Epidemiology and risk factors for delirium across hospital settings

Angiotensin II Brings More Questions Than Answers

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Prospective cohort study.

SETTING

Single-site tertiary university teaching hospital.

PARTICIPANTS

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

INTERVENTIONS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Postoperative cognitive disorders: an update

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cholinesterase inhibitors for the treatment of delirium in non-ICU settings

BACKGROUND

Delirium is a common clinical syndrome defined as alterations in attention with an additional disturbance in cognition or perception, which develop over a short period of time and tend to fluctuate during the course of the episode. Delirium is commonly treated in hospitals or community settings and is often associated with multiple adverse outcomes such as increased cost, morbidity, and even mortality. The first-line intervention involves a multicomponent non-pharmacological approach that includes ensuring effective communication and reorientation in addition to providing reassurance or a suitable care environment. There are currently no drugs approved specifically for the treatment of delirium. Clinically, however, various medications are employed to provide symptomatic relief, such as antipsychotic medications and cholinesterase inhibitors, among others.

OBJECTIVES

To evaluate the effectiveness and safety of cholinesterase inhibitors for treating people with established delirium in a non-intensive care unit (ICU) setting.

SEARCH METHODS

We searched ALOIS, which is the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 26 October 2017. We also cross-checked the reference lists of included studies to identify any potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials, published or unpublished, reported in English or Chinese, which compared cholinesterase inhibitors to placebo or other drugs intended to treat people with established delirium in a non-ICU setting.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were duration of delirium, severity of delirium, and adverse events. The secondary outcomes were use of rescue medications, persistent cognitive impairment, length of hospitalisation, institutionalisation, mortality, cost of intervention, leaving the study early, and quality of life. For dichotomous outcomes, we calculated the risk ratio (RR) with 95% confidence intervals (CIs); for continuous outcomes we calculated the mean difference (MD) with 95% CIs. We assessed the quality of evidence using GRADE to generate a 'Summary of findings' table.

MAIN RESULTS

We included one study involving 15 participants from the UK. The included participants were diagnosed with delirium based on the Confusion Assessment Method (CAM) criteria. Eight males and seven females were included, with a mean age of 82.5 years. Seven of the 15 participants had comorbid dementia at baseline. The risk of bias was low in all domains.The study compared rivastigmine with placebo. We did not find any clear differences between the two groups in terms of duration of delirium (MD -3.6, 95% CI -15.6 to 8.4), adverse events (nausea, RR 0.30, 95% CI 0.01 to 6.29), use of rescue medications (RR 0.13, 95% CI 0.01 to 2.1), mortality (RR 0.10, 95% CI 0.01 to 1.56), and leaving the study early (RR 0.88, 95% CI 0.07 to 11.54). Evidence was not available regarding the severity of delirium, persistent cognitive impairment, length of hospitalisation, cost of intervention, or other predefined secondary outcomes.The quality of evidence is low due to the very small sample size.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the use of cholinesterase inhibitors for the treatment of delirium in non-ICU settings. No clear benefits or harms associated with cholinesterase inhibitors were observed when compared with placebo due to the lack of data. More trials are required.

Antipsychotics for treatment of delirium in hospitalised non-ICU patients

BACKGROUND

Guidelines suggest limited and cautious use of antipsychotics for treatment of delirium where nonpharmacological interventions have failed and symptoms remain distressing or dangerous, or both. It is unclear how well these recommendations are supported by current evidence.

OBJECTIVES

Our primary objective was to assess the efficacy of antipsychotics versus nonantipsychotics or placebo on the duration of delirium in hospitalised adults. Our secondary objectives were to compare the efficacy of: 1) antipsychotics versus nonantipsychotics or placebo on delirium severity and resolution, mortality, hospital length of stay, discharge disposition, health-related quality of life, and adverse effects; and 2) atypical vs. typical antipsychotics for reducing delirium duration, severity, and resolution, hospital mortality and length of stay, discharge disposition, health-related quality of life, and adverse effects.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane EBM Reviews, CINAHL, Thomson Reuters Web of Science and the Latin American and Caribbean Health Sciences Literature (LILACS) from their respective inception dates until July 2017. We also searched the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database, Web of Science ISI Proceedings, and other grey literature.

SELECTION CRITERIA

We included randomised and quasi-randomised trials comparing 1) antipsychotics to nonantipsychotics or placebo and 2) typical to atypical antipsychotics for the treatment of delirium in adult hospitalised (but not critically ill) patients.

DATA COLLECTION AND ANALYSIS

We examined titles and abstracts of identified studies to determine eligibility. We extracted data independently in duplicate. Disagreements were settled by further discussion and consensus. We used risk ratios (RR) with 95% confidence intervals (CI) as a measure of treatment effect for dichotomous outcomes, and between-group standardised mean differences (SMD) with 95% CI for continuous outcomes.

MAIN RESULTS

We included nine trials that recruited 727 participants. Four of the nine trials included a comparison of an antipsychotic to a nonantipsychotic drug or placebo and seven included a comparison of a typical to an atypical antipsychotic. The study populations included hospitalised medical, surgical, and palliative patients.No trial reported on duration of delirium. Antipsychotic treatment did not reduce delirium severity compared to nonantipsychotic drugs (standard mean difference (SMD) -1.08, 95% CI -2.55 to 0.39; four studies; 494 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (SMD -0.17, 95% CI -0.37 to 0.02; seven studies; 542 participants; low-quality evidence). There was no evidence antipsychotics resolved delirium symptoms compared to nonantipsychotic drug regimens (RR 0.95, 95% CI 0.30 to 2.98; three studies; 247 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (RR 1.10, 95% CI 0.79 to 1.52; five studies; 349 participants; low-quality evidence). The pooled results indicated that antipsychotics did not alter mortality compared to nonantipsychotic regimens (RR 1.29, 95% CI 0.73 to 2.27; three studies; 319 participants; low-quality evidence) nor was there a difference between typical and atypical antipsychotics (RR 1.71, 95% CI 0.82 to 3.35; four studies; 342 participants; low-quality evidence).No trial reported on hospital length of stay, hospital discharge disposition, or health-related quality of life. Adverse event reporting was limited and measured with inconsistent methods; in those reporting events, the number of events were low. No trial reported on physical restraint use, long-term cognitive outcomes, cerebrovascular events, or QTc prolongation (i.e. increased time in the heart's electrical cycle). Only one trial reported on arrhythmias and seizures, with no difference between typical or atypical antipsychotics. We found antipsychotics did not have a higher risk of extrapyramidal symptoms (EPS) compared to nonantipsychotic drugs (RR 1.70, 95% CI 0.04 to 65.57; three studies; 247 participants; very-low quality evidence); pooled results showed no increased risk of EPS with typical antipsychotics compared to atypical antipsychotics (RR 12.16, 95% CI 0.55 to 269.52; two studies; 198 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There were no reported data to determine whether antipsychotics altered the duration of delirium, length of hospital stay, discharge disposition, or health-related quality of life as studies did not report on these outcomes. From the poor quality data available, we found antipsychotics did not reduce delirium severity, resolve symptoms, or alter mortality. Adverse effects were poorly or rarely reported in the trials. Extrapyramidal symptoms were not more frequent with antipsychotics compared to nonantipsychotic drug regimens, and no different for typical compared to atypical antipsychotics.

