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Bergjan M, Zilezinski M, Schwalbach T, Franke C, Erdur H, Audebert HJ, Hauß A. Validation of two nurse-based screening tools for delirium in elderly patients in general medical wards. BMC Nurs 2020; 19:72. [PMID: 32760215 PMCID: PMC7393733 DOI: 10.1186/s12912-020-00464-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/23/2020] [Indexed: 01/24/2023] Open
Abstract
Background Delirium is an acute disturbance characterized by fluctuating symptoms related to attention, awareness and recognition. Especially for elderly patients, delirium is frequently associated with high hospital costs and resource consumption, worse functional deterioration and increased mortality rates. Early recognition of risk factors and delirium symptoms enables medical staff to prevent or treat negative effects. Most studies examining screening instruments for delirium were conducted in intensive care units and surgical wards, and rarely in general medical wards. The aim of the study is to validate the Nursing Delirium Screening Scale (Nu-DESC) and the Delirium Observation Screening Scale (DOS) in general medical wards in a German tertiary care hospital, considering predisposing delirium risk factors in patients aged 65 and older. Methods The prospective observational study including 698 patients was conducted between May and August 2018 in two neurological and one cardiology ward. During their shifts, trained nurses assessed all patients aged 65 or older for delirium symptoms using the Nu-DESC and the DOS. Delirium was diagnosed according to the DSM-5 criteria by neurologists. Patient characteristics and predisposing risk factors were obtained from the digital patient management system. Descriptive and bivariate statistics were computed. Results The study determined an overall delirium occurrence rate of 9.0%. Regarding the DOS, sensitivity was 0.94, specificity 0.86, PPV 0.40 NPV 0.99 and regarding the Nu-DESC, sensitivity was 0.98, specificity 0.87, PPV 0.43, NPV 1.00. Several predisposing risk factors increased the probability of delirium: pressure ulcer risk OR: 17.3; falls risk OR: 14.0; immobility OR: 12.7; dementia OR: 5.38. Conclusions Both screening instruments provided high accuracy for delirium detection in general medical wards. The Nu-DESC proved to be an efficient delirium screening tool that can be integrated into routine patient care. According to the study results, pressure ulcer risk, falls risk, and immobility were risk factors triggering delirium in most cases. Impaired mobility, as common risk factor of the before mentioned risks, is well known to be preventable through physical activity programmes.
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Affiliation(s)
- Manuela Bergjan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany
| | - Max Zilezinski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health ,Business Division Nursing Directorate - Nursing Science, Core-Team III Delirium Management and Dementia Care, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Torsten Schwalbach
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health ,Business Division Nursing Directorate - Nursing Science, Core-Team III Delirium Management and Dementia Care, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Christiana Franke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Neurology with Experimental Neurology Campus Benjamin Franklin (CBF), Charité - Universitaetsmedizin Berlin, Hindenburgdamm 30, Berlin, 12200 Germany
| | - Hebun Erdur
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Neurology with Experimental Neurology Campus Benjamin Franklin (CBF), Charité - Universitaetsmedizin Berlin, Hindenburgdamm 30, Berlin, 12200 Germany
| | - Heinrich Jakob Audebert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Neurology with Experimental Neurology Campus Benjamin Franklin (CBF), Charité - Universitaetsmedizin Berlin, Hindenburgdamm 30, Berlin, 12200 Germany
| | - Armin Hauß
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Business Division Nursing Directorate - Nursing Science, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, Berlin, 10117 Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health ,Business Division Nursing Directorate - Nursing Science, Core-Team III Delirium Management and Dementia Care, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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102
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Hayashi A, Kobayashi S, Matsui K, Akaho R, Nishimura K. The accuracy of delirium assessment by cardiologists treating heart failure inpatients: a single center retrospective survey. Biopsychosoc Med 2020; 14:15. [PMID: 32760437 PMCID: PMC7392711 DOI: 10.1186/s13030-020-00188-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023] Open
Abstract
Background Patients with heart failure (HF) accompanied by delirium are at risk of rehospitalization and death, thus early detection and appropriate treatment is imperative. Palliative care for patients with HF is an important issue, particularly for patients who also have delirium. This retrospective study examined the accuracy of delirium assessment by cardiologists treating patients with HF, identified factors related to the detection of delirium, and recorded the initial treatment. Methods This was a retrospective chart survey of 165 patients with HF referred to a consultation liaison (C-L) service during treatment in the cardiology wards of a general hospital over a 6-year period. Diagnosis of delirium by the C-L psychiatrists was based on DSM-IV-TR. Cases in which cardiologists had stated “delirium” in the medical records were classified as an accurate assessment of delirium (Agreement group). Cases in which cardiologists did not state “delirium” were classified as Disagreement. Results Among 81 patients with delirium (51 [62.9%] male; 74.7 ± 13.3 years old), the ratio of accurate assessment of delirium by cardiologists was 50.6% (n = 41; Agreement group). Age, sex, and HF severity did not differ significantly between the two groups. Although disquietedness was identified most frequently (n = 59, 73%), only 33 of these 59 patients (55.9%) were recognized as having delirium by cardiologists. Inappropriate initial treatments were only noted in the Disagreement group. In both groups, most cases were referred to a C-L service without new medication for psychiatric symptoms. Conclusions An accurate assessment of the delirium of inpatients with HF by cardiologists was found in only around half of all cases. Accurate detection is important to avoid harmful drug administration and to provide appropriate palliative care.
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Affiliation(s)
- Anna Hayashi
- Department of Psychiatry, Tokyo Women's Medical University, 8-1, Kawada-cho 8-1, Shinjuku-ku, Tokyo, Japan
| | - Sayaka Kobayashi
- Department of Psychiatry, Tokyo Women's Medical University, 8-1, Kawada-cho 8-1, Shinjuku-ku, Tokyo, Japan.,Department of Psychiatry, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kentaro Matsui
- Department of Psychiatry, Tokyo Women's Medical University, 8-1, Kawada-cho 8-1, Shinjuku-ku, Tokyo, Japan.,Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology & Psychiatry, Tokyo, Japan.,Department of Clinical Laboratory, National Institute of Mental Health, National Center of Neurology & Psychiatry, Tokyo, Japan
| | - Rie Akaho
- Department of Psychiatry, Tokyo Women's Medical University, 8-1, Kawada-cho 8-1, Shinjuku-ku, Tokyo, Japan
| | - Katsuji Nishimura
- Department of Psychiatry, Tokyo Women's Medical University, 8-1, Kawada-cho 8-1, Shinjuku-ku, Tokyo, Japan
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Gagnon P, Gaudreau JD, Roy MA, Le Moignan Moreau J. Letter to the Editor: Correction About the Nursing Delirium Screening Scale in Response to: "A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): A New Screening Tool for the Detection of Delirium". PSYCHOSOMATICS 2020; 61:856-857. [PMID: 32654828 DOI: 10.1016/j.psym.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Pierre Gagnon
- Faculty of Medicine, Department of Psychiatry and Neurosciences, Laval University, Quebec City, QC, Canada; Laval University Cancer Research Center, Quebec City, QC, Canada; CHU de Québec - Université Laval Research Center, Oncology Axis, Quebec City, QC, Canada.
| | - Jean-David Gaudreau
- Faculty of Medicine, Department of Psychiatry and Neurosciences, Laval University, Quebec City, QC, Canada
| | - Marc-André Roy
- Faculty of Medicine, Department of Psychiatry and Neurosciences, Laval University, Quebec City, QC, Canada; CERVO Brain Research Center, Quebec City, QC, Canada; Centre intégré universitaire de la santé et des services sociaux de la Capitale-Nationale, Quebec City, QC, Canada
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104
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Rushani D, Tam DY, Fremes SE. Commentary: Finding delirium: It's harder than you think! J Thorac Cardiovasc Surg 2020; 163:737-738. [PMID: 33268118 DOI: 10.1016/j.jtcvs.2020.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Dinela Rushani
- Division of Cardiac Surgery, Schulich Heart Centre, and Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre, and Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, and Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Depner RM, Grant PC, Byrwa DJ, LaFever SM, Kerr CW, Tenzek KE, LaValley S, Luczkiewicz DL, Wright ST, Levy K, AdvStat MSW. Expanding the Understanding of Content of End-of-Life Dreams and Visions: A Consensual Qualitative Research Analysis. Palliat Med Rep 2020; 1:103-110. [PMID: 34223465 PMCID: PMC8241341 DOI: 10.1089/pmr.2020.0037] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Research has established End-of-Life Dreams and Visions (ELDVs) as prevalent, meaningful valid experiences that may help patients cope with illness and approaching death. However, no inductive qualitative analysis has explored the phenomenology of ELDVs from the perspective of hospice homecare patients. Objective: The purpose of this study is to evaluate the content of ELDVs by using a rigorous qualitative approach. Design: Five hundred forty-eight ELDVs were collected from weekly interviews of hospice homecare patients and analyzed by using Consensual Qualitative Research Methodology. Settings/Subject: Participants were enrolled in a county-wide hospice homecare program between January 2013-March 2015. Results: The following domains emerged: (1) Interpersonal, (2) Affective Experience and Reflection, (3) Activities, and (4) Setting/Location. Conclusions: This study suggests that ELDV content may include a broader spectrum of experiences that reflect waking life than previously believed. Clinical implications suggest that it may be important for providers to engage with ELDVs, as they are psychologically significant experiences that may be a source of clinical insight.
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Affiliation(s)
- Rachel M. Depner
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
- Department of Counseling, School and Educational Psychology, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Pei C. Grant
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
| | - David J. Byrwa
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
- Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Sarah M. LaFever
- Behavioral VA Health Care Line (BVAC), VA Western New York Healthcare System, Buffalo, New York, USA
| | - Christopher W. Kerr
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
| | - Kelly E. Tenzek
- Department of Communication, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Susan LaValley
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Debra L. Luczkiewicz
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
| | - Scott T. Wright
- University Counseling Center, University of Rochester, Rochester New York, USA
| | - Kathryn Levy
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
- Department of Counseling, School and Educational Psychology, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
- Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
- Department of Communication, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
- Behavioral VA Health Care Line (BVAC), VA Western New York Healthcare System, Buffalo, New York, USA
- University Counseling Center, University of Rochester, Rochester New York, USA
- Department of Planning and Research, Trocaire College, Buffalo, New York, USA
| | - MSW AdvStat
- Department of Research, Hospice and Palliative Care Buffalo, Cheektowaga, New York, USA
- Department of Planning and Research, Trocaire College, Buffalo, New York, USA
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106
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Lai XB, Huang Z, Chen CY, Stephenson M. Delirium screening in patients in a palliative care ward: a best practice implementation project. ACTA ACUST UNITED AC 2020; 17:429-441. [PMID: 30870333 DOI: 10.11124/jbisrir-2017-003646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objective was to promote evidence-based practice in screening for delirium in patients in the palliative care ward of a cancer hospital in Shanghai. INTRODUCTION Delirium is common but under recognized among patients in palliative care settings. Early detection is essential for timely management. Practice guidelines recommend an initial screening at first contact, followed by continuous screening. METHODS The Joanna Briggs Institute's three-phase Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback tool were used to enhance evidence-based practice. In phase 1, four audit criteria were developed and a baseline audit was conducted. In phase 2, barriers to compliance were identified, and strategies were adopted to promote best practice. In phase 3, a follow-up audit was conducted. RESULTS In the baseline audit, no delirium screening was performed, either on admission or regularly during hospitalization, hence compliance with these two audit criteria was 0%. Two out of 18 nurses had received training in delirium management, however neither had been trained to use the delirium screening tool. Compliance with the two criteria for nurse training was 11% and 0%, respectively. Four barriers were identified, including lack of a standardized screening tool, lack of a standardized screening procedure, inadequate knowledge on the part of the nurses, and potential inconsistencies between nurses in the rating of screening criteria. After applying strategies to address these barriers, compliance with the four audit criteria was 100%, 100%, 72%, and 72%, respectively, in the follow-up audit. CONCLUSIONS Best practice in delirium screening was successfully established in the ward.
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Affiliation(s)
- Xiao Bin Lai
- School of Nursing, Fudan University, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Zhe Huang
- Palliative Care Ward, Fudan University Shanghai Cancer Center, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Chun Yan Chen
- Palliative Care Ward, Fudan University Shanghai Cancer Center, Shanghai, China.,Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence
| | - Matthew Stephenson
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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107
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Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
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Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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108
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Woodhouse R, Siddiqi N, Boland JW, Featherstone I, Johnson MJ. Delirium screening practice in specialist palliative care units: a survey. BMJ Support Palliat Care 2020; 12:187-190. [PMID: 32414788 DOI: 10.1136/bmjspcare-2020-002251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/18/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Delirium is common and distressing in palliative care settings. This survey aims to describe current practice regarding delirium identification in specialist palliative care units (SPCU), such as inpatient hospices, in the UK. METHODS An 18-item anonymous online survey was distributed by Hospice UK to their network of clinical leads (n=223), and to their research mailing list (n=228). The survey was also sent to the chair of the Hospice UK executive clinical leads forum for direct dissemination to forum representatives (n=20). Clinical leads and forum representatives were asked to distribute the survey to healthcare staff in their SPCUs. RESULTS 220 SPCU staff (48% nurses; 31% doctors; 10% healthcare assistants) completed the survey. Approximately half reported using clinical judgement alone to screen (97/204; 48%) and/or diagnose (124/220; 56%) delirium. Over a third used an assessment tool to screen for delirium (76/204; 37%). The majority (150/220; 68%) reported screening in response to clinical symptoms, while few reported routine on-admission (11/220; 5%) or daily-during-admission (12/220; 6%) screening. Most respondents had received some training on delirium (137/220; 62%). However, 130/220 (59%) said their SPCU did not have a training programme for delirium screening and only 79/220 (36%) reported that their SPCU had delirium clinical guidelines. The main barriers to routine screening included: lack of delirium training, lack of guidelines and complexity of patient's conditions. CONCLUSION There is variation in practice for delirium screening and diagnosis in SPCUs. Clinical guidelines for delirium, including consensus on which screening tools to use, are needed for this setting.
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Affiliation(s)
- Rebecca Woodhouse
- Department of Health Sciences, University of York, York, UK .,Hull York Medical School, University of York, York, North Yorkshire, UK
| | - Najma Siddiqi
- Hull York Medical School, University of York, York, North Yorkshire, UK.,General Adult Psychiatry, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK.,Care Plus Group and St Andrew's Hospice, NE Lincolnshire, UK
| | | | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Abstract
Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.
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Affiliation(s)
- Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Building 10, Level 3, 235 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Shirley H Bush
- The Ottawa Hospital, General Campus, 501 Smyth Road, Box 206, Ottawa, ON K1H 8L6, Canada; Bruyère Research Institute, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada; Ottawa Hospital Research Institute, 053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; Palliative Care, Bruyère Continuing Care, The Ottawa Hospital, 43, Bruyère Street, Ottawa, Ontario K1N 5C8, Canada
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111
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Kim EM, Li G, Kim M. Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture. Anesth Analg 2020; 130:79-86. [PMID: 31478933 DOI: 10.1213/ane.0000000000004386] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed. METHODS The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model. RESULTS Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78-10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05-2.76], 3 points); (3) age (reference, 60-69 years of age) (age 70-79: aOR, 1.60 [95% CI, 1.20-2.12], 2 points; age 80-89: aOR, 2.09 [95% CI, 1.59-2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82-3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13-1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III-V (aOR, 1.40 [95% CI, 1.14-1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17-1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07-1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09-1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14-1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76-0.78) and 0.77 (95% CI, 0.76-0.78), respectively, with similar results in the validation cohort. CONCLUSIONS A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy.
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Affiliation(s)
- Eun Mi Kim
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Anesthesia and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea
| | - Guohua Li
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Minjae Kim
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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112
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Ortner F, Eberl M, Otto S, Wang B, Schauberger G, Hofmann-Kiefer K, Saller T. Patient-related and anesthesia-dependent determinants for postoperative delirium after oral and maxillofacial surgery. Results from a register-based case-control study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2020; 122:62-69. [PMID: 32302798 DOI: 10.1016/j.jormas.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify risk factors for postoperative delirium (POD) after general oral and maxillofacial surgery. MATERIAL AND METHODS 2420 patients were screened postoperatively for POD using the Nursing Delirium Screening Scale (NuDESC) before discharge from the post anesthesia caring unit (PACU). Basic health data and risk factors were collected. For analysis the study group (n=41) was compared to a control group of 164 randomly selected patients (case-control-ratio=1:4). To identify risk factors for POD multivariable logistic regression models were used. To see whether estimations remain stable, regression analysis was repeated for the subgroup of patients not undergoing dentoalveolar surgery (n=105). To estimate the risk for dentoalveolar surgery a logistic regression model was performed. RESULTS Dementia was the only significant risk factor for POD (Odds ratio 41.5; 95% CI 5.48-314), also for patients undergoing other than dentoalveolar surgery (58.1; 1.70-1983). Patients undergoing dentoalveolar surgery were more often suffering from dementia (35.5; 2.85-441), other psychiatric and neurological disorders (3.15; 1.05-9.43), were of younger age (0.97; 0.94-1.00) and had higher anesthesiological risk (3.95; 1.04-14.9). CONCLUSION Patients with dementia are at higher risk to develop POD after oral and maxillofacial surgery. We found a strong interdependence between age, dementia, ASA-Score and dentoalveolar surgery.
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Affiliation(s)
- Florian Ortner
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany
| | - Marian Eberl
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany.
| | - Baocheng Wang
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Gunther Schauberger
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Thomas Saller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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Falk A, Eriksson M, Stenman M. Depressive and/or anxiety scoring instruments used as screening tools for predicting postoperative delirium after cardiac surgery: A pilot study. Intensive Crit Care Nurs 2020; 59:102851. [PMID: 32223922 DOI: 10.1016/j.iccn.2020.102851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Depression is common in patients with cardiac disease. Depression is a risk factor for developing postoperative delirium, a common and serious complication to cardiac surgery. OBJECTIVES The aim was to evaluate if screening tools for depression can be used to predict postoperative delirium after cardiac surgery. METHODS This was a prospective population-based pilot study including 26 patients between 23 and 80 years of age undergoing cardiac surgery in Sweden during 2018. The day before surgery the participants filled out the depression screening instruments Hospital Anxiety and Depression Scale and Patient Health Questionnaire. After discharge the patient charts were examined for documentation of symptoms of delirium. RESULTS Five (20%) patients screened positive regarding depression using the Hospital Anxiety and Depression Scale and 7 patients (27%) screened positive using The Patient Health Questionnaire. Four (22%) patients showed symptoms of postoperative delirium, none of them screened positive for depression prior to surgery. CONCLUSION We found no difference between the questionnaires PHQ-9 and HADS regarding identifying depressive symptoms. Moreover, we found that post-operative delirium, to a certain extent, can be detected by reading the patient́s charts postoperatively. However, this pilot study showed that screening tools for delirium need to be better implemented.
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Affiliation(s)
- Anna Falk
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden; Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Malin Stenman
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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The Intersection of Architecture/Medicine/Quality and the Clinical Nurse Specialist: Designing for the Prevention of Delirium. CLIN NURSE SPEC 2020; 34:5-7. [PMID: 31789956 DOI: 10.1097/nur.0000000000000492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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115
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Müller J, Nowak S, Vogelgesang A, von Sarnowski B, Rathmann E, Schmidt S, Rehberg S, Usichenko T, Kertscho H, Hahnenkamp K, Flöel A, Schroeder HW, Müller JU, Fleischmann R. Evaluating Mechanisms of Postoperative Delirium and Cognitive Dysfunction Following Elective Spine Surgery in Elderly Patients (CONFESS): Protocol for a Prospective Observational Trial. JMIR Res Protoc 2020; 9:e15488. [PMID: 32053113 PMCID: PMC7048391 DOI: 10.2196/15488] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Elderly people are at particular high risk for postoperative delirium (POD) following spine surgery, which is associated with longer hospital stays, higher costs, risk for delayed complications, long-term care dependency, and cognitive dysfunction (POCD). It is insufficiently understood which mechanisms and risk factors contribute to the development of POD and POCD following these major but plannable surgeries. Objective This study aims to identify modifiable risk factors in spine surgery. A better understanding thereof would help adapt medical management and surgical strategies to individual risk profiles. Methods This is a single-center observational study jointly conducted by the departments of neurosurgery, neurology, and anesthesiology at a tertiary care hospital in Germany. All patients aged 60 years and older presenting to the neurosurgery outpatient clinic or ward for elective spine surgery are screened for eligibility. Exclusion criteria include presence of neurodegenerative or history of psychiatric disease and medication with significant central nervous system activity (eg, antidepressants, antipsychotics, sedatives). Surgical and anesthetic procedures including duration of surgery as primary end point of this study are thoroughly documented. All patients are furthermore evaluated for their preoperative cognitive abilities by a number of tests, including the Consortium to Establish a Registry for Alzheimer's Disease Plus test battery. Physical, mental, and social health and well-being are assessed using the Patient-Reported Outcome Measurement Information System Profile 29 and Hospital Anxiety and Depression Scale. Patients additionally receive preoperative cerebrovascular ultrasound and structural and functional brain imaging. The immediate postoperative period includes screening for POD using the Nursing Delirium Screening Scale and validation through Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. We furthermore investigate markers of (neuro)inflammation (eg, interleukins, C-reactive protein, tumor necrosis factor alpha). Preoperative examinations are repeated 3 months postoperatively to investigate the presence of POCD and its mechanisms. Statistical analyses will compare delirious and nondelirious patients for predictors of immediate (POD) and delayed (POCD) cognitive dysfunction. Results This is the first study to prospectively evaluate risk factors for POD and POCD in spine surgery. Recruitment is ongoing, and data collection is estimated to be finished with the inclusion of 200 patients by mid-2020. Conclusions The identification of mechanisms, possibly common, underlying POD and POCD would be a major step toward defining effective interventional strategies early in or even before the postoperative period, including the adaptation of surgical strategies to individual risk profiles. Trial Registration ClinicalTrials.gov NCT03486288; https://clinicaltrials.gov/ct2/show/NCT03486288
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Affiliation(s)
- Jonas Müller
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Antje Vogelgesang
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | | | - Eiko Rathmann
- Department of Radiology, University Medicine Greifswald, Greifswald, Germany
| | - Sein Schmidt
- Clinical Research Unit, Charité Campus Mitte, Berlin Institute of Health, Berlin, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Protestant Hospital of the Bethel Foundation, Bielefeld, Germany
| | - Taras Usichenko
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Harry Kertscho
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,Center for Neurodegenerative Diseases, Greifswald/Rostock, Germany
| | - Henry Ws Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Jan-Uwe Müller
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
