Delirium in your house: a survey during General Practitioner-programmed home visits

The role of hormones in the pathogenesis and treatment mechanisms of delirium in ICU: The past, the present, and the future

Delirium is an acute brain dysfunction. As one of the common psychiatric disorders in ICU, it can seriously affect the prognosis of patients. Hormones are important messenger substances found in the human body that help to regulate and maintain the function and metabolism of various tissues and organs. They are also one of the most commonly used drugs in clinical practice. Recent evidences suggest that aberrant swings in cortisol and non-cortisol hormones might induce severe cognitive impairment, eventually leading to delirium. However, the role of hormones in the pathogenesis of delirium still remains controversial. This article reviews the recent research on risk factors of delirium and the association between several types of hormones and cognitive dysfunction. These mechanisms are expected to offer novel ideas and clinical relevance for the treatment and prevention of delirium.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study

BACKGROUND

Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking.

OBJECTIVE

The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations.

METHODS

This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death.

RESULTS

Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]).

CONCLUSIONS

After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

Proposing a Scientific and Technological Approach to the Summaries of Clinical Issues of Inpatient Elderly with Delirium: A Viewpoint

Background/rationale: Despite mounting evidence about delirium, this complex geriatric syndrome is still not well managed in clinical contexts. The aging population creates a very demanding area for innovation and technology in healthcare. For instance, an outline of an aging-friendly healthcare environment and clear guidance for technology-supported improvements for people at delirium risk are lacking. Objective: We aimed to foster debate about the importance of technical support in optimizing healthcare professional practice and improving the outcomes for inpatients’ at delirium risk. We focused on critical clinical points in the field of delirium worthy of being addressed by a multidisciplinary approach. Methods: Starting from a consensus workshop sponsored by the Management Perfectioning Course based at the Marco Biagi Foundation (Modena, Italy) about clinical issues related to delirium management still not addressed in our healthcare organizations, we developed a requirements’ analysis among the representatives of different disciplines and tried to formulate how technology could support the summaries of the clinical issues. We analyzed the national and international panorama by a PubMed consultation of articles with the following keywords in advanced research: “delirium”, “delirium management”, “technology in healthcare”, and “elderly population”. Results: Despite international recommendations, delirium remains underdiagnosed, underdetected, underreported, and mismanaged in the acute hospital, increasing healthcare costs, healthcare professionals’ job distress, and poor clinical outcomes. Discussion: Although all healthcare professionals recognize delirium as a severe and potentially preventable source of morbidity and mortality for hospitalized older people, it receives insufficient attention in resource allocation and multidisciplinary research. We synthesized how tech-based tools could offer potential solutions to the critical clinical points in delirium management.

Identification through the Manchester Triage System of the older population at risk of delirium: A case-control study

OBJECTIVE

To identify the flow charts and discriminators of the Manchester Triage System that are most likely to identify the onset of delirium in older people.

BACKGROUND

Delirium is an underdiagnosed geriatric syndrome, and up to 80% of all cases of delirium go undetected in emergency departments. Patient triage seeks to manage clinical risk with a view to safely and appropriately managing patient flows.

DESIGN

A case-control study was performed according to the STROBE checklist.

SETTING

The emergency department of a secondary hospital.

PARTICIPANTS

Older adults aged ≥65 years and admitted from 1 January to 31 December 2020.

METHODS

Older patients were identified from the emergency department research database. Cases were defined as patients diagnosed with delirium (n = 128), excluding cases of delirium due to alcohol or substance abuse. Controls were randomised from the remaining patients (n = 128).

RESULTS

A total of 29.35% of the subjects admitted to the emergency department were older adults with an incidence of delirium of 0.7%. The flow charts with the highest probability of delirium were 'unwell adult' [OR = 3.04 (95%CI:1.82-5.1)] and 'behaving strangely' [OR = 16.06 (95%CI:3.72-69.29)], and the discriminators were 'rapid onset' [OR = 3.3 (95%CI:1.85-5.88)] and 'new neurological deficit less than 24 h old' [OR = 4.76 (95%%CI:1.01-22.5). The area under the curve for 'unwell adult' in the presence of dementia, previous stroke and fall in the previous 30 days was 0.73 (95%CI: 0.67-0.79), and that for 'behaving strangely' in the presence of diabetes was 0.75 (95%CI: 0.69-0.81).

CONCLUSIONS

Knowing which flow charts, discriminators and risk factors are most likely to predict delirium allows the identification of the older population at risk for triage screening in emergency departments.

RELEVANCE TO CLINICAL PRACTICE

Risk factors such as diabetes, dementia, previous stroke and recent fall among 'unwell adult' or 'behaving strangely' triaged older persons should be assessed for the probable presence of delirium.