Impact of delirium on the outcome of stroke: a prospective, observational, cohort study

Global prevalence and risk factors of delirium among patients following acute stroke: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The exact prevalence and risk factors of delirium following stroke at an acute stage remains unclear. We aimed to determine the global prevalence and risk factors of delirium following acute stroke.

METHOD

Observational studies reporting the prevalence of or risk factors for delirium following acute stroke published in the PubMed, Embase, and Scopus databases before April 16, 2024, were identified. Data were extracted by two independent reviewers. A random effects model was used for data analysis.

RESULTS

Our meta-analysis included 48 studies on prevalence and 25 studies on risk factors for poststroke delirium. The pooled global prevalence rate of delirium was 24 % (18 %-30 %). Hemorrhagic stroke type, early assessment (within 3 days of stroke onset), older age, and male sex were risk factors for poststroke delirium. Independent factors significantly associated with poststroke delirium (all p < 0.05) were age, dementia, prior stroke, prior total anterior circulation infarct stroke subtype, atrial fibrillation, elevated C-reactive protein levels, aphasia, poor vision, neglect, depression, and the use of urinary catheters and gastric tubes.

CONCLUSION

Approximately a quarter of the included patients with acute stroke experienced delirium. Our findings regarding the risk factors for poststroke delirium can provide an evidence-based approach for future strategies to prevent delirium.

FUNDINGS

NSTC, Taiwan (MOST 113-2628-B- 038-00-MY3 and 111-2314-B-038-033-MY3).

PROTOCOL

The International Prospective Register of Systematic Reviews (CRD42024518119).

Reperfusion therapy and risk of post-stroke delirium

OBJECTIVES

Delirium is a common and serious post-stroke complication. Early reperfusion by ameliorating brain damage could potentially prevent delirium after ischemic stroke, but the impact of this therapy on delirium remains unclear. We aimed to explore the association between reperfusion therapy (RT) and post-stroke delirium.

METHODS

We retrospectively analyzed data from the PRospective Observational POLIsh Study on post-stroke delirium. Symptoms of delirium were examined during the first 7 days after admission and a diagnosis of delirium was made using Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. We used logistic regression to examine the association between RT and delirium.

RESULTS

We included 301 acute stroke patients (median age: 77; median NIHSS: 14; 55.1% female). In the whole group of patients, RT was associated with a lower odds of delirium (34.2% vs 44.8%; adjusted OR: 0.56, 95% CI: 0.32-0.96, p = 0.035). There was a significant interaction between RT and pre-stroke cognitive status. As a result, RT was associated with a lower odds of delirium in patients without premorbid cognitive decline (28.8% vs 48.2%; adjusted OR: 0.34, 95% CI: 0.17-0.66, p = 0.002) and a higher odds of delirium in patients with pre-stroke cognitive decline (72.7% vs 41.0%; adjusted OR: 3.55, 95% CI: 1.03-12.20, p = 0.040).

DISCUSSION

The association between RT and delirium is modified by pre-stroke cognitive status. In patients without cognitive decline, RT is associated with a lower likelihood of delirium. Delirium should be considered as a relevant outcome in future controlled trials.

Characteristics and prognostic impact of unsuccessful recanalization after endovascular therapy for acute ischemic stroke

BACKGROUND

Endovascular therapy (EVT) has shown high therapeutic efficacy for acute large vessel occlusion (LVO); however, recanalization is unsuccessful in some cases. This study aimed to examine the characteristics and prognostic impact of unsuccessful recanalization after EVT compared with medical treatment alone.

METHODS

We conducted a post hoc analysis of RESCUE-Japan Registry 2, a nationwide registry of 2408 consecutive patients with acute LVO. Patients without successful recanalization after EVT (thrombolysis in cerebral infarction grade ≤ 2a) were classified into the Unsuccessful EVT group, and compared with the No-EVT group. To account for selection bias, the outcomes were compared in a propensity score-matched cohort. The outcomes included the modified Rankin Scale (mRS) score at 90 days and intracranial hemorrhage within 72 h after the LVO onset.

RESULTS

Among 188 (14.7 %) patients in the Unsuccessful EVT group out of 1281 who underwent EVT, 147 were matched with the No-EVT group, with comparable baseline characteristics. Patients in the Unsuccessful EVT group had a higher distribution of mRS score at 90 days and were less likely to achieve mRS 0-2 compared to those in the No-EVT group (23 % vs. 34 %, OR:0.58, 95 % CI:0.35-0.98). All-cause mortality was higher in the Unsuccessful EVT group (16 % vs. 6.8 %, OR: 2.54, 95 % CIs: 1.16-5.55). Symptomatic intracranial hemorrhage was more frequently observed in the Unsuccessful EVT group (5.4 % vs. 0.7 %, OR: 8.40, 95 % CIs: 1.04-68.1).

CONCLUSIONS

The clinical outcomes of patients without successful recanalization after EVT were worse than those who did not undergo EVT.

Functional Outcomes After Decompressive Surgery in Patients with Malignant Space-Occupying Cerebellar Infarction

Background and Purpose: Decompressive surgery is a potentially life-saving treatment in patients with malignant space-occupying cerebellar infarction. However, there is only limited literature on functional outcomes and complications after surgery. Our aim was to establish markers which predict poor outcome. Methods: We retrospectively analyzed data of all patients who underwent surgery due to malignant swelling of a space-occupying cerebellar infarction in our hospital between 2005 and 2023. Statistical analyses were conducted on multiple parameters to identify predictors of poor functional outcome (mRS 4-6) 90 days after surgery. Complications during hospitalization were reviewed for each patient. Results: In total, 58 patients received decompressive surgery. The 90-day mortality rate was 27.6% (n = 16). A good functional outcome (mRS 0-3) 90 days after surgery was achieved in 24 patients (41.4%). Multivariable analysis revealed multiple factors associated with a poor outcome on day 90 (mRS 4-6): a higher premorbid mRS score (OR 2.715 [95% CI, 1.166-6.323]; p = 0.021), higher NIHSS score on admission (OR 1.088 [95% CI, 1.014, 1.168]; p = 0.019) and the presence of an additional brainstem infarction (OR 7.035, [95% CI, 1.255, 39.424], p = 0.027). Hyperactive delirium was associated with good clinical outcome (OR 0.020 [95%CI, 0.001-0.623]; p = 0.026). Aspiration pneumonia (n = 22, 37.9%), urinary tract infection (n = 15, 25.9%), and hyperactive delirium (n = 8, 13.8%) were the most common complications during hospitalization. Conclusions: Decompressive surgery is a safe, life-saving treatment for malignant space-occupying cerebellar infarction. Higher premorbid mRS, higher NIHSS score on admission and the presence of brainstem infarction are associated with a poor functional outcome.

The associations of post-stroke delirium with outcomes: a systematic review and meta-analysis

BACKGROUND

Published data on whether post-stroke delirium (PSD) is an independent predictor of outcomes in patients with acute stroke are inconsistent and have not yet been synthesized and quantified via meta-analyses.

METHODS

This systematic review and meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The study protocol involved a search of the PubMed, Embase, PsycINFO, and Medline databases from 1946 to November 1, 2023, of which prospective observational and case-control studies were included. The quality of the included studies was rated using the Newcastle Ottawa Scale. Pooled effect estimates calculated using a random-effects model were expressed as the odds ratios (ORs), hazard ratios (HRs), and standardized mean differences (SMDs) with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD42023472551).

RESULTS

The search yielded 39 eligible articles comprising 3295 and 9643 patients with and without PSD, respectively. Thirty studies were high quality, while 9 had moderate quality. The primary analyses, adequately adjusting for predefined confounders, showed that PSD was significantly associated with mortality risk (average follow-up of 19.50 months; OR, 3.47; 95% CI, 2.35-5.12; I2, 26.0%) and poor neurological function (average follow-up of 21.75 months; OR, 3.62; 95% CI, 2.15-6.09; I2, 0). Secondary analyses, with or without inadequate adjustment, showed that PSD was significantly associated with prolonged hospital length of stay, increased risk of institutionalization, poor cognitive outcomes, and quality of life after discharge.

CONCLUSIONS

This systematic review and meta-analysis provides evidence that PSD was independently associated with mortality and poor neurological function after controlling for pre-specified confounders. The prevention of PSD remains a high clinical and research priority.

Management of delirium in acute stroke patients: a position paper by the Austrian Stroke Society on prevention, diagnosis, and treatment

Delirium is a common complication in acute stroke patients, occurring in 15-35% of all stroke unit admissions and is associated with prolonged hospital stay and a poor post-stroke prognosis. Managing delirium in acute stroke patients necessitates an intensive and multiprofessional therapeutic approach, placing a significant burden on healthcare staff. However, dedicated practical recommendations for delirium management developed for the population of acute stroke patients are lacking. For this purpose, the Austrian Stroke Society, in cooperation with the Austrian Society of Neurology, the Austrian Society of Neurorehabilitation, and the Austrian Society of Psychiatry, Psychotherapy, and Psychosomatics has formulated an evidence-based position paper addressing the management of delirium in acute stroke patients. The paper outlines practical recommendations on the three pillars of care in stroke patients with delirium: (a) Key aspects of delirium prevention including stroke-specific delirium risk factors and delirium prediction scores are described. Moreover, a non-pharmacological delirium prevention bundle is presented. (b) The paper provides recommendations on timing and frequency of delirium screening to ensure early diagnosis of delirium in acute stroke patients. Moreover, it reports on the use of different delirium screening tools in stroke populations. (c) An overview of non-pharmacological and pharmacological treatment strategies in patients with delirium and acute stroke is presented and summarized as key recommendation statements.

Delirium in acute stroke is associated with increased cognitive and psychiatric symptoms over time: The Nor-COAST study

BACKGROUND

Delirium, an acute and fluctuating mental disturbance of attention, cognition, and consciousness, commonly occurs in acute stroke. Research on long-term outcomes of stroke patients experiencing delirium is limited, especially regarding cognitive and psychiatric symptoms.

METHODS

As part of the Nor-COAST study, 373 patients were screened for delirium using the Confusion Assessment Method (CAM) in the acute phase of stroke. Patients were included in the mixed-model linear regression analyses if they had available data from the follow-ups at three, 18 or 36 months, totaling 334 (44.6 % women, mean (SD) age: 72.1 (12.5) years, 17 (5.1 %) diagnosed with delirium). Global cognition was measured using the Montreal Cognitive Assessment (MoCA). Psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q).

RESULTS

At three months, delirium was associated with a higher NPI-Q score (Mean (SD) 2.9 (3.6) vs 1.4 (2.2)). At 18 and 36 months, delirium was associated with a lower MoCA score (Mean (SD) 19.7 (6.6) vs 24.3 (5.0), and 20.6 (7.6) vs 24.6 (4.8)), higher HADS anxiety symptoms (5.0 (4.3) vs 3.3 (3.3), and 5.9 (4.1) vs 3.4 (3.6)), higher HADS depression symptoms (7.2 (4.7) vs 3.4 (3.3), and 6.6 (5.1) vs 3.7 (3.7)), and higher NPI-Q score (2.4 (4.4) vs 1.7 (2.3), 2.6 (4.5) vs 1.0 (1.9)). Delirium significantly predicted the psychiatric symptoms hallucinations and agitation.

CONCLUSIONS

Patients with delirium in the acute phase of stroke may be particularly vulnerable to developing cognitive and psychiatric symptoms in the chronic phase.

Development of insomnia in patients with stroke: A systematic review and meta-analysis

BACKGROUND AND AIM

Stroke is a serious threat to human life and health, and post-stroke insomnia is one of the common complications severely impairing patients' quality of life and delaying recovery. Early understanding of the relationship between stroke and post-stroke insomnia can provide clinical evidence for preventing and treating post-stroke insomnia. This study was to investigate the prevalence of insomnia in patients with stroke.

METHODS

The Web of Science, PubMed, Embase, and Cochrane Library databases were used to obtain the eligible studies until June 2023. The quality assessment was performed to extract valid data for meta-analysis. The prevalence rates were used a random-efect. I2 statistics were used to assess the heterogeneity of the studies.

RESULTS

Twenty-six studies met the inclusion criteria for meta-analysis, with 1,193,659 participants, of which 497,124 were patients with stroke.The meta-analysis indicated that 150,181 patients with stroke developed insomnia during follow-up [46.98%, 95% confidence interval (CI): 36.91-57.18] and 1806 patients with ischemic stroke (IS) or transient ischemic attack (TIA) developed insomnia (47.21%, 95% CI: 34.26-60.36). Notably, 41.51% of patients with the prevalence of nonclassified stroke developed insomnia (95% CI: 28.86-54.75). The incidence of insomnia was significantly higher in patients with acute strokes than in patients with nonacute strokes (59.16% vs 44.07%, P < 0.0001).Similarly, the incidence of insomnia was significantly higher in the patients with stroke at a mean age of ≥65 than patients with stroke at a mean age of <65 years (47.18% vs 40.50%, P < 0.05). Fifteen studies reported the follow-up time. The incidence of insomnia was significantly higher in the follow-up for ≥3 years than follow-up for <3 years (58.06% vs 43.83%, P < 0.05). Twenty-one studies used the Insomnia Assessment Diagnostic Tool, and the rate of insomnia in patients with stroke was 49.31% (95% CI: 38.59-60.06). Five studies used self-reporting, that the rate of insomnia in patients with stroke was 37.58% (95% CI: 13.44-65.63).

CONCLUSIONS

Stroke may be a predisposing factor for insomnia. Insomnia is more likely to occur in acute-phase stroke, and the prevalence of insomnia increases with patient age and follow-up time. Further, the rate of insomnia is higher in patients with stroke who use the Insomnia Assessment Diagnostic Tool.

Five-year stroke prognosis. Influence of post-stroke delirium and post-stroke dementia on mortality and disability (Research Study - Part of the PROPOLIS Study)

INTRODUCTION

With increasing life expectancy and the rising incidence of stroke in young adults, it is important to know the long-term prognosis of this condition. Post-stroke delirium and post-stroke dementia are common complications of stroke that negatively affect prognosis. The purpose of this study was to evaluate five-year mortality from stroke and to assess the influence of post-stroke delirium and post-stroke dementia on mortality and disability over the five-year period.

METHODS

Consecutive patients admitted to the stroke unit for acute stroke or transient ischemic attacks were screened for in-hospital delirium. At the three- and twelve-month follow-up, the same patients underwent neurocognitive testing. Diagnoses of in-hospital delirium and dementia after three and twelve months based on DSM-5 criteria. Five years after stroke surviving patients were reevaluated. Outcome assessment included place of stay, current functional status assessed by the modified Rankin Scale (mRS), or death.

RESULTS

At the five-years of follow-up, data were collected from 575 of 750 patients originally included in the study (76.67%). The mortality rate was 51.65%. In-hospital post-stroke delirium and post-stroke dementia diagnosed three and twelve months after stroke were independent risk factors for death and an increase in mRS score of ≥ 1 or ≥ 2 points. There was no significant association with institutionalization rate.

CONCLUSIONS

More than half of post-stroke patients die within five years of follow-up. Post-stroke delirium and post-stroke dementia are associated with an increased risk of death and disability.

The Rehabilitation of Cognitive Impairment Following Stroke: A Commentary on a Systematic Review

Stroke is regarded as one of the leading causes of death and disability worldwide. Cognitive impairment occurs in nearly 60% of stroke survivors. Despite the high prevalence and significant impact on post-stroke functioning, there remains a lack of clarity regarding effective interventions to support rehabilitation of cognitive impairment. This article critically appraises a systematic review which assessed the effectiveness of interventions to improve clinical outcomes associated with cognition for adults, post-onset of stroke.

Commentary on O'Donoghue M, Leahy S, Boland P, Galvin R, McManus J, Hayes S. Rehabilitation of cognitive deficits poststroke: systematic review and meta-analysis of randomized controlled trials. Stroke. 2022;53(5):1700–1710. 10.1161/strokeaha.121.034218

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.