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Greaves D, Psaltis PJ, Lampit A, Davis DHJ, Smith AE, Bourke A, Worthington MG, Valenzuela MJ, Keage HAD. Computerised cognitive training to improve cognition including delirium following coronary artery bypass grafting surgery: protocol for a blinded randomised controlled trial. BMJ Open 2020; 10:e034551. [PMID: 32029497 PMCID: PMC7045123 DOI: 10.1136/bmjopen-2019-034551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) surgery is known to improve vascular function and cardiac-related mortality rates; however, it is associated with high rates of postoperative cognitive decline and delirium. Previous attempts to prevent post-CABG cognitive decline using pharmacological and surgical approaches have been largely unsuccessful. Cognitive prehabilitation and rehabilitation are a viable yet untested option for CABG patients. We aim to investigate the effects of preoperative cognitive training on delirium incidence, and preoperative and postoperative cognitive training on cognitive decline at 4 months post-CABG. METHODS AND ANALYSIS This study is a randomised, single-blinded, controlled trial investigating the use of computerised cognitive training (CCT) both pre-CABG and post-CABG (intervention group) compared with usual care (control group) in older adults undergoing CABG in Adelaide, South Australia. Those in the intervention group will complete 1-2 weeks of CCT preoperatively (45-60 min sessions, 3.5 sessions/week) and 12 weeks of CCT postoperatively (commencing 1 month following surgery, 45-60 min sessions, 3 sessions/week). All participants will undergo cognitive testing preoperatively, over their hospital stay including delirium, and postoperatively for up to 1 year. The primary delirium outcome variable will be delirium incidence (presence vs absence); the primary cognitive decline variable will be at 4 months (significant decline vs no significant decline/improvement from baseline). Logistic regression modelling will be used, with age and gender as covariates. Secondary outcomes include cognitive decline from baseline to discharge, and at 6 months and 1 year post-CABG. ETHICS AND DISSEMINATION Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (South Australia, Australia) and the University of South Australia Human Ethics Committee, with original approval obtained on 13 December 2017. It is anticipated that approximately two to four publications and multiple conference presentations (national and international) will result from this research. TRIAL REGISTRATION NUMBER This clinical trial is registered with the Australian New Zealand Clinical Trials Registry and relates to the pre-results stage. Registration number: ACTRN12618000799257.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Amit Lampit
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Ashleigh E Smith
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Alice Bourke
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael G Worthington
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael J Valenzuela
- Brain and Mind Centre and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
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Effects of protocol on prevention of delirium in hospitalized hip fracture patients: A quality improvement project. Int J Orthop Trauma Nurs 2020; 36:100710. [DOI: 10.1016/j.ijotn.2019.100710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 07/25/2019] [Accepted: 07/31/2019] [Indexed: 11/22/2022]
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118
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Mossello E, Lucchini F, Tesi F, Rasero L. Family and healthcare staff’s perception of delirium. Eur Geriatr Med 2020; 11:95-103. [DOI: 10.1007/s41999-019-00284-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022]
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119
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Abstract
Hospital-acquired delirium often goes unnoticed because the signs and symptoms resemble those of dementia and depression, making diagnosis difficult. This article explores the differences between delirium, dementia, and depression and discusses the role of nursing in patient assessment and education.
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120
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Maldonado JR, Sher YI, Benitez-Lopez MA, Savant V, Garcia R, Ament A, De Guzman E. A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): A New Screening Tool for the Detection of Delirium. PSYCHOSOMATICS 2019; 61:116-126. [PMID: 31926650 DOI: 10.1016/j.psym.2019.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium is a prevalent neuropsychiatric disorder associated with increased morbidity and mortality. Half the cases remain misdiagnosed. OBJECTIVE Assess the effectiveness of the Stanford Proxy Test for Delirium (S-PTD) in detecting delirium in an inpatient setting. METHODS This is a comparison study. Daily assessment with S-PTD, by the patient's nurse, and a neuropsychiatric assessment by a psychiatrist. Assessments were blinded. Inclusion criteria included 18 years or older. Exclusion criteria included patient's or surrogate's unwillingness to participate, inability to consent if a surrogate was not available, and inability to communicate in English or Spanish. A total of 309 patients were approached: 27 declined participation, 4 were excluded, and 278 subjects were followed up throughout their hospital stay. In the end, 78 were excluded for lack of neuropsychiatric assessment, S-PTD, or both. One was excluded for lack of demographic data. The sensitivity and specificity of the S-PTD in detecting delirium when compared with a neuropsychiatric assessment. RESULTS Participants were on average 60.8 years old and 54.3% were male. Patients who developed delirium were, on average, older (15.12 y, confidence interval: 8.94-21.32). A total of 199 patients were analyzed; 43 patients (21.6%) met criteria for delirium. S-PTD detected 67 days with delirium (16.5%) of 405 hospital days, while neuropsychiatric evaluation identified 83 (20.5%). S-PTD had a sensitivity of 80.72% and a specificity of 90.37%. CONCLUSION S-PTD is an effective, comprehensive, and simple screening tool for delirium, which is robust despite fluctuating symptoms and lack of cooperation. The use of S-PTD may enhance early diagnosis of delirium.
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Affiliation(s)
- Jose R Maldonado
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
| | - Yelizaveta I Sher
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Mario Alberto Benitez-Lopez
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Vidushi Savant
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Renee Garcia
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Andrea Ament
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Earl De Guzman
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
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Mansutti I, Saiani L, Palese A. Detecting delirium in patients with acute stroke: a systematic review of test accuracy. BMC Neurol 2019; 19:310. [PMID: 31791260 PMCID: PMC6889202 DOI: 10.1186/s12883-019-1547-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/27/2019] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Patients with acute stroke are particularly vulnerable to delirium episodes. Although delirium detection is important, no evidence-based recommendations have been established to date on how these patients should be routinely screened for delirium or which tool should be used for this purpose in this population. Therefore, the aim of this study was to identify delirium screening tools for patients with acute stroke and to summarise their accuracy. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of Medline, CINAHL and Scopus databases was performed to include: (a) diagnostic test accuracy studies; (b) evaluating tools detecting delirium among patients with acute stroke; (c) written in English; (d) published up to September 2018. The included studies were assessed in their quality by using the Quality Assessment of Diagnostic Accuracy Studies-2. RESULTS A total of four studies have been performed to date in the field with a variable quality for the methodology used and documentation of the accuracy of mainly two tools, as (1) the 4-Assessment Test for delirium (4AT), reporting a range of sensitivity from 90.2 to 100% and a specificity from 64.5 to 86%; and (2) the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) showing a sensitivity of 76% (95% Confidence of Interval [CI] 55-91) and a specificity of 98% (95%CI 93-100). Other tools have been studied as: The Abbreviated Mental Test-10, the Abbreviated Mental Test short form, the Clock Drawing Test, the Cognitive Examination derived from the National Institutes of Health Stroke Scale and the Glasgow Coma Scale. Moreover, the use of a single question-namely, 'Does this patient have cognitive issues?' as answered by the multidisciplinary team-has been subjected to a validation process. CONCLUSIONS To date a few primary studies have been published to test the accuracy of tools in their ability to detect post-stroke delirium; among those available, the 4AT and the CAM-ICU tools have been mostly studied. Research has just started to add evidence to the challenge of detecting and usefully assessing newly-acquired delirium among stroke patients: therefore, more studies are needed to improve the knowledge and allow a robust selection of the most useful tool to use in this population.
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Affiliation(s)
- Irene Mansutti
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Luisa Saiani
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alvisa Palese
- Department of Medical Science, University of Udine, Viale Ungheria 20, 33100 Udine, Italy
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. Delirium screening instruments administered by nurses for hospitalized patients - literature review. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2019. [DOI: 10.15452/cejnm.2019.10.0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Waterfield K, Weiand D, Dewhurst F, Kiltie R, Pickard J, Karandikar U, MacCormick F, Vidrine J, Rowley G, Coulter P, Lee M, Frew K. A qualitative study of nursing staff experiences of delirium in the hospice setting. Int J Palliat Nurs 2019; 24:524-534. [PMID: 30457465 DOI: 10.12968/ijpn.2018.24.11.524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND: Delirium is a common condition occurring in 13-42% of people admitted to palliative care units and up to 88% of these patients are at the end of their lives. It is frequently unrecognised and distressing to all those affected-patients, families and health professionals. In addition, there is considerable uncertainty surrounding its trajectory and optimal management, both of which can be inconsistent. AIMS: This study aims to explore the experience of nursing staff who are caring for patients with delirium in the hospice environment and understand any potential barriers to its management. METHODS: Semistructured interviews using emotional touchpoints were conducted with 12 nurses and six healthcare assistants in three hospices in North East England. Data was analysed using interpretative phenomenological analysis. FINDINGS: The results highlighted gaps in knowledge and understanding in the management of delirium. The results demonstrated delirium had significant emotional effects, which were associated with uncertainty in managing the condition and the impact of this uncertainty on the relationship between staff and patients. CONCLUSION: This study highlights the emotional impact of caring for patients with delirium. Future work is needed to address the areas of uncertainty identified and ascertain how to best support nursing staff in these challenges.
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Affiliation(s)
- Kerry Waterfield
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Donna Weiand
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Felicity Dewhurst
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Rachel Kiltie
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jonathan Pickard
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Ulka Karandikar
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Fiona MacCormick
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jen Vidrine
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Grace Rowley
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Paul Coulter
- Consultant, Palliative Medicine, Queen Elizabeth Hospital, Gateshead
| | - Mark Lee
- Consultant, Palliative Medicine, St Benedict's hospice, Sunderland
| | - Katie Frew
- Consultant, Palliative Medicine, Northumbria Healthcare NHS Foundation Trust
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Outen K, Akintade BF. Implementation of the Confusion Assessment Method for Noncritically Ill Adult Patients. Crit Care Nurs Clin North Am 2019; 31:475-480. [PMID: 31685113 DOI: 10.1016/j.cnc.2019.07.002] [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: 10/26/2022]
Abstract
Several hospital interventions increase patient risk for developing delirium, including mechanical ventilation, monitoring devices, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to increased length of hospital stay, likelihood of requiring long-term care services after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensorimotor functioning. Routine screening and early recognition prevent or reduce the long-term health and financial effects of delirium. The Confusion Assessment Method is a useable tool for screening noncritically ill adult patients for delirium.
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Affiliation(s)
- Katharine Outen
- University of Maryland Medical Center, Baltimore, MD 21201, USA.
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Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia. Geriatrics (Basel) 2019; 4:geriatrics4030052. [PMID: 31514465 PMCID: PMC6787739 DOI: 10.3390/geriatrics4030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022] Open
Abstract
The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.
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Khan A, Boukrina O, Oh-Park M, Flanagan NA, Singh M, Oldham M. Preventing Delirium Takes a Village: Systematic Review and Meta-analysis of Delirium Preventive Models of Care. J Hosp Med 2019; 14:558-564. [PMID: 31112492 DOI: 10.12788/jhm.3212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/15/2019] [Accepted: 03/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Each hospital day of delirium incurs greater healthcare costs, higher levels of care, greater staff burden, and higher complication rates. Accordingly, administrators are incentivized to identify models of care that reduce delirium rates and associated costs. PURPOSE We present a systematic review and meta-analysis of delirium prevention models of care. DATA SOURCES Ovid MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, and PsycINFO. STUDY SELECTION Eligible models of care were defined as provider-oriented interventions involving revision of professional roles, multidisciplinary teams, and service integration. Included studies implemented multidomain, multicomponent interventions, used a validated delirium instrument, and enrolled a control group to evaluate efficacy or effectiveness. DATA EXTRACTION We extracted data on study design; Population, model of care, outcomes, and results. DATA SYNTHESIS A total of 15 studies were included. All but two studies reported reduction in delirium or its duration, and 11 studies reported statistically significant improvements. Using random effects models, the pooled odds ratios of delirium incidence were 0.56 (95% CI: 0.37-0.85) from three randomized controlled trials, 0.63 (95% CI 0.37-1.07) from four pre-post intervention studies, and 0.79 (95% CI: 0.46-1.37) from three additional nonrandomized studies. CONCLUSIONS Several models of care can prevent delirium. In general, higher quality studies were more likely to demonstrate statistical significance of an effect. The diverse models of care included here explored interventions adapted to specific care settings, especially by addressing setting-specific delirium risk factors. These care models illustrate a range of promising strategies that deserve growing recognition, refinement, and implementation.
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Affiliation(s)
- Ariba Khan
- Department of Geriatrics, Advocate Aurora Health Care, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - Olga Boukrina
- Kessler Foundation, Center for Stroke Rehabilitation Research, West Orange, New Jersey
| | | | - Nina A Flanagan
- Decker School of Nursing Binghamton University, Vestal, New York
| | - Maharaj Singh
- Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Mark Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, New York
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Abstract
Delirium is an acute and fluctuating disturbance in cognition attention and awareness that is often a reflection of abnormal physiological condition of an individual. Delirium is highly prevalent among an older population and is associated with high mortality, poor medical and functional outcomes, and high healthcare cost. Delirium often has iatrogenic triggers, and it has been recognized as a quality indicator of healthcare organizations. Despite its high prevalence and significance, more than 50% of the delirium cases are underrecognized by healthcare professionals and remained untreated. Most patients in inpatient rehabilitation facilities are older adults with multiple risk factors for delirium including operation, intensive care stay, multiple co-morbidities, and impaired mobility. Early detection, intervention, and primary prevention of delirium will allow patients to avoid additional morbidities and reach their maximum functional potential during their rehabilitation stay. After the systematic implementation of delirium screening in our inpatient rehabilitation facility, we found that 10.3% of patients were screened positive for delirium at admission. This review discusses the systematic implementation of screening and intervention for delirium as well as the epidemiology of delirium to increase the awareness and guide clinical practice for clinicians in inpatient rehabilitation facilities.
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Dexmedetomidine for the prevention of postoperative delirium in elderly patients undergoing noncardiac surgery: A meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0218088. [PMID: 31419229 PMCID: PMC6697366 DOI: 10.1371/journal.pone.0218088] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 05/26/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) among the elderly population that undergoes noncardiac surgery is significantly associated with adverse clinical outcomes. We conducted this meta-analysis to evaluate the effectiveness and safety of dexmedetomidine for the prophylaxis of POD among the elderly population after noncardiac surgery. METHODS We searched Embase, PubMed, and the Cochrane Library from inception date to March 2019 for randomized controlled trials (RCTs) that compared dexmedetomidine and placebo for the prevention of POD and evaluated the major cardiovascular outcomes among elderly people after noncardiac surgery. Two authors independently screened the studies and extracted data from the published articles. The main outcome was the incidence of POD. The secondary outcomes included the occurrence of bradycardia, hypotension, hypertension, tachycardia, myocardial infarction, stroke, hypoxaemia, and all-cause mortality. RESULTS A total of 6 RCTs with 2102 participants were included. Compared with placebo, dexmedetomidine significantly reduced the prevalence of POD (RR = 0.61, 95% CI 0.34-0.76, P = 0.001, I2 = 66%), and the risk of tachycardia (RR = 0.48, 95% CI 0.30-0.76, P = 0.002, I2 = 0%), hypertension (RR = 0.59, 95% CI 0.44-0.79, P < 0.001, I2 = 20%), stroke (RR = 0.22, 95% CI 0.06-0.76, P = 0.02, I2 = 0%), and hypoxaemia (RR = 0.50, 95% CI 0.32-0.78, P = 0.002, I2 = 0%) in elderly patients who underwent noncardiac surgery. However, dexmedetomidine accelerated the occurrence of bradycardia (RR = 1.36, 95% CI 1.11-1.67, P = 0.003, I2 = 0%). Furthermore, no significant differences were observed in the incidence of hypotension, myocardial infarction, and all-cause mortality between the dexmedetomidine and placebo groups. CONCLUSIONS Among elderly patients after noncardiac surgery, the prophylactic use of dexmedetomidine, compared with the use of placebo, was related to a decline in the incidence of POD.
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Abstract
Associated with substantial morbidity and mortality, delirium is a syndrome commonly experienced by hospitalized adults. This article presents a case study highlighting how delirium may go unrecognized by the healthcare team and provides 10 suggestions for improving delirium assessment, prevention, and management in the acute care setting.
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Affiliation(s)
- Elizabeth Cullen
- Michele Balas is an associate professor at the Ohio State University College of Nursing, Center of Excellence in Critical and Complex Care, Columbus, Ohio. Elizabeth Cullen is a clinical instructor at the Ohio State University College of Nursing, Columbus, Ohio
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17:138. [PMID: 31337404 PMCID: PMC6651960 DOI: 10.1186/s12916-019-1367-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). METHODS This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. RESULTS Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). CONCLUSIONS The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. TRIAL REGISTRATION International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
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Affiliation(s)
- Susan D. Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mary Godfrey
- Elderly Care and Rehabilitation and Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L. Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
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Steensma E, Zhou W, Ngo L, Gallagher J, Inouye S, Leslie D, Boltz M, Kolanowski A, Mion L, Marcantonio ER, Fick D. Ultra-brief Screeners for Detecting Delirium Superimposed on Dementia. J Am Med Dir Assoc 2019; 20:1391-1396.e1. [PMID: 31279670 DOI: 10.1016/j.jamda.2019.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Delirium superimposed on dementia (DSD) is common, morbid, and costly, yet frequently undiagnosed. Our study aimed to develop a brief screening test to improve health care worker recognition of DSD. DESIGN/SETTING/PARTICIPANTS Older hospitalized adults with dementia were prospectively enrolled from medical and surgical inpatient units of 3 hospitals (2 in Pennsylvania, 1 in Tennessee). MEASURES The reference standard delirium assessment used Confusion Assessment Method (CAM) criteria and was based on a structured interview including the Mini-Mental State Examination, interviewer observations, and medical record review. To develop the screening test, 1-, 2-, and 3-item combinations from the reference standard assessment were analyzed to determine their sensitivity and specificity in diagnosing delirium presence in a dementia population compared to the reference standard. For multiple-item screeners, error on 1 or more items was considered a positive screen. RESULTS Overall, 391 older adults with dementia were enrolled (mean age: 83.9 years, 71.1% female), and 95 (24.4%) developed DSD during their hospitalization, based on the reference standard. The best single-item screen for DSD was "What day of the week is it?" with 84% sensitivity [95% confidence interval (CI): 0.75, 0.91] and 41% specificity (CI: 0.35, 0.47). The best 2-item screen was "list the days of the week backwards" and "What day of the week is it?" with 93% sensitivity (CI: 0.85, 0.97) and 30% specificity (CI: 0.25, 0.36). The best 3-item screen was "list the days of the week backwards," "What type of place is this? [hospital]" and "Does the patient appear sleepy?" with 94% sensitivity (CI: 0.87, 0.98) and 42% specificity (CI: 0.36, 0.48). CONCLUSIONS/IMPLICATIONS We identified a 3-item DSD screener with excellent sensitivity but limited specificity. This screener can be used to quickly rule out DSD in populations with a high prevalence of dementia and is a promising step toward developing efficient tools for DSD recognition among care providers.
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Affiliation(s)
| | - Wenxiao Zhou
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Sharon Inouye
- Harvard Medical School, Boston, MA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Douglas Leslie
- College of Medicine, Pennsylvania State University, Hershey, PA
| | - Marie Boltz
- College of Nursing, College of Medicine, Penn State University, University Park, PA
| | - Ann Kolanowski
- College of Nursing, College of Medicine, Penn State University, University Park, PA
| | - Lorraine Mion
- College of Nursing, Ohio State University, Columbus, OH
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Donna Fick
- College of Nursing, College of Medicine, Penn State University, University Park, PA
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Malik BH. The National Early Warning Score 2 (NEWS2) - Elderly patients and training of nursing / allied healthcare professionals in using NEWS2. Clin Med (Lond) 2019; 19:261. [PMID: 31092527 PMCID: PMC6542221 DOI: 10.7861/clinmedicine.19-3-261a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mansutti I, Saiani L, Palese A. Delirium in patients with ischaemic and haemorrhagic stroke: findings from a scoping review. Eur J Cardiovasc Nurs 2019; 18:435-448. [PMID: 31027426 DOI: 10.1177/1474515119846226] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delirium is a complex syndrome characterised by disturbances in attention and awareness, associated with alterations in cognitive functions, which can emerge in a time frame of hours or days and tend to fluctuate in severity over time. Delirium is a clinical manifestation of the brain's vulnerability and diminished resilience to insult. Stroke patients are particularly vulnerable to delirium episodes. AIMS The aim of this study was to map: (a) studies focused on ischaemic or haemorrhagic post-stroke delirium; (b) factors that have been investigated as being possibly associated with post-stroke delirium; and (c) outcomes that have been studied to date. METHODS A scoping review was performed. Medline, CINAHL, Cochrane Database of Systematic Reviews, PsycINFO and Scopus databases were searched. Eligible studies were those: (a) exploring any variable regarding delirium in patients with stroke; (b) involving adults; (c) as primary studies; (d) written in English; and (e) published before April 2017. RESULTS To date 25 studies have been published, mainly prospective or cohort studies. The most commonly studied predisposing factors have been the older age, gender, aetiology of the stroke and its location, and the presence of previous cognitive decline/dementia. The most studied precipitating factors to date have been pneumonia, urinary tract infections and symptoms of neglect. Functional dependence, length of inhospital stays, post-stroke cognitive impairments or dementia, short and long-term mortality have been the most studied post-stroke delirium outcomes. CONCLUSIONS Studies across different clinical settings, also at the international level, including more female patients and a wider range of ages should be designed in order to improve the evidence available to develop specific clinical guidelines. Standardised frameworks of research addressing the great variability of methods and measures used in the field should be established at the international level by clinicians and researchers' experts in the field.
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Affiliation(s)
- Irene Mansutti
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Luisa Saiani
- 2 Department of Diagnostics and Public Health, University of Verona, Italy
| | - Alvisa Palese
- 3 Department of Medical Science, University of Udine, Italy
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Lawlor PG, Rutkowski NA, MacDonald AR, Ansari MT, Sikora L, Momoli F, Kanji S, Wright DK, Rosenberg E, Hosie A, Pereira JL, Meagher D, Rice J, Scott J, Bush SH. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. J Pain Symptom Manage 2019; 57:661-681.e12. [PMID: 30550832 DOI: 10.1016/j.jpainsymman.2018.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
CONTEXT Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.
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Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | | | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David K Wright
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Critical Care, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jose L Pereira
- Department of Family Medicine, University of Ottawa, Ontario, Canada; Division of Palliative Medicine, McMaster University, Ontario, Canada
| | - David Meagher
- University of Limerick School of Medicine, Limerick, Ireland
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Scott
- The Ottawa Hospital, Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Fleischmann R, Tränkner S, Bathe-Peters R, Rönnefarth M, Schmidt S, Schreiber SJ, Brandt SA. Diagnostic Performance and Utility of Quantitative EEG Analyses in Delirium: Confirmatory Results From a Large Retrospective Case-Control Study. Clin EEG Neurosci 2019; 50:111-120. [PMID: 29631447 DOI: 10.1177/1550059418767584] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The lack of objective disease markers is a major cause of misdiagnosis and nonstandardized approaches in delirium. Recent studies conducted in well-selected patients and confined study environments suggest that quantitative electroencephalography (qEEG) can provide such markers. We hypothesize that qEEG helps remedy diagnostic uncertainty not only in well-defined study cohorts but also in a heterogeneous hospital population. Methods. In this retrospective case-control study, EEG power spectra of delirious patients and age-/gender-matched controls (n = 31 and n = 345, respectively) were fitted in a linear model to test their performance as binary classifiers. We subsequently evaluated the diagnostic performance of the best classifiers in control samples with normal EEGs (n = 534) and real-world samples including pathologic findings (n = 4294). Test reliability was estimated through split-half analyses. Results. We found that the combination of spectral power at F3-P4 at 2 Hz (area under the curve [AUC] = .994) and C3-O1 at 19 Hz (AUC = .993) provided a sensitivity of 100% and a specificity of 99% to identify delirious patients among normal controls. These classifiers also yielded a false positive rate as low as 5% and increased the pretest probability of being delirious by 57% in an unselected real-world sample. Split-half reliabilities were .98 and .99, respectively. Conclusion. This retrospective study yielded preliminary evidence that qEEG provides excellent diagnostic performance to identify delirious patients even outside confined study environments. It furthermore revealed reduced beta power as a novel specific finding in delirium and that a normal EEG excludes delirium. Prospective studies including parameters of pretest probability and delirium severity are required to elaborate on these promising findings.
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Affiliation(s)
- Robert Fleischmann
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Neurointensive Care Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Steffi Tränkner
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rouven Bathe-Peters
- St. Hedwig Hospital, Department of Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Rönnefarth
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sein Schmidt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Stephan A Brandt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Heinrich TW, Kato H, Emanuel C, Denson S. Improving the Validity of Nurse-Based Delirium Screening: A Head-to-Head Comparison of Nursing Delirium-Screening Scale and Short Confusion Assessment Method. PSYCHOSOMATICS 2019; 60:172-178. [DOI: 10.1016/j.psym.2018.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 11/16/2022]
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Jones RN, Cizginer S, Pavlech L, Albuquerque A, Daiello LA, Dharmarajan K, Gleason LJ, Helfand B, Massimo L, Oh E, Okereke OI, Tabloski P, Rabin LA, Yue J, Marcantonio ER, Fong TG, Hshieh TT, Metzger ED, Erickson K, Schmitt EM, Inouye SK. Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review. JAMA Intern Med 2019; 179:231-239. [PMID: 30556827 PMCID: PMC6382582 DOI: 10.1001/jamainternmed.2018.6975] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. Objectives To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. Evidence Review This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. Findings Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. Conclusions and Relevance The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.
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Affiliation(s)
- Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sevdenur Cizginer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Laura Pavlech
- Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Lori A Daiello
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kumar Dharmarajan
- Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Benjamin Helfand
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
- University of Massachusetts Medical School, Worcester
| | - Lauren Massimo
- Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia
| | - Esther Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olivia I Okereke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patricia Tabloski
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
| | - Laura A Rabin
- Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kristen Erickson
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Pérez-Ros P, Martínez-Arnau FM. Delirium Assessment in Older People in Emergency Departments. A Literature Review. Diseases 2019; 7:E14. [PMID: 30704024 PMCID: PMC6473718 DOI: 10.3390/diseases7010014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022] Open
Abstract
Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.
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Affiliation(s)
- Pilar Pérez-Ros
- School of Nursing, Universidad Católica de Valencia San Vicente Mártir, Calle Espartero, 7, 46007 València, Spain.
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139
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Fleischmann R, Traenkner S, Kraft A, Schmidt S, Schreiber SJ, Brandt SA. Delirium is associated with frequency band specific dysconnectivity in intrinsic connectivity networks: preliminary evidence from a large retrospective pilot case-control study. Pilot Feasibility Stud 2019; 5:2. [PMID: 30631448 PMCID: PMC6322230 DOI: 10.1186/s40814-018-0388-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Pathophysiological concepts in delirium are not sufficient to define objective biomarkers suited to improve clinical approaches. Advances in neuroimaging have revalued electroencephalography (EEG) as a tool to assess oscillatory network activity in neuropsychiatric disease. Yet, research in the field is limited to small populations and largely confined to postoperative delirium, which impedes generalizability of findings and planning of prospective studies in other populations. This study aimed to assess effect sizes of connectivity measures in a large mixed population to demonstrate that there are measurable EEG differences between delirium and control patients. Methods This retrospective pilot study investigated EEG measures as biomarkers in delirium using a case-control design including patients diagnosed with delirium (DSM-5 criteria) and age-/gender-matched controls drawn from a database of 9980 patients (n = 129 and 414, respectively). Assessors were not blinded for groups. Power spectra and connectivity estimates, using the weighted phase log index, of continuous EEG data were compared between conditions. Alterations of information flow through nodes of intrinsic connectivity networks (ICN; default mode, salience, and executive control network) were evaluated in source space using betweenness centrality. This was done frequency specific and network nodes were defined by the multimodal human cerebral cortex parcellation based on human connectome project data. Results Delirium and control patients exhibited distinct EEG power, connectivity, and network characteristics (F(72,540) = 70.3, p < .001; F(493,1079) = 2.69, p < .001; and F(718,2159) = 1.14, p = .007, respectively). Connectivity analyses revealed global alpha and regional beta band disconnectivity that was accompanied by theta band hyperconnectivity in delirious patients. Source and network analyses yielded that these changes are not specific to single intrinsic connectivity networks but affect multiple nodes of networks engaged in level of consciousness, attention, working memory, executive control, and salience detection. Effect sizes were medium to strong in this mixed population of delirious patients. Conclusions We quantified effect sizes for EEG connectivity and network analyses to be expected in delirium. This study implicates that theta band hyperconnectivity and alpha band disconnectivity may be essential mechanisms in the pathophysiology of delirium. Upcoming prospective studies will build upon these results and evaluate the clinical utility of identified EEG measures as therapeutic and prognostic biomarkers. Electronic supplementary material The online version of this article (10.1186/s40814-018-0388-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert Fleischmann
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany.,2Department of Neurology, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Steffi Traenkner
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Antje Kraft
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Sein Schmidt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Stephan J Schreiber
- 3Department of Neurology, Asklepios Fachklinikum Brandenburg, 14772 Brandenburg an der Havel, Brandenburg Germany
| | - Stephan A Brandt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
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Maybrier HR, Mickle AM, Escallier KE, Lin N, Schmitt EM, Upadhyayula RT, Wildes TS, Mashour GA, Palihnich K, Inouye SK, Avidan MS. Reliability and accuracy of delirium assessments among investigators at multiple international centres. BMJ Open 2018; 8:e023137. [PMID: 30467132 PMCID: PMC6252643 DOI: 10.1136/bmjopen-2018-023137] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Delirium is a common, serious postoperative complication. For clinical studies to generate valid findings, delirium assessments must be standardised and administered accurately by independent researchers. The Confusion Assessment Method (CAM) is a widely used delirium assessment tool. The objective was to determine whether implementing a standardised CAM training protocol for researchers at multiple international sites yields reliable inter-rater assessment and accurate delirium diagnosis. METHODS Patients consented to video recordings of CAM delirium assessments for research purposes. Raters underwent structured training in CAM administration. Training entailed didactic education, role-playing with intensive feedback, apprenticeship with experienced researchers and group discussions of complex cases. Raters independently viewed and scored nine video-recorded CAM interviews. Inter-rater reliability was determined using Fleiss kappa. Accuracy was judged by comparing raters' scores with those of an expert delirium researcher. RESULTS Twenty-seven raters from eight international research centres completed the study and achieved almost perfect agreement for overall delirium diagnosis, kappa=0.88 (95% CI 0.85 to 0.92). Agreement of the four core CAM features ranged from fair to substantial. The sensitivity and specificity for identifying delirium were 72% (95% CI 60% to 81%) and 99% (95% CI 96% to 100%), considering an expert rater's scores as the reference standard (delirious, n=3; non-delirious, n=6). Delirium severity ratings were tightly clustered, with most scores within 5% of the median. CONCLUSION Our results demonstrate that, with appropriate training and ongoing scoring discussions, researchers at multiple sites can reliably detect delirium in postsurgical patients. These results support the premise that methodologically rigorous multi-centre studies can yield standardised and accurate determinations of delirium.
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Affiliation(s)
- Hannah R Maybrier
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Krisztina E Escallier
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Nan Lin
- Department of Mathematics, Washington University in Saint Louis, St. Louis, Missouri, USA
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Ravi T Upadhyayula
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kerry Palihnich
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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Kang B, Kim YJ, Suh SW, Son KL, Ahn GS, Park HY. Delirium and its consequences in the specialized palliative care unit: Validation of the Korean version of Memorial Delirium Assessment Scale. Psychooncology 2018; 28:160-166. [DOI: 10.1002/pon.4926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/09/2018] [Accepted: 10/18/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Beodeul Kang
- Department of Internal Medicine, Yonsei Cancer Center; Yonsei University College of Medicine; Seoul South Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine; Seoul National University Bundang Hospital; Seongnam South Korea
| | - Seung Wan Suh
- Department of Psychiatry; Seoul National University Bundang Hospital; Seongnam South Korea
| | - Kyung-Lak Son
- Department of Psychiatry; Dongguk University Ilsan Hospital; Goyang South Korea
| | - Grace S. Ahn
- Division of Hematology and Medical Oncology, Department of Internal Medicine; Seoul National University Bundang Hospital; Seongnam South Korea
| | - Hye Youn Park
- Department of Psychiatry; Seoul National University Bundang Hospital; Seongnam South Korea
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Alosaimi FD, Alghamdi A, Alsuhaibani R, Alhammad G, Albatili A, Albatly L, Althomali B, Aljamaan F, Maldonado JR. Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients. J Psychosom Res 2018; 114:8-14. [PMID: 30314583 DOI: 10.1016/j.jpsychores.2018.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings. METHODS A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). RESULTS A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients. CONCLUSION The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.
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Affiliation(s)
- Fahad D Alosaimi
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia.
| | - Ayedh Alghamdi
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Raya Alsuhaibani
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Ghadah Alhammad
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Amjad Albatili
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Latifah Albatly
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Bandar Althomali
- Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- Department of Critical Care Medicine, King Saud University, Riyadh, Saudi Arabia
| | - José R Maldonado
- Psychosomatic Medicine Service, Departments of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Perioperative dexmedetomidine reduces delirium after cardiac surgery: A meta-analysis of randomized controlled trials. J Clin Anesth 2018; 50:33-42. [DOI: 10.1016/j.jclinane.2018.06.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/19/2018] [Accepted: 06/21/2018] [Indexed: 11/19/2022]
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Balková M, Tomagová M. Use of measurement tools for screening of postoperative delirium in nursing practice. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2018. [DOI: 10.15452/cejnm.2018.09.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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145
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Susano MJ, Vasconcelos L, Lemos T, Amorim P, Abelha FJ. Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 30049480 PMCID: PMC9391822 DOI: 10.1016/j.bjane.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background and objectives Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists’ perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients. Methods We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don’t know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals. Results We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology. Conclusions Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.
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Affiliation(s)
- Maria J Susano
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal; Centro Hospitalar do Porto, Centro de Investigação Clínica em Anestesiologia, Departamento de Anestesiologia, Porto, Portugal.
| | | | - Tiago Lemos
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal
| | - Pedro Amorim
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal; Centro Hospitalar do Porto, Centro de Investigação Clínica em Anestesiologia, Departamento de Anestesiologia, Porto, Portugal
| | - Fernando J Abelha
- Universidade do Porto, Faculdade de Medicina, Centro Hospitalar de São João, Departamento de Anestesiologia e de Cirurgia e Fisiologia, Porto, Portugal
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146
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Bauernfreund Y, Butler M, Ragavan S, Sampson EL. TIME to think about delirium: improving detection and management on the acute medical unit. BMJ Open Qual 2018; 7:e000200. [PMID: 30167472 PMCID: PMC6109807 DOI: 10.1136/bmjoq-2017-000200] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/29/2018] [Accepted: 07/08/2018] [Indexed: 11/09/2022] Open
Abstract
Delirium affects 18%–35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.
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Affiliation(s)
| | | | - Sumathi Ragavan
- Care of the Elderly Department, North Middlesex Hospital, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London Medical School, London, UK.,Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex Hospital, London, UK
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147
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Susano MJ, Vasconcelos L, Lemos T, Amorim P, Abelha FJ. [Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists]. Rev Bras Anestesiol 2018; 68:472-483. [PMID: 30049480 DOI: 10.1016/j.bjan.2018.02.009] [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: 10/09/2017] [Accepted: 02/27/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists' perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients. METHODS We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don't know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals. RESULTS We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology. CONCLUSIONS Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.
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Affiliation(s)
- Maria J Susano
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal; Centro Hospitalar do Porto, Centro de Investigação Clínica em Anestesiologia, Departamento de Anestesiologia, Porto, Portugal.
| | | | - Tiago Lemos
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal
| | - Pedro Amorim
- Centro Hospitalar do Porto, Departamento de Anestesiologia, Porto, Portugal; Centro Hospitalar do Porto, Centro de Investigação Clínica em Anestesiologia, Departamento de Anestesiologia, Porto, Portugal
| | - Fernando J Abelha
- Universidade do Porto, Faculdade de Medicina, Centro Hospitalar de São João, Departamento de Anestesiologia e de Cirurgia e Fisiologia, Porto, Portugal
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Israni J, Lesser A, Kent T, Ko K. Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months. BMJ Open 2018; 8:e021258. [PMID: 29730630 PMCID: PMC5942463 DOI: 10.1136/bmjopen-2017-021258] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/08/2018] [Accepted: 03/19/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Delirium is common among seniors discharged from the emergency department (ED) and associated with increased risk of mortality. Prior research has addressed mortality associated with seniors discharged from the ED with delirium, however has generally relied on data from one or a small number of institutions and at single time points. OBJECTIVES Analyse mortality rates among seniors discharged from the ED with delirium up to 12 months at the national level. DESIGN Retrospective cohort study. SETTING Analysed data from the Centers for Medicare & Medicaid Services limited data sets for 2012-2013. PARTICIPANTS Medicare fee-for-service beneficiaries aged 65 years or older discharged from the ED. We focused on new incident cases of delirium, patients with any prior claims for delirium, hospice claims or end-stage renal disease were excluded. Sample size included 26 245 delirium claims, and a randomly selected sample of 262 450 controls. OUTCOME MEASURES Mortality within 12 months after discharge from the ED, excluding patients transferred or admitted as inpatients. RESULTS Among all beneficiaries, 46 508 (16.1%) died within 12 months, of which 39 404 (15.0%) were in the non-delirium (ie, control group) and 7104 (27.1%) were in the delirium cohort, respectively. Mortality was strongest at 30 days with an adjusted HR of 4.82 (95% CI 4.60 to 5.04). Over time, delirium was consistently associated with increased mortality risk compared with controls up to 12 months (HR 2.07; 95% CI 2.01 to 2.13). Covariates that affected mortality included older age, comorbidity and presence of dementia. CONCLUSIONS Our results demonstrate delirium is a significant marker of mortality among seniors in the ED, and mortality risk is most salient in the first 3 months following an ED visit. Given the significant clinical and financial implications, there is a need to increase delirium screening and management within the ED to help identify and treat this potentially fatal condition.
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Affiliation(s)
- Juhi Israni
- West Health Institute, San DIego, California, USA
| | | | - Tyler Kent
- West Health Institute, San DIego, California, USA
| | - Kelly Ko
- West Health Institute, San DIego, California, USA
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150
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Gotur DB. Delirium in the Critically Ill. JOURNAL OF MEDICAL SCIENCES AND HEALTH 2018. [DOI: 10.46347/jmsh.2018.v04i01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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