Providing Palliative Care in the Medical ICU: A Qualitative Study of MICU Physicians' Beliefs and Practices

CONTEXT

With the current and projected shortage of palliative care (PC) specialists, an integrative model of PC will be needed to meet the needs of patients in intensive care units (ICUs). Prior studies of PC interventions suggest that success depends upon meeting the needs of individual institutions or ICUs.

OBJECTIVE

The objective of this study was to qualitatively explore the beliefs and practices of one institution's medical ICU (MICU) physicians in regard to providing an integrative model of PC.

METHODS

This qualitative study used semistructured interviews of 17 physicians within a Department of Allergy, Pulmonary, and Critical Care Medicine at one large academic hospital. Interviews were conducted, transcribed, and coded according to qualitative research methods. Selected interviews were tested for interrater reliability and negotiated agreeability.

RESULTS

All critical care physicians interviewed affirmed that providing PC was part of their job, and the majority expressed that providing PC gave them professional or personal satisfaction. Physicians also identified many ways that PC consultants enhance patient care in the MICU. They discussed several motivations for obtaining a PC consult, with the most frequently acknowledged motivation being lack of time.

CONCLUSION

Developing an integrative model of PC in the ICU ought to take into account both studied interventions shown likely to be effective in the ICU setting and the specific needs and barriers to PC in that unit. This study demonstrates one way that needs and barriers can be identified and provides important findings that might be applicable to other institutions.

Tools to screen and measure cognitive impairment after surgery and anesthesia

Cognition is essential to all aspects of our everyday life. Although we take our cognitive function for granted, the perioperative period is prone to several aggressions that might impair it. Postoperative cognitive dysfunction, has been the aim of many studies recently, and was shown to be very common with an incidence that can reach 40%, yielding not only impairment in cognition, but also longer hospital stays, higher costs and greater mortality. While several studies have revealed some of the mechanisms contributing to postoperative cognitive dysfunction, the search for the perfect instrument to screen and measure cognitive (dys)function has proven more elusive. The present paper aims to review several cognitive evaluation methods, discussing their advantages and disadvantages as well as their potential clinical applications in evaluating the dynamics of the recovery of cognitive function after anesthesia and surgery. The current availability of easy to use computerized tests might provide the tools necessary to identify patients at risk, and promptly provide them with the adequate course of action.

Prevalence and risk factors for delirium diagnosis in patients followed in general practices in Germany

ABSTRACTBackground:The aim of this study is to identify the prevalence and risk factors of documented delirium in general practices in Germany.

METHODS

The present study includes 2,194 patients over the age of 65 years with delirium and 2,194 controls without delirium from a sample of 6,180,042 patients from 1,262 general practices. Multivariate logistic regression models were fitted with delirium as a dependent variable and other disorders and drugs as potential predictors.

RESULTS

A five-year-prevalence of 0.08% and an average of 0.7 (SD: 1.5) patients per practice per year were found. Among the study participants, 43.0% were men, and the mean age was 82.2 years (SD = 7.1 years). 24.2% of delirium patients and 10.3% of controls lived in nursing homes. Delirium was found to be positively associated with nursing home residence (OR: 1.69), dementia (OR = 3.45), epilepsy (OR = 2.16), stroke (OR = 1.80), Parkinson's disease (OR = 1.78), sleep disorder (OR = 1.64), renal insufficiency (OR = 1.57), fractures (OR = 1.56), and the prescription of benzodiazepines (OR = 1.62) and antiepileptics (OR = 1.53). Finally, the number of different drug classes prescribed within one year prior to the index date was positively associated with a risk of delirium. Compared to patients without medication therapy, the OR for delirium was 3.21 when more than four drug classes were prescribed.

CONCLUSIONS

In primary care, neuropsychiatric risk factors and polymedication were particularly important for the diagnosis of delirium compared to inpatient care. The methodological limitations of the analysis of data from routine care must be considered. Delirium is rarely diagnosed in primary care. Risk factors in primary care differ from those found in inpatient care. The reasons for this need to be further investigated.

Safety of brotizolam in hospitalized patients

PURPOSE

The objective of this study was to evaluate the safety of brotizolam in hospitalized patients.

METHODS

A single-center, comparative retrospective cohort analysis of patients hospitalized in internal medicine wards. Patients treated with brotizolam were compared to patients not treated with any benzodiazepines during hospitalization. Primary outcome was any of the following safety events: mechanical ventilation, delirium, and falls.

RESULTS

Six hundred patients were included after exclusion in the final analysis; 300 treated with brotizolam (treatment) and 300 not treated with any benzodiazepines (comparator). The brotizolam-treated patients were older with more comorbidities and psychotropic medications. After adjustment using multivariate logistic regression analysis with propensity score, the primary outcomes occurred at significantly higher rates in treated patients than in untreated patients (17 vs. 2 events; OR = 7.33). Any psychotropic medication administered during hospitalization was found by logistic regression to be the main independent risk factor for the studied safety outcomes while age, comorbidities, and the cause of hospitalization were not.

CONCLUSIONS

Treatment with brotizolam during hospitalization in internal medicine wards is linked to a higher risk of respiratory deterioration, delirium, and falls. Use of psychotropic medications during hospitalization is the main independent risk factor of safety outcomes. Further research is needed to fully evaluate the risks and benefits of sleep induction medications in hospitals.

Genome-wide association identifies a novel locus for delirium risk

We aimed to identify common genetic variations associated with delirium through genome-wide association testing in a hospital biobank. We applied a published electronic health record-based definition of delirium to identify cases of delirium, and control individuals with no history of delirium, from a biobank spanning 2 Boston academic medical centers. Among 6035 individuals of northern European ancestry, including 421 with a history of delirium, we used logistic regression to examine genome-wide association. We identified one locus spanning multiple genes, including 3 interleukin-related genes, associated with p = 1.41e-8, and 5 other independent loci with p < 5e-7. Our results do not support previously reported candidate gene associations in delirium. Identifying common-variant associations with delirium may provide insight into the mechanisms responsible for this complex and multifactorial outcome. Using standardized claims-based phenotypes in biobanks should allow the larger scale investigations required to confirm novel loci such as the one we identify.

Diagnostic Overshadowing of the Psychiatric Population in the Emergency Department: Physiological Factors Identified for an Early Warning System

BACKGROUND

Many people with mental disorders in the United States remain either medically untreated or inadequately treated, which is often attributed to diagnostic overshadowing, a common occurrence across the nation in emergency departments.

OBJECTIVE

The aim of this research is to create a tool that supports accurate assessment and distinguishing behavioral symptoms between psychiatric illness and coexisting medical conditions in the emergency department, thus leading to appropriate care and placement.

DESIGN

Retrospective cohort design of 133 psychiatric admissions were reviewed between the years 2011 and 2015.

RESULTS

Logistic regression retained three factors: age greater than 70 years (odds ratio [OR] = 6.575, 95% confidence interval [CI] = 2.58-16.76), abnormal heart rate (OR = 8.48, 95% CI = 3.39-28.42), and abnormal temperature (OR = 9.82, 95% CI = 3.91-18.40). The three factors were then placed into a screening tool. The presence of each factor equaled 1 point. If the total score was greater than 2, the sensitivity of the tool was 68.7% and the specificity of the tool was 85.8%.

CONCLUSIONS

Coexisting medical conditions in the psychiatric population may present as behavioral symptoms; however, the use of a tool that focuses assessment toward medical factors such as abnormal heart rate, abnormal temperature, and advanced age can direct further investigation of behavioral symptoms.

Neuroprotective effect of bispectral index-guided fast-track anesthesia using sevoflurane combined with dexmedetomidine for intracranial aneurysm embolization

Dexmedetomidine has sedative, anxiolytic, analgesic, anti-sympathetic, and anti-shivering effects. Dexmedetomidine might be effective in combination with sevoflurane for anesthesia, but prospective randomized controlled clinical trials with which to verify this hypothesis are lacking. In total, 120 patients who underwent embolization of an intracranial aneurysm were recruited from Anhui Provincial Hospital and Renmin Hospital of Wuhan University of China and randomly allocated to two groups. After intraoperative administration of 2% to 3% sevoflurane inhalation, one group of patients received pump-controlled intravenous injection of 1.0 μg/kg dexmedetomidine for 15 minutes followed by maintenance with 0.3 μg/kg/h until the end of surgery; the other group of patients only underwent pump-controlled infusion of saline. Bispectral index monitoring revealed that dexmedetomidine-assisted anesthesia can shorten the recovery time of spontaneous breathing, time to eye opening, and time to laryngeal mask removal. Before anesthetic induction and immediately after laryngeal mask airway removal, the glucose and lactate levels were low, the S100β and neuron-specific enolase levels were low, the perioperative blood pressure and heart rate were stable, and postoperative delirium was minimal. These findings indicate that dexmedetomidine can effectively assist sevoflurane for anesthesia during surgical embolization of intracranial aneurysms, shorten the time to consciousness and extubation, reduce the stress response and energy metabolism, stabilize hemodynamic parameters, and reduce adverse reactions, thereby reducing the damage to the central nervous system. This trial was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/) (registration number: ChiCTR-IPR-16008113).

Patient-Reported Outcome Measures (PROM) as A Preoperative Assessment Tool

AIM OF REVIEW

Patient-reported outcomes (PRO) on functional, social, and behavioral factors might be important preoperative predictors of postoperative outcomes. We conducted a literature review to explore associations of preoperative depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, and nutritional status with surgical outcomes.

METHODS

Two electronic data bases, including PubMed and Google Scholar, were searched linking either depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, or nutritional status with surgery, postoperative complications, or perioperative period within the past 2 decades.

RECENT FINDINGS

Preoperative depression has been linked to postoperative delirium, complications, persistent pain, longer lengths of stay, and mortality. Socioeconomic status associates with overall and cancer-free survival. Low socioeconomic status has also been connected to medication non- compliance. Social support can predict overall and cancer- free survival, as well as physical, social and emotional quality of life. Poor functional status and frailty have been related to postoperative complications, longer lengths of stay, post-discharge institutionalization, and higher costs. Preoperative cognitive impairment also associates with self-medication management errors, postoperative cognitive impairment, delirium, complications and mortality. In addition, a greater tendency for reduced adherence to preoperative medication instructions has been linked to health illiteracy. Preoperative malnutrition is prevalent and associates with postoperative morbidity.

CONCLUSION

Efficient and effective assessments of social and behavioral determinants of health, functional status, health literacy, patient's perception of health, and preferences for self-management may improve postoperative management and surgical outcomes, particularly among vulnerable patients undergoing elective surgery who might have subtle physical, social, or psychological deficits or challenges, otherwise missed upon routine evaluation. Patient Reported Outcome Measures (PROMs) can be used to effectively and efficiently collect these factors in the preoperative period, thereby identifying areas that can be intervened preemptively. (Partially Funded by the National Institute on Aging and the Wake Forest University Claude D. Pepper Older Americans Independence Center.).

Fluoroquinolone-Related Neuropsychiatric Events in Hospitalized Veterans

OBJECTIVE

To measure the incidence and risk factors for fluoroquinolone (ciprofloxacin, moxifloxacin, and levofloxacin)-associated psychosis or delirium in a veteran population.

METHODS

A retrospective study was conducted in the Western New York Veterans Affairs Health System (2005-2013). Participants were hospitalized veterans receiving a fluoroquinolone for at least 48 hours (n = 631). Cases of delirium or psychosis were defined by the Diagnostic and Statistical Manual of Mental Disorders-IV criteria, and the Naranjo scale (score ≥ 1) was used to determine the probability of the adverse drug reaction being related to fluoroquinolones. A bivariate analysis of covariates followed by a multivariate logistic regression was used to determine predisposing factors to the development of delirium/psychosis.

RESULTS

The mean age of the population was 71.5 years (range: 22-95). Fluoroquinolone-associated delirium/psychosis occurred in 3.7% of the inpatients studied (n = 23). The median Naranjo score was 3 indicating a possible association. Psychosis/delirium occurred in 3.6% of ciprofloxacin-treated patients (n = 14/391), 4.5% of patients-treated with moxifloxacin (n = 9/200), and 0% of those receiving levofloxacin (n = 0/40); p = 0.4. Significant risk factors for development of delirium/psychosis in patients receiving a fluoroquinolone in the multivariate logistical regression included typical antipsychotic use (OR, 5.4; 95% CI: 1.4-16.7) and age. A 10-year increase in age was associated with a 1.8-fold greater odds of a neuropsychiatric event.

CONCLUSIONS

Fluoroquinolones may be more commonly associated with delirium/psychosis than originally reported in this veteran population. Caution should be used when prescribing a fluoroquinolone for patients on typical antipsychotics and those of advanced age.

Psychiatric symptomatology after delirium: a systematic review

Delirium is an acute and usually transient severe neuropsychiatric syndrome associated with significant long-term physical morbidity. However, its chronic psychiatric sequelae remain poorly characterized. To investigate the prevalence of psychiatric symptoms, namely anxiety, depressive, and post-traumatic stress disorder (PTSD) symptoms after delirium, a systematic literature search of MEDLINE, EMBASE and PsycINFO databases was performed independently by two authors in March 2016. Bibliographies were hand-searched, and a forward- and backward-citation search using Web of Science was performed for all included studies. Of 6411 titles, we included eight prospective cohort studies, including 370 patients with delirium and 1073 without delirium. Studies were heterogeneous and mostly included older people from a range of clinical groups. Consideration of confounders was variable. The prevalence of depressive symptoms was almost three times higher in patients with delirium than in patients without delirium (22.2% vs 8.0%, risk ratio = 2.79; 95% confidence interval = 1.36-5.73). There was no statistically significant difference between the prevalence of anxiety symptoms between patients with and without delirium. The prevalence of PTSD symptoms after delirium was inconclusive: only one study investigated this and no association between PTSD symptoms after delirium was reported. There is limited published evidence of the prevalence of psychiatric symptoms after non-ICU delirium and the strongest evidence is for depressive symptoms. Further longitudinal studies are warranted to investigate the prevalence of anxiety and PTSD symptoms.

Utilization of healthcare services among elderly with cognitive impairment no dementia and influence of depression and anxiety: a longitudinal study

OBJECTIVES

Little objective and nationally representative data are available concerning the influence of cognitive impairment no dementia (CIND) on utilization of healthcare services. The main objective was to compare the use of healthcare services over three years, between elders with current or incident CIND and those without CIND. A second objective was to evaluate the effect of depression and anxiety.

METHODS

Cross-sectional and longitudinal data from a population-based survey of 2265 older adults living in Quebec (Canada) were used. CIND was identified using normative data for the Mini-Mental State Examination and was linked with medical records from public health insurance plan. Multinomial logistic regressions adjusted for relevant socio-demographic, social network and health-related confounders were conducted for each service. Interaction between CIND and depression/anxiety was also examined.

MAIN RESULTS

Current CIND was a predictor of longer anxiolytic/sedative/hypnotic medication use. Incident CIND led to longer hospital stay. Depression raised the likelihood of frequenting geriatricians, psychiatrists or neurologists and emergency department, but lessened the likelihood of visiting general practitioners. The addition of the psychiatric conditions to the incident CIND did not increase the likelihood of consuming antidepressants, while the incident CIND cases without psychiatric conditions increased this likelihood.

DISCUSSION

Compared to older adults without CIND, older adults with CIND have a distinct utilization of healthcare services. Multiple evaluations over many years may help to better understand the utilization of healthcare services in individuals with CIND. In the meantime, evaluations of these conditions at key moments could allow a more efficient use of health resources.

Identifying delirium in older adults with pre-existing mental illness

Acute delirium complicates care and can be easily overlooked in older adults with preexisting mental illness. Evidence-based measures have demonstrated that early diagnosis, identification, and correction of modifiable factors can lead to improved care and less morbidity in these patients.

Environmental and Clinical Risk Factors for Delirium in a Neurosurgical Center: A Prospective Study

BACKGROUND

Few reports of delirium-related risk factors have focused on environmental risk factors and clinical risk factors, such as white matter signal abnormalities on magnetic resonance imaging fluid attenuated inversion recovery images.

METHODS

We prospectively enrolled 253 patients admitted to our neurosurgical center between December 2014 and June 2015 and analyzed 220 patients (100 male patients; mean age, 64.1 years; age range, 17-92 years). An Intensive Care Delirium Screening Checklist score ≥4 points indicated delirium. We evaluated patient factors consisting of baseline characteristics and related factors, such as white matter lesions (WMLs), as well as the surrounding environment.

RESULTS

Delirium occurred in 29/220 cases (13.2%). Regarding baseline characteristics, there were significant statistical correlations between delirium and age (P = 0.0187), Hasegawa Dementia Scale-Revised score (P = 0.0022) on admission, and WMLs (P < 0.0001). WMLs were related to age (P < 0.0001) and atherosclerotic disease (P = 0.004). Regarding related factors, there were significant statistical correlations between delirium and stay in a neurosurgical care unit (P = 0.0245). Multivariate logistic regression analyses showed statistically significant correlations of delirium with WMLs (P < 0.0001) and surrounding patients with delirium (P = 0.026).

CONCLUSIONS

WMLs in patients and the surrounding environment are risk factors for delirium in a neurosurgical center. To prevent delirium, clinicians must recognize risk factors, such as high-grade WMLs, and manage environmental factors.

The incidence of delirium after cardiac surgery in the elderly: protocol for a systematic review and meta-analysis

INTRODUCTION

Delirium is one of the most common complications after cardiac surgery in the elderly. Future studies aimed at preventing postoperative delirium will need an accurate estimate of incidence. However, there are no available systematic reviews on the incidence, and reports of incidence of postoperative delirium after a cardiac operation vary widely with significant heterogeneity. Therefore, we aim to perform a systematic review and meta-analysis to determine the most accurate incidence possible of postoperative delirium in individuals aged >65 years after cardiac surgery.

METHODS AND ANALYSES

We will undertake a comprehensive literature search among PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL, from their inception to January 2017. Prospective cohort and cross sectional studies that described the incidence of delirium will be eligible for inclusion. The primary outcome will be the incidence of delirium. Risk of bias and methodological quality for the included studies will be assessed using a risk of bias tool for prevalence studies and the Cochrane guidelines. Heterogeneity of the estimates across studies will be assessed. Incidence data will be pooled by selective or emergency surgery. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

ETHICS AND DISSEMINATION

This proposed systematic review and meta-analysis is based on published data, and thus there is no requirement for ethics approval. The study will provide an up to date and accurate incidence of postoperative delirium among the older population after cardiac surgery, which is necessary for future research in this area. The findings of this study will be presented at conferences and disseminated through publication in a peer reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42016047773.

Sleep Disruption at Home As an Independent Risk Factor for Postoperative Delirium

OBJECTIVES

To determine whether sleep disruption at home or in hospital is an independent risk factor for postoperative delirium in older adults undergoing elective surgery.

DESIGN

Prospective cohort study.

SETTING

German teaching hospital.

PARTICIPANTS

Individuals aged 65 and older undergoing elective arthroplasty (N = 101).

MEASUREMENTS

Preoperative questionnaires were used to assess sleep disruption at home (Pittsburgh Sleep Quality Index). Actigraphy was used to objectively measure sleep disruption in the hospital before and after surgery. Delirium was assessed daily after surgery using the Confusion Assessment Method and, if there was uncertainty, validated according to International Classification of Diseases, Tenth Revision (ICD-10), criteria.

RESULTS

Twenty-seven participants developed postoperative delirium. Those with sleep disruption at home were 3.26 times as likely to develop postoperative delirium as those without (95% confidence interval (CI) = 1.34-7.92, P = .009). Participants with sleep disruption in hospital were 1.21 times as likely to develop postoperative delirium as those without (95% CI = 1.03-1.41, P = .02). When adjusting for other variables, risk remained significant for sleep disruption at home (risk ratio (RR) = 3.90, 95% CI = 2.14-7.11, P < .001) but not in the hospital (RR = 1.19, 95% CI = 0.69-2.07). Jointly modeling sleep disruption at home and in the hospital, adjusted for covariates, resulted in significant contributions of both (home: RR = 3.10, 95% CI = 1.34-7.17, P = .008; hospital: RR = 1.38 95% CI = 1.13-1.68, P = .002).

CONCLUSIONS

Older people with sleep disruption at home are at significantly higher risk of developing postoperative delirium than those without. Sleep disruption in the hospital may further heighten this risk.

Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Delirium is a postoperative complication that occurs frequently in patients older than 65 years, and presages adverse outcomes. We investigated whether prophylactic low-dose dexmedetomidine, a highly selective α₂ adrenoceptor agonist, could safely decrease the incidence of delirium in elderly patients after non-cardiac surgery.

METHODS

We did this randomised, double-blind, placebo-controlled trial in two tertiary-care hospitals in Beijing, China. We enrolled patients aged 65 years or older, who were admitted to intensive care units after non-cardiac surgery, with informed consent. We used a computer-generated randomisation sequence (in a 1:1 ratio) to randomly assign patients to receive either intravenous dexmedetomidine (0·1 μg/kg per h, from intensive care unit admission on the day of surgery until 0800 h on postoperative day 1), or placebo (intravenous normal saline). Participants, care providers, and investigators were all masked to group assignment. The primary endpoint was the incidence of delirium, assessed twice daily with the Confusion Assessment Method for intensive care units during the first 7 postoperative days. Analyses were done by intention-to-treat and safety populations. This study is registered with Chinese Clinical Trial Registry, www.chictr.org.cn, number ChiCTR-TRC-10000802.

FINDINGS

Between Aug 17, 2011, and Nov 20, 2013, of 2016 patients assessed, 700 were randomly assigned to receive either placebo (n=350) or dexmedetomidine (n=350). The incidence of postoperative delirium was significantly lower in the dexmedetomidine group (32 [9%] of 350 patients) than in the placebo group (79 [23%] of 350 patients; odds ratio [OR] 0·35, 95% CI 0·22-0·54; p<0·0001). Regarding safety, the incidence of hypertension was higher with placebo (62 [18%] of 350 patients) than with dexmedetomidine (34 [10%] of 350 patients; 0·50, 0·32-0·78; p=0·002). Tachycardia was also higher in patients given placebo (48 [14%] of 350 patients) than in patients given dexmedetomidine (23 [7%] of 350 patients; 0·44, 0·26-0·75; p=0·002). Occurrence of hypotension and bradycardia did not differ between groups.

INTERPRETATION

For patients aged over 65 years who are admitted to the intensive care unit after non-cardiac surgery, prophylactic low-dose dexmedetomidine significantly decreases the occurrence of delirium during the first 7 days after surgery. The therapy is safe.

FUNDING

Braun Anaesthesia Scientific Research Fund and Wu Jieping Medical Foundation, Beijing, China. Study drugs were manufactured and supplied by Jiangsu Hengrui Medicine Co, Ltd, Jiangsu, China.

Postoperative use of hypnotics is associated with increased length of stay after uncomplicated surgery for colorectal cancer

Background/Aims:

Hypnotics are used to treat perioperative sleep disorders. These drugs are associated with a higher risk of adverse effects among patients undergoing surgery. This study aims to quantify the use of hypnotics and factors influencing the administration of hypnotics in relation to colorectal cancer surgery.

Method:

A retrospective cohort study of 1979 patients undergoing colorectal cancer surgery.

Results:

In all, 381 patients (19%) received new treatment with hypnotics. Two of the six surgical centres used hypnotics less often (odds ratio (95% confidence interval), 0.24 (0.16–0.38) and 0.20 (0.12–0.35)). Active smokers (odds ratio (95% confidence interval), 1.57 (1.11–2.24)) and patients receiving perioperative blood transfusion (odds ratio (95% confidence interval), 1.58 (1.10–2.26)) had increased likelihood of receiving hypnotics. In the uncomplicated cases, a multivariable linear regression analysis showed that consumption of hypnotics postoperatively was significantly associated with increased length of stay (1.5 (0.9–2.2) days).

Conclusion:

One in five patients began treatment with hypnotics after colorectal cancer surgery. Postoperative use of hypnotics was associated with an increased length of stay for uncomplicated cases of colorectal cancer surgery.

Comparative Study of Delirium in Emergency and Consultation Liaison- A Tertiary Care Hospital Based Study in Northern India

INTRODUCTION

Delirium is an acute and often fluctuating disturbance in level of consciousness and thought process (cognition) that develops over a short period of time and is a significant change from previous level of functioning. Its prevalence increases with age, complexity of medical co- morbidities and number of medications prescribed.

AIM

To compare the cause and severity of delirium in patients in emergency and consultation liaison psychiatry group.

MATERIALS AND METHODS

A cross-sectional, tertiary care hospital based study was conducted on the patients who presented with delirium from emergency department (50) and consultation-liaison psychiatry groups (50), over a period of one year. The diagnosis was made on the basis of DSM- 5 criteria. The Delirium Rating Scale (DRS-R-98) was applied to know the severity of delirium, cognitive and non-cognitive symptoms of delirium in patients. The results were subjected to appropriate statistical analysis.

RESULTS

In emergency group, 42% patients had metabolic abnormalities, while in consultation-liaison, 38% patients had hyponatremia and hypokalemia and the difference was found to be statistically non-significant (p>0.05). In emergency group, 21(42%) patients were diagnosed as delirium due to other medical condition, followed by 13 (26%) and 8(16%) patients, who were diagnosed as delirium due to multiple aetiologies and substance intoxication each respectively. In only 33(66%) cases in consultation liaison group patients had delirium secondary to other medical conditions. As per DRS-R98 Scale, mean severity score was found to be statistically significant (p<0.05) in consultation liaison group as compared to emergency department group (p> 0.05).

CONCLUSION

Delirium is multifactorial aetiological disease, with variable but preventable outcome. Approach should be aimed at finding the treatable causes to reduce morbidity and mortality.

Recent trends in surgical research of cancer treatment in the elderly, with a primary focus on lung cancer: Presentation at the 2015 annual meeting of SIOG

Surgical research concentrating on cancer in the elderly has changed from small single institution outcome studies of carefully selected patients to larger studies that test specific aspects of surgical selection, treatment, and outcome. The purpose of this paper is to review major new trends in surgical geriatric oncology research within the last decade. Reviewing PubMed listings of the last 10years reveals several identifiable areas of particular concentration. Although we use specific studies primarily from lung cancer treatment, the generalizations can be seen across the spectrum of geriatric cancers. These trends include screening for disease that can be successfully treated, integration of operative and non-operative therapies that are changing the indications for surgery, the use of prehabilitation to allow more borderline frail patients to be treated surgically, the use of rehabilitation to facilitate rapid and complete recovery, prevention and treatment of common morbidities, with a special recent focus on delirium and cognitive impairment. New areas of surgical research include research on team building in the OR and ICU. Recent surgical research is becoming quantitative and multi-institutionally based. Overall surgical mortality has dropped over the past 25years in both academic and community hospitals. Prevention of morbidity and loss of functional status is a major focus of research. Funding for new Quality Assurance Projects for elderly patients has been awarded to the American College of Surgeons, and should provide multi-institutional quality outcome data within 5years.

Battery of behavioral tests in mice to study postoperative delirium

Postoperative delirium is associated with increased morbidity, mortality and cost. However, its neuropathogenesis remains largely unknown, partially owing to lack of animal model(s). We therefore set out to employ a battery of behavior tests, including natural and learned behavior, in mice to determine the effects of laparotomy under isoflurane anesthesia (Anesthesia/Surgery) on these behaviors. The mice were tested at 24 hours before and at 6, 9 and 24 hours after the Anesthesia/Surgery. Composite Z scores were calculated. Cyclosporine A, an inhibitor of mitochondria permeability transient pore, was used to determine potential mitochondria-associated mechanisms of these behavioral changes. Anesthesia/Surgery selectively impaired behaviors, including latency to eat food in buried food test, freezing time and time spent in the center in open field test, and entries and duration in the novel arm of Y maze test, with acute onset and various timecourse. The composite Z scores quantitatively demonstrated the Anesthesia/Surgery-induced behavior impairment in mice. Cyclosporine A selectively ameliorated the Anesthesia/Surgery-induced reduction in ATP levels, the increases in latency to eat food, and the decreases in entries in the novel arm. These findings suggest that we could use a battery of behavior tests to establish a mouse model to study postoperative delirium.

Decreases in cerebral saturation in patients with septic shock are associated with increased risk of death: a prospective observational single center study

Background

The mortality rate from septic shock has been declining. Cerebral hypoxia, measured non-invasively with cerebral oximetry, has been correlated with neurologic and non-neurologic sequelae. Whether cerebral desaturations occur in septic shock patients and what consequences these may have is untested.

Methods

Adult patients with septic shock had cerebral saturation monitoring initiated. The primary objective was to determine if the incidence and magnitude of cerebral desaturations in septic shock patients correlated with delirium. We also compared the incidence and magnitude of cerebral desaturations in patients with septic shock with patients undergoing high-risk non-cardiac surgical procedures, a group known to be at high risk for cerebral desaturations.

Results

Fifteen patients were enrolled. Twelve (80 %) patients had a decrease in SctO₂ below 65 %. Delirium was not associated with the area under the curve of an SctO₂ of 65 % (p = 0.84).

Patients who died of septic shock had more significant decreases in SctO₂ than those who survived (p = 0.04).

Decreased SctO₂ was more common in patients with septic shock and was of greater magnitude than those undergoing high-risk non-cardiac surgery.

Conclusions

Cerebral desaturations occur more commonly and are of a greater magnitude in septic shock patients compared with those undergoing high-risk non-cardiac surgery. There did not appear to be a relationship between the incidence or magnitude of decreases in SctO₂ and ICU delirium. Patients who died of septic shock had more significant decreases in SctO₂ than patients who survived.

Triggers and nursing influences on delirium in intensive care units

Among care providers, nurses have the most influence on the occurrence of delirium in patients. To identify and investigate the risk factors associated with delirium and analyse the nurse's influence on delirium, a secondary data analysis approach was used with clinical data from the electronic medical record and health care provider data from the management information systems of a university hospital. Data of 3284 patients (delirium = 688, non-delirium = 2596) hospitalized in the medical and surgical intensive care units containing 2178 variables were analysed. Donabedian's structure-process-outcome model was applied to categorize the factors for multilevel hierarchical logistic regression analysis. Sixteen factors (10 patient factors, 1 provider factor, 1 environmental factor, 2 nursing intervention factors and 2 medical intervention factors) were identified as significant in the final model. Longer intensive care unit experience of nurses did not decrease the risk of delirium. Greater number of nursing intervention needs and greater use of restraints were associated with an increased risk of delirium. The duration of nursing career did not affect the reduction of the risk of delirium. Nurses should therefore endeavour to acquire nursing experience specific for delirium care and attend training courses for delirium management.

Depressive Symptoms and Risk of Postoperative Delirium

OBJECTIVE

Previous studies have shown that elevated depressive symptoms are associated with increased risk of postoperative delirium. However, to our knowledge no previous studies have examined whether different components of depression are differentially predictive of postoperative delirium.

METHODS

One thousand twenty patients were screened for postoperative delirium using the Confusion Assessment Method and through retrospective chart review. Patients underwent cognitive, psychosocial, and medical assessments preoperatively. Depression was assessed using the Geriatric Depression Scale-Short Form.

RESULTS

Thirty-eight patients developed delirium (3.7%). Using a factor structure previously validated among geriatric medical patients, the authors examined three components of depression as predictors of postoperative delirium: negative affect, cognitive distress, and behavioral inactivity. In multivariate analyses controlling for age, education, comorbidities, and cognitive function, the authors found that greater behavioral inactivity was associated with increased risk of delirium (OR: 1.95 [1.11, 3.42]), whereas negative affect (OR: 0.65 [0.31, 1.36]) and cognitive distress (OR: 0.95 [0.63, 1.43]) were not.

CONCLUSION

Different components of depression are differentially predictive of postoperative delirium among adults undergoing noncardiac surgery.

How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups

OBJECTIVES

The aim of this study was to explore the experiences of doctors and nurses caring for patients with delirium in the intensive care unit (ICU) and to describe the process of delirium management.

SETTING

This study was performed in 5 ICUs located within 4 hospitals in Madrid (Spain).

PARTICIPANTS

Purposeful sampling was performed which included (1) doctors and nurses working in ICUs, (2) with >1 year experience in the ICU and (3) clinical experience with delirium. 38 professionals participated (19 doctors, 19 nurses), including 22 women and 16 men. The total mean age was 39 years.

DESIGN

A qualitative study using focus groups.

METHODS

7 focus groups were held to collect data: 3 nurse focus groups, 3 doctor focus groups and 1 mixed focus group. Each group comprised 6-10 participants. A semistructured questions guide was used. Thematic analysis methods were used to analyse the data.

RESULTS

3 themes were identified: (1) the professional perspective on delirium; (2) implementing pharmacological and non-pharmacological treatment for delirium and (3) work organisation in the ICU. The professionals regarded patients with delirium with uncertainty, and felt they were often underdiagnosed and poorly managed. Doctors displayed discrepancies regarding pharmacological prescriptions and decision-making. The choice of medication was determined by experience. Nurses felt that, for many doctors, delirium was not considered a matter of urgency in the ICU. Nurses encountered difficulties when applying verbal restraint, managing sleep disorders and providing early mobilisation. The lack of a delirium protocol generates conflicts regarding what type of care management to apply, especially during the night shift. A degree of group pressure exists which, in turn, influences the decision-making process and patient care.

CONCLUSIONS

Patients with delirium represent complex cases, requiring the implementation of specific protocols. These results serve to improve the process of care in patients with delirium.

Pregabalin Has Analgesic, Ventilatory, and Cognitive Effects in Combination with Remifentanil

Background

Pregabalin is widely used perioperatively. The authors explored the effects of pregabalin, remifentanil, and their combination on experimental pain, ventilatory, and cognitive function.

Methods

In a randomized, double-blinded crossover study, 12 volunteers received (1) pregabalin + placebo, (2) placebo + remifentanil, (3) pregabalin + remifentanil, and (4) placebo + placebo. Pregabalin 150 mg/placebo was administered twice orally. After baseline, remifentanil/placebo was given as effect-site target-controlled infusion (TCI): 0.6, 1.2, and 2.4 ng/ml. Pain during cold pressor test was scored on visual analog scale (0 to 100 mm). Ventilation was measured by spirometry and cognition tested with Color-Word Interference and Rapid Information Processing tests.

Results

Pain intensity after placebo was (mean) 72 mm (95% CI, 62 to 83). Pregabalin reduced pain score by −10 mm (−14 to −7, P &lt; 0.001). Remifentanil had dose-dependent analgesic effect, reducing pain score by −47 mm (−54 to −39, P &lt; 0.001) on highest TCI level, whereas pregabalin + remifentanil exerted additive effect, reducing pain score by −57 mm (−64 to −50, P &lt; 0.001). Respiratory depression was potentiated by adding pregabalin to remifentanil; end-tidal carbon dioxide was 39.3 mmHg (37.2 to 41.3) with placebo, increased 1.8 mmHg (−0.9 to 4.6, P = 0.4) with pregabalin, 10.1 mmHg (4.9 to 15.4, P &lt; 0.001) with remifentanil, and 16.4 mmHg (11.3 to 21.5, P &lt; 0.001) with pregabalin + remifentanil on highest TCI level. The combination pregabalin + remifentanil, but not either drug alone, adversely affected all cognitive tests.

Conclusions

The combination of pregabalin and remifentanil had additive analgesic effects, pregabalin potentiated remifentanil ventilatory depression, and the combination adversely affected cognition. These results question the clinical benefit of the combination compared with higher doses of opioids.

Impact of Sedation on Cognitive Function in Mechanically Ventilated Patients

The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function.

How do healthcare workers judge pain in older palliative care patients with delirium near the end of life?

Objective:

Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging, and there is currently no validated assessment tool for this task. The present retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain.

Method:

We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (N= 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome.

Results:

We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behavior. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting.

Significance of results:

These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.

Different MMSE Score Is Associated with Postoperative Delirium in Young-Old and Old-Old Adults

Background

Postoperative delirium is one of the most common postoperative complications in geriatric patients. Mini-mental state examination (MMSE) assesses cognitive function in patients and is associated with postoperative delirium. However, whether there is an age-dependent relationship between preoperative MMSE score and postoperative delirium remains unknown.

Methods

We therefore set out to investigate the association between preoperative MMSE score and postoperative delirium in young-old (≤80 year-old, 75.46±4.69 years, 27.0% male, n = 63) and old-old (>80 year-old, 84.51±3.46 years, 20.9% male, n = 67) participants, who had repairs of hip fractures under general anesthesia. The Confusion Assessment Method and Memorial Delirium Assessment Scale were administrated before surgery, and on the first, second and fourth days after surgery, to assess the incidence and severity of the delirium, respectively. A receiver operating characteristic curve analysis was used to calculate the optimal cutoff score of MMSE in predicting postoperative delirium.

Results

Thirty-four (26.2%) of 130 patients (80.12±6.12 years, 23.8% male) developed postoperative delirium. Preoperative MMSE scores were negatively associated with higher incidences and greater severity of postoperative delirium. The optimal cutoff scores of MMSE associated with postoperative delirium for young-old and old-old participants were 18.4 and 21.4, with a sensitivity of 60% and 83.8%, and a specificity of 92.5% and 62.8%, respectively.

Conclusion

The data demonstrated the optimal cutoff score of MMSE associated with postoperative delirium in young-old adults might be lower than that in old-old adults. Pending further investigation, these findings suggest that the association between preoperative MMSE score and postoperative delirium is age-dependent.

The diurnal profile of melatonin during delirium in elderly patients--preliminary results

Delirium is an acute-onset syndrome that exacerbates patients' condition and significantly increases consequential morbidity and mortality. There is no comprehensive, cellular and tissue-level, pathophysiological theory. The melatonin hormone imbalance has been shown to be linked to circadian rhythms, sleep-wake cycle disturbances, and delirium incidence. There has been relatively little research about melatonin in delirium, and there has been no such study done in the group of elderly patients of a general medicine ward yet. The aim of our study was to compare melatonin hormone concentration in relation to the presence of delirium in elderly patients hospitalized in the general medicine ward. Blood samples were collected four times a day for two days (at 12:00, 18:00, 00:00 and 6:00), on the day when delirium was diagnosed and 72 h after the delirium resolution. Delirium was diagnosed with the Confusion Assessment Method and the criteria of the Diagnostic and Statistic Manual of Mental Disorders, 4th Revision. The mean age of 30 patients (73.3% women) was 86.5 ± 5.2 years. Delirium was diagnosed most often on the second and third day of hospitalization. A lot of predisposing and precipitating factors for delirium were identified. There was a significant difference in the melatonin hormone concentration measurement at 12:00 when patients had acute delirium and after its resolution [18.5 (13.8, 27.5) vs 12.9 (9.8, 17.8), p<0.01]. Different patterns of the melatonin hormone concentration were shown in analyses in the subgroups defined according to the patients' diagnosis of dementia. We found that the delirium recovery was, in fact, associated with the alteration of the daily profile of melatonin.

Surgery plus anesthesia induces loss of attention in mice

There is a need to develop animal models to study postoperative delirium. Inattention is one of the symptoms of delirium. Increases in the levels of α-synuclein and S100β have been reported to be associated with delirium. Therefore, we set out to determine the effects of surgery plus general anesthesia on the behavioral changes (including loss of attention) in mice and on the levels of α-synuclein and S100β in the brain tissues of these mice. C57BL/6J mice (2- to 8-months-old) had a simple laparotomy plus isoflurane anesthesia. The behavioral changes, including attention level and the speed of movements, were determined 12, 24, and 48 h after the surgery plus anesthesia in the mice. The levels of α-synuclein and S100β in the cortex of these mice following the surgery plus anesthesia were determined by Western blot analysis. We found that there was a loss of attention at 24, but not 12 or 48 h following the surgery plus anesthesia (49% ± 5 vs. 33% ± 2.9, P = 0.011, N = 12) in the mice without significantly affecting the speed of their movements. There were increases in the levels of total α-synuclein (139% ± 33.5 vs. 100% ± 13.7, P = 0.037, N = 6) and S100β (142% ± 7.7 vs. 100% ± 6, P = 0.002, N = 6) in the cortex of the mice 12 h following the surgery plus anesthesia. These findings suggested that the surgery plus isoflurane anesthesia might induce behavioral and biochemical/cellular changes associated with delirium. We could use the surgery plus anesthesia in mice to develop an animal model to study postoperative delirium.

A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment

BACKGROUND

Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear.

AIM

To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment.

DESIGN AND METHODS

This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication.

SETTINGS

The study was conducted within four medical wards of an acute care university hospital in urban Switzerland.

PARTICIPANTS

A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively.

RESULTS

Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units.

CONCLUSIONS

The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.

Risk Factors for Delirium After Spinal Surgery: A Meta-Analysis

OBJECTIVE

Postoperative delirium can occur following various types of surgeries. The specific risk factors for delirium following spinal surgery have not been systematically evaluated. The aim of this study is to conduct a meta-analysis of the risk factors for delirium after spinal surgery.

METHODS

PubMed, EMBASE, the Cochrane Library, and Science Citation Index were searched from inception to October 2014 for original research studies. Relevant studies on patients with delirium following spinal surgery were included if they identified at least 1 risk factor as being associated with delirium. The Newcastle-Ottawa Scale (NOS) was used for the study quality assessment, and the pooled odds ratios (ORs) were used for determining the risk factors.

RESULTS

Six articles met the inclusion criteria. Twenty-four risk factors in the multivariate analyses and 22 factors in the univariate analyses were significantly associated with delirium following spinal surgery. In the pooled analyses, age >65 years (OR: 6.13; 95% confidence interval [CI]: 5.75, 6.54); female sex (OR: 1.21; 95% CI: 1.15, 1.28); number of medications (mean difference [MD]: 1.36; 95% CI: 0.73, 2.00); low preoperative hematocrit (MD: -1.67; 95% CI: -2.97, -0.38) and albumin (MD: -0.33; 95% CI: -0.53, -0.13); duration of surgery (MD: 35.79; 95% CI: 1.42, 70.16); intraoperative blood loss (MD: 124.44; 95% CI: 100.03, 148.85); low postoperative hematocrit (MD: -2.58; 95% CI: -3.70, -1.46), hemoglobin (MD: -1.10; 95% CI: -1.86, -0.35), and sodium (MD: -2.97; 95% CI: -5.42, -0.51); and postoperative fever (OR: 4.52; 95% CI: 2.94, 6.95) were significantly associated with delirium.

CONCLUSIONS

Several risk factors were consistently associated with delirium following spinal surgery, which can be used to identify high-risk patients. Recognizing these patients is important for physicians to develop preventive strategies to reduce postoperative delirium and its negative consequences.