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Azizi Z, O'Regan N, Dukelow T, Bohane T, Harkin E, Donnellan C, Carroll I, Costello M, O'Reilly S, Noonan C, Walsh E, Timmons S. Delirium care in hospitals in Ireland on World Delirium Awareness Day 2023. Ir J Med Sci 2024; 193:2485-2493. [PMID: 38819733 PMCID: PMC11449950 DOI: 10.1007/s11845-024-03692-8] [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: 12/21/2023] [Accepted: 04/22/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Acute, transient, but sometimes persistent, delirium is characterized by a sharp disruption in attention, consciousness, and cognitive function, and can be caused by many medications and disorders. Delirium occurrence and negative consequences, such as falls and functional decline, can be decreased with multifactorial prevention and timely detection. AIMS To describe current clinical practice in relation to the prevention, assessment, and management of delirium in Irish hospitals; awareness-raising and educational activities; and barriers to good practice. METHODS On World Delirium Awareness Day (15th March 2023), a global survey was conducted of delirium prevalence and care. A senior clinical staff member on each participating ward reported on delirium prevalence at 8AM and 8PM, and on usual ward practice; this data was entered into an online survey by a data collector (typically a clinician from the site, visiting several wards to record data). This study reports data from Irish hospitals. RESULTS In total, 132 wards from 15 hospitals across Ireland participated. Almost 60% of wards used 'personal judgment' for delirium assessment. Having at least one delirium training session in the preceding year was associated with greater use of a formal assessment tool (60.3% versus 18.8%; p < 0.001). Wards reported staff training/education as the main priority to improve care, but 72.7% of wards identified insufficient time to train staff as a key barrier. CONCLUSIONS Clinical practice related to delirium care requires improvement. Awareness raising and staff training require more focus and time in busy clinical settings.
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Affiliation(s)
- Zahra Azizi
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Niamh O'Regan
- Department of Geriatric Medicine, Waterford Integrated Care for Older People, University Hospital Waterford, Waterford, Ireland
| | | | | | | | | | - Ida Carroll
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Maria Costello
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Galway, Ireland
| | | | | | - Erica Walsh
- St Luke's General Hospital Kilkenny, Kilkenny, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.
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Molitor V, Busse TS, Giehl C, Lauer R, Otte IC, Vollmar HC, Thürmann P, Holle B, Palm R. Educational interventions aimed at improving knowledge of delirium among nursing home staff-a realist review. BMC Geriatr 2024; 24:633. [PMID: 39054433 PMCID: PMC11274774 DOI: 10.1186/s12877-024-05213-9] [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: 04/05/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Delirium is a neuropathological syndrome that is characterised by fluctuating impairments in attention, cognitive performance, and consciousness. Since delirium represents a medical emergency, it can be associated with adverse clinical and economic outcomes. Although nursing home residents face a high risk of developing delirium, health care professionals in this field appear to have limited knowledge of delirium despite the critical role they play in the prevention, diagnosis, and treatment of delirium in nursing homes. OBJECTIVE The purpose of this realist review is to develop an initial programme theory with the goal of understanding how, why, and under what circumstances educational interventions can improve the delirium-specific knowledge of health care professionals in nursing homes. METHODS This realist review was conducted in accordance with the RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines and includes the following steps: (1) search strategy and literature review; (2) study selection and assessment; (3) data extraction; (4) data synthesis; and (5) development of an initial programme theory. It also included stakeholder discussions with health care professionals recruited from nursing home care, which focused on their experiences with delirium. RESULTS From a set of 1703 initially identified publications, ten publications were included in this realist review. Based on these publications, context-mechanism-outcome configurations were developed; these configurations pertained to (1) management support, (2) cognitive impairments among residents, (3) familiarity with residents, (4) participatory intervention development, (5) practical application, (6) case scenarios, (7) support from experts and (8) relevance of communication. CONCLUSIONS Educational interventions aimed at improving the delirium-specific knowledge of health care professionals should feature methodological diversity if they are to enhance health care professionals' interest in delirium and highlight the fundamental contributions they make to the prevention, diagnosis, and treatment of delirium. Educational interventions should also take into account the multidimensional contextual factors that can have massive impacts on the relevant mode of action as well as the responses of health care professionals in nursing homes. The identification of delirium in residents is a fundamental responsibility for nursing home staff. TRIAL REGISTRATION This review has been registered at Open Science Framework https://doi.org/10.17605/OSF.IO/6ZKM3.
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Affiliation(s)
- Vincent Molitor
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany.
- School VI -School of Medicine and Health Sciences, Carl von Ossietzky Universität, Oldenburg, Germany.
| | - Theresa Sophie Busse
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Chantal Giehl
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Romy Lauer
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Ina Carola Otte
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Petra Thürmann
- Faculty of Health, School of Medicine, Chair of Clinical Pharmacology, Witten Herdecke University, Witten, Germany
- Philipp Klee-Institute of Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Bernhard Holle
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany
- German Center for, Deutsches Zentrum fur Neurodegenerative Erkrankungen (DZNE) Standort Witten, Witten, Germany
| | - Rebecca Palm
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany
- School VI -School of Medicine and Health Sciences, Carl von Ossietzky Universität, Oldenburg, Germany
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Aksnes M, Schibstad MH, Chaudhry FA, Neerland BE, Caplan G, Saltvedt I, Eldholm RS, Myrstad M, Edwin TH, Persson K, Idland AV, Pollmann CT, Olsen RB, Wyller TB, Zetterberg H, Cunningham E, Watne LO. Differences in metalloproteinases and their tissue inhibitors in the cerebrospinal fluid are associated with delirium. COMMUNICATIONS MEDICINE 2024; 4:124. [PMID: 38937571 PMCID: PMC11211460 DOI: 10.1038/s43856-024-00558-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 06/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The aetiology of delirium is not known, but pre-existing cognitive impairment is a predisposing factor. Here we explore the associations between delirium and cerebrospinal fluid (CSF) levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs), proteins with important roles in both acute injury and chronic neurodegeneration. METHODS Using a 13-plex Discovery Assay®, we quantified CSF levels of 9 MMPs and 4 TIMPs in 280 hip fracture patients (140 with delirium), 107 cognitively unimpaired individuals, and 111 patients with Alzheimer's disease dementia. The two delirium-free control groups without acute trauma were included to unravel the effects of acute trauma (hip fracture), dementia, and delirium. RESULTS Here we show that delirium is associated with higher levels of MMP-2, MMP-3, MMP-10, TIMP-1, and TIMP-2; a trend suggests lower levels of TIMP-4 are also associated with delirium. Most delirium patients had pre-existing dementia and low TIMP-4 is the only marker associated with delirium in adjusted analyses. MMP-2, MMP-12, and TIMP-1 levels are clearly higher in the hip fracture patients than in both control groups and several other MMP/TIMPs are impacted by acute trauma or dementia status. CONCLUSIONS Several CSF MMP/TIMPs are significantly associated with delirium in hip fracture patients, but alterations in most of these MMP/TIMPs could likely be explained by acute trauma and/or pre-fracture dementia. Low levels of TIMP-4 appear to be directly associated with delirium, and the role of this marker in delirium pathophysiology should be further explored.
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Affiliation(s)
- Mari Aksnes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | | | - Farrukh Abbas Chaudhry
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Rannveig S Eldholm
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Trine Holt Edwin
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Karin Persson
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Vestfold Hospital Trust, Norwegian National Centre for Ageing and Health, Tønsberg, Vestfold, Norway
| | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Department of Anesthesiology, Akershus University Hospital, Lørenskog, Norway
| | | | - Roy Bjørkholt Olsen
- Department of Anesthesiology and Intensive Care, Sørlandet Hospital, Arendal, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Emma Cunningham
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Leiv Otto Watne
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Akershus University Hospital, Lørenskog, Norway
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Gjestad E, Nerdal V, Saltvedt I, Lydersen S, Kliem E, Ryum T, Grambaite R. Delirium in acute stroke is associated with increased cognitive and psychiatric symptoms over time: The Nor-COAST study. J Stroke Cerebrovasc Dis 2024; 33:107667. [PMID: 38423153 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/21/2024] [Accepted: 02/26/2024] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Elise Gjestad
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Vilde Nerdal
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway; Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Kliem
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
| | - Truls Ryum
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ramune Grambaite
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.
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5
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Watne LO, Pollmann CT, Neerland BE, Quist-Paulsen E, Halaas NB, Idland AV, Hassel B, Henjum K, Knapskog AB, Frihagen F, Raeder J, Godø A, Ueland PM, McCann A, Figved W, Selbæk G, Zetterberg H, Fang EF, Myrstad M, Giil LM. Cerebrospinal fluid quinolinic acid is strongly associated with delirium and mortality in hip-fracture patients. J Clin Invest 2023; 133:163472. [PMID: 36409557 PMCID: PMC9843060 DOI: 10.1172/jci163472] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/15/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUNDThe kynurenine pathway (KP) has been identified as a potential mediator linking acute illness to cognitive dysfunction by generating neuroactive metabolites in response to inflammation. Delirium (acute confusion) is a common complication of acute illness and is associated with increased risk of dementia and mortality. However, the molecular mechanisms underlying delirium, particularly in relation to the KP, remain elusive.METHODSWe undertook a multicenter observational study with 586 hospitalized patients (248 with delirium) and investigated associations between delirium and KP metabolites measured in cerebrospinal fluid (CSF) and serum by targeted metabolomics. We also explored associations between KP metabolites and markers of neuronal damage and 1-year mortality.RESULTSIn delirium, we found concentrations of the neurotoxic metabolite quinolinic acid in CSF (CSF-QA) (OR 2.26 [1.78, 2.87], P < 0.001) to be increased and also found increases in several other KP metabolites in serum and CSF. In addition, CSF-QA was associated with the neuronal damage marker neurofilament light chain (NfL) (β 0.43, P < 0.001) and was a strong predictor of 1-year mortality (HR 4.35 [2.93, 6.45] for CSF-QA ≥ 100 nmol/L, P < 0.001). The associations between CSF-QA and delirium, neuronal damage, and mortality remained highly significant following adjustment for confounders and multiple comparisons.CONCLUSIONOur data identified how systemic inflammation, neurotoxicity, and delirium are strongly linked via the KP and should inform future delirium prevention and treatment clinical trials that target enzymes of the KP.FUNDINGNorwegian Health Association and South-Eastern Norway Regional Health Authorities.
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Affiliation(s)
- Leiv Otto Watne
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Department of Geriatric Medicine and
| | | | | | | | | | - Ane-Victoria Idland
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Department of Anesthesiology, Akershus University Hospital, Lørenskog, Norway
| | - Bjørnar Hassel
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
| | - Kristi Henjum
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frede Frihagen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Aasmund Godø
- Department of Anesthesiology, Diakonhjemmet Hospital, Oslo, Norway
| | | | | | - Wender Figved
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Orthopaedic Department, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Geir Selbæk
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom.,Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Evandro F. Fang
- Department of Clinical Molecular Biology, University of Oslo, and Akershus University Hospital, Lørenskog, Norway.,The Norwegian Centre on Healthy Ageing (NO-Age), Oslo, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Lasse M. Giil
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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6
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Nerdal V, Gjestad E, Saltvedt I, Munthe-Kaas R, Ihle-Hansen H, Ryum T, Lydersen S, Grambaite R. The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study. BMC Neurol 2022; 22:234. [PMID: 35761180 PMCID: PMC9235162 DOI: 10.1186/s12883-022-02756-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/14/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later. METHOD As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia. RESULTS Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)). CONCLUSIONS Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.
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Affiliation(s)
- Vilde Nerdal
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
| | - Elise Gjestad
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
- Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ragnhild Munthe-Kaas
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hege Ihle-Hansen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Sandvika, Norway
| | - Truls Ryum
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ramune Grambaite
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway.
- Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.
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7
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Neerland BE, Busund R, Haaverstad R, Helbostad JL, Landsverk SA, Martinaityte I, Norum HM, Ræder J, Selbaek G, Simpson MR, Skaar E, Skjærvold NK, Skovlund E, Slooter AJ, Svendsen ØS, Tønnessen T, Wahba A, Zetterberg H, Wyller TB. Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e057460. [PMID: 35725264 PMCID: PMC9214392 DOI: 10.1136/bmjopen-2021-057460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status. METHODS AND ANALYSIS This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery. ETHICS AND DISSEMINATION This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT05029050.
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Affiliation(s)
| | - Rolf Busund
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Jorunn L Helbostad
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Ieva Martinaityte
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
- Department of Geriatric Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Hilde Margrethe Norum
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Johan Ræder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir Selbaek
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Melanie R Simpson
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Skaar
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Nils Kristian Skjærvold
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anesthesia and Intensive Care Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussel, Brussel, Belgium
| | - Øyvind Sverre Svendsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Theis Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alexander Wahba
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Cardiothoracic Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute, UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, People's Republic of China
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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The detection of delirium in admitted oncology patients: a scoping review. Eur Geriatr Med 2022; 13:33-51. [PMID: 35032322 PMCID: PMC8860783 DOI: 10.1007/s41999-021-00586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
Aim To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting. Findings Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias. Message In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1. Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1.
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Song J, Cheng C, Sheng K, Jiang LL, Li Y, Xia XQ, Hu XW. Association between the reactivity of local cerebral oxygen saturation after hypo-to-hypercapnic tests and delirium after abdominal surgery in older adults: A prospective study. Front Psychiatry 2022; 13:907870. [PMID: 36405895 PMCID: PMC9672925 DOI: 10.3389/fpsyt.2022.907870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between changes in regional cerebral oxygen saturation (rSO2) and postoperative delirium in older adults undergoing major abdominal surgery. MATERIALS AND METHODS This prospective study enrolled older adults scheduled for elective major abdominal surgery at the Second Affiliated Hospital of Anhui Medical University from August 2021 to January 2022. The change in rSO2 from baseline was determined using the hypo-to-hypercapnic test. The main study outcome was the occurrence of postoperative delirium. RESULTS A total of 101 participants were included for analysis, of whom 16 (15.8%) developed postoperative delirium. Compared with non-delirium participants, the mean arterial pressure and heart rate were not significantly different in the postoperative delirium group at T0, T1, T2, T3, T4, and T6 (all Pinteraction > 0.05), but the delirium group had lower pH, lower PaO2, and higher lactate levels at T4, T5, and T6 (all Pinteraction < 0.05). rSO2 at T0, T1, T2, T3, T4, and T6 was 69.0 (63.2-75.2), 70.7 ± 7.3, 68.2 ± 7.5, 72.1 ± 8.0, 69.9 ± 7.8, 67.4 ± 7.2, and 71.7 ± 8.1, respectively. The postoperative change in rSO2 during the hypercapnia test (TΔrSO2%) was 6.62 (5.31-9.36). Multivariable analysis showed that the Cumulative Illness Rating Scale (odd ratio, OR = 1.89, 95% confidence interval, CI: 1.10-3.25, P = 0.021), preoperative albumin levels (OR = 0.67, 95% CI: 0.48-0.94, P = 0.022), rSO2 at T4 (OR = 0.61, 95% CI: 0.41-0.89, P = 0.010), and postoperative TΔrSO2% (OR = 0.80, 95% CI: 0.66-0.98, P = 0.028) were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery. CONCLUSION The rSO2 measured at T4 and postoperative TΔrSO2% were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.
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Affiliation(s)
- Jie Song
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chen Cheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kui Sheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ling-Ling Jiang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yun Li
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Qiong Xia
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.,Department of Anaesthesiology, The Chaohu Affliated Hospital of Anhui Medical University, Hefei, China
| | - Xian-Wen Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Hasegawa T, Seo T, Kubota Y, Sudo T, Yokota K, Miyazaki N, Muranaka A, Hirano S, Yamauchi A, Nagashima K, Iyo M, Sakai I. Reliability and validity of the Japanese version of the 4A's Test for delirium screening in the elderly patient. Asian J Psychiatr 2022; 67:102918. [PMID: 34798384 DOI: 10.1016/j.ajp.2021.102918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 12/15/2022]
Abstract
Although many screening tools for delirium are available, delirium is still occasionally overlooked or misdiagnosed. One of the reasons for this is the lack of brief screening tools that do not require specialized training to use. The 4 'A's test (the 4AT) is a validated screening tool for delirium that can be administered in a very short time without specialized training. Herein, we evaluated the reliability and validity of the Japanese version of the 4AT (the 4AT-J). A total of 150 patients aged ≥ 65 years were enrolled. Their demographics and clinical characteristics were obtained within 24 hr of their hospitalization. On each patient's high-risk day of developing delirium, the 4AT-J was administered by a nurse, and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-Ⅴ) and the Japanese version of Delirium Rating Scale-Revised-98 (DRS-98-J) were administered by a psychiatrist. Our analyses revealed that when a cut-off score of 4, the 4AT-J showed high sensitivity and specificity. The Cronbach's α-coefficient was similar to that of the original version. A receiver operating curve analysis showed sufficient power of the 4AT-J to discriminate delirium. The 4AT-J showed adequate reliability and validity for delirium screening in elderly patients.
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Affiliation(s)
- Tadashi Hasegawa
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan.
| | - Tomomi Seo
- Department of Nursing, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Yoko Kubota
- Department of Nursing, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Tomoko Sudo
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Kumi Yokota
- Department of Rehabilitation Medicine, Chiba University Hospital, 1-8-1 Inohana Chuou-ku, Chiba-shi, Chiba 260-8677, Japan
| | - Nao Miyazaki
- Kokorono-mori Clinic, 1-16-1 Yatsu, Narashino-shi, Chiba 275-0026, Japan
| | - Akira Muranaka
- Oyumino Central Hospital, 6-49-9 Oyumino-minami, Midori-ku, Chiba-shi, Chiba 266-0033, Japan
| | - Shigeki Hirano
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Atsushi Yamauchi
- Chiba Rosai Hospital, 2-16 Tatsumidai-Higashi, Ichihara-shi, Chiba 290-0003, Japan
| | - Kengo Nagashima
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Ikuko Sakai
- Interprofessional Education Research Center, Graduate School of Nursing, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8672, Japan
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Pollmann CT, Mellingsæter MR, Neerland BE, Straume-Næsheim T, Årøen A, Watne LO. Orthogeriatric co-management reduces incidence of delirium in hip fracture patients. Osteoporos Int 2021; 32:2225-2233. [PMID: 33963884 PMCID: PMC8563591 DOI: 10.1007/s00198-021-05974-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/21/2021] [Indexed: 01/07/2023]
Abstract
UNLABELLED Hip fracture patients often display an acute confusional state (delirium) which is associated with worse outcomes. In this observational study, we found that co-management of hip fracture patients by a multidisciplinary team including a geriatrician and an orthopaedic surgeon could reduce the incidence of delirium. INTRODUCTION Delirium after hip fracture is common and is associated with negative outcomes. We investigated if orthogeriatric co-management reduced the incidence of delirium in hip fracture patients. METHODS In this single-centre, prospective observational study, we compared the incidence of delirium and subsyndromal delirium (SSD) before (usual care group, n = 94) and after (orthogeriatric group, n = 103) the introduction of orthogeriatric co-management as an integrated care model. The outcome measure 'no delirium/SSD/delirium' was treated as an ordinal variable and analysed using the chi-squared test and multivariable ordinal logistic regression. RESULTS The groups had similar baseline characteristics except for a higher proportion of patients with pre-existing cognitive impairment in the usual care group (51% vs. 37%, p = 0.045). Fewer patients in the orthogeriatric group developed SSD or delirium (no delirium: 59% vs. 40%/SSD: 6% vs. 13%/delirium: 35% vs. 47%; p = 0.021). The number needed to treat (NNT) to avoid one case of SSD or delirium was 5.3 (95% CI: 3.1 to 19.7). In a multivariable analysis adjusted for age, sex, ASA class, pre-existing cognitive impairment, time to surgery, type of surgery, and medical or surgical complications, the odds ratio for the development of SSD/delirium was lower in the orthogeriatric group (OR = 0.46, 95% CI: 0.23-0.89, p = 0.023). CONCLUSION Orthogeriatric co-management as an integrated care model reduced the incidence of SSD/delirium in hip fracture patients.
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Affiliation(s)
- C T Pollmann
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B E Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - T Straume-Næsheim
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway
- Oslo Sports Trauma Research Center (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway
| | - A Årøen
- Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
- Oslo Sports Trauma Research Center (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway
| | - L O Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
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Zastrow I, Tohsche P, Loewen T, Vogt B, Feige M, Behnke M, Wolff A, Kiefmann R, Olotu C. Comparison of the '4-item assessment test' and 'nursing delirium screening scale' delirium screening tools on non-intensive care unit wards: A prospective mixed-method approach. Eur J Anaesthesiol 2021; 38:957-965. [PMID: 33606422 DOI: 10.1097/eja.0000000000001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In elderly patients following surgery, postoperative delirium (POD) is the most frequent complication and is associated with negative outcomes. The 2017 European Society of Anaesthesiology guideline on POD aims to improve patient care by implementing structured delirium prevention, diagnosis and treatment. However, these recommendations, especially systematic delirium screening, are still incompletely adopted in clinical practice. The aim of this study was to evaluate the feasibility and acceptance of validated delirium screening tools and to identify barriers to their implementation on nonintensive care unit wards. METHODS Screening rates, as well as practicability, acceptance and the interprofessional handling of positive results, were assessed for each group. Screening rates were calculated as a percentage of the total potential testing episodes completed (up to 15 per patient). Patients were considered eligible when aged 65 years and above. Barriers and motivating factors were assessed in a mixed method approach by utilising questionnaires and focus group discussions. INTERVENTION In a 3-month phase, a guideline-compliant screening protocol involving screening for POD three times daily for 5 days following surgery was introduced in five wards: both the 4-item assessment test (4AT) and the nursing delirium screening scale (NuDESC) were used. Before commencing the study and again after 6 weeks, medical staff of the respective wards underwent a 45 min training session. RESULTS Of a total of 3183 potential testing episodes, 999 (31.4%) were completed, with more NuDESC observational tests (43%) than 4AT bedside tests completed (20%). The 4AT was considered more difficult to integrate into daily working routines, it took longer to administer, and nurses felt uncomfortable conducting the screening (53 vs. 13%). Screening results indicating delirium were often not discussed within the team (47%), and nurses felt that often such results were not taken seriously by physicians (54%). CONCLUSION The observational NuDESC showed a higher completion rate than the bedside 4AT, although overall testing rates were low. The necessary time needed to conduct the screening, the negative reactions by patients, insufficient team communication and a lack of initiation of any therapy were identified as major barriers in the implementation of the guideline-compliant screening protocol. For all staff, further education and awareness of the importance of POD diagnosis and treatment might improve the screening rates. The NuDesc received better results concerning acceptance, practicability and introduction into daily work routine, leading to higher screening rates compared with the 4AT. The latter instrument, which was intended to be used rather selectively or when POD is suspected, might therefore not be suitable for guideline-compliant regular and repeated screening for POD.
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Affiliation(s)
- Inke Zastrow
- From the Department of Patient and Care Management (IZ, BV, MF), Department of Intensive Care Medicine (PT, AW) and Department of Anaesthesiology (TL, MB, RK, CO), Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Hamburg, Germany
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13
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Franco JG, Ocampo MV, Velásquez-Tirado JD, Zaraza DR, Giraldo AM, Serna PA, López C, Zuluaga A, Sepúlveda E, Kean J, Trzepacz PT. Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) With Medical Inpatients and Comparison With the Confusion Assessment Method Algorithm. J Neuropsychiatry Clin Neurosci 2021; 32:213-226. [PMID: 31662094 DOI: 10.1176/appi.neuropsych.18110255] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Delirium remains underdetected as a result of its broad constellation of symptoms and the inadequate neuropsychiatric expertise of most medical-surgical clinicians. Brief, accurate tools are needed to enhance detection. METHODS The authors extended validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro), originally validated in a study of inpatients with traumatic brain injury for diagnosis of delirium by nonexpert clinicians, for 200 general medical inpatients in Colombia. The three structured, quantitatively rated items in DDT-Pro represent the three core delirium domains. RESULTS High interrater reliability between physician and nurse (0.873) administrators, internal consistency (>0.81), and content validity were found. Compared with independent reference standard diagnosis with DSM-5 or the Delirium Rating Scale-Revised-98, the area under the receiver operating characteristic (ROC) curve (global diagnostic accuracy) range was 93.8%-96.3%. ROC analysis revealed the same cutoff score (≤6) as that for the original study, with somewhat lower sensitivities of 88.0%-90.0% and specificities of 85.3%-81.2% (independent expert physician or nurse ratings). Even when rated by a trained expert physician, the original version of the Confusion Assessment Method algorithm (CAM-A) performed moderately, with lower sensitivities (61.8%-70.0%) than the DDT-Pro (88.0%-100%) and somewhat higher specificities (84.8%-95.3% versus 67.4%-86.7%), with values depending on dementia status, reference standard, and rater type. Accuracies for the DDT-Pro and CAM-A were comparable (DDT-Pro: 83.0%-87.5% versus CAM-A: 87.5%-88.5%), although lower in the dementia subgroup, especially for CAM-A. However, these tools were significantly discordant, especially in negative cases, which suggests that they do not detect diagnosis of patients in the same way. CONCLUSIONS The DDT-Pro had high validity and reliability in provisional delirium diagnosis by physicians and nonexpert clinicians, although further validation is warranted before widespread use can be recommended.
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Affiliation(s)
- José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - María V Ocampo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Juan D Velásquez-Tirado
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Daniel R Zaraza
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Alejandra M Giraldo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Paola A Serna
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Carolina López
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Adolfo Zuluaga
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Esteban Sepúlveda
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Jacob Kean
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Paula T Trzepacz
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia (Franco, Ocampo, Velásquez-Tirado, Giraldo, Serna, López, Zuluaga); Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia (Zaraza); Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain (Sepúlveda); the Departments of Population Health Sciences and Communication Sciences and Disorders, VA Salt Lake City Health Care System, and Health System Innovation and Research, University of Utah, Salt Lake City (Kean); and the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
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14
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Bellelli G, Brathwaite JS, Mazzola P. Delirium: A Marker of Vulnerability in Older People. Front Aging Neurosci 2021; 13:626127. [PMID: 33994990 PMCID: PMC8119654 DOI: 10.3389/fnagi.2021.626127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | | | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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15
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Carin-Levy G, Nicol K, van Wijck F, Mead G, McVittie C. Identifying and Responding to Delirium in Acute Stroke: Clinical Team Members' Understandings. QUALITATIVE HEALTH RESEARCH 2021; 31:137-147. [PMID: 32969764 PMCID: PMC7750676 DOI: 10.1177/1049732320959295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Delirium is associated with increased mortality, morbidity, and length of hospital stay. In the acute stroke setting, delirium identification is challenging due to the complexity of cognitive screening in this patient group. The aim of this study was to explore how members of interprofessional stroke-unit teams identified and responded to a potential delirium in a patient. Online focus groups and interviews utilizing case vignettes were conducted with 15 participants: nurses, occupational therapists, speech and language therapists, and physiotherapists working in acute stroke services. Participants' understandings of delirium varied, most participants did not identify the symptoms of a possible hypoactive delirium, and nearly all participants discussed delirium symptoms in tentative terms. Aspects of interprofessional working were discussed through the expression of distinct roles around delirium identification. Although participants demonstrated an ethos of person-focused care, there are ongoing challenges involved in early identification and management of delirium in stroke survivors.
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Affiliation(s)
- Gail Carin-Levy
- Queen Margaret University
Edinburgh, Musselburgh, United Kingdom
| | - Kath Nicol
- Queen Margaret University
Edinburgh, Musselburgh, United Kingdom
| | | | - Gillian Mead
- The University of Edinburgh,
Edinburgh, United Kingdom
| | - Chris McVittie
- Queen Margaret University
Edinburgh, Musselburgh, United Kingdom
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16
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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17
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Evensen S, Saltvedt I, Lydersen S, Wyller TB, Taraldsen K, Sletvold O. Environmental factors and risk of delirium in geriatric patients: an observational study. BMC Geriatr 2018; 18:282. [PMID: 30442109 PMCID: PMC6238358 DOI: 10.1186/s12877-018-0977-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/06/2018] [Indexed: 11/22/2022] Open
Abstract
Background Patients with delirium have increased risk of death, dementia and institutionalization, and prognosis differs between delirium motor subtypes. A few studies have identified associations between environmental factors like room-transfers and time spent in the emergency department (ED) and delirium, but no studies have investigated if environmental factors may influence delirium motor subtypes. We wanted to explore if potentially stressful events like ward-transfers, arriving ED at nighttime, time spent in ED and nigthttime investigations were associated with development of delirium (incident delirium) and delirium motor subtypes. Methods We used the DSM-5 criteria to diagnose delirium and the Delirium Motor Subtype Scale for motor subtyping. We defined hyperactive and mixed delirium as delirium with hyperactive symptoms, and hypoactive and no-subtype delirium as delirium without hyperactive symptoms. We registered ward-transfers, time of arrival in ED, time spent in ED and nighttime investigations (8 p.m. to 8 a.m.), and calculated Global Deterioration Scale (GDS) and Cumulative Illness Rating Scale (CIRS) to adjust for cognitive impairment and comorbidity. We used logistic regression analyses with incident delirium and delirium with hyperactive symptoms as outcome variables, and ward-transfers, arriving ED at nighttime, time spent in ED and nighttime investigations as exposure variables, adjusting for age, GDS and CIRS in the analyses for incident delirium. Results We included 254 patients, mean age 86.1 years (SD 5.2), 49 (19.3%) had incident delirium, 22 with and 27 without hyperactive symptoms. There was a significant association between nighttime investigations and incident delirium in both the unadjusted (odds ratio (OR) 2.22, 95% confidence interval (CI) 1.17 to 4.22, p = 0.015) and the multiadjusted model (OR 2.61, CI 1.26 to 5.40, p = 0.010). There were no associations between any other exposure variables and incident delirium. No exposure variables were associated with delirium motor subtypes. Conclusions Nighttime investigations were associated with incident delirium, even after adjusting for age, cognitive impairment and comorbidity. We cannot out rule that the medical condition leading to nighttime investigations is the true delirium-trigger, so geriatric patients must still receive emergency investigations at nighttime. Hospital environment in broad sense may be a target for delirium prevention.
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Affiliation(s)
- Sigurd Evensen
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway.
| | - Ingvild Saltvedt
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin Taraldsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
| | - Olav Sletvold
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
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18
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Smith J, Ryan T, Hanley J, MacRaild A, Steven J, Black PL, Boyd J, Weir CJ, MacLullich AM. Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study. BMJ Open 2018; 8:e015572. [PMID: 29440152 PMCID: PMC5879933 DOI: 10.1136/bmjopen-2016-015572] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Delirium is a severe neuropsychiatric syndrome of rapid onset, commonly precipitated by acute illness. It is common in older people in the emergency department (ED) and acute hospital, but greatly under-recognised in these and other settings. Delirium and other forms of cognitive impairment, particularly dementia, commonly coexist. There is a need for a rapid delirium screening tool that can be administered by a range of professional-level healthcare staff to patients with sensory or functional impairments in a busy clinical environment, which also incorporates general cognitive assessment. We developed the 4 'A's Test (4AT) for this purpose. This study's primary objective is to validate the 4AT against a reference standard. Secondary objectives include (1) comparing the 4AT with another widely used test (the Confusion Assessment Method (CAM)); (2) determining if the 4AT is sensitive to general cognitive impairment; (3) assessing if 4AT scores predict outcomes, including (4) a health economic analysis. METHODS AND ANALYSIS 900 patients aged 70 or over in EDs or acute general medical wards will be recruited in three sites (Edinburgh, