Delirium risk in non-surgical patients: systematic review of predictive tools

A family intervention to prevent postoperative delirium in patients undergoing cardiac valve surgery: A randomized controlled study

BACKGROUND

Multiple guidelines recommend that families be involved in the care of ICU patients, which has been widely used in ICU delirium management in recent years. Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with poor outcomes; however, the effects of family intervention on this group are rarely studied.

OBJECTIVES

This study aimed to investigate the effects of family intervention on the incidence of POD and the ICU prognoses of patients undergoing cardiac valve surgery.

METHODS

This was a two-group, single-blind, randomized controlled trial involving 80 patients undergoing cardiac valve surgery, with 40 patients in each group. The control group received routine ICU visits, and the experimental group implemented a family intervention that instructed family caregivers to participate in delirium management during ICU visits. The occurrence of POD, ICU stay, mechanical ventilation time of patients; as well as the anxiety, depression, and satisfaction levels of family caregivers were compared between the two groups.

RESULTS

The incidence of POD and ICU stay of patients were significantly lower in the experimental group compared to the control group (P < 0.05). The anxiety and depression incidence of family caregivers in the experimental group was lower than those of the control group (P < 0.05), and satisfaction scores were higher than those of the control group (P < 0.05).

CONCLUSIONS

Family intervention has the potential to reduce the incidence of POD in patients undergoing cardiac valve surgery, shorten ICU stays, reduce the incidence of anxiety and depression in family caregivers, and improve their satisfaction. These findings suggest that family intervention could be incorporated into routine nursing practice.

A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study

OBJECTIVE

This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner.

METHODS

This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic.

RESULTS

In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values.

CONCLUSION

Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.

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.

Effects of non-pharmacological interventions for preventing delirium in general ward inpatients: A systematic review & meta-analysis of randomized controlled trials

The purpose of this study was to identify the types and contents of non-pharmacological delirium prevention interventions applied to inpatients in general wards, and to verified the effectiveness of the interventions on the incidence of delirium. We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform, PubMed and Google Scholar, and Korean DB such as RISS, DBpia, KISS, NDSL and KCI) using terms to identify delirium, prevention, and non-pharmacological. We searched all databases from their inception to January 2021 and imposed restriction on language of publication in English and Korean. We included studies if they were conducted as all types of randomized controlled trials (RCT), involving adult patients aged 19 years or more who were admitted to a general ward. We included trials comparing non-pharmacological intervention versus usual care. The entire process of data selection and extraction, assessment of risk of bias with ROB2.O was independently performed by three researchers. The estimated effect size was an odds ratio (OR) and 95% confidence interval. The fixed effects model and general inverse variance estimation method were adopted. The type of non-pharmacological delirium prevention interventions for inpatients in general ward was mainly multi-component intervention to correct delirium risk factors. The content and intensity of non-pharmacological interventions varied greatly depending on the characteristics of the patient and the clinical situation. As a result of the meta-analysis, non-pharmacological multi-component intervention was effective in reducing the incidence of delirium, and it was confirmed that it was effective in reducing the incidence of delirium in both the internal and surgical wards. It was confirmed by quantitative evidence that non-pharmacological interventions, especially multi-component interventions, were effective in preventing delirium in general ward inpatients.

Does delirium prevention reduce risk of in-patient falls among older adults? A systematic review and trial sequential meta-analysis

OBJECTIVES

To determine whether delirium prevention interventions reduce the risk of falls among older hospitalised patients.

METHODS

A systematic search of health-care databases was undertaken. Given the frequency of small sample sized trials, a trial sequential meta-analysis was conducted to present estimate summary effects to date. A Bayesian approach was used to estimate the posterior probability of the delirium prevention interventions reducing falls risk by various clinically relevant levels.

RESULTS

Five randomised controlled trials were included in our final meta-analysis. There was a 43% reduction in the risk of falls among participants in the delirium prevention intervention arm, compared to the control; however, confidence intervals were wide (RE RR = 0.57, 95% CI 0.32; 1.00, p = 0.05). This result was found to be statistically significant, according to traditional significance levels (z > 1.96) and the more conservative trial sequential analysis monitoring boundaries. The posterior probabilities of the delirium prevention intervention reducing the risk of falls by 10%, 20% and 30% were 0.86, 0.63 and 0.29 respectively.

CONCLUSIONS

The results of this systematic review and trial sequential meta-analysis suggest that delirium prevention trials may reduce the risk of in-hospital falls among older patients by 43%. However, despite significant risk reduction found upon meta-analysis, the variation among study populations and intervention components raised questions around its application in clinical practice. Further research is required to investigate what the necessary components of a multifactorial intervention are to reduce both delirium and fall incidence among older adult in-patients.

Non-Pharmacological Nursing Interventions for Prevention and Treatment of Delirium in Hospitalized Adult Patients: Systematic Review of Randomized Controlled Trials

Delirium is a common neurobehavioral complication in hospitalized patients that can occur in the acute phase and lead to poor long-term outcomes. The purpose of this study was to identify non-pharmacological nursing interventions for the prevention and treatment of delirium in hospitalized adult patients. We conducted a systematic review to synthesize the findings of published studies. We searched the PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL databases for randomized controlled trials in January 2021. We report this systematic review according to the PRISMA 2009 checklist. The study was registered on PROSPERO (CRD42021226538). Nine studies were systematically reviewed for non-pharmacological nursing interventions for the prevention and treatment of delirium. The types of non-pharmacological nursing interventions included multicomponent intervention, multidisciplinary care, multimedia education, music listening, mentoring of family caregivers concerning delirium management, bright light exposure, ear plugs, and interventions for simulated family presence using pre-recorded video messages. These results could help nurses select and utilize non-pharmacological nursing interventions for the prevention and treatment of delirium in clinical nursing practice.

Stratified delirium risk using prescription medication data in a state-wide cohort

OBJECTIVE

Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list.

METHOD

Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort.

RESULTS

The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender.

CONCLUSION

Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.

Predictors of Delirium in Octogenarian Patients Hospitalized for a Hip Fracture

INTRODUCTION

Since delirium is a major complication that can arise after a patient with a hip fracture has been hospitalized, it is considered to be one of the most common geriatric conditions. Therefore, its prevention and early detection are essential for reducing both the length of the patient's stay in the hospital and complications during the hospitalization process.

OBJECTIVE

To identify and analyze the predictors for developing delirium in octogenarians who were admitted to hospital for a hip fracture.

METHODOLOGY

A prospective study conducted with a sample of 287 patients aged 80 years and older (mean age 87.2 ± 3.2 years; 215 women, 72 men), recruited from the Trauma Unit of the University Hospital of León (Spain). Further, 71.1% of the patients lived in a family member's home, while the other 28.9% lived in a nursing home. After observing each patient's interactions with their doctor in a clinical setting, the data for this study were obtained by reviewing the selected patients' charts. The variables analyzed were sociodemographic information (age, sex, and place of residence), medical information (type of hip break and surgical intervention), cognitive impairment (MMSE score), functional level (Barthel Index score), and clinical information (pharmacological, comorbidities, complications, and the diagnosis and assessment of the severity of delirium in a patient). The univariate and multivariate logistic regression analysis showed a significant relationship between acute confusional state and the following variables: anemia, American Society of Anesthesiologists (ASA) III and IV patients, state of cognitive frailty and functional level, a urinary tract infection, changes in the visual field, renal arterial occlusion, and the type and dosage of drugs administered (this variable was identified in the multivariate model). The inverse relationship between anemia and acute confusional state is surprising.

CONCLUSION

This research shows that clinical observation of acute confusional state is necessary but not sufficient for addressing this condition early and adequately in older adults who have been hospitalized for a hip fracture.

Development of a clinical score, PANDA, to predict delirium in stroke care unit

BACKGROUND AND PURPOSE

Delirium frequently complicates acute stroke and worsens outcomes. Because delirium is potentially preventable, predicting its occurrence is essential. Although several prediction scores have been proposed, nurses need to quickly predict delirium in stroke care units (SCUs). We aimed to develop a simple tool for this purpose by examining a comprehensive set of potential predictors.

METHODS

This is a prospective cohort study on acute stroke patients admitted to an SCU. Patients without stupor, coma, or delirium upon admission were eligible. Participants were followed for 5 days from admission. Delirium was defined as Intensive Care Delirium Screening Checklist ≥4 points. We examined 27 potential predictors, of which 13 predictors were used to developed a least absolute shrinkage and selection operator-penalized logistic regression model. Five variables with the largest coefficients were assigned one point each in the prediction score. The internal validation was performed by bootstrapping.

RESULTS

Delirium occurred in 42 of the 387 participants. The score consisted of prior delirium, alcohol, NIHSS ≥5, dementia, and auditory/visual impairment (PANDA). The apparent AUC was 0.84 (95% confidence interval [CI], 0.78-0.89), and the optimism-corrected AUC was 0.81 (95% CI, 0.73-0.88). With a cutoff of ≥2 points, sensitivity was 0.78 (95% CI, 0.65-0.90), and specificity was 0.74 (95% CI, 0.70-0.79).

CONCLUSIONS

PANDA score is simple and predicts delirium in an SCU satisfactorily.