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Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients. J Neurol 2019; 266:3065-3075. [PMID: 31520105 DOI: 10.1007/s00415-019-09533-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Predisposing and precipitating factors for delirium are well known; however, their interaction and impact on delirium in neurological patients remains largely unknown. Therefore, those factors were evaluated in hospitalized patients with neurological disorders. METHODS In this prospective cohort study, 1487 neurological patients were included, 356 patients with delirium and 1131 without delirium. Relevant neurological- and medical-related clusters were assessed with multiple regression analyses, prediction models, and cluster analysis evaluating their association with delirium. RESULTS The 1-year incidence of delirium in this cohort was 23.9%. Delirium developed in 31% of patients with stroke, in 39.5% with epilepsy, and in 58.4% with ICH. The most relevant predisposing factors were substance-use disorders (OR 4.24, 2.28-7.78, p < 0.001), advanced age (OR 3.44, CI 2.40-4.92, p < 0.001), and neurodegenerative disorders (OR 2.58, CI 1.47-4.54, p = 0.001). The most relevant precipitating factors were meningitis (OR 21.52, CI 1.22-379.83, p = 0.036), acute renal failure (OR 10.01, CI 1.13-88.73, p = 0.039), and intracranial hemorrhage (OR 3.62, CI 2.08-6.30, p < 0.001). Delirious patients were hospitalized 6 days longer, had higher in-hospital mortality, and were discharged more often to nursing homes and rehabilitation. Best predictor for delirium was the coexistence of advanced age with epilepsy (58.3%, p < 0.001), while patients aged < 65 years without epilepsy and stroke rarely developed delirium (5.1%, p < 0.001). CONCLUSIONS Delirium is common in elder neurological patients and associated with worse outcome. Primary cerebral conditions most frequently precipitate delirium in neurology. Neurologists are advised to monitor symptoms of delirium in the presence of risk factors to enable both timely diagnostic work-up and management of delirium.
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202
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
Background Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. Main body The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). Short conclusion In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy. .,Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands.,International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK.,Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy.,University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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203
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Brennan MJ, Knee AB, Leahy EJ, Ehresman MJ, Courtney HA, Coffelt P, Stefan MS. An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System. J Hosp Med 2019; 14:527-533. [PMID: 31112495 PMCID: PMC6715051 DOI: 10.12788/jhm.3198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity. OBJECTIVE To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden. DESIGN Cross-sectional quality improvement study. SETTING A 716-bed teaching hospital. PARTICIPANTS Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017. INTERVENTION ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score. RESULTS A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups. CONCLUSION The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.
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Affiliation(s)
- Maura J Brennan
- Department of Medicine, Baystate Health, Springfield, Massachusetts
| | - Alexander B Knee
- Baystate Medical Center Office of Research, Springfield, Massachusetts
| | - Erin J Leahy
- Department of Medicine, Baystate Health, Springfield, Massachusetts
| | - Michael J Ehresman
- Clinical Financial and Decision Support, Baystate Medical Center, Springfield, Massachusetts
| | | | - Patricia Coffelt
- Department of Nursing, Baystate Medical Center, Springfield, Massachusetts
| | - Mihaela S Stefan
- Department of Medicine, Baystate Health, Springfield, Massachusetts
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
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204
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State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth 2019; 123:464-478. [PMID: 31439308 DOI: 10.1016/j.bja.2019.07.004] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.
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205
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Amare M, McEvoy M, Smith A. The effect of intravenous and inhalational maintenance of anaesthesia on postoperative cognitive outcomes in elderly people. Anaesthesia 2019; 74:1068. [DOI: 10.1111/anae.14758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. Amare
- Cochrane Anaesthesia Review Group
- Northwest School of Anaesthesia UK
| | - M. McEvoy
- Cochrane Anaesthesia Review Group
- Northwest School of Anaesthesia UK
| | - A. Smith
- Cochrane Anaesthesia Review Group Lancaster University UK
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206
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Baessler F, Ciprianidis A, Rizvi AZ, Weidlich J, Wagner FL, Klein SB, Baumann TC, Nikendei C, Schultz JH. Delirium: Medical Students' Knowledge and Effectiveness of Different Teaching Methods. Am J Geriatr Psychiatry 2019; 27:737-744. [PMID: 31005497 DOI: 10.1016/j.jagp.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 03/05/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Medical schools are often blamed for inadequately training doctors on delirium. This study assesses the knowledge of medical students regarding delirium and evaluates different teaching methods for comparing learning outcomes. METHODS A video, a handout, and a video+handout were used as three different teaching methods. Students were randomly assigned to three groups and pre- and postintervention knowledge gains were compared. Interventions were held between 2015 and 2018 at the University of Heidelberg Medical School in Germany. Seventy-eight (video intervention 33; handout 26; video+handout 19) sixth-year medical students participated. Participants learned about delirium with the help of a video, a handout, and both a video+handout at the start of one-hour lectures dedicated to teaching about delirium. Pre- and postintervention questionnaires, comprising five multiple-choice questions and a self-estimated grade of knowledge about delirium, were used. Variables calculated were objective and subjective knowledge, recall, and accuracy of self-assessment. Microsoft Excel and analysis of covariance were used to analyze data. RESULTS Knowledge gains for all interventions were large (d>0.8) irrespective of gender. Post hoc comparison showed video and video+handout methods were more effective with high recall for video (92.8%). Students rated their knowledge as satisfactory, although they scored 11.4 out of 20. Preintervention knowledge level was correctly estimated by 31% of students, and postintervention by 40.3% students. CONCLUSION Teaching about delirium to medical students with a video resulted in better knowledge transfer and recall. Most medical students, particularly men, overestimated their knowledge about delirium.
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Affiliation(s)
- Franziska Baessler
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany.
| | - Anja Ciprianidis
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Z Rizvi
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua Weidlich
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabienne L Wagner
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sonja B Klein
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Tabea C Baumann
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
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207
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Simpson M, Macias Tejada J, Driscoll A, Singh M, Klein M, Malone M. The Bundled Hospital Elder Life Program-HELP and HELP in Home Care-and Its Association With Clinical Outcomes Among Older Adults Discharged to Home Healthcare. J Am Geriatr Soc 2019; 67:1730-1736. [PMID: 31220334 DOI: 10.1111/jgs.15979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. DESIGN Matched case-control study. SETTING Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). PARTICIPANTS Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. MEASUREMENTS The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. RESULTS Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). CONCLUSION HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.
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Affiliation(s)
- Michelle Simpson
- Aurora Research Institute, Ed Howe Center for Health Care Transformation, Aurora Health Care, Milwaukee, Wisconsin
| | | | - Amy Driscoll
- Aurora at Home, Aurora Health Care, Milwaukee, Wisconsin
| | - Maharaj Singh
- Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Matthew Klein
- Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Michael Malone
- Senior Services, Aurora Health Care, Milwaukee, Wisconsin.,Department of Senior Services, Aurora Health Care, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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208
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Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study. PLoS One 2019; 14:e0218152. [PMID: 31194798 PMCID: PMC6564537 DOI: 10.1371/journal.pone.0218152] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients. Methods A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients’ physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality. Result A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes. Conclusion Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation. Trial registration Dutch Trial Registration, NTR5932.
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209
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Delirium: Evaluation and Management. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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210
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Abstract
Delirium is a serious complication of acute illness. Little is known, however, regarding the neurobiology of delirium, largely due to challenges in studying the complex inpatient population. Neuroimaging is one noninvasive method that can be used to study structural and functional brain abnormalities associated with delirium. The purpose of this integrative literature review was to examine the content and quality of current structural neuroimaging evidence in delirium. After meeting inclusion criteria, 11 articles were included in the review. Commonly noted structural abnormalities were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures. Limitations of the studies in this review included small sample sizes, inappropriate or questionable delirium measurements, and failure to consider confounding variables. This review provides insight into possible structural changes responsible for the signs and symptoms seen in patients with delirium, but more high-quality studies are needed.
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Affiliation(s)
| | - Todd B Monroe
- 1 The Ohio State University College of Nursing, Columbus, OH, USA
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211
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Abstract
Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Consciousness Science, University of Michigan Medical School,, Ann Arbor, MI, USA
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, USA
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212
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Abstract
PURPOSE OF REVIEW With a continuously growing number of older patients undergoing major surgical procedures, reliable parameters practicable in perioperative routine revealing those patients at risk are urgently needed. Recently, the concept of 'prehabilitation' with its key elements exercise, nutrition and psychological stress reduction especially in frail patients is attracting increasing attention. RECENT FINDINGS Literature search revealed a huge amount of publications in particular within the last 12 months. Although a single definition of both frailty and prehabilitation is still to be made, various players in the perioperative setting obviously are becoming increasingly convinced about a possible benefit of the program - referring to different components and measures performed. Although physiologically advantages seem obvious, there is hardly any reliable data on clinical outcomes resulting from properly performed studies. This applies especially to octogenarians; thus those at risk for adverse events the concept originally addresses. SUMMARY Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients. However, further studies on effectiveness in a highly heterogeneous population and agreement on a common concept are mandatory before a final judgement can be given.
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213
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Bryant EA, Tulebaev S, Castillo-Angeles M, Moberg E, Senglaub SS, O'Mara L, McDonald M, Salim A, Cooper Z. Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients. J Am Coll Surg 2019; 228:852-859.e1. [PMID: 30959106 DOI: 10.1016/j.jamcollsurg.2019.02.052] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/08/2019] [Accepted: 02/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions. STUDY DESIGN This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes. RESULTS There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients. CONCLUSIONS An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.
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Affiliation(s)
- Elizabeth A Bryant
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Samir Tulebaev
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Esther Moberg
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Steven S Senglaub
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Lynne O'Mara
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Meghan McDonald
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
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Sillner AY, Holle CL, Rudolph JL. The Overlap Between Falls and Delirium in Hospitalized Older Adults: A Systematic Review. Clin Geriatr Med 2019; 35:221-236. [PMID: 30929884 DOI: 10.1016/j.cger.2019.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Falls frequently occur in persons with cognitive impairment, including delirium. This article presents a systematic review of the association between falls and delirium in adults aged 65 years or older. For the studies that compared falls and delirium, the risk ratio was consistently elevated (median RR 4.5, range 1.4-12.6) and statistically significant in all but one study. These results suggest that falls and delirium are inextricably linked. There is a need to further refine fall risk assessment tools and protocols to specifically include delirium for consideration as a risk factor that needs additional assessment and management.
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Affiliation(s)
- Andrea Yevchak Sillner
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center (650), 830 Chalkstone Avenue, Providence, RI 02908 USA; College of Nursing, The Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA 16802, USA
| | - Cynthia L Holle
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center (650), 830 Chalkstone Avenue, Providence, RI 02908 USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center (650), 830 Chalkstone Avenue, Providence, RI 02908 USA; Department of Medicine, Warren Alpert Medical School, Brown University, Box G-A1, Providence, RI 02912, USA; Center of Gerontology and Health Research, Brown University School of Public Health, Providence, RI, USA.
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215
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McCoy TH. Mapping the Delirium Literature Through Probabilistic Topic Modeling and Network Analysis: A Computational Scoping Review. PSYCHOSOMATICS 2019; 60:105-120. [DOI: 10.1016/j.psym.2018.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/09/2018] [Accepted: 12/13/2018] [Indexed: 01/21/2023]
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216
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Meehan AJ, Maher AB, Brent L, Copanitsanou P, Cross J, Kimber C, MacDonald V, Marques A, Peng L, Queirós C, Roigk P, Sheehan KJ, Skúladóttir SS, Hommel A. The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture. Int J Orthop Trauma Nurs 2019; 32:3-26. [DOI: 10.1016/j.ijotn.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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217
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Affiliation(s)
- D. A. Scott
- Department of Anaesthesia and Acute Pain Medicine; St. Vincent's Hospital Melbourne; University of Melbourne; Vic. Australia
| | - L. A. Evered
- Department of Anaesthesia and Acute Pain Medicine; St. Vincent's Hospital Melbourne; University of Melbourne; Vic. Australia
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218
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Sanford AM, Berg-Weger M, Lundy J, Morley JE. Editorial: Aging Friendly Health Systems. J Nutr Health Aging 2019; 23:119-121. [PMID: 30697619 DOI: 10.1007/s12603-019-1154-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A M Sanford
- John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104, USA,
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219
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Calandriello A, Tylka JC, Patwari PP. Sleep and Delirium in Pediatric Critical Illness: What Is the Relationship? Med Sci (Basel) 2018; 6:E90. [PMID: 30308998 PMCID: PMC6313745 DOI: 10.3390/medsci6040090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/28/2018] [Accepted: 10/03/2018] [Indexed: 12/18/2022] Open
Abstract
With growing recognition of pediatric delirium in pediatric critical illness there has also been increased investigation into improving recognition and determining potential risk factors. Disturbed sleep has been assumed to be one of the key risk factors leading to delirium and is commonplace in the pediatric critical care setting as the nature of intensive care requires frequent and invasive monitoring and interventions. However, this relationship between sleep and delirium in pediatric critical illness has not been definitively established and may, instead, reflect significant overlap in risk factors and consequences of underlying neurologic dysfunction. We aim to review the existing tools for evaluation of sleep and delirium in the pediatric critical care setting and review findings from recent investigations with application of these measures in the pediatric intensive care unit.
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Affiliation(s)
- Amy Calandriello
- Pediatric Critical Care Medicine, Rush Children's Hospital, Rush University Medical Center, 1750 W. Harrison Street, Chicago, IL 606012, USA.
| | - Joanna C Tylka
- Pediatric Critical Care Medicine, Rush Children's Hospital, Rush University Medical Center, 1750 W. Harrison Street, Chicago, IL 606012, USA.
| | - Pallavi P Patwari
- Pediatric Critical Care Medicine, Rush Children's Hospital, Rush University Medical Center, 1750 W. Harrison Street, Chicago, IL 606012, USA.
- Pediatric Sleep Medicine, Rush Children's Hospital, Rush University Medical Center, 1750 W. Harrison Street, Chicago, IL 606012, USA.
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220
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Scheunemann LP, Girard TD, Skidmore ER, Resnick NM. The Hospital Elder Life Program: Past and Future. Am J Geriatr Psychiatry 2018; 26:1034-1035. [PMID: 30146370 PMCID: PMC6545575 DOI: 10.1016/j.jagp.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/17/2023]
Affiliation(s)
| | - Timothy D Girard
- Scheunemann: Divisions of Geriatric Medicine and Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh; Girard: Department of Critical Care Medicine, University of Pittsburgh; Skidmore: Department of Occupational Therapy, University of Pittsburgh; Resnick: Division of Geriatric Medicine, University of Pittsburgh
| | - Elizabeth R Skidmore
- Scheunemann: Divisions of Geriatric Medicine and Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh; Girard: Department of Critical Care Medicine, University of Pittsburgh; Skidmore: Department of Occupational Therapy, University of Pittsburgh; Resnick: Division of Geriatric Medicine, University of Pittsburgh
| | - Neil M Resnick
- Scheunemann: Divisions of Geriatric Medicine and Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh; Girard: Department of Critical Care Medicine, University of Pittsburgh; Skidmore: Department of Occupational Therapy, University of Pittsburgh; Resnick: Division of Geriatric Medicine, University of Pittsburgh
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