidence was 5.3%. The AUC-ROC for Neural Net was 0.841 [95% CI 0. 816–0.863] and for XGBoost was 0.851 [95% CI 0.827–0.874], which was significantly better than the clinician-guided (AUC-ROC 0.763 [0.734–0.793], p < 0.001) and ML hybrid (AUC-ROC 0.824 [0.800–0.849], p < 0.001) regression models and AWOL-S (AUC-ROC 0.762 [95% CI 0.713–0.812], p < 0.001). Neural Net, XGBoost, and ML hybrid models demonstrated excellent calibration, while calibration of the clinician-guided and AWOL-S models was moderate; they tended to overestimate delirium risk in those already at highest risk. Conclusion Using pragmatically collected EHR data, two ML models predicted POD in a broad perioperative population with high discrimination. Optimal application of the models would provide automated, real-time delirium risk stratification to improve perioperative management of surgical patients at risk for POD. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01543-y.
Collapse
|
123
|
Castro VM, Hart KL, Sacks CA, Murphy SN, Perlis RH, McCoy TH. Longitudinal validation of an electronic health record delirium prediction model applied at admission in COVID-19 patients. Gen Hosp Psychiatry 2022; 74:9-17. [PMID: 34798580 PMCID: PMC8562039 DOI: 10.1016/j.genhosppsych.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To validate a previously published machine learning model of delirium risk in hospitalized patients with coronavirus disease 2019 (COVID-19). METHOD Using data from six hospitals across two academic medical networks covering care occurring after initial model development, we calculated the predicted risk of delirium using a previously developed risk model applied to diagnostic, medication, laboratory, and other clinical features available in the electronic health record (EHR) at time of hospital admission. We evaluated the accuracy of these predictions against subsequent delirium diagnoses during that admission. RESULTS Of the 5102 patients in this cohort, 716 (14%) developed delirium. The model's risk predictions produced a c-index of 0.75 (95% CI, 0.73-0.77) with 27.7% of cases occurring in the top decile of predicted risk scores. Model calibration was diminished compared to the initial COVID-19 wave. CONCLUSION This EHR delirium risk prediction model, developed during the initial surge of COVID-19 patients, produced consistent discrimination over subsequent larger waves; however, with changing cohort composition and delirium occurrence rates, model calibration decreased. These results underscore the importance of calibration, and the challenge of developing risk models for clinical contexts where standard of care and clinical populations may shift.
Collapse
Affiliation(s)
- Victor M. Castro
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA
| | - Kamber L. Hart
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Chana A. Sacks
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114, USA
| | - Shawn N. Murphy
- Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA,Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Roy H. Perlis
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Thomas H. McCoy
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Corresponding author at: Simches Research Building, Massachusetts General Hospital, 185 Cambridge St, 6th Floor, Boston, MA 02114, USA
| |
Collapse
|
124
|
Wang L, Chignell M, Zhang Y, Pinto A, Razak F, Sheehan K, Verma A. Physician Experience Design (PXD): More Usable Machine Learning Prediction for Clinical Decision Making. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2022:476-485. [PMID: 35854747 PMCID: PMC9285165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Delirium is an acute neurocognitive disorder, which is difficult to identify and predict. Using GEMINI, Canada's largest hospital data and analytics study, we had a labeled sample of around 4,000 cases with approximately 25% of cases being labeled as having delirium. Based on this labeled data, we developed machine learning (ML) models and interacted with physicians to interpret the ML models and their predictions. We developed a preliminary Explainable Artificial Intelligence (XAI) framework for physician experience design (PXD) to improve the uptake of ML models by improving the transparency of model results, thereby increasing physician trust in models as well as the uptake of model results for clinical decision making. We developed our PXD approach first with Conceptual Investigation to collect and extract physicians' feedback on ML models and their evaluation requirements. We carried out a case study, working closely with the physicians in a participatory design process to develop a dashboard that presents ML delirium identification results interactively based on physician selections and inputs. In this approach a physician-preferred ML model for clinical decision making is selected through PXD evaluation.
Collapse
Affiliation(s)
- Lu Wang
- Dept. of Mechanical & Industrial Engineering, University of Toronto (UofT), Toronto, ON M5S 2E4, Canada (CA)
| | - Mark Chignell
- Dept. of Mechanical & Industrial Engineering, University of Toronto (UofT), Toronto, ON M5S 2E4, Canada (CA)
| | - Yilun Zhang
- Dept. of Mechanical & Industrial Engineering, University of Toronto (UofT), Toronto, ON M5S 2E4, Canada (CA)
| | - Andrew Pinto
- Dalla Lana School of Public Health, UofT, Toronto, ON M5S 3G8, CA
- Dept. of Family and Community Medicine, St. Michael's Hospital, Unity Health, Toronto, ON M5B 1W8, CA
| | - Fahad Razak
- Dept. of Psychiatry, UofT, Toronto, ON M5B 1W8, CA
- Dept. of Medicine, UofT, Toronto, ON M5S 1A8, CA
- Inst. of Health Policy, Management and Evaluation, UofT, Toronto, ON M5T 3M6, CA
| | - Kathleen Sheehan
- GEMINI, Unity Health, Toronto, ON M5B 1W8, CA
- Dalla Lana School of Public Health, UofT, Toronto, ON M5T 2S8, CA
| | - Amol Verma
- Dept. of Psychiatry, UofT, Toronto, ON M5B 1W8, CA
- Dept. of Medicine, UofT, Toronto, ON M5S 1A8, CA
- Inst. of Health Policy, Management and Evaluation, UofT, Toronto, ON M5T 3M6, CA
| |
Collapse
|
125
|
Oldham MA. Delirium disorder: Unity in diversity. Gen Hosp Psychiatry 2022; 74:32-38. [PMID: 34875568 DOI: 10.1016/j.genhosppsych.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing them through the model of delirium disorder. METHOD This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets. RESULTS Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies. CONCLUSIONS Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.
Collapse
Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
| |
Collapse
|
126
|
Apolinario D, Yamaguti STF, Dutra AF, Lara EMDS, Coli RDCP, Weber B. Programa Hospital Seguro para a Pessoa Idosa: estudo observacional do impacto na redução de declínio funcional. CAD SAUDE PUBLICA 2022. [DOI: 10.1590/0102-311x00305620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ao ser hospitalizado, o idoso apresenta maior risco de complicações e declínio funcional. O presente estudo avaliou os resultados do Programa Hospital Seguro para a Pessoa Idosa. A intervenção foi realizada em um hospital filantrópico da cidade de São Paulo, Brasil, por meio de uma estratégia de implantação estruturada em 10 passos, incluindo rastreio de fragilidade, avaliação multidimensional, plano terapêutico singular, implementação de protocolos e estratégias de gestão de alta. Foram analisadas ao longo de dois anos 865 internações de idosos frágeis. Indicadores de processo e de resultado foram comparados entre o primeiro ano (período de implementação) e o segundo ano (período de consolidação). A comparação dos indicadores entre os dois períodos revelou que o programa melhorou os processos assistenciais fundamentais na qualidade do cuidado para essa população, incluindo reabilitação motora iniciada nas primeiras 72 horas (74,1 vs. 84,3%; p < 0,001), triagem de risco de broncoaspiração (38,5 vs. 82,8%; p < 0,001) e suplementação nutricional oral (55,6 vs. 76,4%; p < 0,001). A taxa de declínio funcional, que era 17,2% no ano de implantação, caiu para 11,7% no ano de consolidação, com diferença significativa após ajuste em modelo multivariável (p = 0,009). Em conclusão, desenvolvemos um programa factível para a realidade dos hospitais brasileiros e que pode ser reproduzido em outros centros usando-se uma metodologia sistematizada de implantação. Os resultados relativos aos indicadores de processos assistenciais e desfechos clínicos parecem promissores. A disseminação dessa iniciativa deve ser considerada no planejamento das políticas de saúde pública para a rede hospitalar.
Collapse
|
127
|
Chou ST, Pogach M, Rock LK. Less pharmacotherapy is more in delirium. Intensive Care Med 2022; 48:743-745. [PMID: 35487973 PMCID: PMC9054501 DOI: 10.1007/s00134-022-06707-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/16/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Shinn-Te Chou
- Lahey Hospital and Medical Center, Burlington, MA USA
| | - Melanie Pogach
- St. Elizabeth’s Medical Center, Brighton, MA USA ,Tufts University School of Medicine, Boston, MA USA
| | - Laura K. Rock
- Harvard Medical School, Boston, MA USA ,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, KSB23, Boston, MA 02118 USA ,15 Borland Street, Brookline, MA 02446 USA
| |
Collapse
|
128
|
Assis LDO, Pinto ACDS, Moraes END, Cintra MTG, Bicalho MAC. HospitalElder Life Program na unidade de urgência e emergência de um hospital público universitário: um programa de intervenção multicomponente para prevenção de delirium. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoao232830641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo Avaliar a viabilidade da implementação de uma adaptação do Hospital Elder Life Program (HELP) com a participação de cuidadores familiares em hospital público universitário. Método Estudo piloto descritivo exploratório desenvolvido com 30 pacientes internados e seus cuidadores. Os Formulários de Registro foram aplicados para identificar fatores de risco para delirium, selecionar protocolos de intervenção e acompanhar a implementação. Nível de satisfação dos participantes e barreiras para implementar o programa foram avaliados por meio de entrevistas qualitativas. Resultados secundários foram coletados dos prontuários médicos. Análise estatística descritiva foi realizada para caracterizar a amostra e análise de conteúdo foi usada para analisar dados qualitativos. Resultados A maioria dos pacientes era do sexo feminino (60%), com idade média de 74,3 anos, ensino fundamental incompleto (60%), viúvo/divorciado (56,7%) e morava com familiares (83,3%) em casa (93,3%). Haviam sido hospitalizados 56,7% no último ano e 93,3% tinham pelo menos um fator de risco para delirium. Assistência alimentar e reposição de líquidos foi o protocolo com maior adesão (96,2%) e orientação (76,5%) com menor. Os participantes ficaram satisfeitos e acreditam que o HELP contribuiu para melhorar os resultados dos pacientes. Os motivos para não realização da intervenção proposta estavam relacionados à estrutura ou organização hospitalar, ao paciente e ao acompanhante. Conclusão Nossos resultados sugerem que ter membros da família atuando como “voluntários” é uma estratégia viável para implementar o HELP. Essa estratégia pode promover sua implementação em hospitais públicos de países de baixa e média renda.
Collapse
|
129
|
Daly RM, Iuliano S, Fyfe JJ, Scott D, Kirk B, Thompson MQ, Dent E, Fetterplace K, Wright ORL, Lynch GS, Zanker J, Yu S, Kurrle S, Visvanathan R, Maier AB. Screening, Diagnosis and Management of Sarcopenia and Frailty in Hospitalized Older Adults: Recommendations from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group. J Nutr Health Aging 2022; 26:637-651. [PMID: 35718874 DOI: 10.1007/s12603-022-1801-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sarcopenia and frailty are highly prevalent conditions in older hospitalized patients, which are associated with a myriad of adverse clinical outcomes. This paper, prepared by a multidisciplinary expert working group from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR), provides an up-to-date overview of current evidence and recommendations based on a narrative review of the literature for the screening, diagnosis, and management of sarcopenia and frailty in older patients within the hospital setting. It also includes suggestions on potential pathways to implement change to encourage widespread adoption of these evidence-informed recommendations within hospital settings. The expert working group concluded there was insufficient evidence to support any specific screening tool for sarcopenia and recommends an assessment of probable sarcopenia/sarcopenia using established criteria for all older (≥65 years) hospitalized patients or in younger patients with conditions (e.g., comorbidities) that may increase their risk of sarcopenia. Diagnosis of probable sarcopenia should be based on an assessment of low muscle strength (grip strength or five times sit-to-stand) with sarcopenia diagnosis including low muscle mass quantified from dual energy X-ray absorptiometry, bioelectrical impedance analysis or in the absence of diagnostic devices, calf circumference as a proxy measure. Severe sarcopenia is represented by the addition of impaired physical performance (slow gait speed). All patients with probable sarcopenia or sarcopenia should be investigated for causes (e.g., chronic/acute disease or malnutrition), and treated accordingly. For frailty, it is recommended that all hospitalized patients aged 70 years and older be screened using a validated tool [Clinical Frailty Scale (CFS), Hospital Frailty Risk Score, the FRAIL scale or the Frailty Index]. Patients screened as positive for frailty should undergo further clinical assessment using the Frailty Phenotype, Frailty Index or information collected from a Comprehensive Geriatric Assessment (CGA). All patients identified as frail should receive follow up by a health practitioner(s) for an individualized care plan. To treat older hospitalized patients with probable sarcopenia, sarcopenia, or frailty, it is recommended that a structured and supervised multi-component exercise program incorporating elements of resistance (muscle strengthening), challenging balance, and functional mobility training be prescribed as early as possible combined with nutritional support to optimize energy and protein intake and correct any deficiencies. There is insufficient evidence to recommend pharmacological agents for the treatment of sarcopenia or frailty. Finally, to facilitate integration of these recommendations into hospital settings organization-wide approaches are needed, with the Spread and Sustain framework recommended to facilitate organizational culture change, with the help of 'champions' to drive these changes. A multidisciplinary team approach incorporating awareness and education initiatives for healthcare professionals is recommended to ensure that screening, diagnosis and management approaches for sarcopenia and frailty are embedded and sustained within hospital settings. Finally, patients and caregivers' education should be integrated into the care pathway to facilitate adherence to prescribed management approaches for sarcopenia and frailty.
Collapse
Affiliation(s)
- R M Daly
- Professor Robin M. Daly, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, Melbourne, Victoria, Australia 3125, Phone: +61 3 9244 6040, , ORCID ID: 0000-0002-9897-1598
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
130
|
Hernandez-Torres C, Korc-Grodzicki B, Hsu T. Models of clinical care delivery for geriatric oncology in Canada and the United States: A survey of geriatric oncology care providers. J Geriatr Oncol 2022; 13:447-453. [DOI: 10.1016/j.jgo.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/19/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
|
131
|
Assis LDO, Pinto ACDS, Moraes END, Cintra MTG, Bicalho MAC. Modified Hospital Elder Life Program in the emergency department of a public university hospital: a multicomponent intervention program for preventing delirium. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoao232830642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective To evaluate the feasibility of implementing an adaptation of the Hospital Elder Life Program (HELP) with the participation of family caregivers in a public university hospital. Method Descriptive exploratory pilot study developed with 30 hospitalized patients and their caregivers. Registration Forms were applied to identify risk factors for delirium, to select intervention protocols, and track implementation. Participants' level of satisfaction and barriers to implementing the program were assessed through qualitative interviews. Secondary results were collected from medical records. Descriptive statistical analysis was performed to characterize the sample and content analysis was used to analyze qualitative data. Results Most patients were female (60%), with a mean age of 74.3 years, incomplete elementary school (60%), widowed/divorced (56.7%) and living with family members (83.3%) at home (93.3%). 56.7% had been hospitalized in the last year and 93.3% had at least one risk factor for delirium. Food assistance and fluid replacement was the protocol with the highest adherence (96.2%) and guidance (76.5%) with the lowest. Participants were satisfied and believe that HELP contributed to improving patient outcomes. The reasons for not performing the proposed intervention were related to the hospital structure or organization, the patient and the companion. Conclusion Our results suggest that having family members act as “volunteers” is a viable strategy to implement HELP. This strategy can promote its implementation in public hospitals in low and middle-income countries.
Collapse
|
132
|
O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
Collapse
Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| |
Collapse
|
133
|
Wray F, Coleman S, Clarke D, Hudson K, Forster A, Teale E. Risk factors for manifestations of frailty in hospitalized older adults: A qualitative study. J Adv Nurs 2021; 78:1688-1703. [PMID: 34850424 PMCID: PMC9299686 DOI: 10.1111/jan.15120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/02/2021] [Accepted: 11/10/2021] [Indexed: 01/03/2023]
Abstract
Aims To explore the experiences of older people and ward staff to identify modifiable factors (risk factors) which have the potential to reduce development or exacerbation of manifestations of frailty during hospitalization. To develop a theoretical framework of modifiable risk factors. Design Qualitative descriptive study. Methods Qualitative interviews with recently discharged older people (n = 18) and focus groups with ward staff (n = 22) were undertaken between July and October 2019. Data were analysed using directed content analysis. Results Themes identified related to attitude to risk, communication and, loss of routine, stimulation and confidence. Using findings from this study and previously identified literature, we developed a theoretical framework including 67 modifiable risk factors. Risk factors are grouped by patient risk factor domains (pain, medication, nutritional/fluid intake, mobility, elimination, infection, additional patient risk factors) and linked care management sub‐domains (including risk factors relating to the ward environment, process of care, ward culture or broader organizational set up). Many of the additional 36 risk factors identified by this study were related to care management sub‐domains. Conclusion A co‐ordinated approach is needed to address modifiable risk factors which lead to the development or exacerbation of manifestations of frailty in hospitalized older people. Risk assessment and management practices should not be duplicative and, should recognize and address modifiable risk factors which occur at the ward and organizational level. Impact Some older people leave hospital more dependent than when they come in and this is, in part, due to the environment and process of care and not just the severity of their presenting illness. Many of the risk factors identified need to be addressed at an organizational rather than individual level. Findings will inform a programme of research to develop and test a novel system of care aimed at preventing loss of independence in hospitalized older people.
Collapse
Affiliation(s)
- Faye Wray
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - David Clarke
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kristian Hudson
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anne Forster
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Elizabeth Teale
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| |
Collapse
|
134
|
Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 11:CD013307. [PMID: 34826144 PMCID: PMC8623130 DOI: 10.1002/14651858.cd013307.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
Collapse
Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
135
|
Leinert C, Brefka S, Braisch U, Denninger N, Mueller M, Benzinger P, Bauer J, Bahrmann A, Frey N, Katus HA, Geisler T, Eschweiler G, Klaus J, Seufferlein T, Schuetze K, Gebhard F, Dreyhaupt J, Muche R, Pahmeier K, Biermann-Stallwitz J, Wasem J, Flagmeier L, Dallmeier D, Denkinger M. A complex intervention to promote prevention of delirium in older adults by targeting caregiver's participation during and after hospital discharge - study protocol of the TRAnsport and DElirium in older people (TRADE) project. BMC Geriatr 2021; 21:646. [PMID: 34784883 PMCID: PMC8594294 DOI: 10.1186/s12877-021-02585-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022] Open
Abstract
Background Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults. Methods The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days. Discussion TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study. Trial registration DRKS (Deutsches Register für klinische Studien) DRKS00017828. Registered on 17th September 2019. Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02585-0.
Collapse
Affiliation(s)
- Christoph Leinert
- Agaplesion Bethesda Clinic Ulm, Zollernring 26, 89073, Ulm, Germany. .,Geriatric Center Ulm/ Alb-Donau, Ulm, Germany. .,Institute for Geriatric Research, Ulm University, Ulm, Germany.
| | - Simone Brefka
- Agaplesion Bethesda Clinic Ulm, Zollernring 26, 89073, Ulm, Germany.,Geriatric Center Ulm/ Alb-Donau, Ulm, Germany.,Institute for Geriatric Research, Ulm University, Ulm, Germany
| | - Ulrike Braisch
- Agaplesion Bethesda Clinic Ulm, Zollernring 26, 89073, Ulm, Germany.,Institute for Geriatric Research, Ulm University, Ulm, Germany.,Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Natascha Denninger
- Center for Research, Development and Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany.,International Graduate Academy, Institute for Health and Nursing Science, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Martin Mueller
- Faculty of Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
| | - Petra Benzinger
- Center for Geriatric Medicine, Agaplesion Bethanien Krankenhaus Heidelberg, Heidelberg University, Heidelberg, Germany.,Institute of Health and Generations, Faculty of Social and Health Studies, University of Applied Sciences Kempten, Kempten, Germany
| | - Juergen Bauer
- Center for Geriatric Medicine, Agaplesion Bethanien Krankenhaus Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Anke Bahrmann
- Department of Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Tobias Geisler
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Gerhard Eschweiler
- Geriatric Center at the University Hospital Tuebingen, Tuebingen, Germany
| | - Jochen Klaus
- Department of Medicine I, University Hospital Ulm, Ulm, Germany
| | | | - Konrad Schuetze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Kathrin Pahmeier
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | | | - Juergen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Lena Flagmeier
- AOK - Allgemeine Ortskrankenkasse Baden-Wuerttemberg, Stuttgart, Germany
| | - Dhayana Dallmeier
- Agaplesion Bethesda Clinic Ulm, Zollernring 26, 89073, Ulm, Germany.,Geriatric Center Ulm/ Alb-Donau, Ulm, Germany.,Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Zollernring 26, 89073, Ulm, Germany.,Geriatric Center Ulm/ Alb-Donau, Ulm, Germany.,Institute for Geriatric Research, Ulm University, Ulm, Germany
| |
Collapse
|
136
|
Vaughan CP, Hwang U, Vandenberg AE, Leong T, Wu D, Stevens MB, Clevenger C, Eucker S, Genes N, Huang W, Ikpe-Ekpo E, Nassisi D, Previl L, Rodriguez S, Sanon M, Schlientz D, Vigliotti D, Hastings SN. Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. BMJ Open Qual 2021; 10:bmjoq-2021-001369. [PMID: 34750188 PMCID: PMC8576471 DOI: 10.1136/bmjoq-2021-001369] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022] Open
Abstract
Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme. EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution. The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%–12% postimplementation, although not all reached statistical significance. EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.
Collapse
Affiliation(s)
- Camille P Vaughan
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA .,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Ula Hwang
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Ann E Vandenberg
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Traci Leong
- Biostatistics and Bioinformatics, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Daniel Wu
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Melissa B Stevens
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA.,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | | | - Stephanie Eucker
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Nick Genes
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wennie Huang
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Edidiong Ikpe-Ekpo
- Emergency Medicine, The Southeast Permanente Medical Group, Atlanta, Georgia, USA
| | - Denise Nassisi
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Previl
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Sandra Rodriguez
- Columbia University School of Social Work, New York, New York, USA
| | - Martine Sanon
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Schlientz
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | | | - S Nicole Hastings
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA.,Centre of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| |
Collapse
|
137
|
Mcswain JR, Sirianni JM, Wilson SH. Perioperative Considerations for Patients with a Known Diagnosis of Dementia. Adv Anesth 2021; 39:113-132. [PMID: 34715970 DOI: 10.1016/j.aan.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julie R Mcswain
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Suite 4200 MSC 240, Charleston, SC 29425, USA.
| | - Joel M Sirianni
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301 MSC 912, Charleston, SC, USA
| | - Sylvia H Wilson
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301 MSC 912, Charleston, SC, USA
| |
Collapse
|
138
|
Abstract
Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.
Collapse
Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Mount Sinai Medical Center, New York, New York
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
139
|
Kappen P, Jeekel J, Dirven CMF, Klimek M, Kushner SA, Osse RJ, Coesmans M, Poley MJ, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial. BMJ Open 2021; 11:e048270. [PMID: 34598983 PMCID: PMC8488750 DOI: 10.1136/bmjopen-2020-048270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Delirium is a neurocognitive disorder characterised by an acute and temporary decline of mental status affecting attention, awareness, cognition, language and visuospatial ability. The underlying pathophysiology is driven by neuroinflammation and cellular oxidative stress.Delirium is a serious complication following neurosurgical procedures with a reported incidence varying between 4% and 44% and has been associated with increased length of hospital stay, increased amount of reoperations, increased costs and mortality.Perioperative music has been reported to reduce preoperative anxiety, postoperative pain and opioid usage, and attenuates stress response caused by surgery. We hypothesize that this beneficial effect of music on a combination of delirium eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. METHODS This protocol concerns a single-centred prospective randomised controlled trial with 6 months follow-up. All adult patients undergoing a craniotomy at the Erasmus Medical Center in Rotterdam are eligible. The music group will receive recorded music through an overear headphone before, during and after surgery until postoperative day 3. Patients can choose from music playlists, offered based on music importance questionnaires administered at baseline. The control group will receive standard of clinical careDelirium is assessed by the Delirium Observation Scale and confirmed by a delirium-expert psychiatrist according to the DSM-5 criteria. Risk factors correlated with the onset of delirium, such as cognitive function at baseline, preoperative anxiety, perioperative medication use, depth of anaesthesia and postoperative pain, and delirium-related health outcomes such as length of stay, daily function, quality of life (ie, EQ-5D, EORTC questionnaires), costs and cost-effectiveness are collected. ETHICS AND DISSEMINATION This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Center Rotterdam, The Netherlands, approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBERS NL8503 and NCT04649450.
Collapse
Affiliation(s)
- Pablo Kappen
- Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Neuroscience, Erasmus MC, Rotterdam, The Netherlands
- Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Klimek
- Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
- Medical Technology Assessment (iMTA), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| | | |
Collapse
|
140
|
Hong H, Zhang DZ, Li M, Wang G, Zhu SN, Zhang Y, Wang DX, Sessler DI. Impact of dexmedetomidine supplemented analgesia on delirium in patients recovering from orthopedic surgery: A randomized controlled trial. BMC Anesthesiol 2021; 21:223. [PMID: 34517840 PMCID: PMC8435562 DOI: 10.1186/s12871-021-01441-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/28/2021] [Indexed: 12/19/2022] Open
Abstract
Background Dexmedetomidine promotes normal sleep architecture; the drug also improves analgesia. We therefore tested the hypothesis that supplementing intravenous analgesia with dexmedetomidine reduces delirium in older patients recovering from orthopedic surgery. Methods In this double-blinded randomized controlled trial, we enrolled 712 older (aged 65–90 years) patients scheduled for major orthopedic surgery. Postoperative analgesia was provided by patient-controlled intravenous sufentanil, supplemented by randomly assigned dexmedetomidine (1.25 μg/mL) or placebo, for up to three days. The primary outcome was the incidence of delirium assessed twice daily with the Confusion Assessment Method. Among secondary outcomes, pain severity was assessed twice daily and sleep quality once daily, each with an 11-point scale where 0 = no pain/the best possible sleep and 10 = the worst pain/the worst possible sleep. Results The incidence of postoperative delirium was 7.3% (26 of 354) with placebo and 4.8% (17 of 356) with dexmedetomidine; relative risk 0.65, 95% CI 0.36 to 1.18; P = 0.151. Dexmedetomidine reduced pain both at rest (median difference -1 to 0 points, P ≤ 0.001) and with movement (-1 points, P < 0.001) throughout the first 5 postoperative days; it also improved subjective sleep quality during the first 3 postoperative days: day one median difference -1 point (95% CI -1 to 0), P = 0.007; day two 0 point (-1 to 0), P = 0.010; and day three 0 point (-1 to 0), P = 0.003. The incidence of adverse events was similar in each group. Conclusions Supplementing sufentanil intravenous analgesia with low-dose dexmedetomidine did not significantly reduce delirium, but improved analgesia and sleep quality without provoking adverse events. Trial registration
www.chictr.org.cn: ChiCTR1800017182 (Date of registration: July 17, 2018); ClinicalTrials.gov:NCT03629262 (Date of registration: August 14, 2018). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01441-3.
Collapse
Affiliation(s)
- Hong Hong
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Da-Zhi Zhang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Mo Li
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Peking University Clinical Research Institute, Shenzhen, China
| | - Dong-Xin Wang
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China. .,Outcomes Research Consortium, Cleveland, OH, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
141
|
Abstract
ABSTRACT Injurious falls remain among the most common, dangerous, and costly adverse events in hospitals, despite the widespread implementation of fall prevention programs. Many current health care system policies and nursing practices oversimplify fall prevention by focusing on limiting the person's mobility and making the environment safer, or simply documenting a fall risk score. But most falls are caused by factors intrinsic to that individual; merely limiting their mobility can increase preventable hospital complications and readmissions, and still leaves them at risk for falls. This article proposes a new approach to reducing injurious falls in older adults-one grounded in evidence-based protocols known to positively impact the health of older adults. The approach, called by the acronym ERA-Electronic health record integration, Risk factors that matter, Assessment and care plans-allows nurses to use a validated fall risk assessment tool to reframe fall risk factors as part of the comprehensive care plan, and to map modifiable risk factors to interventions that address the underlying causes of falls and promote safer mobility. The ERA approach can help nurses use their time more effectively by focusing on targeted actions that improve patient outcomes, working in coordination with an interprofessional, cross-continuum care team.
Collapse
Affiliation(s)
- Ann L Hendrich
- Ann L. Hendrich is the builder of the Hendrich II Fall Risk Model and a trustee of AHI of Indiana, Inc., St. Louis. She was a founding cochair of the Age-Friendly Health Systems initiative and currently serves as an adviser, mentors fellowship recipients of the American Hospital Association (AHA), and often speaks at national clinical and patient safety and AHA meetings. The author has received speaking honoraria from the New Jersey Hospital Association, The John A. Hartford Foundation, and the AHA. She receives a percentage of consultant fees from AHI. The author acknowledges Susan Duhig, PhD, for assistance with manuscript development. Contact author: . The author and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com
| |
Collapse
|
142
|
Ghezzi ES, Psaltis PJ, Loetscher T, Davis D, Montarello J, Lau JK, Delacroix S, Bourke A, McLoughlin J, Keage M, Keage HAD. Identifying New Factors Associated With Cognitive Decline and Delirium After Transcatheter Aortic Valve Implantation: A Study Protocol. Front Cardiovasc Med 2021; 8:657057. [PMID: 34458327 PMCID: PMC8385234 DOI: 10.3389/fcvm.2021.657057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Transcatheter aortic valve implantation (TAVI) has become the standard-of-care for treatment of severe symptomatic aortic stenosis and is also being increasingly recommended for low-risk patients. While TAVI boasts positive post-procedural outcomes, it is also associated with cognitive complications, namely delirium and cognitive decline. There is a pressing need for accurate risk tools which can identify TAVI patients at risk of delirium and cognitive decline, as risk scores designed for general cardiovascular surgery fall short. The present effect-finding exploratory study will assess the utility of various measures in the context of aging and frailty in predicting who will and who will not develop delirium or cognitive impairment following TAVI. The measures we propose include gait, visual symptoms, voice, swallowing, mood and sleep. Methods: This is an observational prospective cohort study focused on identifying pre-procedural risk factors for the development of delirium and cognitive decline following TAVI. Potential risk factors will be measured prior to TAVI. Primary outcomes will be post-procedure cognitive decline and delirium. Secondary outcomes include activities of daily living, quality of life, and mortality. Delirium presence will be measured on each of the first 2 days following TAVI. All other outcomes will be assessed at 3-, 6-, and 12-months post-operatively. A series of logistic regressions will be run to investigate the relationship between potential predictors and outcomes (presence vs. absence of either delirium or cognitive decline). Discussion: This study will assess the strengths of associations between a range of measures drawn from frailty and aging literature in terms of association with cognitive decline and delirium following TAVI. Identified measures can be used in future development of TAVI risk prediction models, which are essential for the accurate identification of cognitive at-risk patients and successful application of pre-procedural interventions. Clinical Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry. [https://bit.ly/2PAotP5], [ACTRN12618001114235].
Collapse
Affiliation(s)
- Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, SA, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide University Medical School, University of Adelaide, Adelaide, SA, Australia.,Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Tobias Loetscher
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, SA, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at UCL, London, United Kingdom
| | - Joseph Montarello
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jerrett K Lau
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Sinny Delacroix
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Alice Bourke
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - James McLoughlin
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Megan Keage
- Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, VIC, Australia.,Department of Audiology and Speech Pathology, The University of Melbourne, Melbourne, VIC, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, SA, Australia
| |
Collapse
|
143
|
Nilsson U, Bergman L. "Never the Same" After Surgery: Postoperative Delirium and Early Postoperative Cognitive Decline. J Perianesth Nurs 2021; 36:321-322. [PMID: 34112368 DOI: 10.1016/j.jopan.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Ulrica Nilsson
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Lina Bergman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
144
|
Enhanced Recovery After Surgery in Older Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Dis Colon Rectum 2021; 64:1020-1028. [PMID: 34214055 DOI: 10.1097/dcr.0000000000002128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhanced recovery after surgery is increasingly applied in older adults undergoing colorectal surgery. OBJECTIVE This systematic review and meta-analysis evaluated the impact of enhanced recovery protocols on clinical outcomes including hospital-acquired geriatric syndromes in older adults undergoing colorectal surgery. DATA SOURCES This review was conducted according to PRISMA guidelines. Ovid MEDLINE, Embase, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched (January 1980 to April 2020). STUDY SELECTION Two researchers independently screened all articles for eligibility. Randomized controlled trials evaluating enhanced recovery protocols in older adults undergoing colorectal surgery were included. INTERVENTION The enhanced recovery protocol was utilized. MAIN OUTCOME MEASURES Primary outcomes of interest were functional decline and delirium. Other outcomes studied were length of stay, complications, readmission, mortality, gut function, mobilization, pain, reoperation, quality of life, and psychological status. RESULTS Seven randomized trials (n = 1277 participants) were included. In terms of hospital-acquired geriatric syndromes, functional decline was reported in 1 study with benefits reported in enhanced recovery after surgery participants, and meta-analyses showed reduced incidence of delirium (risk ratio, 0.45; 95% CI, 0.21-0.98). Meta-analyses also showed reduction in urinary tract infections (risk ratio, 0.53; 95% CI, 0.31-0.90), time to first flatus (standardized mean differences, -1.00; 95% CI, -1.98 to -0.02), time to first stool (standardized mean differences, -0.59; 95% CI, -0.76 to -0.42), time to mobilize postoperatively (standardized mean differences, -0.92; 95% CI, -1.27 to -0.58), time to achieve pain control (standardized mean differences, -0.59; 95% CI, -0.90 to -0.28), and hospital stay (mean differences, -2.20; 95% CI, -3.46 to -0.94). LIMITATIONS The small number of randomized trials in older adults is a limitation of this study. CONCLUSIONS Enhanced recovery protocols in older adults undergoing colorectal surgery appear to reduce the incidence of delirium and functional decline, 2 important hospital-acquired geriatric syndromes, as well as to improve other clinical outcomes. Future research should measure these geriatric syndromes and focus on high-risk older adults including those with frailty.
Collapse
|
145
|
Howlett SE, Rutenberg AD, Rockwood K. The degree of frailty as a translational measure of health in aging. NATURE AGING 2021; 1:651-665. [PMID: 37117769 DOI: 10.1038/s43587-021-00099-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 07/06/2021] [Indexed: 04/30/2023]
Abstract
Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.
Collapse
Affiliation(s)
- Susan E Howlett
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew D Rutenberg
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada.
| |
Collapse
|
146
|
Burton JK, Craig LE, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 7:CD013307. [PMID: 34280303 PMCID: PMC8407051 DOI: 10.1002/14651858.cd013307.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
Collapse
Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise E Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
147
|
Hollmann P. Targeting Delirium Risk Factors During a Pandemic: AGS CoCare ®: HELP ® in the Era of COVID-19 and Beyond. J Gerontol Nurs 2021; 47:51-52. [PMID: 34191649 DOI: 10.3928/00989134-20210604-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
148
|
Norcott AE, Min LC, Bynum JPW. Preoperative Cognitive Evaluations: An Opportunity to Protect the Vulnerable Brain. Ann Surg 2021; 274:e85-e87. [PMID: 33156058 PMCID: PMC10653644 DOI: 10.1097/sla.0000000000004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Alexandra E Norcott
- Department of Internal Medicine, Division of Geriatric Research, Education, and Clinical Centers (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
| | - Lillian C Min
- Department of Internal Medicine, Division of Geriatric Research, Education, and Clinical Centers (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
| | - Julie P W Bynum
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine: University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
149
|
Oliven R, Rotfeld M, Gino-Moor S, Schiff E, Odeh M, Gil E. Early Detection and Intervention for Patients with Delirium Admitted to the Department of Internal Medicine: Lessons from a Pilot Initiative. Dement Geriatr Cogn Dis Extra 2021; 11:134-139. [PMID: 34178018 PMCID: PMC8215981 DOI: 10.1159/000515958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Older patients who arrive to the emergency room with delirium have a worse prognosis than others. Early detection and treatment of this problem has been shown to improve outcome. We have launched a project at our hospital to improve the care of patients who arrive delirious to the medical emergency room. The present article describes lessons that can be learned from this pilot initiative. Methods All patients older than 70 years admitted to the department of internal medicine were screened for delirium in the emergency room using the 4AT screening tool. Data of patients with a 4AT score ≥5 (or with incomplete score) were transferred to the geriatric unit of the hospital. On the ward, the presence of delirium was confirmed by a geriatric nurse that validated that the patient could walk with support and ordered mobilization and physiotherapy (M&P). Results Over the 2 and a half years (10 quarters) allocated for the pilot project, 1,078 medical patients with delirium were included in this survey. In 59.3%, the diagnosis of delirium could be confirmed only after admission. Due to budgetary constraints, only 54.7% received the allocated specific intervention − early M&P. Since it was decided that randomization was not appropriate for our initiative, we found that patients who received M&P had lower (better) 4AT scores on admission, and lower mortality. No significant difference was found between the patients who received M&P and the others in length of hospitalization and discharge to nursing homes. Retrospective comparison of the two groups did not enable to determine whether M&P was given to the patients for whom it was most effective. Conclusions It is often not possible to verify in the emergency room that the cognitive decline is indeed new, that is, is due to delirium, and measures must be taken to verify this point as soon as possible after admission. Due to numerous constraints, the availability of early M&P is often insufficient. Whenever resources are scarce and randomization is avoided, adequate criteria should be found for allocating existing dedicated staff to patients for whom early mobilization is likely to be most beneficial.
Collapse
Affiliation(s)
- Ron Oliven
- Geriatric Unit, Bnai Zion Medical Center, Haifa, Israel.,Department of Medicine, Bnai Zion Medical Center, Haifa, Israel.,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | | | - Sharon Gino-Moor
- Department of Medicine, Bnai Zion Medical Center, Haifa, Israel.,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Elad Schiff
- Department of Medicine, Bnai Zion Medical Center, Haifa, Israel.,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Majed Odeh
- Department of Medicine, Bnai Zion Medical Center, Haifa, Israel.,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Efrat Gil
- Geriatric Service, Clalit Health Services, Haifa and West Galilee, Haifa, Israel.,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| |
Collapse
|
150
|
Kakiuchi S, Burger K, Lo SHY. Improving Delirium Care in Hospitalized Older Adults: Impact of Education on Hospital Aides as Sitters. J Gerontol Nurs 2021; 47:20-26. [PMID: 34044684 DOI: 10.3928/00989134-20210507-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
As one of several hospital team members involved in the management of care for older adults with delirium, hospital aides (HAs) are often relied on to provide direct patient care in the role of a sitter. Yet, many HAs have not received training about delirium, its associated behaviors, or appropriate interventions. As a consequence, there are gaps in quality of care for older adults with delirium and potential missed opportunities for HA sitters to contribute to the interdisciplinary team (IDT) care of these patients. In the current study, a quality improvement project at an urban hospital provided an educational session on delirium to HAs. Accuracy of HA delirium knowledge, delirium behavior recognition, and delivery of care to patients with delirium significantly increased across three postintervention measures (p = <0.001 to 0.016). HAs also reported increased confidence in caring for patients with delirium and in their perceived role on the IDT. [Journal of Gerontological Nursing, 47(6), 20-26.].
Collapse
|