Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review

Electroencephalographic Measures of Delirium in the Perioperative Setting: A Systematic Review

Postoperative delirium (POD) is frequent in older adults and is associated with adverse cognitive and functional outcomes. In the last several decades, there has been an increased interest in exploring tools that easily allow the early recognition of patients at risk of developing POD. The electroencephalogram (EEG) is a widely available tool used to understand delirium pathophysiology, and its use in the perioperative setting has grown exponentially, particularly to predict and detect POD. We performed a systematic review to investigate the use of EEG in the pre-, intra-, and postoperative settings. We identified 371 studies, and 56 met the inclusion criteria. A range of techniques was used to obtain EEG data, from limited 1-4 channel setups to complex 256-channel systems. Power spectra were often measured preoperatively, yet the outcomes were inconsistent. During surgery, the emphasis was primarily on burst suppression (BS) metrics and power spectra, with a link between the frequency and timing of BS, and POD. The EEG patterns observed in POD aligned with those noted in delirium in different contexts, suggesting a reduction in EEG activity. Further research is required to investigate preoperative EEG indicators that may predict susceptibility to delirium.

Risk Factors for Postoperative Delirium Severity After Deep Brain Stimulation Surgery in Parkinson's Disease

Background

Postoperative delirium (POD) is a serious complication following deep brain stimulation (DBS) but only received little attention. Its main risk factors are higher age and preoperative cognitive deficits. These are also main risk factors for long-term cognitive decline after DBS in Parkinson's disease (PD).

Objective

To identify risk factors for POD severity after DBS surgery in PD.

Methods

57 patients underwent DBS (21 female; age 60.2±8.2; disease duration 10.5±5.9 years). Preoperatively, general, PD- and surgery-specific predictors were recorded. Montreal Cognitive Assessment and the neuropsychological test battery CANTAB ConnectTM were used to test domain-specific cognition. Volumes of the cholinergic basal forebrain were calculated with voxel-based morphometry. POD severity was recorded with the delirium scales Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Nursing Delirium Scale (NU-DESC). Spearman correlations were calculated for univariate analysis of predictors and POD severity and linear regression with elastic net regularization and leave-one-out cross-validation was performed to fit a multivariable model.

Results

21 patients (36.8%) showed mainly mild courses of POD following DBS. Correlation between predicted and true POD severity was significant (spearman rho = 0.365, p = 0.001). Influential predictors were age (p < 0.001), deficits in attention and motor speed (p = 0.002), visual learning (p = 0.036) as well as working memory (p < 0.001), Nucleus basalis of Meynert volumes (p = 0.003) and burst suppression (p = 0.005).

Conclusions

General but also PD- and surgery-specific factors were predictive of POD severity. These findings underline the multifaceted etiology of POD after DBS in PD. Valid predictive models must therefore consider general, PD- and surgery-specific factors.

The prognostic validity of delirium severity as measured by Delirium Observation Screening Scale (DOS scale) on adverse outcomes

OBJECTIVE

To investigate whether an assessment of delirium severity at diagnosis using the Delirium Observation Screening Scale (DOS scale) predicts adverse outcomes in hospital and on discharge.

METHODS

A prospective cohort study was conducted on a convenience sample of patients admitted to an acute geriatric ward with delirium over an eight-month period. DOS scale was administered to the patients within 48 h of delirium diagnosis to measure delirium severity. Univariate logistic regression analysis was performed to evaluate the correlation between DOS scale and adverse outcomes.

RESULTS

Fifty-nine patients were included in the study. There was a moderate correlation between increasing DOS scores and duration of delirium (r = 0.46, p < 0.001), as well as increasing DOS scores and decline in mobility on discharge (r = 0.35, p = 0.007). There was a weak correlation between increasing DOS scores and functional decline as measured by change in Katz Index from admission to discharge (r = -0.27, p = 0.04). No statistically significant correlations were found between DOS scores and in-hospital mortality, inpatient complication rates or discharge to higher level of care.

CONCLUSION

Delirium severity as measured by DOS scale may be useful in predicting delirium duration and decline in mobility and function on discharge. Further research with larger sample sizes is needed to establish if this finding can be replicated and whether delirium severity predicts additional adverse outcomes. Measuring delirium severity at diagnosis may be useful for communicating prognostic information to family members and setting expectations and treatment goals.

Fluid Status Vulnerability in Older Adults

There is a growing body of evidence about physiological changes with age that impact fluid and electrolyte balance. It is important that infusion nurses have knowledge in managing care for geriatric patients so they can identify these changes when they are exhibited. Knowing how to minimize the effect of these changes on the health of older adults is critical. The infusion nurse with knowledge of geriatric-focused care can avoid complications and critical illness in older adults. In addition, it is important to provide specific patient education that is grounded in geriatric best practices. This information will assist older adults to better protect themselves from dehydration, kidney injury, and other complications associated with fluid balance, such as delirium. This article reviews the literature on specific changes with aging that predispose older adults to adverse complications with fluid imbalance. New technology in geriatrics that can improve management of fluid status, such as dehydration and electrolyte monitors, are also discussed. This review included searches of the Medline®/PubMed® Database using MeSH terms (National Library of Medicine). Search terms included the following: aging-biological; aging kidney; water-electrolyte imbalance; dehydration; hypo-hypernatremia; hypo-hyperkalemia; delirium; wearable technology; and hydration monitors.

Advancing specificity in delirium: The delirium subtyping initiative

BACKGROUND

Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology.

METHODS

The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts.

RESULTS

Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations.

DISCUSSION

The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes.

HIGHLIGHTS

Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.

Application of Multiple Omics to Understand Postoperative Delirium Pathophysiology in Humans

Delirium, an acute change in cognition, is common, morbid, and costly, particularly among hospitalized older adults. Despite growing knowledge of its epidemiology, far less is known about delirium pathophysiology. Initial work understanding delirium pathogenesis has focused on assaying single or a limited subset of molecules or genetic loci. Recent technological advances at the forefront of biomarker and drug target discovery have facilitated application of multiple "omics" approaches aimed to provide a more complete understanding of complex disease processes such as delirium. At its basic level, "omics" involves comparison of genes (genomics, epigenomics), transcripts (transcriptomics), proteins (proteomics), metabolites (metabolomics), or lipids (lipidomics) in biological fluids or tissues obtained from patients who have a certain condition (i.e., delirium) and those who do not. Multi-omics analyses of these various types of molecules combined with machine learning and systems biology enable the discovery of biomarkers, biological pathways, and predictors of delirium, thus elucidating its pathophysiology. This review provides an overview of the most recent omics techniques, their current impact on identifying delirium biomarkers, and future potential in enhancing our understanding of delirium pathogenesis. We summarize challenges in identification of specific biomarkers of delirium and, more importantly, in discovering the mechanisms underlying delirium pathophysiology. Based on mounting evidence, we highlight a heightened inflammatory response as one common pathway in delirium risk and progression, and we suggest other promising biological mechanisms that have recently emerged. Advanced multiple omics approaches coupled with bioinformatics methodologies have great promise to yield important discoveries that will advance delirium research.

Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study

BACKGROUND

Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time.

OBJECTIVE

To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery.

DESIGN

Retrospective cohort study.

SETTING

U.S. hospitals in the Premier Healthcare Database.

PATIENTS

17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018.

INTERVENTIONS

Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg).

MEASUREMENTS

The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.

RESULTS

The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.

LIMITATION

Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment.

CONCLUSION

These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.

PRIMARY FUNDING SOURCE

National Institute on Aging.

The Relationship Between Rejection of Care Behaviors and Pain and Delirium Severity in Hospital Dementia Care

Background and Objectives

Rejection of care is common in hospitalized persons living with dementia. However, distinguishing between rejection of care behaviors related to care practices or other causes, such as pain or delirium, is challenging. The purpose of this study is to further understand the relationship between rejection of care and pain and delirium in hospitalized patients with dementia by identifying which rejection of care behaviors are associated with pain and delirium.

Research Design and Methods

Care encounters between hospitalized patients with dementia (n = 16) and nursing staff (n = 53) were observed on 88 separate occasions across 35 days. Rejection of care was measured using the 13 behaviors from the Resistiveness to Care Scale. Pain and delirium severity were measured using a variety of scales including the Pain Assessment in Advanced Dementia Scale, Checklist of Nonverbal Pain Indicators, and numeric rating scale for pain severity and the Confusion Assessment Method-Severity short form and Delirium Observation Screening Scale for delirium severity. Linear mixed modeling was used to determine the relationship between rejection of care behaviors and pain and delirium severity for each measure.

Results

About 48.9% of the observations included rejection of care, 49.9% included a patient in pain, and 12.5% included a patient with delirium. Cry, push away, scream/yell, and turn away indicated a higher pain severity across pain measures. No rejection of care behaviors were found to indicate delirium severity.

Discussion and Implications

Certain rejection of care behaviors may be helpful in identifying pain in hospitalized patients with dementia, suggesting that caregivers should be cognizant of pain when these rejection of care behaviors are present. However, in this sample rejection of care behaviors was not found to be useful for identifying delirium severity in hospital dementia care.

A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial

OBJECTIVE

Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery.

METHODS

Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score.

RESULTS

There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups.

CONCLUSIONS

A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery.

TRIAL REGISTRATION

ChiCTR2200055281.

Measures for the Core Outcome Set for Research Evaluating Interventions to Prevent and/or Treat Delirium in Critically Ill Adults: An International Consensus Study (Del-COrS)

To gain consensus on measurement methods for outcomes (delirium occurrence, severity, time to resolution, mortality, health-related quality of life [HrQoL], emotional distress including anxiety, depression, acute stress, and post-traumatic stress disorder, and cognition) of our Core Outcome Set (COS) for trials of interventions to prevent and/or treat delirium in critically ill adults.

Understanding the association between admission source and in-hospital delirium: A cross-sectional study

Patients admitted via interhospital transfer (IHT) experience increased risk-adjusted mortality, adverse events, length of stay, and discharge to facility; however, the etiology is not well understood. We hypothesize that IHTs are more likely to experience in-hospital delirium as compared with admissions to the hospital via the emergency department (ED) and clinic. This is a cross-sectional study of all adult admissions to medical, surgical, neurological, and obstetrics and gynecology services at an academic medical center who were screened for delirium between August 2018 and January 2020. Unit of analysis was admission source (IHT vs ED vs clinic) as the independent variable and the primary outcome was in-hospital delirium, assessed with initial brief confusion assessment method (bCAM) screening. 30,100 hospitalizations were included in this study with 3925 admissions (13.0%) screening positive for delirium at the initial bCAM assessment. The prevalence of delirium was much higher in IHTs at 22.3% (1334/5971) when compared with clinic at 5.8% (244/4214) and ED at 11.8% (2347/19,915) admissions. Multivariable logistic regression adjusting for demographics and comorbidities showed that IHT admissions had higher odds (OR 1.91, 95% CI 1.74 to 2.10) and clinic admissions had lower odds (OR 0.56, 95% CI 0.48 to 0.64) of in-hospital delirium compared with ED admissions. Increased odds of delirium in IHT admissions may contribute to the observed increased length of stay, discharge to facility, and mortality. These results emphasize the importance of routine screening and possible intervention prior to patient transfer.

Effectiveness of a multicomponent exercise training program for the management of delirium in hospitalized older adults using near-infrared spectroscopy as a biomarker of brain perfusion: Study protocol for a randomized controlled trial

Delirium is an important cause of morbidity and mortality in older adults admitted to hospital. Multicomponent interventions targeting delirium risk factors, including physical exercise and mobilization, have been shown to reduce delirium incidence by 30-40% in acute care settings. However, little is known about its role in the evolution of delirium, once established. This study is a randomized clinical trial conducted in the Acute Geriatric Unit of Hospital Universitario de Navarra (Pamplona, Spain). Hospitalized patients with delirium who meet the inclusion criteria will be randomly assigned to the intervention or the control group. The intervention will consist of a multicomponent exercise training program, which will be composed of supervised progressive resistance and strength exercise over 3 consecutive days. Functional Near-Infrared Spectroscopy (NIRS) will be used for assessing cerebral and muscle tissue blood flow. The objective is to assess the effectiveness of this intervention in modifying the following primary outcomes: duration and severity of delirium and functional status. This study will contribute to determine the effectiveness of physical exercise in the management of delirium. It will be the first study to evaluate the impact of a multicomponent intervention based on physical exercise in the evolution of delirium.

Clinical trial registration

ClinicalTrials.gov. identifier: NCT05442892 (date of registration June 26, 2022).

Predisposing and precipitating risk factors for delirium in gastroenterology and hepatology: Subgroup analysis of 718 patients from a hospital-wide prospective cohort study

BACKGROUND AND AIMS

Delirium is the most common acute neuropsychiatric syndrome in hospitalized patients. Higher age and cognitive impairment are known predisposing risk factors in general hospital populations. However, the interrelation with precipitating gastrointestinal (GI) and hepato-pancreato-biliary (HPB) diseases remains to be determined.

PATIENTS AND METHODS

Prospective 1-year hospital-wide cohort study in 29'278 adults, subgroup analysis in 718 patients hospitalized with GI/HPB disease. Delirium based on routine admission screening and a DSM-5 based construct. Regression analyses used to evaluate clinical characteristics of delirious patients.

RESULTS

Delirium was detected in 24.8% (178/718). Age in delirious patients (median 62 years [IQR 21]) was not different to non-delirious (median 60 years [IQR 22]), p = 0.45). Dementia was the strongest predisposing factor for delirium (OR 66.16 [6.31-693.83], p < 0.001). Functional impairment, and at most, immobility increased odds for delirium (OR 7.78 [3.84-15.77], p < 0.001). Patients with delirium had higher in-hospital mortality rates (18%; OR 39.23 [11.85-129.93], p < 0.001). From GI and HPB conditions, cirrhosis predisposed to delirium (OR 2.11 [1.11-4.03], p = 0.023), while acute renal failure (OR 4.45 [1.61-12.26], p = 0.004) and liver disease (OR 2.22 [1.12-4.42], p = 0.023) were precipitators. Total costs were higher in patients with delirium (USD 30003 vs. 10977; p < 0.001).

CONCLUSION

Delirium in GI- and HPB-disease was not associated with higher age per se, but with cognitive and functional impairment. Delirium needs to be considered in younger adults with acute renal failure and/or liver disease. Clinicians should be aware about individual risk profiles, apply preventive and supportive strategies early, which may improve outcomes and lower costs.

Deconstructing delirium in the post anaesthesia care unit

The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ −2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ −2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.

Recipe for primary prevention of delirium in hospitalized older patients

Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.

Utilizing timed categorical recall (naming US cities) for rapid bedside dementia screening

The availability of fast validated screening for dementia is a critical clinical need to improve neurologic examination time efficiency. This study validated a 1-minute timed categorical recall (TCR) method, naming as many US cities as possible and compared TCR to the Folstein Minimental Status Exam (MMSE) as a preliminary cognitive screening tool. Random uncompensated 349 volunteers were recruited ages 18 to 97 from local free clinics, retirement homes, university faculty, and students in Lynchburg, Virginia 2015 to 2020. Participants' demographic and medical information were collected. After 1 minute preparation, participants were rapidly named as many US cities as possible until they were told to stop (1 minute). The time limitation was withheld in advance. Number of cities and organizational strategies were recorded. Folstein MMSE administration immediately after TCR was administered to 122 subjects recruited in the final 2 study years as a comparison benchmark. A multiple linear regression model and a regression tree model were used to identify important variables for the number of cities named and determine subgroups and their thresholds. TCR resulted in accuracy rate (0.80), sensitivity (0.78), and specificity (0.81). The global TCR threshold (9 cities named) is superseded by 4 subgroup thresholds, categorized by statistically important variables (age, education level, and number of states visited) as follows: For those visiting ≥8 states and 1. 18 to 71 ages with a master's degree or above, the threshold was naming 20 cities; 2. 18 to 29 ages with a bachelor's degree or below, the threshold was naming 17 cities; 3. 30 to 71 ages with a bachelor's degree or below, the threshold was naming 10 cities. For those visiting <8 states or for ages 72 to 97 (regardless of education levels and number of states visited), the threshold was naming 8 cities. American cities are common knowledge across ages and backgrounds, making it a useful bedside screen for dementia. In clinical practice, patients who report fewer cities than the threshold of 9 cities should receive further cognitive testing. If the patient meets the criteria for a subgroup, then the higher subgroup thresholds apply. TCR is a more time-efficient preliminary dementia screening tool with improved sensitivity and similar specificity compared with MMSE.

Characteristics of elderspeak communication in hospital dementia care: Findings from The Nurse Talk observational study

BACKGROUND

Elderspeak communication is typically viewed as patronizing and infantilizing by older adults and can lead to resistive behaviors in persons living with dementia. Little is known about the presence of elderspeak communication in hospitals in the United States. Understanding this phenomenon in the hospital setting is needed in order to improve hospital dementia care.

OBJECTIVES

The purpose of the Nurse Talk study was to (1) describe attributes of elderspeak use in hospital dementia care and to (2) determine what characteristics are associated with nursing staff use of elderspeak communication with hospitalized patients with dementia.

DESIGN

A cross-sectional observational study design was used to collect and analyze audio-recordings of nursing staff during care for hospitalized patients with dementia.

SETTING

Three hospital units in one Midwestern university hospital in the United States.

PARTICIPANTS

A convenience sample of 53 staff nurses and nursing assistants that provided direct care to 16 patients with mild or more severe dementia recruited from October 2019 through mid-March 2020.

METHODS

Eighty-eight care encounters were audio-recorded and coded for elderspeak communication using the Iowa Coding of Elderspeak scheme to determine the frequency and characteristics of elderspeak communication. A linear mixed effects model was used to determine what characteristics were associated with elderspeak and the frequency of elderspeak use by nursing staff to hospitalized patients with dementia.

RESULTS

Over a quarter (28.7%) of all nursing staff speech directed towards patients with dementia constituted elderspeak and nearly all (96.6%) care encounters included some elderspeak. Particularly common attributes of elderspeak were minimizing words and mitigating expressions, childish terms and phrases, and collective pronoun substitution. A statistically significant interaction was identified between staff role and age (95% CI: -0.02, -0.00, p = .008) in predicting the frequency of elderspeak use, indicating that elderspeak was used more often by older staff nurses, whereas the age of nursing assistants remained constant across elderspeak use. Statically significant effects for delirium and length of stay were also demonstrated. Elderspeak use was 12.5% higher with patients with delirium (95% CI: 0.02, 0.23, p = .025) and increased 1.5% for each additional day the patient with dementia was hospitalized (95% CI: 0.00, 0.03, p = .035).

CONCLUSIONS

Elderspeak is present and pervasive in the acute care setting. Interventions targeted towards older staff nurses and nursing staff from hospital units that care for patients with delirium and longer lengths of stay are needed.

TWEETABLE ABSTRACT

This study identified that nursing staff are frequently using elderspeak (infantilizing speech) with hospitalized patients with dementia. @claireshaw_phd @IowaNursing.

Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study

Introduction: Delirium in end-of-life patients is reported to be between 13% and 42% and up to 80% in the terminal phase. It is a serious clinical situation, often a cause of death due to the frequent ineffectiveness of treatments. This study aimed to assess whether and how much precocity of diagnosis, hitherto little considered, could affect the outcomes and prognosis of delirium in palliative care settings.

Methods: Patients consecutively admitted to a palliative care unit (PCU) between October 2018 and December 2019, cared for both in hospice and home programs, were analyzed. All patients were subjected to a careful procedure aimed at recognizing the onset of delirium. The first step was the detection of prodromal "sentinel" symptoms related to incoming delirium. PCU staff and family members/caregivers were trained to observe the patients and immediately identify the appearance of even one symptom. The final diagnosis was performed with the 4AT (4 A’s test). Patients were then included in the categories of "early" or "slow" diagnosis (cut-off: four hours) depending on the time between sentinel symptom observation and the final diagnosis of delirium.

Results: Among 503 admitted patients, 95 developed delirium. Confusion was the most frequent sentinel symptom (49.5%). The early diagnosis was more frequent in hospice than in home care (p-value<0.0001). Delirium was positively resolved in 43 patients, of which 25 with an early diagnosis (p-value=0.038). Time to resolution was shorter in the case of early diagnosis (7.1 vs. 13.7 hours in hospice patients; p-value=0.018). Palliative sedation was performed on 25 patients, but only 8 of them had an early diagnosis.

Conclusion: Time of diagnosis was important in determining the clinical outcomes of patients in charge of PCU who experienced delirium. The early diagnosis reduced both mortality and the necessity of palliative sedation.

Delirium detection methodologies: Implications for outcome measurement in clinical trials in postoperative delirium

OBJECTIVE

Delirium is a common postoperative complication of hip fracture. Various methods exist to detect delirium as a reference standard. The goal of this study was to characterize the properties of the measures obtained in a randomized controlled trial, to document their relationship to the Diagnostic and Statistical Manual of Mental Disorders:Text Revision based diagnosis of postoperative delirium by a consensus panel, and to describe the method in detail to allow replication by others.

METHODS

A secondary analysis of the randomized trial STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) was conducted. Delirium assessments were performed in 200 consecutive hip fracture repair patients ≥65 years old. Assessors underwent extensive training in delirium assessment and the final delirium diagnosis was adjudicated by a consensus panel of three physicians with expertise in delirium assessment.

RESULTS

A total of 680 consensus panel delirium diagnoses were completed. There were only 19 (2.8%, 19/678) evaluations where the delirium adjudication by the consensus panel differed from delirium findings by the Confusion Assessment Method (CAM). In 16 (84%, 16/19) of the cases, CAM was negative but the consensus panel diagnosed the patient as having delirium based on all of the available information including the CAM.

CONCLUSION

The consensus panel diagnosis was more sensitive compared to CAM alone, however the magnitude of the difference was not large. When assessors are well trained and delirium assessments are closely supervised throughout the study, CAM may be adequate for delirium diagnosis in a clinical trial. Future studies are needed to test this hypothesis.

Effect of seasons on delirium in postoperative critically ill patients: a retrospective analysis

BACKGROUND AND OBJECTIVES

Postoperative delirium is common in critically ill patients and is known to have several predisposing and precipitating factors. Seasonality affects cognitive function which has a more dysfunctional pattern during winter. We, therefore, aimed to test whether seasonal variation is associated with the occurrence of delirium and hospital Length Of Stay (LOS) in critically ill non-cardiac surgical populations.

METHODS

We conducted a retrospective analysis of adult patients recovering from non-cardiac surgery at the Cleveland Clinic between March 2013 and March 2018 who stayed in Surgical Intensive Care Unit (SICU) for at least 48 hours and had daily Confusion Assessment Method Intensive Care Unit (CAM-ICU) assessments for delirium. The incidence of delirium and LOS were summarized by season and compared using chi-square test and non-parametric tests, respectively. A logistic regression model was used to assess the association between delirium and LOS with seasons, adjusted for potential confounding variables.

RESULTS

Among 2300 patients admitted to SICU after non-cardiac surgeries, 1267 (55%) had postoperative delirium. The incidence of delirium was 55% in spring, 54% in summer, 55% in fall and 57% in winter, which was not significantly different over the four seasons (p = 0.69). The median LOS was 12 days (IQR = [8, 19]) overall. There was a significant difference in LOS across the four seasons (p = 0.018). LOS during summer was 12% longer (95% CI: 1.04, 1.21; p = 0.002) than in winter.

CONCLUSIONS

In adult non-cardiac critically ill surgical patients, the incidence of postoperative delirium is not associated with season. Noticeably, LOS was longer in summer than in winter.

Delirium on stroke units: a prospective, multicentric quality-improvement project

Background

Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management.

Methods

Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others.

Results

Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved.

Conclusions

Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke.

Registry

DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11000-6.

Perioperative Neurocognitive Screening Tools for At-Risk Surgical Patients

Purpose of Review

Perioperative neurocognitive disorders are common after surgery and have serious socioeconomic impacts. Despite this, these disorders remain under-recognized and underdiagnosed. To facilitate detection and direct patients toward appropriate preventative interventions, assessment of cognition during the perioperative period is of critical importance. However, there are considerable barriers to the widespread clinical implementation of cognitive assessments, including a lack of consensus regarding the optimal tool for use in specific clinical scenarios.

Recent Findings

We provide an overview of the most widely used and validated cognitive assessment tools, including those that permit telemedicine-enabled patient encounters.

Summary

No single tool is optimal for all contexts. This narrative review can help clinicians to identify the appropriate cognitive screening tool for their needs by describing the advantages and disadvantages of several available tools, thereby enabling the identification of patients at risk of cognitive decline and facilitating optimization of patient-focused perioperative care.

Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System

OBJECTIVES

Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services.

DESIGN

Pragmatic prospective cohort study of consecutive admissions to a large health care system.

SETTING AND PARTICIPANTS

A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014.

METHODS

Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI).

RESULTS

Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001).

CONCLUSIONS AND IMPLICATIONS

This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.

Safety of ibogaine administration in detoxification of opioid-dependent individuals: a descriptive open-label observational study

BACKGROUND AND AIMS

Ibogaine is an indole alkaloid used in rituals of the African Bwiti tribe. It is also used in non-medical settings to treat addiction. However, ibogaine has been linked to several deaths, mainly due to cardiac events called torsades des pointes preceded by QTc prolongation as well as other safety concerns. This study aimed to evaluate the cardiac, cerebellar and psychomimetic safety of ibogaine in patients with opioid use disorder.

DESIGN

A descriptive open-label observational study.

SETTING

Department of psychiatry in a university medical center, the Netherlands.

PARTICIPANTS

Patients with opioid use disorder (n = 14) on opioid maintenance treatment with a lasting wish for abstinence, who failed to reach abstinence with standard care.

INTERVENTION AND MEASUREMENTS

After conversion to morphine-sulphate, a single dose of ibogaine-HCl 10 mg/kg was administered and patients were monitored at regular intervals for at least 24 hours assessing QTc, blood pressure and heart rate, scale for the assessment and rating of ataxia (SARA) to assess cerebellar side effects and the delirium observation scale (DOS) to assess psychomimetic effects.

FINDINGS

The maximum QTc (Fridericia) prolongation was on average 95ms (range 29-146ms). Fifty percent of subjects reached a QTc of over 500ms during the observation period. In six out 14 subjects prolongation above 450ms lasted beyond 24 hours after ingestion of ibogaine. No torsades des pointes were observed. Severe transient ataxia with inability to walk without support was seen in all patients. Withdrawal and psychomimetic effects were mostly well-tolerated and manageable (11/14 did not return to morphine within 24 hours, DOS scores remained below threshold).

CONCLUSIONS

This open-label observational study found that ibogaine treatment of patients with opioid use disorder can induce a clinically relevant but reversible QTc prolongation, bradycardia, and severe ataxia.

A scientometric study of publications on delirium from 2001 to 2020

AIM

This study aims to evaluate the publications on delirium by using bibliometric analysis.

METHODOLOGY

The Scopus database was evaluated for publications on delirium, during the period of 2001-20. The search results were analyzed for the origin of country, origin of institution, authorship, collaborations, type of article, source of funding, and number of citations.

RESULTS

The searches of Scopus database yielded 22,941 publications, originating from 139 countries. Compared to the decade of 2001-2010, the number of publications on delirium doubled in the decade of 2011-2020. The majority of the papers were research articles (58.26%), and the papers were cited for mean number of 20.53 times. Only a small proportion of the papers were based on funding (13.14%). Maximum number of papers emerged from United States of America. In terms of institutional affiliations, among the authors from top 20 institutes, 15 were from United States, 2 from Netherlands and 1 each from Canada, Germany and United Kingdom. In terms of authors, the research productivity of the top 20 most productive authors varied from 172 to 612 publications with 12 authors belonging to United States, 2 from Italy and 1 each from Canada, Greece, India, Ireland, Netherland and the United Kingdom. The maximum number of papers were published in Journal of the American Geriatric Society and based on the number of citations the New England Journal of Medicine was the most impactful journal.

CONCLUSION

Over the years number of publications on delirium have increased, majority of the publications have emerged from United States.

Physiological Assessment of Delirium Severity: The Electroencephalographic Confusion Assessment Method Severity Score (E-CAM-S)

OBJECTIVES

Delirium is a common and frequently underdiagnosed complication in acutely hospitalized patients, and its severity is associated with worse clinical outcomes. We propose a physiologically based method to quantify delirium severity as a tool that can help close this diagnostic gap: the Electroencephalographic Confusion Assessment Method Severity Score (E-CAM-S).

DESIGN

Retrospective cohort study.

SETTING

Single-center tertiary academic medical center.

PATIENTS

Three-hundred seventy-three adult patients undergoing electroencephalography to evaluate altered mental status between August 2015 and December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We developed the E-CAM-S based on a learning-to-rank machine learning model of forehead electroencephalography signals. Clinical delirium severity was assessed using the Confusion Assessment Method Severity (CAM-S). We compared associations of E-CAM-S and CAM-S with hospital length of stay and inhospital mortality. E-CAM-S correlated with clinical CAM-S (R = 0.67; p < 0.0001). For the overall cohort, E-CAM-S and CAM-S were similar in their strength of association with hospital length of stay (correlation = 0.31 vs 0.41, respectively; p = 0.082) and inhospital mortality (area under the curve = 0.77 vs 0.81; p = 0.310). Even when restricted to noncomatose patients, E-CAM-S remained statistically similar to CAM-S in its association with length of stay (correlation = 0.37 vs 0.42, respectively; p = 0.188) and inhospital mortality (area under the curve = 0.83 vs 0.74; p = 0.112). In addition to previously appreciated spectral features, the machine learning framework identified variability in multiple measures over time as important features in electroencephalography-based prediction of delirium severity.

CONCLUSIONS

The E-CAM-S is an automated, physiologic measure of delirium severity that predicts clinical outcomes with a level of performance comparable to conventional interview-based clinical assessment.

Geriatric Implications of Surgical Oncology

Surgical oncology is cancer care that focuses on using surgery to diagnose, stage, and treat cancer and is one of the main treatments for malignancy. Patients older than 65 years are generally considered geriatric. The incidence of cancer in geriatric patients is increasing annually. Candidacy for surgical intervention depends on factors such as cancer type, size, location, grade and stage of the tumor, and the patient's overall health status and age. Despite increasing agreement that age should not limit treatment options, geriatric patients tend to be undertreated. Cancer in geriatric patients has different features than in younger patients. As such, treatment options may be dissimilar in these 2 cohorts. Here, care of the geriatric patient undergoing surgical oncology interventions is discussed.

Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression

Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.

Economic Impact of Poststroke Delirium and Associated Risk Factors: Findings From a Prospective Cohort Study

BACKGROUND AND PURPOSE

Delirium is a common severe complication of stroke. We aimed to determine the cost-of-illness and risk factors of poststroke delirium (PSD).

METHODS

This prospective single-center study included n=567 patients with acute stroke from a hospital-wide delirium cohort study and the Swiss Stroke Registry in 2014. Delirium was determined by Delirium Observation Screening Scale or Intensive Care Delirium Screening Checklist 3 times daily during the first 3 days of admission. Costs reflected the case-mix index and diagnosis-related groups from 2014 and were divided into nursing, physician, and total costs. Factors associated with PSD were assessed with multiple regression analysis. Partial correlations and quantile regression were performed to assess costs and other factors associated with PSD.

RESULTS

The incidence of PSD was 39.0% (221/567). Patients with delirium were older than non-PSD (median 76 versus 70 years; P<0.001), 52% male (115/221) versus 62% non-PSD (214/346) and hospitalized longer (mean 11.5 versus 9.3 days; P<0.001). Dementia was the most relevant predisposing factor for PSD (odds ratio, 16.02 [2.83-90.69], P=0.002). Moderate to severe stroke (National Institutes of Health Stroke Scale score 16-20) was the most relevant precipitating factor (odds ratio, 36.10 [8.15-159.79], P<0.001). PSD was a strong predictor for 3-month mortality (odds ratio, 15.11 [3.33-68.53], P<0.001). Nursing and total costs were nearly twice as high in PSD (P<0.001). There was a positive correlation between total costs and admission National Institutes of Health Stroke Scale (correlation coefficient, 0.491; P<0.001) and length of stay (correlation coefficient, 0.787; P<0.001) in all patients. Quantile regression revealed rising nursing and total costs associated with PSD, higher National Institutes of Health Stroke Scale, and longer hospital stay (all P<0.05).

CONCLUSIONS

PSD was associated with greater stroke severity, prolonged hospitalization, and increased nursing and total costs. In patients with severe stroke, dementia, or seizures, PSD is anticipated, and additional costs are associated with hospitalization.

The effect of foot massage on the level of consciousness and delirium of intensive care patients: A randomized single-blind controlled trial

INTRODUCTION

Depressed level of consciousness and delirium are associated with multiple complications in cognitive, perceptual and sensory functions in the patients of the intensive care units. The present study aimed to determine the effect of foot massage by a nurse and patient's family on the level of consciousness and delirium in patients admitted to the intensive care units (ICU).

METHODS

This was a randomized parallel single-blind controlled trial. Seventy-five ICU were assigned in three groups (massage by a nurse, massage by patient's family and control group) by stratified block randomization method. Both feet were massaged with Swedish massage (10 min) once a day for six days by a nurse or patient's family. Delirium and level of consciousness was measured before, and post-intervention.

RESULTS

The mean level of consciousness in all the three groups increased significantly one-week post-intervention. However, there was no significant difference in the level of consciousness among the three groups during the study. The frequency of delirium in the massage group by the family was 20% before the intervention, which decreased to 12% after intervention. In the massage group by a nurse and control group, 16% of the samples had delirium before the intervention. After the intervention, the prevalence of delirium was 8% in the massage group by a nurse, and it decreased to 12% in the control group, none of which was statistically significant.

CONCLUSION

The use of Swedish foot massage did not change the level of consciousness and delirium of patients admitted to the ICU.

Rapid Fire: Acute Brain Failure in Older Emergency Department Patients

Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery

STUDY OBJECTIVE

Our goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing'.

DESIGN

This was a retrospective study that used a database from a five-center randomized trial.

SETTING

Postoperative cardiothoracic ICU and surgical wards.

PARTICIPANT

Adults scheduled for elective coronary artery bypass and/or valve surgery.

INTERVENTION AND MEASUREMENTS

Postoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1-5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions.

MAIN RESULTS

A total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium.

CONCLUSIONS

Postoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.

Enfermería en la monitorización del delirium en cuidado intensivo adulto: una revisión de alcance

Introducción. El delirium es una alteración cognitiva secundaria a una situación clínica aguda que puede estar presente en el paciente crítico, y la enfermería juega un rol protagónico en la prevención, monitoreo y tratamiento no farmacológico del delirium en el paciente en unidad de cuidado intensivo. Objetivo. Identificar las investigaciones actuales que describen las estrategias que utilizan las enfermeras para la monitorización del delirium en la unidad de cuidado intensivo adulto. Método. Revisión de alcance, utilizando la pregunta orientadora ¿qué estrategias utiliza enfermería en la monitorización del delirium en la unidad de cuidado intensivo?, estudios obtenidos en las bases de datos PubMed, Biblioteca Virtual en Salud, Science Direct y Cochrane. Se realizó una revisión crítica con el instrumento CASPe, los datos se extrajeron, y se llevaron a cabo registros en tablas de gráficos elaboradas para condensar la información. Resultados. Trece estudios se consideraron relevantes y fueron analizados. Las estrategias de monitorización del delirium empleadas por enfermería son, principalmente, el juicio clínico, la observación de la agitación y, en menor medida, el empleo de instrumentos validados para la detección. Conclusión. La enfermería requiere comprender mejor el delirium, y para esto la educación es vital para mejorar su conocimiento, y aumentar la autoconfianza y competencia en la evaluación a través del uso correcto de instrumentos.

Association between components of the delirium syndrome and outcomes in hospitalised adults: a systematic review and meta-analysis

Background

Delirium is a heterogeneous syndrome with inattention as the core feature. There is considerable variation in the presence and degree of other symptom domains such as altered arousal, psychotic features and global cognitive dysfunction. Delirium is independently associated with increased mortality, but it is unclear whether individual symptom domains of delirium have prognostic importance. We conducted a systematic review and meta-analysis of studies in hospitalised adults in general settings to identify the relationship between symptom domains of delirium and outcomes.

(PROSPERO: CRD42018093935).

Methods

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials from inception to November 2019. We included studies of hospitalised adults that reported associations between symptom domains of delirium and 30-day mortality (primary outcome), and other outcomes including mortality at other time points, length of stay, and dementia. Reviewer pairs independently screened articles, extracted data, and assessed risk of bias (Risk of Bias Assessment tool for Non-randomized Studies) and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework. We performed random-effects meta-analyses stratified by delirium domain where possible.

Results

From 7092 citations we included 6 studies (6002 patients, 1112 with delirium). Higher mortality (ranging from in-hospital to follow-up beyond 12 months) was associated with altered arousal (pooled Odds Ratio (OR) 2.80, 95% Confidence Interval (CI) 2.33–3.37; moderate-quality evidence), inattention (pooled OR 2.57, 95% CI 1.74–3.80; low-quality evidence), and in single studies with disorientation, memory deficits and disorganised thoughts. Risk of bias varied across studies but was moderate-to-high overall, mainly due to selection bias, lack of blinding of assessments and unclear risk of selective outcome reporting. We found no studies on the association between psychotic features, visuospatial deficits or affective disturbances in delirium and outcomes, or studies reporting non-mortality outcomes.

Conclusions

Few studies have related symptom domains of delirium to outcomes, but the available evidence suggests that altered arousal and inattention in delirium are associated with higher mortality than normal arousal and attention in people with or without delirium. Measurable symptom domains of delirium may have value in predicting survival and stratifying patients for treatment. We recommend that future delirium studies report outcomes by symptom domain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02095-z.

Family automated voice reorientation (FAVoR) intervention for mechanically ventilated patients in the intensive care unit: Study protocol for a randomized controlled trial

Delirium in the intensive care unit (ICU) affects up to 80% of critically ill, mechanically ventilated (MV) adults. Delirium is associated with substantial negative outcomes, including increased hospital complications and long-term effects on cognition and health status in ICU survivors. The purpose of this randomized controlled trial is to test the effectiveness of a Family Automated Voice Reorientation (FAVoR) intervention on delirium among critically ill MV patients. The FAVoR intervention uses scripted audio messages, which are recorded by the patient's family and played at hourly intervals during daytime hours. This ongoing orientation to the ICU environment through recorded messages in a voice familiar to the patient may enable the patient to more accurately interpret the environment and thus reduce risk of delirium. The study's primary aim is to test the effect of the FAVoR intervention on delirium in critically ill MV adults in the ICU. The secondary aims are to explore: (1) if the effect of FAVoR on delirium is mediated by sleep, (2) if selected biobehavioral factors moderate the effects of FAVoR on delirium, and (3) the effects of FAVoR on short-term and long-term outcomes, including cognition and health status. Subjects (n = 178) are randomly assigned to the intervention or control group within 48 h of initial ICU admission and intubation. The intervention group receives FAVoR over a 5-day period, while the control group receives usual care. Delirium-free days, sleep and activity, cognition, patient-reported health status and sleep quality, and data regarding iatrogenic/environmental and biobehavioral factors are collected.

Reducing Perioperative Neurocognitive Disorders (PND) Through Depth of Anesthesia Monitoring: A Critical Review

General anesthesia has been administered for over 150 years, and in that time, has become progressively safer. Improvements in outcomes have been driven by multiple advances, including the use of non-invasive monitors to assess cardiovascular and respiratory status. More recent advances have included the development and use of monitors to measure neurologic status by means of “processed” electroencephalography (pEEG), wherein the frontal EEG signal is analyzed by proprietary algorithms to produce a dimensionless number (scaled from 0 to 100), wherein low values are associated with deepening levels of sedation that progresses to loss of consciousness. Such monitors have been shown to enable anesthetic titration so as to expedite emergence and early recovery, and their use is advocated for the prevention of intraoperative awareness in the setting of administration of total intravenous anesthesia and neuromuscular blockade. Whether their use can minimize, or prevent, longer term adverse events is a matter of debate. In this narrative review of the most recent literature, we provide an assessment on the use of pEEG monitors in the prevention of a notable, and important, postoperative adverse outcome – delirium – in elderly patients. As we will discuss, the existing data do not support its routine use for the prevention of postoperative delirium in this, or any other, patient population.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

BACKGROUND

Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions.

METHODS

GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci.

RESULTS

In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research.

CONCLUSIONS

Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

Delusion and Delirium in Neurodegenerative Disorders: An Overlooked Relationship?

Delusions are part of the neuropsychiatric symptoms that patients suffering from neurodegenerative conditions frequently develop at some point of the disease course and are associated with an increased risk of cognitive and functional decline. Delirium is a syndrome characterized by acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over a short time period. Delusions and delirium are frequently observed in the context of neurodegeneration, and their presence can easily mislead clinicians toward a misdiagnosis of psychiatric disorder further delaying the proper treatment. Risk factors for developing delusion and delirium in neurodegenerative conditions have been investigated separately while the possible interplay between these two conditions has not been explored so far. With this study, we aim to achieve a more comprehensive picture of the relationship between delusions and delirium in neurodegeneration by analyzing prevalence and subtypes of delusions in different neurodegenerative disorders; providing an overview of clinical tools to assess delusions in neurodegenerative patients and how delusions are covered by delirium assessment tools and discussing the possible common pathophysiology mechanisms between delusion and delirium in neurodegenerative patients. A more extensive characterization of the relationship between delusions and delirium may help to understand whether delusions may constitute a risk factor for delirium and may ameliorate the management of both conditions in patients with neurodegenerative disorders.

Consciousness and the rabbit holes of delirium

Delirium is a common disorder in hospitalized older adults and the defining characteristic is a disturbance of consciousness. Unfortunately, there are currently no testable measures of consciousness as pertains to its disruption in delirium. Not surprisingly rates of recognition of delirium suffer. Arguably, a greater understanding of the quantum of consciousness may improve delirium diagnosis through better diagnostic tools. Candidate dimensions of consciousness derived from fields of psychology, psychiatry, and philosophy are discussed and relevance to delirium explored. Based upon existing literature in the field of consciousness we identify the pre-reflective state, experiential awareness, and functional networks as candidate sites that may be affected in delirium. Opportunities for clinical instrument development and how these tools can be tested are discussed. We conclude that consciousness content may not hold to a unitary measurement, but facets of its integrity that are impacted in delirium are open to further exploration. Disorders in pre-reflective status, experiential awareness, and functional networks may represent the measurable "rabbit holes" of consciousness disturbance.

The CAM-ICU-7 and ICDSC as measures of delirium severity in critically ill adult patients

Background

In clinical practice, a dichotomous approach to delirium identification may no longer be relevant when existing delirium screening tools measure a range of scores. The objective of this study was to compare the Confusion Assessment Method for the Intensive Care Unit 7-item (CAM-ICU-7) and the Intensive Care Delirium Screening Checklist (ICDSC) as measures of the spectrum of delirium severity in critically ill adult patients.

Methods

In this cross-sectional study, 218 patients underwent 641 paired assessments by bedside nurses (ICDSC, as per usual care) and trained research assistants (CAM-ICU-7). Correlation between the CAM-ICU-7 and ICDSC scores was evaluated. Logistic regression was used to explore associations between CAM-ICU-7 or ICDSC score and length of ICU stay and mechanical ventilation (receipt, ≥96 hours).

Results

Delirium prevalence evaluated by the CAM-ICU-7 and ICDSC were 46.3% (95% CI:39.7–53.0) and 34.4% (95% CI:28.3–41.0). Prevalence of less than clinical threshold symptoms of delirium evaluated by the CAM-ICU-7 (score: 1–2) and ICDSC (score: 1–3) were 30.3% (95%CI:24.5–36.7) and 50.9% (95%CI:44.3–57.6). The CAM-ICU-7 and ICDSC had significant positive correlation (0.58, p<0.001). Agreement between the tools as measures of delirium was moderate (kappa = 0.51) and as measures of less than clinical threshold symptoms of delirium was fair (kappa = 0.21). Less than clinical threshold symptoms of delirium identified by the ICDSC, not CAM-ICU-7, were associated with prolonged length of ICU stay (≥7 days) in patients <65 years of age [Odds Ratio (OR) 9.2, 95% CI:2.5–34.0] and mechanical ventilation (receipt: OR 2.8, 95% CI:1.3–6.4; ≥96 hours: OR 6.6, 95% CI:1.9–22.9), when compared to patients with no delirium.

Conclusions

The CAM-ICU-7 and ICDSC are measures of the spectrum of delirium severity that are closely correlated. Less than clinical threshold symptoms of delirium measure by the ICDSC is a better predictor of outcomes, when compared with the CAM-ICU-7.

Delirium

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.

Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings

BACKGROUND/OBJECTIVES

Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research.

DESIGN

We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments.

MEASUREMENTS

Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework.

RESULTS

Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale.

CONCLUSION

Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.

Delirium

Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called acute brain failure, acute brain dysfunction, or altered mental status. All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.

Melatonin for delirium prevention in acute medically ill, and perioperative geriatric patients

Delirium is a challenging neuropsychiatric ailment that has a negative impact on morbidity and mortality and is difficult to treat once it has developed. The purpose of this review was to analyze the efficacy of melatonin in the prevention of delirium in hospitalized geriatric patients in the acute medically ill and perioperative wards. The databases searched included PubMed (1946 to February 12, 2020), CINAHL (1982 to February 12, 2020), EMBASE (1974 to February 12, 2020), and Web of Science (1900 to February 12, 2020) using search terms related to melatonin, delirium, and prevention. Meta-analyses, randomized controlled trials, and observational studies were included. We excluded publications pertaining to the intensive care unit or oncology, case reports/series, and those not in English. Seven full-text publications were included for qualitative analysis. Patient comorbidities, patient medications, melatonin dosing, dosing regimens, and duration of treatment varied between the studies, which yielded heterogeneous results. Overall, this literature review yielded four studies that showed positive results and three that showed negative results for delirium prevention. The current data for the use of melatonin in delirium is conflicting. This area requires further research of more homogeneous studies with larger sample sizes.

New Delirium Severity Indicators: Generation and Internal Validation in the Better Assessment of Illness (BASIL) Study

BACKGROUND

Delirium is a common and preventable geriatric syndrome. Moving beyond the binary classification of delirium present/absent, delirium severity represents a potentially important outcome for evaluating preventive and treatment interventions and tracking the course of patients. Although several delirium severity assessment tools currently exist, most have been developed in the absence of advanced measurement methodology and have not been evaluated with rigorous validation studies.

OBJECTIVE

We aimed to report our development of new delirium severity items and the results of item reduction and selection activities guided by psychometric analysis of data derived from a field study.

METHODS

Building on our literature review of delirium instruments and expert panel process to identify domains of delirium severity, we adapted items from existing delirium severity instruments and generated new items. We then fielded these items among a sample of 352 older hospitalized patients.

RESULTS

We used an expert panel process and psychometric data analysis techniques to narrow a set of 303 potential items to 17 items for use in a new delirium severity instrument. The 17-item set demonstrated good internal validity and favorable psychometric characteristics relative to comparator instruments, including the Confusion Assessment Method - Severity (CAM-S) score, the Delirium Rating Scale Revised 98, and the Memorial Delirium Assessment Scale.

CONCLUSION

We more fully conceptualized delirium severity and identified characteristics of an ideal delirium severity instrument. These characteristics include an instrument that is relatively quick to administer, is easy to use by raters with minimal training, and provides a severity rating with good content validity, high internal consistency reliability, and broad domain coverage across delirium symptoms. We anticipate these characteristics to be represented in the subsequent development of our final delirium severity instrument.