Delirium: an important (but often unrecognized) clinical syndrome

[Delirium-an interdisciplinary challenge]

BACKGROUND

Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients.

DIAGNOSTIC

Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential.

TREATMENT

In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.

The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome

BACKGROUND

With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment).

OBJECTIVES

To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay.

METHOD

This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models.

RESULTS

The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67; OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009).

CONCLUSION

Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.

Is anemia associated with cognitive impairment and delirium among older acute surgical patients?

AIM

The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients.

METHODS

Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only.

RESULTS

A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group.

CONCLUSIONS

There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.

Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium

Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.

Efficacy and safety of dexmedetomidine for postoperative delirium in adult cardiac surgery on cardiopulmonary bypass

Background

Delirium after cardiac surgery is associated with serious long-term negative outcomes and high costs. The aim of this study is to evaluate neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine, compared with the current postoperative sedative protocol (remifentanil) in patients undergoing open heart surgery with cardiopulmonary bypass (CPB).

Methods

One hundred and forty two eligible patients who underwent cardiac surgery on CPB between April 2012 and March 2013 were randomly divided into two groups. Patients received either dexmedetomidine (range, 0.2 to 0.8 μg/kg/hr; n=67) or remifentanil (range, 1,000 to 2,500 μg/hr, n=75). The primary end point was the prevalence of delirium estimated daily via the confusion assessment method for intensive care.

Results

When the delirium incidence was compared with the dexmedetomidine group (6 of 67 patients, 8.96%) and the remifentanil group (17 of 75 patients, 22.67%) it was found to be significantly less in the dexmedetomidine group (p<0.05). There were no statistically significant differences between two groups in the extubation time, ICU stay, total hospital stay, and other postoperative complications including hemodynamic side effects.

Conclusion

This preliminary study suggests that dexmedetomidine as a postoperative sedative agent is as sociated with significantly lower rates of delirium after cardiac surgery.

An instrumental variables approach to post-acute care nursing home quality: is there a dime's worth of evidence that continuing care retirement communities provide higher quality?

For the affluent elderly, continuing care retirement communities (CCRCs) have become a popular option for long term care and other health care needs related to aging. While CCRCs have experienced significant growth over the last few decades, very little is known about the quality of care CCRCs provide. This paper is the first to rigorously study CCRCs on a national scale and the only study that focuses on nursing home quality. Using a national sample from 2005, we determine if the quality of post-acute care provided by CCRC nursing homes is superior to traditional nursing homes. To mimic randomization of patients, instrumental variables analysis is used with relative distance as an exclusion restriction to handle the endogeneity of the type of facility where care is provided. After adjusting for endogeniety, we find that CCRC nursing homes provide post-acute care quality that is similar or lower to traditional nursing homes, depending on the quality measure.

Treatment of delirium following cardiac surgery

Postoperative delirium is a common medical complication following cardiac surgery. This paper will outline the treatment options for delirium with a focus on prophylactic use of risperidone before cardiac surgery.

Delirium: its historical evolution and current interpretation

Delirium was one of the first mental disorders ever to be described, though it remains an elusive concept to this day. Historically, delirium has developed from the prototype of acute confusion with psychomotor agitation. It was thought to be caused by the withdrawal of substance dependence or severe somatic diseases accompanying by fever; however only in the 20th century, it was concluded that delirium and similar states manifest themselves as a consciousness disorder, and is not a specific state of somatic diseases. Four core features defines delirium at present: a disturbance of consciousness, a disturbance of cognition, limited course and external causation. However, these features do not include common manifestations of delirium in elderly patients with dementia; therefore the concept of delirium should be revised and corrected.

Delirium epidemiology in critical care (DECCA): an international study

Introduction

Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU.

Methods

A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain.

Results

In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%).

Conclusions

In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

Surgical intensive care unit (ICU) delirium: a "psychosomatic" problem?

OBJECTIVE

Intensive Care Unit (ICU) delirium is a common complication after major surgery and related among other potential medical precipitants to either pre-existing cognitive impairment or the intensity and length of anesthesiology or the type of surgery. Nevertheless, in some rare situations, an organic etiology is not always found, which can be frustrating for the medical team. Some clinicians working in an intensive care unit have a reluctance to seek another hypothesis in the psychological field.

METHOD

To illustrate this, we report the case of a 59-year-old woman who developed a massive delirium during her intensive care unit stay after being operated on for a left retroperitoneal sarcoma. Interestingly, she had had no previous cognitive disorders and a somatic explanation for her psychiatric disorder could not been found. Just before the surgery, she was grieving the recent loss of a colleague of the same age, and also a close friend, and therefore had a death anxiety.

RESULTS

With this case report, we would like to point out the importance of psychological factors that might precipitate delirium in a predominately somatic environment such as an intensive care unit.

SIGNIFICANCE OF RESULTS

ICU delirium can sometimes be considered as a "psychosomatic" problem with either a stress response syndrome after surgery or a defense mechanism against death anxiety. Clinicians should be aware of the possibility of such psychological factors even if they always must first rule out potential somatic causes for delirium and encourage thorough investigation and treatment of these medical causes. A collaboration with the psycho-oncologist is recommended to better manage this "psychosomatic" problem.

Delirium in the acute care setting: characteristics, diagnosis and treatment

Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. It is also the most common psychiatric syndrome found in the general hospital setting, its prevalence surpassing better known psychiatric disorders. This article reviews the published literature on delirium and addresses the epidemiology, known etiologic factors, presentation and characteristics of delirium, while emphasizing what is known about treatment strategies and prevention. Given increasing evidence that delirium is not always reversible and the many sequelae associated with its development, physicians must do everything possible to prevent its occurrence or shorten its duration, by recognizing its symptoms early, correcting underlying contributing causes, and using treatment strategies proven to help recover functional status.

Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit

STUDY OBJECTIVE

To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU).

DESIGN

Retrospective observational study of a quality improvement project.

SETTING

Medical intensive care unit at a Veterans Affairs medical center.

PATIENTS

Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptom-driven protocol in 1998, and 24 episodes (21 patients) occurred after implementation.

MEASUREMENTS AND MAIN RESULTS

Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean +/- SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus 7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours (p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21), and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43).

CONCLUSIONS

Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity.

Prevention, diagnosis and treatment of delirium: staff educational approaches

Delirium is a common disorder especially among older people admitted to medical and surgical units. Research has demonstrated that many cases are underdiagnosed, misdiagnosed or not properly managed. Some of the difficulties encountered in the diagnosis, treatment and prevention may, in part, stem from a historical low emphasis on delirium in medical and nursing education. In recent years, attempts have been made to understand the impact of education on the prevention and management of delirium. In this review, diagnosis, treatment and prevention of delirium are considered in relation to the difficulties encountered in each of these areas. The role of increasing doctors' and nurses' awareness in the understanding of delirium through educational programs is also reviewed. The outcome of many cases of delirium is not changed by current treatment; however, there is increasing evidence that strategies employing appropriate multicomponent and/or educational staff intervention programs may decrease the prevalence of delirium.

Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures

OBJECTIVE

To describe the incidence, risk factors and clinical features (subtypes) of delirium during the postoperative period after hip fracture surgery in elderly patients.

DESIGN

Prospective study.

METHODS

Thirty-four consecutive patients (9 men and 25 women) were included in this study between June 16 to July 14, 2003. All patients underwent surgery for a fractured neck of femur and were pre- and postoperatively cared for at a combined geriatric/orthopedic ward.

ASSESSMENT

The diagnosis of delirium was based on the criteria of the DSM-IV and the Confusion Assessment Method Scale. Subtypes of delirium were classified according to the criteria proposed by Lipowski: hyperactive-hyperalert (or agitated), hypoactive-hypoalert (somnolent) and mixed delirium.

RESULTS

Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The development of delirium was associated with the medication midazolam taken perioperatively. Nine (47%) of the delirious patients had a hyperactive type of delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed type. We did not find any association among subtypes of delirium and clinical features.

CONCLUSIONS

Delirium is a common complication in the postoperative period of elderly patients treated for hip fractures. The use of midazolam in the perioperative period increased the risk of developing postoperative delirium. The hyperactive type of delirium was the most common subtype of delirium.

Screening for delirium in an adult intensive care unit

Delirium is an acute, reversible disorder of attention and cognition and may be viewed as cerebral dysfunction similar to the failure of any other organ. The development of delirium is associated with increased morbidity and mortality, extended length-of-stay in the intensive care unit and longer time spent sedated and ventilated. Nearly every clinical, pharmacological and environmental factor present and necessary in the ICU setting has the potential to cause delirium. Since all of these factors cannot be removed, it is paramount to increase the awareness amongst health care professionals so as to minimise under-recognition and encourage future research into factors that may improve the long-term outcome for ICU patients. There is a need for user-friendly, validated assessment tools for the intubated and ventilated ICU patient, which can be applied at the time of ICU admission without the need for lengthy psychiatric assessment. Nursing professionals are at the forefront of those who are able to provide holistic care through meaningful conversation and empathetic touch. A 6-month Quality Improvement (QI) project screening patients for signs of delirium provided a foundation for discussion. All patients admitted to ICU for more than 72 h, with a hospital length-of-stay less than 96 h prior to ICU admission were screened. Patients admitted following neurological insults or with pre-existing altered mental state were excluded. The QI project showed the incidence of delirium to be 40% of the total sample (n = 73) in a mixed medical/surgical and elective/emergency patient population.