Delirium in the Elderly

Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.

Delirium-A Framework to Improve Acute Care for Older Persons

This article is based on the M. Powell Lawton Award Lecture that I delivered at the 2016 Gerontological Society of America Annual Meeting. I provide an overview of my journey in geriatric medicine and delirium research. I created new measures, including the Confusion Assessment Method, for identification of delirium; conceptualized a multifactorial risk model; and developed and tested intervention strategies for delirium prevention. The Hospital Elder Life Program arose from this work. In addition, like Dr. Lawton, I am working to apply my work to the policy arena. As the population ages, we face an unprecedented opportunity to realize the full benefit of aging in our society, an untapped resource. The field of aging is facing innumerable challenges in terms of continued stigma and funding shortfalls for clinical care and research. I issue a call to action to clinicians, researchers, and leaders in aging to seize this opportunity to use our know-how and expertise to transform the experience of aging for all.

Cerebral oximetry during preoperative resuscitation in elderly patients with hip fracture: a prospective observational study

This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO₂), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO₂ was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO₂ was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO₂ values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO₂ was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO₂ nadir values were also significant lower (p = 0.047). Low ScO₂ during initial resuscitation (defined as ScO₂ < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO₂ was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.

PROPRIEDADES PSICOMÉTRICAS DE INSTRUMENTOS DE MEDIDAS: BASES CONCEITUAIS E MÉTODOS DE AVALIAÇÃO - PARTE I

RESUMO Objetivo: apresentar e discutir bases conceituais e métodos de avaliações que fundamentam importantes propriedades de instrumentos de medidas. Método: estudo teórico embasado na literatura internacional e nacional e nos instrumentos Consensus-based Standards for the selection of health Measurement Instruments e Evaluating the Measurement of Patient-Reported Outcomes que contemplam conceitos de avaliação de instrumentos para apreciação de resultados relatados pelo paciente. Inicialmente são apresentados e discutidos os conceitos de confiabilidade, responsividade e interpretabilidade, citados exemplos das principais formas de avaliação dessas propriedades. Resultados: pode-se perceber que ainda há divergências em algumas descrições conceituais. Entretanto, os autores ressaltam a importância da confiabilidade para avaliar o instrumento de medida. Destaca-se a importância do conhecimento do Modelo Conceitual, das propriedades de medidas e dos diferentes métodos de avaliação para garantir, principalmente em estudo de validação de instrumentos, resultados confiáveis e válidos. Conclusões: a discussão apresentada sobre a confiabilidade, responsividade e interpretabilidade contribui para os profissionais de saúde no conhecimento teórico e senso crítico na escolha de instrumentos e na condução de análises sobre essas propriedades de medida.

Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population

OBJECTIVE

To measure the diagnostic accuracy of the 4A's test in screening for delirium in geriatric inpatients from culturally diverse backgrounds.

METHODS

A prospective study was conducted with patients admitted to the geriatric and orthogeriatric services of a tertiary teaching hospital. Consenting participants aged 65 years and over were screened for delirium with the 4AT by nursing staff within 72 h of admission. The diagnosis of delirium was made separately by expert assessors, responsible for the participant's clinical care, blinded to the 4AT score, within 30 min of the 4AT assessment using the DSM 5 criteria and the Confusion Assessment Method. Interpreters were used for non-English speaking patients. The Informant Questionnaire for Cognitive Decline in the Elderly was completed by a carer/relative to assess for probable dementia.

RESULTS

A total of 257 participants (mean age 85) were recruited over five months. Delirium was diagnosed in 159 (62%) by the expert assessors and 158 (62%) by the 4AT assessment. A total of 205 participants (80% of total population) had probable dementia. The sensitivity and specificity of the 4AT were 87% and 80%, respectively, in detecting delirium overall, 86% and 71% in people with probable dementia and 91% and 71% for non-English speaking participants. The area under the receiver operating characteristic curve for delirium in the whole population was 0.92, 0.89 in the probable dementia subgroup and 0.90 in non-English speaking participants.

CONCLUSIONS

The 4AT is a sensitive and specific screening tool for delirium in geriatric inpatients, including those with probable dementia or who are non-English speaking. Copyright © 2016 John Wiley & Sons, Ltd.

Screening Older Adults for Mental Disorders

Avoidable disability associated with depression, anxiety, and impaired cognition among older adults is pervasive. Incentives for detection of mental disorders in late life include increased reimbursement, reduced cost, and less burden for patients and families. However, screening not aligned with diagnosis, intervention, and outcome assessment has questionable utility. The link between screening, treatment, and outcomes is well established for depression, less so for anxiety and impaired cognition. This article details the use of common instruments to screen and assess depression, anxiety, and cognitive impairment.

A Comparison of the Severe Cognitive Impairment Rating Scale With the Mini-Mental State Examination and Delirium Rating Scale-Revised-98 for Delirium: A Cross-sectional Study

BACKGROUND

Cognitive impairment including attention deficits, disorientation, memory impairment, language disturbance, and impaired visuospatial ability are core symptoms of delirium. The Severe Cognitive Impairment Rating Scale (SCIRS) was developed to assess cognition in patients with severe dementia, but may also be useful in elderly people with delirium.

OBJECTIVE

We investigated the use of the SCIRS to assess cognition in elderly patients with delirium.

METHODS

We recruited 147 participants, aged ≥65 years, referred for psychiatric consultation at a tertiary-care university hospital. The diagnosis and severity of delirium were assessed using the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). Cognitive function was assessed using the SCIRS and the Mini-Mental State Examination (MMSE) in the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Assessment Packet (MMSE-KC).

RESULTS

There was a strong correlation of SCIRS scores with K-DRS-98 cognition domain (r = -0.796), severity scores (r = -0.742), total scores (r = -0.734), and the MMSE-KC (r = 0.905). Analysis of variance incorporating the severity of delirium suggested that while the MMSE showed a floor effect, the SCIRS could discriminate between moderate and severe delirium.

CONCLUSION

The SCIRS is a useful instrument to assess cognitive function in elderly patients with moderate to severe delirium.

Update in perioperative medicine: practice changing evidence published in 2016

This summary reviews 18 key articles published in 2016 which have significant practice implications for the perioperative medical care of surgical patients. Due to the multi-disciplinary nature of the practice of perioperative medicine, important new evidence is published in journals representing a variety of medical and surgical specialties. Keeping current with the evidence that drives best practice in perioperative medicine is therefore challenging. We set out to identify, critically review, and summarize key evidence which has the most potential for practice change. We integrated the new evidence into the existing body of medical knowledge and identified practical implications for real world patient care. The articles address issues related to anticoagulation, transfusion threshold, immunosuppressive medications, postoperative delirium, myocardial injury after noncardiac surgery, postoperative pain management, perioperative management of antihypertensives, perioperative fasting, and perioperative diabetic control.

Delirium in Older Persons: Advances in Diagnosis and Treatment

Importance

Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.

Objective

To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence Review

Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Findings

Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and Relevance

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

Incidence of delirium after cardiac surgery: protocol for the DELIRIUM-CS Canada cross-sectional cohort study

BACKGROUND

Delirium is a recognized complication of cardiac surgery and is the focus of increasing attention owing to its negative effect on postoperative outcomes. However, little is known about the actual incidence of delirium following cardiac surgery, with published rates ranging widely, from 3%-78%. We describe the protocol for the DELIRIUM-CS Canada study, which will use validated and easily implementable bedside tools to determine the incidence of postoperative delirium in a contemporary cardiac surgery population. We hypothesize that delirium, identified through a systematic and standardized screening protocol, is a highly prevalent, though variable, condition following cardiac surgery.

METHODS

The DELIRIUM-CS Canada study is a multicentre cross-sectional cohort study. Over a 3-month period, all patients undergoing major cardiac surgical procedures at 10 participating centres will be screened for postoperative delirium by means of the Intensive Care Delirium Screening Checklist or the Confusion Assessment Method for the Intensive Care Unit. Delirium screening will be conducted for 7 days following the date of surgery or until the initial discharge from the intensive care unit. In addition to reporting an overall rate of delirium, we will report unadjusted and adjusted incidence rates of delirium by institution and for the entire cohort. Risk adjustment will be performed with the use of multivariate regression modelling techniques.

INTERPRETATION

The results of this study will provide valuable insight into the true burden of delirium among patients having undergone a major cardiac surgical procedure in the current era. This is the first step in creating a multifaceted delirium prevention/treatment clinical pathway for patients undergoing cardiac surgery. Trial registration: ClinicalTrials.gov, no. NCT02206880.

Complementary medicine for treatment of agitation and delirium in older persons: a systematic review and narrative synthesis

BACKGROUND

Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions.

METHODS

Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness.

RESULTS

Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported.

CONCLUSION

Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.

Postoperative Delirium After Liver Transplantation is Associated With Increased Length of Stay and Lower Survival in a Prospective Cohort

Introduction:

Although postoperative delirium (POD) is a common in-hospital complication associated with negative outcomes, evidence in liver transplantation (LT) is scarce.

Objective:

We examined the incidence and duration of POD, its impact on outcomes and health-care utilization, and described predisposing and precipitating factors favoring POD development.

Design:

This prospective cohort study included adults undergoing transplantation in a tertiary hospital. Postoperative delirium was assessed 3 times daily until 24 days post-LT, with the Intensive Care Delirium Screening Checklist on the intensive care unit (ICU) and the Delirium Observation Screening Scale on the ward. Postoperative delirium was noted if any of the daily measurements was positive.

Results:

Forty-two patients (69% male, mean age 55 years, median Model for End-Stage Liver Disease score 15 [interquartile range 8-26]) were included. The incidence of POD was 45.2%, with a median duration of 5 days. Patients with POD had longer ICU (median 8 vs 2 days, P = .000) and hospital stays (median 32 vs 14 days, P = .000) as well as shorter survival (Breslow test P = .045, log-rank test P = .150). Pre-LT comorbidities and perioperative factors might be related to POD development.

Conclusion:

Nurses are key persons in the detection of POD in the daily clinical routine. The high incidence of POD and its negative association with patient outcomes highlight not only the relevance of systematic assessment of POD after LT but also the need for preventive interventions.

Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study

INTRODUCTION

screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment.

AIM

to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice.

METHODS

a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD).

RESULTS

we assessed 500 patients, mean age 83 years (range = 66-101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point < 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8-97.3), with a specificity of 53.7% (95% CI: 48.1-59.2); AMT-10 (<4/10), MOTYB (<4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5-80.3) with a specificity of 91.4% (95% CI: 87.7-94.3). 4AT (>4/12) had a sensitivity of 86.7% (95% CI: 77.5-93.2) and specificity of 69.5% (95% CI: 64.4-74.3).

CONCLUSIONS

short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity.