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Ajmera Y, Paul K, Khan MA, Kumari B, Kumar N, Chatterjee P, Dey AB, Chakrawarty A. The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'. Asian J Psychiatr 2024; 94:103990. [PMID: 38447233 DOI: 10.1016/j.ajp.2024.103990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes. AIM To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults. METHODS A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge. RESULTS The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up. CONCLUSION Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.
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Affiliation(s)
- Yamini Ajmera
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Karandeep Paul
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Bharti Kumari
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nand Kumar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Prasun Chatterjee
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Aparajit Ballav Dey
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avinash Chakrawarty
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Zhao Q, Liu S, Zhao H, Dong L, Zhu X, Liu J. Non-pharmacological interventions to prevent and treat delirium in older people: An overview of systematic reviews. Int J Nurs Stud 2023; 148:104584. [PMID: 37826889 DOI: 10.1016/j.ijnurstu.2023.104584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND As advanced age is a major risk factor for confusion status, delirium has become prevalent in the older population, contributing to longer hospital stays, cognitive impairment, and higher risks of complications and mortality. Compared with pharmacological methods, non-pharmacological interventions are preferred and are recommended by the National Institute for Health and Care Excellence for the prevention of delirium. Numerous systematic reviews and meta-analyses have been carried out to investigate the effects of non-pharmacological interventions. However, the outcomes were diverse and the quality varied widely, making it challenging to draw firm conclusions from the evidence. OBJECTIVE To summarize the contents and evaluate the effects of non-pharmacological interventions to prevent and treat delirium among older people. DESIGN Overview of systematic reviews. METHODS A comprehensive literature search was conducted in Medline, Cochrane Library, EMBASE, CINAHL, PsycINFO, JBI EBP Database, China's SinoMed, CNKI, and Wangfang databases from inception to 2nd December 2022. Two reviewers performed the study selection, quality appraisal, and data extraction independently. The AMSTAR 2 tool was used to appraise the methodological quality of eligible reviews. The results were presented in narrative synthesis based on types of intervention, including multicomponent and single-component interventions. RESULTS Twenty-four systematic reviews were included in this overview, of which four reviews were of high quality. Multicomponent interventions were the most widely disseminated non-pharmacological strategy, which were effective in preventing delirium with 27 %-54 % reduction in delirium incidence. Additionally, the multicomponent strategy also reduced the incidence of falls and pressure ulcers, and showed trends toward shortening the length of stay and improving cognitive function. Among single-component interventions, physical training, geriatric risk assessment, and reorientation protocol revealed positive effects in delirium prevention. However, the effectiveness of non-pharmacological interventions for treating delirium was limited, and while multicomponent methods had inconsistent impacts on the duration and severity of delirium, single-component methods showed no significant impact. CONCLUSION Non-pharmacological interventions are effective in reducing the incidence of delirium and improving other health outcomes among older patients. However, the effects on the duration and severity of delirium need more evidence to confirm. REGISTRATION NUMBER CRD42022376651 in PROSPERO.
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Affiliation(s)
- Qin Zhao
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China
| | - Shan Liu
- College of Nursing and Public Health, Adelphi University 1 South Ave., Garden City, NY, USA
| | - Hongyu Zhao
- Xiangya Nursing School, Central South University, Changsha, China
| | - Lei Dong
- Xiangya Nursing School, Central South University, Changsha, China
| | - Xiao Zhu
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China; Research Center of Chinese Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
| | - Jia Liu
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China; Research Center of Chinese Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China.
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Wiedemann A, Stein J, Manseck A, Kirschner-Hermanns R, Bannowsky A, Wirz S, Kuru TH, Salem J. [Polypharmacy and medication review in the context of prehabilitation]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:1025-1033. [PMID: 37682348 DOI: 10.1007/s00120-023-02174-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 09/09/2023]
Abstract
Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.
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Affiliation(s)
- A Wiedemann
- Urologische Abteilung, Evangelisches Krankenhaus Witten gGmbH, Pferdebachstr. 27, 58455, Witten, Deutschland.
- Lehrstuhl für Geriatrie, Universität Witten/Herdecke, Witten, Deutschland.
| | - J Stein
- Urologische Abteilung, Klinikum Großburgwedel, Großburgwedel, Deutschland
| | - A Manseck
- Urologische Abteilung, Klinikum Ingolstadt GmbH, Ingolstadt, Deutschland
| | - R Kirschner-Hermanns
- Neuro-Urologie/Klinik für Urologie und Kinderurologie, Universitätsklinikum Bonn, Bonn, Deutschland
- Neuro-Urologie, Johanniter Neurologisches Rehabilitationszentrum Bonn-Godeshöhe, Bonn-Godeshöhe, Deutschland
| | - A Bannowsky
- Klinik für Urologie, Imland-Klinik Rendsburg, Rendsburg, Deutschland
| | - S Wirz
- Abteilung für Anästhesiologie, Intensivmedizin, Schmerz und Palliativmedizin, Zentrum für Schmerzmedizin, Weaningzentrum, GFO-Kliniken Bonn/Cura Bad Honnef, Bonn, Deutschland
| | - T H Kuru
- Curos urologisches Zentrum, Köln, Abteilung für Urologie, Klinik Links vom Rhein, Köln, Deutschland
- Klinik für Urologie und Kinderurologie, Universitätsklinikum Brandenburg a.d. Havel, MHB Brandenburg Theodor Fontane, Brandenburg a.d. Havel, Deutschland
| | - J Salem
- Curos urologisches Zentrum, Köln, Abteilung für Urologie, Klinik Links vom Rhein, Köln, Deutschland
- Klinik für Urologie und Kinderurologie, Universitätsklinikum Brandenburg a.d. Havel, MHB Brandenburg Theodor Fontane, Brandenburg a.d. Havel, Deutschland
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Faeder M, Hale E, Hedayati D, Israel A, Moschenross D, Peterson M, Peterson R, Piechowicz M, Punzi J, Gopalan P. Preventing and treating delirium in clinical settings for older adults. Ther Adv Psychopharmacol 2023; 13:20451253231198462. [PMID: 37701890 PMCID: PMC10493062 DOI: 10.1177/20451253231198462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
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Affiliation(s)
- Morgan Faeder
- University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15261, USA
| | - Elizabeth Hale
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel Hedayati
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Israel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Melanie Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariel Piechowicz
- University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Jonathan Punzi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Korkatti-Puoskari N, Tiihonen M, Caballero-Mora MA, Topinkova E, Szczerbińska K, Hartikainen S. Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review. Eur Geriatr Med 2023; 14:709-720. [PMID: 37495836 PMCID: PMC10447285 DOI: 10.1007/s41999-023-00837-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/06/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing. METHODS A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium. RESULTS Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication. CONCLUSIONS Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.
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Affiliation(s)
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | | | - Eva Topinkova
- Geriatric Department, First Faculty of Medicine, Charles University, General Faculty Hospital, Prague and Faculty of Health and Social Sciences, South Bohemian University, Ceske Budejovice, Czech Republic
| | - Katarzyna Szczerbińska
- Medical Faculty, Epidemiology and Preventive Medicine Chair, Laboratory for Research on Ageing Society, Jagiellonian University Medical College, Kraków, Poland
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Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study. Anesthesiol Res Pract 2022; 2022:2711310. [PMID: 36119120 PMCID: PMC9481404 DOI: 10.1155/2022/2711310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021. Methods A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium. Results Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium. Conclusion The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.
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