151
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FitzGerald JM, Price A. Delirium in the acute hospital setting: the role of psychiatry. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2020.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
SUMMARYIn this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.
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152
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McCoy TH, Castro VM, Hart KL, Perlis RH. Stratified delirium risk using prescription medication data in a state-wide cohort. Gen Hosp Psychiatry 2021; 71:114-120. [PMID: 34091195 PMCID: PMC8249339 DOI: 10.1016/j.genhosppsych.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list. METHOD Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort. RESULTS The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender. CONCLUSION Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.
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Affiliation(s)
- Thomas H McCoy
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Victor M Castro
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Kamber L Hart
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Roy H Perlis
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
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153
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Pernik MN, Deme PR, Nguyen ML, Aoun SG, Adogwa O, Hall K, Stewart NA, Dosselman LJ, El Tecle NE, McDonald SR, Bagley CA, Wingfield SA. Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium. J Am Geriatr Soc 2020; 69:1240-1248. [PMID: 33382460 DOI: 10.1111/jgs.17006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is a common postoperative complication in geriatric patients, especially in those with underlying risk factors. Multicomponent nonpharmacologic interventions are effective in preventing delirium, however, implementation of these measures is variable in perioperative care. The aim of our study was to assess the impact of our Perioperative Optimization of Senior Health Program (UTSW POSH) on postoperative delirium in patients undergoing elective spine surgery. STUDY DESIGN The UTSW POSH program is an interdisciplinary perioperative initiative involving geriatrics, surgery, and anesthesiology to improve care for high-risk geriatric patients undergoing elective spine surgery. Preoperatively, enrolled patients (n = 147) were referred for a geriatric assessment and optimization for surgery. Postoperatively, patients were co-managed by the primary surgical team and the geriatrics consult service. UTSW POSH patients were retrospectively compared to a matched historical control group (n = 177) treated with usual care. Main outcomes included postoperative delirium and provider recognition of delirium. RESULTS UTSW POSH patients were significantly older (75.5 vs 71.5 years; P < .001), had more comorbidities (8.02 vs 6.58; P < .001), and were more likely to undergo pelvic fixation (36.1% vs 17.5%; P < .001). The incidence of postoperative delirium was lower in the UTSW POSH group compared to historical controls, although not statistically significant (11.6% vs 19.2%; P = .065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N = 106) in the UTSW POSH group (11.7% vs 28.9%, P = .03). There was a threefold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs 23.5%; P = .001). CONCLUSIONS This study suggests that interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.
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Affiliation(s)
- Mark N Pernik
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Palvasha R Deme
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Madelina L Nguyen
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Owoicho Adogwa
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Kristen Hall
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Nick A Stewart
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Luke J Dosselman
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Najib E El Tecle
- Department of Neurological Surgery, St Louis University Hospital, St. Louis, Missouri, USA
| | - Shelley R McDonald
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, UT Southwestern Medical School, Dallas, Texas, USA.,Department of Orthopedic Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Sarah A Wingfield
- Department of Internal Medicine, Geriatrics Division, UT Southwestern Medical School, Dallas, Texas, USA
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154
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Young D, Kudchadkar SR, Friedman M, Lavezza A, Kumble S, Daley K, Flanagan E, Hoyer E. Using Systematic Functional Measurements in the Acute Hospital Setting to Combat the Immobility Harm. Arch Phys Med Rehabil 2020; 103:S162-S167. [PMID: 33373600 DOI: 10.1016/j.apmr.2020.10.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/22/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022]
Abstract
Hospitalized patients often experience unnecessary immobility and inactivity leading to direct harms and poor outcomes. Despite growing evidence that early and regular mobility and activity are safe and helpful for patients in the hospital, there remains substantial room for improvement in clinical practice. Key to improvement is establishing an interdisciplinary approach to measurement and communication using a common language of function. Here we provide a framework for systematic functional measurement in the hospital. We also provide 3 specific examples of how this framework has been used to improve care: (1) targeting specialized rehabilitation providers to the patients most likely to need their services, (2) generating a daily mobility goal for all patients, and (3) identifying patients early who are likely to require postacute care.
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Affiliation(s)
- Daniel Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland.
| | - Sapna R Kudchadkar
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland; Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Annette Lavezza
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sowmya Kumble
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kelly Daley
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Eleni Flanagan
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Erik Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
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155
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Whitlock EL, Braehler MR, Kaplan JA, Finlayson E, Rogers SE, Douglas V, Donovan AL. Derivation, Validation, Sustained Performance, and Clinical Impact of an Electronic Medical Record-Based Perioperative Delirium Risk Stratification Tool. Anesth Analg 2020; 131:1901-1910. [PMID: 33105280 DOI: 10.1213/ane.0000000000005085] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is an important problem for surgical inpatients and was the target of a multidisciplinary quality improvement project at our institution. We developed and tested a semiautomated delirium risk stratification instrument, Age, WORLD backwards, Orientation, iLlness severity, Surgery-specific risk (AWOL-S), in 3 independent cohorts from our tertiary care hospital and describe its performance characteristics and impact on clinical care. METHODS The risk stratification instrument was derived with elective surgical patients who were admitted at least overnight and received at least 1 postoperative delirium screen (Nursing Delirium Screening Scale [NuDESC] or Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]) and preoperative cognitive screening tests (orientation to place and ability to spell WORLD backward). Using data pragmatically collected between December 7, 2016, and June 15, 2017, we derived a logistic regression model predicting probability of delirium in the first 7 postoperative hospital days. A priori predictors included age, cognitive screening, illness severity or American Society of Anesthesiologists physical status, and surgical delirium risk. We applied model odds ratios to 2 subsequent cohorts ("validation" and "sustained performance") and assessed performance using area under the receiver operator characteristic curves (AUC-ROC). A post hoc sensitivity analysis assessed performance in emergency and preadmitted patients. Finally, we retrospectively evaluated the use of benzodiazepines and anticholinergic medications in patients who screened at high risk for delirium. RESULTS The logistic regression model used to derive odds ratios for the risk prediction tool included 2091 patients. Model AUC-ROC was 0.71 (0.67-0.75), compared with 0.65 (0.58-0.72) in the validation (n = 908) and 0.75 (0.71-0.78) in the sustained performance (n = 3168) cohorts. Sensitivity was approximately 75% in the derivation and sustained performance cohorts; specificity was approximately 59%. The AUC-ROC for emergency and preadmitted patients was 0.71 (0.67-0.75; n = 1301). After AWOL-S was implemented clinically, patients at high risk for delirium (n = 3630) had 21% (3%-36%) lower relative risk of receiving an anticholinergic medication perioperatively after controlling for secular trends. CONCLUSIONS The AWOL-S delirium risk stratification tool has moderate accuracy for delirium prediction in a cohort of elective surgical patients, and performance is largely unchanged in emergent/preadmitted surgical patients. Using AWOL-S risk stratification as a part of a multidisciplinary delirium reduction intervention was associated with significantly lower rates of perioperative anticholinergic but not benzodiazepine, medications in those at high risk for delirium. AWOL-S offers a feasible starting point for electronic medical record-based postoperative delirium risk stratification and may serve as a useful paradigm for other institutions.
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Affiliation(s)
| | | | | | | | | | | | - Anne L Donovan
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
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156
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Abstract
Introduction: Hallucinations in Parkinson's disease are common, can complicate medication management and significantly impact upon the quality of life of patients and their carers.Areas covered: This review aims to examine current evidence for the management of hallucinations in Parkinson's disease.Expert opinion: Treatment of hallucinations in Parkinson's disease should be both individualized and multifaceted. Screening, education, medication review and the avoidance of common triggers are important. For well-formed visual hallucinations, acetylcholinesterase inhibitors are recommended first-line. Refractory or severe symptoms may require the cautious use of atypical antipsychotics. Antidepressants may be beneficial in the appropriate setting. Unfortunately, current therapies for hallucinations offer only limited benefits and future research efforts are desperately required to improve the management of these challenging symptoms.
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Affiliation(s)
- Alice Powell
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia.,Department of Geriatric Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Elie Matar
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
| | - Simon J G Lewis
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
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157
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Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2020; 21:1833-1843.e20. [DOI: 10.1016/j.jamda.2020.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/12/2020] [Accepted: 03/21/2020] [Indexed: 12/12/2022]
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158
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Chen M, Chen X, Dai Y, Yang Z, Zhang X, Li D. Excision combined with photodynamic therapy for scrotal Paget's disease in patients aged over 60 years. Aging Male 2020; 23:854-859. [PMID: 31033366 DOI: 10.1080/13685538.2019.1607284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To investigate the safety and efficacy of wide local excision combined with aminolevulinic acid (ALA) photodynamic therapy (PDT) for the treatment of scrotal Paget's disease in patients of advanced age. METHODS Data were collected for 16 patients (mean age, 68.44 years) with scrotal Paget's disease treated with wide local excision combined with ALA PDT and followed up from June 2014 to February 2018. Pathological examination after wide local excision confirmed Paget's disease. The patients underwent three courses of ALA PDT postoperatively and were followed up to determine the curative effect and complications in the short and middle term. RESULTS The disease duration ranged from 4 to 76 months (mean, 36 months). Ten patients underwent simple excision, six underwent skin flap transfer, and two required reoperations due to skin flap necrosis and infection. The patients were followed up for 3 to 42 months after ALA PDT, during which time two patients developed metastasis (recurrence rate, 12.50%). No other serious complications occurred during follow-up except for lower limb movement disorder in one patient (6.25%). CONCLUSIONS Wide local excision combined with ALA PDT shows good clinical efficacy and a low complication rate in patients of advanced age with scrotal Paget's disease.
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Affiliation(s)
- Mingquan Chen
- Department of Geriatric Urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Xiong Chen
- Department of Geriatric Urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Yuanqing Dai
- National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Zhiming Yang
- Department of Geriatric Urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
| | - Xiaobo Zhang
- Department of Geriatric Urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Urolithiasis Institute, Central South University, Changsha, China
| | - Dongjie Li
- Department of Geriatric Urology, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
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159
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Baldwin CE, Phillips AC, Edney SM, Lewis LK. Core Domains for Research on Hospital Inactivity in Acutely Ill Older Adults: A Delphi Consensus Study. Arch Phys Med Rehabil 2020; 102:664-674. [PMID: 33253693 DOI: 10.1016/j.apmr.2020.10.136] [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: 05/26/2020] [Revised: 08/24/2020] [Accepted: 10/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify core domains for research studies of physical activity and sedentary behavior during hospitalization for older adults with an acute medical illness. DESIGN A 4-Round Delphi consensus process. Round 1 invited responses to open-ended questions to generate items for the core domains research. In rounds 2-4, participants were invited to use a Likert scale (1-9) to rate the importance of each core domain for research studies of physical activity and/or sedentary behavior in hospitalized older adults with an acute medical illness. SETTING Online surveys. PARTICIPANTS A total of 49 participants were invited to each round (international researchers, clinicians, policy makers and patients). Response rates across rounds 1-4 were 94%, 88%, 83% and 81%, respectively. INTERVENTIONS None. MAIN OUTCOME MEASURES Consensus was defined a priori as ≥70% of respondents rating an item as "critical" (score≥7) and ≤15% of respondents rating an item as "not important" (score≤3). RESULTS In round 2, a total of 9 of 25 core domains reached consensus agreement (physical functioning, general, role functioning, emotional functioning, global quality of life, hospital, psychiatric, cognitive functioning, carer burden). In round 3, an additional 8 reached consensus (adverse events, perceived health status, musculoskeletal, social functioning, vascular, cardiac, mortality, economic). Round 4 participants provided further review and a final rating of all 17 core domains that met consensus in previous rounds. Four core domains were rated as "critically important" to evaluate: physical functioning, social functioning, emotional functioning, and hospital outcomes. CONCLUSIONS This preliminary work provides international and expert consensus-based core domains for development toward a core-outcome set for research, with the ultimate goal of fostering consistency in outcomes and reporting to accelerate research on effective strategies to address physical activity and/or sedentary behavior in older adults while hospitalized.
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Affiliation(s)
- Claire E Baldwin
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.
| | - Anna C Phillips
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Sarah M Edney
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Lucy K Lewis
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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160
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Salian P. The German hospital tackling delirium in patients with dementia. BMJ 2020; 371:m4361. [PMID: 33229396 DOI: 10.1136/bmj.m4361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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161
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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162
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LaHue SC, Douglas VC, Miller BL. The One-Two Punch of Delirium and Dementia During the COVID-19 Pandemic and Beyond. Front Neurol 2020; 11:596218. [PMID: 33224102 PMCID: PMC7674550 DOI: 10.3389/fneur.2020.596218] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/07/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Vanja C Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Bruce L Miller
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
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163
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Friedman JI, Li L, Kirpalani S, Zhong X, Freeman R, Cheng YT, Alfonso FL, McAlpine G, Vakil A, Macon B, Francaviglia P, Cassara M, LoPachin V, Reina K, Davis K, Reich D, Craven CK, Mazumdar M, Siu AL. A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons. J Am Geriatr Soc 2020; 69:216-224. [PMID: 33150615 DOI: 10.1111/jgs.16897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium. DESIGN Hypothesis testing was carried out using a pretest-posttest design on program administrative data. SETTING Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium. INTERVENTION A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system. MEASUREMENTS Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units. RESULTS There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units. CONCLUSION Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.
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Affiliation(s)
- Joseph I Friedman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lihua Li
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | | | - Xiaobo Zhong
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Robert Freeman
- Clinical Operations, Mount Sinai Hospital, New York, New York
| | - Yim Tan Cheng
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Francis L Alfonso
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - George McAlpine
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Aditi Vakil
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Bernard Macon
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Paul Francaviglia
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Margherita Cassara
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Vicki LoPachin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katherine Reina
- Department of Nursing, Mount Sinai Hospital, New York, New York
| | - Kenneth Davis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,President's Office, Mount Sinai Health System, New York, New York
| | - David Reich
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine K Craven
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Albert L Siu
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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164
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Delirium After TAVR. JACC Cardiovasc Interv 2020; 13:2453-2466. [DOI: 10.1016/j.jcin.2020.07.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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165
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Yerra S, Yarra P. Best practices to prevent delirium in hospitalised patients. Evid Based Nurs 2020; 25:14. [PMID: 33106246 DOI: 10.1136/ebnurs-2020-103336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Sandeep Yerra
- Physical Medicine and Rehabilitation, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Pradeep Yarra
- Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
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166
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Lawlor PG, McNamara-Kilian MT, MacDonald AR, Momoli F, Tierney S, Lacaze-Masmonteil N, Dasgupta M, Agar M, Pereira JL, Currow DC, Bush SH. Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial. Palliat Care 2020; 19:163. [PMID: 33087111 PMCID: PMC7579814 DOI: 10.1186/s12904-020-00669-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .
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Affiliation(s)
- Peter G. Lawlor
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | | | - Franco Momoli
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, London, Canada
| | - Sallyanne Tierney
- grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | - Monidipa Dasgupta
- grid.39381.300000 0004 1936 8884Department of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, Canada
| | - Meera Agar
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Jose L. Pereira
- grid.25073.330000 0004 1936 8227Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada
| | - David C. Currow
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Shirley H. Bush
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
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167
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Liang CK, Chu CS, Hsu YH, Chou MY, Wang YC, Lin YT, Renn JH, Liu TY, Yang CC. Effects of modified version of the Hospital Elder Life Program on post-discharge cognitive function and activities of daily living among older adults undergoing total knee arthroplasty. Arch Gerontol Geriatr 2020; 93:104284. [PMID: 33157357 DOI: 10.1016/j.archger.2020.104284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study aimed to investigate the effects of a modified Hospital Elder Life Program (mHELP) on post-discharge cognition and physical function among older adults undergoing total knee arthroplasty (TKA), and to evaluate the incidence of postoperative delirium. DESIGN Non-randomized intervention trial. SETTING AND PARTICIPANTS A total of 140 patients aged 60 years and older scheduled for elective orthopedic surgery at our institution between August 2017 and December 2018 were included. METHODS Ward-level stratification was used with one surgical ward receiving mHELP (intervention group), including orientation communication, early mobilization, vision/hearing impairment equipment, and dehydration prevention, and another ward providing usual care (control group). All participants were assigned to two surgical wards. Outcome measures were collected using MMSE telephone version (tMMSE), activities of daily living (ADL) and instrumental activities of daily living (IADL) instruments at 1, 6, and 12 months after discharge. Multiple linear regression analysis was used to measure effects of mHELP intervention on mean differences in tMMSE, ADL and IADL scores from baseline to 1-, 6- and 12-months. RESULTS Effects of mHELP intervention significantly preserved cognitive function at 1 and 12 months, but not at 6 months, compared with controls, regardless of adjustments for confounders. However, no intervention effects were noted in ADL and IADL scores. Postoperative delirium in the whole cohort was 3.6 % (2.5 % in intervention group, 5.1 % in control group, P = 0.41). CONCLUSIONS mHELP intervention preserves post-discharge cognitive function, but has no notable effect on ADL and IADL function in older adults undergoing elective TKA surgery.
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Affiliation(s)
- Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming University, Taipei, Taiwan; Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ying-Hsin Hsu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jenn-Huei Renn
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Medical Affair Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Yun Liu
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang Ming University, Taipei, Taiwan; Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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168
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Curtis MS, Forman NA, Donovan AL, Whitlock EL. Postoperative delirium: why, what, and how to confront it at your institution. Curr Opin Anaesthesiol 2020; 33:668-673. [PMID: 32796170 PMCID: PMC7489931 DOI: 10.1097/aco.0000000000000907] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW The current article reviews the importance of postoperative delirium (POD), focusing on the older surgical population, and summarizes the best-practice guidelines about POD prevention and treatment which have been published within the last several years. We also describe our local experience with implementing a perioperative delirium risk stratification and prevention pathway, and review implementation science principles which others may find useful as they move toward risk stratification and prevention in their own institutions. RECENT FINDINGS There are few areas of consensus, backed by strong experimental data, in POD best-practice guidelines. Most guidelines recommend preoperative cognitive screening, nonpharmacologic delirium prevention measures, and avoidance of deliriogenic medications. The field of implementation science offers strategies for closing the evidence-practice gap, which we supplement with lessons learned from our own experience implementing a perioperative delirium risk stratification and prevention pathway. SUMMARY POD continues to be a serious perioperative complication commonly experienced by older adults. Growing appreciation of its prognostic implications and evidence behind multidisciplinary, collaborative, and focused prevention strategies rooted in implementation science have prompted several major groups to issue consensus guidelines. Adopting best practices POD risk stratification and prevention pathways will improve perioperative care for older adults.
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Affiliation(s)
- Michael S. Curtis
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Nell A. Forman
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Anne L. Donovan
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Elizabeth L. Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
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169
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Li HC, Wei YC, Hsu RB, Chi NH, Wang SS, Chen YS, Chen SY, Chen CCH, Inouye SK. Surviving and Thriving 1 Year After Cardiac Surgery: Frailty and Delirium Matter. Ann Thorac Surg 2020; 111:1578-1584. [PMID: 32949611 DOI: 10.1016/j.athoracsur.2020.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery. RESULTS Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (β = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group. CONCLUSIONS Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes.
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Affiliation(s)
- Hsiu-Ching Li
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Wei
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
| | - Ron-Bin Hsu
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Nai-Hsin Chi
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shoei-Shen Wang
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, Division of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan
| | - Yih-Sharng Chen
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ssu-Yuan Chen
- Division of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan
| | - Cheryl Chia-Hui Chen
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
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170
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Hong JM. Perioperative brain health: strategies to prevent perioperative neurocognitive disorders. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.9.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cognitive changes in patients after anesthesia and surgery have been recognized for over 100 years. Research on postoperative cognitive changes accelerated in the 1980s and the term postoperative cognitive dysfunction emerged, which was used until recently. Postoperative cognitive dysfunction has been used in research to describe an objectively measurable decline in cognitive function using neuropsychological tests. This dysfunction had significant heterogeneity in the type, number of tests, timing of tests, and the criteria for change. Therefore, a recent article recommended a new nomenclature for perioperative neurocognitive disorders including neurocognitive disorder, postoperative delirium, delayed neurocognitive recovery, and postoperative neurocognitive disorder. Since old age and baseline cognitive impairment are important risk factors for these perioperative neurocognitive disorders, routine preoperative cognitive assessment in all elderly patients is recommended. A preventive strategy is important, since effective modality for the treatment of perioperative neurocognitive disorders is not yet known. Intraoperative monitoring of age-adjusted end-tidal minimal alveolar concentration fraction, electroencephalography-based anesthetic management, and perioperative non-pharmacological methods are recommended for effective prevention.
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171
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Roijers JP, Spillenaar Bilgen R, Hopmans CJ, Mulder PG, Buimer MG, Ho GH, de Groot HG, Veen EJ, Besselink-Lobanova A, van der Meer NJ, van der Laan L. Abdominal aortic aneurysm patients remain at risk for delirium on the surgical ward after intensive care unit dismissal. Minerva Anestesiol 2020; 86:930-938. [DOI: 10.23736/s0375-9393.20.14281-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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172
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Livingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, Brayne C, Burns A, Cohen-Mansfield J, Cooper C, Costafreda SG, Dias A, Fox N, Gitlin LN, Howard R, Kales HC, Kivimäki M, Larson EB, Ogunniyi A, Orgeta V, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020; 396:413-446. [PMID: 32738937 PMCID: PMC7392084 DOI: 10.1016/s0140-6736(20)30367-6] [Citation(s) in RCA: 4238] [Impact Index Per Article: 1059.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/31/2020] [Accepted: 02/07/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK.
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - David Ames
- National Ageing Research Institute and Academic Unit for Psychiatry of Old Age, University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | | | - Sube Banerjee
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Alistair Burns
- Department of Old Age Psychiatry, University of Manchester, Manchester, UK
| | - Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Heczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel; Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Sergi G Costafreda
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Amit Dias
- Department of Preventive and Social Medicine, Goa Medical College, Goa, India
| | - Nick Fox
- Dementia Research Centre, UK Dementia Research Institute, University College London, London, UK; Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Laura N Gitlin
- Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MA, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Helen C Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Karen Ritchie
- Inserm, Unit 1061, Neuropsychiatry: Epidemiological and Clinical Research, La Colombière Hospital, University of Montpellier, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Rockwood
- Centre for the Health Care of Elderly People, Geriatric Medicine Dalhousie University, Halifax, NS, Canada
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London, London, UK; Barnet, Enfield, and Haringey Mental Health Trust, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MA, USA
| | - Lon S Schneider
- Department of Psychiatry and the Behavioural Sciences and Department of Neurology, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Geriatric Department, Oslo University Hospital, Oslo, Norway
| | - Linda Teri
- Department Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
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173
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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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174
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Reyes BJ, Mendelson DA, Mujahid N, Mears SC, Gleason L, Mangione KK, Nana A, Mijares M, Ouslander JG. Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935100. [PMID: 32728485 PMCID: PMC7366407 DOI: 10.1177/2151459320935100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.
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Affiliation(s)
- Bernardo J. Reyes
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | | - Nadia Mujahid
- Warren Alpert School of Brown University, Rhode Island, USA
| | | | - Lauren Gleason
- The University of Chicago Medical and Biological Science, IL,
USA
| | | | - Arvind Nana
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | - Maria Mijares
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
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175
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Tasbihgou SR, Absalom AR. Postoperative neurocognitive disorders. Korean J Anesthesiol 2020; 74:15-22. [PMID: 32623846 PMCID: PMC7862941 DOI: 10.4097/kja.20294] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.
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Affiliation(s)
- Setayesh Reza Tasbihgou
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony Ray Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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176
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Janssen TL, Steyerberg EW, van Hoof-de Lepper CCHA, Seerden TCJ, de Lange DC, Wijsman JH, Ho GH, Gobardhan PD, van der Laan L. Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients. Surg Today 2020; 50:1461-1470. [PMID: 32542413 DOI: 10.1007/s00595-020-02044-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The long-term outcomes of surgery followed by delirium after multimodal prehabilitation program are largely unknown. We conducted this study to assess the effects of prehabilitation on 1-year mortality and of postoperative delirium on 1-year mortality and functional outcomes. METHODS The subjects of this study were patients aged ≥ 70 years who underwent elective surgery for abdominal aortic aneurysm (AAA) or colorectal cancer (CRC) between January 2013, and June 2018. A prehabilitation program was implemented in November 2015, which aimed to optimize physical health, nutritional status, factors of frailty and preoperative anemia prior to surgery. The outcomes were assessed as mortality after 6 and 12 months, compared between the two treatment groups; and mortality and functional outcomes, compared between patients with and those without delirium. RESULTS There were 627 patients (controls N = 360, prehabilitation N = 267) included in this study. Prehabilitation did not reduce mortality after 1 year (HR 1.31 [95% CI 0.75-2.30]; p = 0.34). Delirium was significantly associated with 1-year mortality (HR 4.36 [95% CI 2.45-7.75]; p < 0.001) and with worse functional outcomes after 6 and 12 months (KATZ ADL p = 0.013 and p = 0.004; TUG test p = 0.041 and p = 0.011, respectively). CONCLUSIONS The prehabilitation program did not reduce 1-year mortality. Delirium and the burden of comorbidity are both independently associated with an increased risk of 1-year mortality and delirium is associated with worse functional outcomes. TRIAL REGISTRATION Dutch Trial Registration, NTR5932. https://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932 .
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | | | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.,Department of Cardiovascular Science, UZ Leuven, Leuven, Belgium
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177
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Ludolph P, Stoffers-Winterling J, Kunzler AM, Rösch R, Geschke K, Vahl CF, Lieb K. Non-Pharmacologic Multicomponent Interventions Preventing Delirium in Hospitalized People. J Am Geriatr Soc 2020; 68:1864-1871. [PMID: 32531089 DOI: 10.1111/jgs.16565] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES Delirium is a common neurobehavioral complication in hospitalized patients with a high prevalence in various clinical settings. Prevention of delirium is critical due to its common occurrence and associated poor outcomes. Our objective was to evaluate the efficacy of multicomponent interventions in preventing incident delirium in hospitalized patients at risk. DESIGN Systematic review and meta-analysis. SETTING Hospital. PARTICIPANTS We included a study if it was a randomized controlled trial and was evaluating effects of coordinated non-pharmacologic multicomponent interventions in the prevention of delirium. MEASUREMENTS We performed a systematic literature search in PubMed and CENTRAL (PROSPERO: CRD42019138981; last update May 24, 2019). We assessed the quality of included studies by using the criteria established by the Cochrane Collaboration. We extracted the measured outcomes for delirium incidence, duration of delirium, length of hospital stay, falls during hospital stay, discharge to institutional care, and inpatient mortality. RESULTS In total, we screened 1,027 eligible records and included eight studies with 2,105 patients in the review. We found evidence of an effect (ie, reduction) of multicomponent interventions on the incidence of delirium (risk ratio = .53; 95% confidence interval = .41-.69; I2 = 0). We detected no clear evidence of an effect for delirium duration, length of hospital stay, accidental falls, and mortality. Subgroup analyses did not result in findings of substantial effect modifiers, which can be explained by the high homogeneity within studies. CONCLUSION Our findings confirm the current guidelines that multicomponent interventions are effective in preventing delirium. Data are still lacking to reach evidence-based conclusions concerning potential benefits for hard outcomes such as length of hospital stay, return to independent living, and mortality. J Am Geriatr Soc 68:1864-1871, 2020.
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Affiliation(s)
- Paul Ludolph
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Jutta Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany.,Leibniz Institute for Resilience Research (LIR), Mainz, Germany
| | | | - Romina Rösch
- Department of Cardiothoracic and Vascular Surgery, University Medical Center Mainz, Mainz, Germany
| | - Katharina Geschke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Christian Friedrich Vahl
- Department of Cardiothoracic and Vascular Surgery, University Medical Center Mainz, Mainz, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany.,Leibniz Institute for Resilience Research (LIR), Mainz, Germany
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178
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Oldham MA, Holloway RG. Delirium disorder. Neurology 2020; 95:173-178. [DOI: 10.1212/wnl.0000000000009949] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
ObjectiveAs the US population ages and with no definitive delirium treatments on the horizon, the delirium epidemic is on course to expand over the coming decades. Recognizing the import of this condition, a recent position statement from 10 medical societies—among whom the American Academy of Neurology was represented—issued recommendations on preferred nomenclature of delirium and acute encephalopathy: it concluded by preferring both terms. Urgently needed is an integrated model that addresses the near-total segregation of these separate bodies of literature, ideally one that offers an interdisciplinary framework to bring these 2 terms and those who use them together.MethodsWe review the historical forces that have led these terms to diverge and consider the unique benefits of each approach as well as their liabilities when considered in isolation. We then explore the potential implications of integrating these concepts and propose a hybrid model to capitalize on the strengths of both the model of delirium and that of acute encephalopathy.ResultsThe model we propose—delirium disorder—builds on the recommendations of this recent position statement and provides a unifying framework designed to have clinical utility and interdisciplinary appeal. It also broadens the translational landscape by identifying 4 distinct treatment targets: underlying causes, procognitive factors, delirium (phenotype alone), and neurophysiologic targets.ConclusionsThis person-centered model aims to integrate delirium and acute encephalopathy within a single framework and shared nomenclature. It is hoped that this model aids in harmonizing research efforts and advancing clinical practice.
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179
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Baldwin CE, Phillips AC, Edney SM, Lewis LK. Recommendations for older adults' physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international Delphi study. Int J Behav Nutr Phys Act 2020; 17:69. [PMID: 32450879 PMCID: PMC7249667 DOI: 10.1186/s12966-020-00970-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/11/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Immobility is major contributor to poor outcomes for older people during hospitalisation with an acute medical illness. Yet currently there is no specific mobility guidance for this population, to facilitate sustainable changes in practice. This study aimed to generate draft physical activity (PA) and sedentary behaviour (SB) recommendations for older adults' during hospitalisation for an acute medical illness. METHODS A 4-Round online Delphi consensus survey was conducted. International researchers, medical/nursing/physiotherapy clinicians, academics from national PA/SB guideline development teams, and patients were invited to participate. Round 1 sought responses to open-ended questions. In Rounds 2-3, participants rated the importance of items using a Likert scale (1-9); consensus was defined a priori as: ≥70% of respondents rating an item as "critical" (score ≥ 7) and ≤ 15% of respondents rating an item as "not important" (score ≤ 3). Round 4 invited participants to comment on draft statements derived from responses to Rounds 1-3; Round 4 responses subsequently informed final drafting of recommendations. RESULTS Forty-nine people from nine countries were invited to each Round; response rates were 94, 90, 85 and 81% from Rounds 1-4 respectively. 43 concepts (items) from Rounds 2 and 3 were incorporated into 29 statements under themes of PA, SB, people and organisational factors in Round 4. Examples of the final draft recommendations (being the revised version of statements with highest participant endorsement under each theme) were: "some PA is better than none", "older adults should aim to minimise long periods of uninterrupted SB during waking hours while hospitalised", "when encouraging PA and minimising SB, people should be culturally responsive and mindful of older adults' physical and mental capabilities" and "opportunities for PA and minimising SB should be incorporated into the daily care of older adults with a focus on function, independence and activities of daily living". CONCLUSIONS These world-first consensus-based statements from expert and stakeholder consultation provide the starting point for recommendations to address PA and SB for older adults hospitalised with an acute medical illness. Further consultation and evidence review will enable validation of these draft recommendations with examples to improve their specificity and translation to clinical practice.
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Affiliation(s)
- Claire E Baldwin
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Flinders Drive, Bedford Park, Adelaide, South Australia, 5042, Australia.
| | - Anna C Phillips
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Sarah M Edney
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Lucy K Lewis
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Flinders Drive, Bedford Park, Adelaide, South Australia, 5042, Australia.,Sport, Health, Activity, Performance and Exercise (SHAPE) Research Centre, Flinders University, Adelaide, Australia
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180
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Kennedy M, Hwang U, Han JH. Delirium in the Emergency Department: Moving From Tool-Based Research to System-Wide Change. J Am Geriatr Soc 2020; 68:956-958. [PMID: 32274813 PMCID: PMC7891178 DOI: 10.1111/jgs.16437] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 12/22/2022]
Abstract
AbstractThis editorial comments on the article by.Malihot et al.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General
Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ula Hwang
- Icahn School of Medicine at Mount Sinai Department of
Emergency Medicine, New York, NY, Icahn School of Medicine at Mount Sinai
- Brookdale Department of Geriatrics and Palliative Medicine,
New York, NY
- James J. Peters VAMC, Geriatric Research, Education and
Clinical Center, Bronx, NY
| | - Jin H. Han
- Department of Emergency Medicine, Vanderbilt University
Medical Center, Nashville, TN
- Tennessee Valley Healthcare System, Geriatric Research,
Education and Clinical Center, Nashville TN
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181
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Lynch J, Rolls K, Hou YC, Hedges S, Al Sayfe M, Shunker SA, Brennan K, Sanchez D, Bogdanovski T, Hunt L, Alexandrou E, Frost SA. Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol). Aust Crit Care 2020; 33:475-479. [PMID: 32317213 DOI: 10.1016/j.aucc.2019.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/04/2019] [Accepted: 12/20/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU). OBJECTIVES This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium. STUDY PLAN A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).
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Affiliation(s)
- Joan Lynch
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Intensive Care Unit Liverpool Hospital, Australia
| | - Kaye Rolls
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Intensive Care Fairfield Hospital, Australia; School of Nursing, University of Wollongong, Australia.
| | - Yu Chin Hou
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; Intensive Care Unit Liverpool Hospital, Australia; Centre for Applied Nursing Research, SWSLHD, Australia
| | - Sonja Hedges
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; Intensive Care Bankstown Hospital, Australia; Centre for Applied Nursing Research, SWSLHD, Australia
| | | | | | - Kathleen Brennan
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; Intensive Care Bankstown Hospital, Australia; Centre for Applied Nursing Research, SWSLHD, Australia
| | - David Sanchez
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; Intensive Care Unit Campbelltown Hospital, South Western Sydney Local Health District, Australia
| | | | - Leanne Hunt
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Intensive Care Unit Liverpool Hospital, Australia
| | - Evan Alexandrou
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Intensive Care Unit Liverpool Hospital, Australia
| | - Steven A Frost
- Critical Care Research in Collaboration and Evidence Translation (CCRICET), Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Intensive Care Unit Liverpool Hospital, Australia; Centre for Applied Nursing Research, SWSLHD, Australia
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182
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Oh ES, Akeju O, Avidan MS, Cunningham C, Hayden KM, Jones RN, Khachaturian AS, Khan BA, Marcantonio ER, Needham DM, Neufeld KJ, Rose L, Spence J, Tieges Z, Vlisides P, Inouye SK. A roadmap to advance delirium research: Recommendations from the NIDUS Scientific Think Tank. Alzheimers Dement 2020; 16:726-733. [PMID: 32291901 PMCID: PMC7317361 DOI: 10.1002/alz.12076] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Delirium is an acute disorder of attention and cognition. It occurs across the life span, yet it is particularly common among older adults, and is closely linked with underlying neurocognitive disorders. Evidence is mounting that intervening on delirium may represent an important opportunity for delaying the onset or progression of dementia. To accelerate the current understanding of delirium, the Network for Investigation of Delirium: Unifying Scientists (NIDUS) held a conference “Advancing Delirium Research: A Scientific Think Tank” in June 2019. This White Paper encompasses the major knowledge and research gaps identified at the conference: advancing delirium definition and measurement, understanding delirium pathophysiology, and prevention and treatment of delirium. A roadmap of research priorities is proposed to advance the field in a systematic, interdisciplinary, and coordinated fashion. A call is made for an international consortium and biobank targeted to delirium, as well as a public health campaign to advance the field.
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Affiliation(s)
- Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Colm Cunningham
- School of Biochemistry and Immunology & Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Kathleen M Hayden
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | | | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Jessica Spence
- Departments of Anesthesiology and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
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183
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Incidence and Risk Factors for Delirium in Elderly Patients with Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2020; 59:598-605. [DOI: 10.1016/j.ejvs.2019.11.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 10/24/2019] [Accepted: 11/21/2019] [Indexed: 01/03/2023]
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184
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Singu S, Koneru M, Robinson KA, Neufeld KJ, Oh ES, Wilson LM, Needham DM, Balagani A, Aldabain L, Nikooie R, Fick DM. Are Antipsychotics Helpful for Preventing or Treating Delirium? J Gerontol Nurs 2020; 46:3-5. [DOI: 10.3928/00989134-20200303-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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185
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Dechnik A, Traube C. Delirium in hospitalised children. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:312-321. [PMID: 32087768 DOI: 10.1016/s2352-4642(19)30377-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 01/15/2023]
Abstract
Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).
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Affiliation(s)
- Andzelika Dechnik
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
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186
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van Yperen DT, Raats JW, Dokter J, Ziere G, Roukema GR, van Baar ME, van der Vlies CH. Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study. J Burn Care Res 2020; 41:371-376. [PMID: 31504611 DOI: 10.1093/jbcr/irz161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.
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Affiliation(s)
- Daan T van Yperen
- Burn Center, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA, The Netherlands
| | - Jelle W Raats
- Department of Surgery, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
| | - Jan Dokter
- Burn Center, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
| | - Gijsbertus Ziere
- Geriatric Medicine, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
| | - Gert R Roukema
- Burn Center, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands.,Department of Surgery, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
| | - Margriet E van Baar
- Association of Dutch Burn Centers, Burn Center, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
| | - Cornelis H van der Vlies
- Burn Center, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3000 CA, The Netherlands.,Department of Surgery, Maasstad Hospital, Maasstadweg 31, 3079 DZ Rotterdam, The Netherlands
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Gual N, García-Salmones M, Brítez L, Crespo N, Udina C, Pérez LM, Inzitari M. The role of physical exercise and rehabilitation in delirium. Eur Geriatr Med 2020; 11:83-93. [PMID: 32297245 PMCID: PMC7224129 DOI: 10.1007/s41999-020-00290-6] [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: 10/04/2019] [Accepted: 01/15/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research. METHODS In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other. RESULTS This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function. CONCLUSION The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.
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Affiliation(s)
- N Gual
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain. .,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M García-Salmones
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - L Brítez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - N Crespo
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - C Udina
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L M Pérez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - M Inzitari
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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189
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Wang YY, Yue JR, Xie DM, Carter P, Li QL, Gartaganis SL, Chen J, Inouye SK. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:17-25. [PMID: 31633738 PMCID: PMC6806427 DOI: 10.1001/jamainternmed.2019.4446] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline. OBJECTIVE To investigate the effectiveness of the Tailored, Family-Involved Hospital Elder Life Program (t-HELP) for preventing POD and functional decline in older patients after a noncardiac surgical procedure. DESIGN, SETTING, AND PARTICIPANTS A 2-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted from August 24, 2015, to February 28, 2016, on 6 surgical floors (gastric, colorectal, pancreatic, biliary, thoracic, and thyroid) of West China Hospital in Chengdu, China. Eligible participants (n = 281) admitted to each of the 6 surgical floors were randomized into a nursing unit providing t-HELP (intervention group) or a nursing unit providing usual care (control group). All randomized patients were included in the intention-to-treat analyses for the primary outcome of POD incidence. Statistical analysis was performed from April 3, 2016, to December 30, 2017. INTERVENTIONS In addition to receiving usual care, all participants in the intervention group received the t-HELP protocols, which addressed each patient's risk factor profile. Besides nursing professionals, family members and paid caregivers were involved in the delivery of many of the program interventions. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of POD, evaluated with the Confusion Assessment Method. Secondary outcomes included the pattern of functional and cognitive changes (activities of daily living [ADLs], instrumental activities of daily living [IADLs], Short Portable Mental Status Questionnaire [SPMSQ]) from hospital admission to 30 days after discharge, and the length of hospital stay (LOS). RESULTS Of the 475 patients screened for eligibility, 281 (171 [60.9%] male, mean [SD] age 74.7 [5.2] years) were enrolled and randomized to receive t-HELP (n = 152) or usual care (n = 129). Postoperative delirium occurred in 4 participants (2.6%) in the intervention group and in 25 (19.4%) in the control group, with a relative risk of 0.14 (95% CI, 0.05-0.38). The number needed to treat to prevent 1 case of POD was 5.9 (95% CI, 4.2-11.1). Participants in the intervention group compared with the control group showed less decline in physical function (median [interquartile range] for ADLs: -5 [-10 to 0] vs -20 [-30 to -10]; P < .001; for IADLs: -2 [-2 to 0] vs -4 [-4 to -2]; P < .001) and cognitive function (for the SPMSQ level: 1 [0.8%] vs 8 [7.0%]; P = .009) at discharge, as well as shorter mean (SD) LOS (12.15 [3.78] days vs 16.41 [4.69] days; P < .001). CONCLUSIONS AND RELEVANCE The findings suggest that t-HELP, with family involvement at its core, is effective in reducing POD for older patients, maintaining or improving their physical and cognitive functions, and shortening the LOS. The results of this t-HELP trial may improve generalizability and increase the implementation of this program. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR-POR-15006944.
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Affiliation(s)
- Yan-Yan Wang
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,School of Nursing, The University of Texas at Austin, Austin
| | - Ji-Rong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Dong-Mei Xie
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Patricia Carter
- School of Nursing, The University of Texas at Austin, Austin
| | - Quan-Lei Li
- School of Nursing, The Johns Hopkins University, Baltimore, Maryland
| | - Sarah L Gartaganis
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Sharon K Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Cacchione PZ. Innovative care models across settings: Providing nursing care to older adults. Geriatr Nurs 2020; 41:16-20. [DOI: 10.1016/j.gerinurse.2020.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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191
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Tobar E, Alvarez E. DELIRIUM EN EL ADULTO MAYOR HOSPITALIZADO. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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192
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Caplan GA, Teodorczuk A, Streatfeild J, Agar MR. The financial and social costs of delirium. Eur Geriatr Med 2019; 11:105-112. [DOI: 10.1007/s41999-019-00257-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/29/2019] [Indexed: 12/22/2022]
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193
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Derwall M, Coburn M. „Frailty“ als potenzieller Indikator des perioperativen Risikos alter Patienten. Anaesthesist 2019; 69:151-158. [DOI: 10.1007/s00101-019-00699-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Balasundaram B, Yoon PS, Rosario BH, Kam JW, Tan LMY, Varman S. Geriatric psychiatry liaison programme in a Singapore public hospital geriatric ward setting: descriptive and evaluation study on delirium and dementia. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105819869031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Comprehensive geriatric psychiatry liaison services are in early and evolving stages in Singapore. A description and evaluation of a geriatric psychiatry liaison programme in geriatric wards was undertaken describing programme activity and clinical outcomes in patients with neurocognitive disorders. Dementia training and staff upskilling are also discussed. Methods: This study included all referred patients by the geriatric team in Changi General Hospital over a one-year period from 15 June 2017 to 14 June 2018. As measures of good clinical practice, diagnosis of delirium and new diagnosis of dementia made during the inpatient admission following liaison consultation were included in the study. Patient-related outcomes that included length of stay (LOS), institutionalisation rates and in-hospital mortality were evaluated. Results: Dementia (53%), delirium (49%) and depression (28%) were the commonest diagnoses in this study. Dementia was newly diagnosed in 30% of cases. The median LOS in those with delirium was 19 days; 19% with a delirium diagnosis had new institutionalisation rates. In-hospital mortality in this study was 2%. Conclusions: The geriatric psychiatry liaison programme in geriatric wards in Changi General Hospital improved detection rates of delirium and new diagnoses of dementia. It also reports increased LOS and new institutionalisation rates in those with a diagnosis of delirium. Nursing staff education in neurocognitive disorders is enhanced. This article has outlined the importance of team-based care, joint specialist care and staff training in recognition of delirium and dementia in an acute hospital setting to improve outcomes for older patients.
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Affiliation(s)
- Bharathi Balasundaram
- Medical Centre Department of Psychological Medicine, Changi General Hospital, Singapore
| | | | | | - Jia Wen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
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196
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Risk factors for postoperative delirium after elective major abdominal surgery in elderly patients: A cohort study. Int J Surg 2019; 71:29-35. [DOI: 10.1016/j.ijsu.2019.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/30/2019] [Accepted: 09/05/2019] [Indexed: 12/22/2022]
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198
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Saunders R, Seaman K, Graham R, Christiansen A. The effect of volunteers' care and support on the health outcomes of older adults in acute care: A systematic scoping review. J Clin Nurs 2019; 28:4236-4249. [PMID: 31429987 PMCID: PMC7328779 DOI: 10.1111/jocn.15041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/14/2019] [Accepted: 08/03/2019] [Indexed: 01/03/2023]
Abstract
Aim To examine the available evidence on the effects of care and support provided by volunteers on the health outcomes of older adults in acute care services. Background Acute hospital inpatient populations are becoming older, and this presents the potential for poorer health outcomes. Factors such as chronic health conditions, polypharmacy and cognitive and functional decline are associated with increased risk of health care‐related harm, such as falls, delirium and poor nutrition. To minimise the risk of health care‐related harm, volunteer programmes to support patient care have been established in many hospitals worldwide. Design A systematic scoping review. Methods The review followed the PRISMA Extension for Scoping Reviews (PRISMA‐ScR) (File S1). Nine databases were searched (CINAHL, MEDLINE, EMBASE, Cochrane, Scopus, Web of Science, PubMed, ScienceDirect and JBI) using the following key terms: ‘hospital’, ‘volunteer’, ‘sitter’, ‘acute care’, ‘older adults’, ‘confusion’, ‘dementia’ and ‘frail’. The search was limited to papers written in English and published from 2002–2017. Inclusion criteria were studies involving the use of hospital volunteers in the care or support of older adult patients aged ≥ 65 years, or ≥ 50 years for Indigenous peoples, with chronic health conditions, cognitive impairment and/or physical decline or frailty, within the acute inpatient settings. Results Of the 199 articles identified, 17 articles that met the inclusion criteria were critically appraised for quality, and 12 articles were included in the final review. Conclusions There is evidence that the provision of volunteer care and support with eating and drinking, mobilising and therapeutic activities can impact positively upon patient health outcomes related to nutrition, falls and delirium. Further robust research is needed to determine the impact of volunteers in acute care and the specific care activities that can contribute to the best outcomes for older adults. Relevance to clinical practice Volunteers can play a valuable role in supporting care delivery by nurses and other health professionals in acute care services, and their contribution can improve health outcomes for older adults in this setting.
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Affiliation(s)
- Rosemary Saunders
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia
| | - Karla Seaman
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia
| | - Renée Graham
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia
| | - Angela Christiansen
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia
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Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med 2019; 75:136-145. [PMID: 31563402 DOI: 10.1016/j.annemergmed.2019.07.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.
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Affiliation(s)
- Christina Shenvi
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC.
| | - Maura Kennedy
- Massachusetts General Hospital Department of Emergency Medicine and Harvard Medical School, Boston, MA
| | - Charles A Austin
- Department of Internal Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, AR
| | - Michael Gerardi
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ; Coalition on Psychiatric Emergencies
| | - Sandy Schneider
- American College of Emergency Physicians, Irving, TX; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX; Hofstra Northwell School of Medicine, Hempstead, NY
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Vlisides PE, Ragheb JW, Leis A, Schoettinger A, Hickey K, McKinney A, Brooks J, Zierau M, Norcott A, Yang S, Avidan MS, Min L. Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial. F1000Res 2019; 8:1683. [PMID: 32934794 PMCID: PMC7471625 DOI: 10.12688/f1000research.20597.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jacqueline W. Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Aleda Leis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | | | - Kim Hickey
- University of Michigan School of Nursing, Ann Arbor, MI, 48109, USA
| | - Amy McKinney
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Joseph Brooks
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Mackenzie Zierau
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Alexandra Norcott
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
| | - Shirley Yang
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lillian Min
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Geriatric Research Education and Clinical Care, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
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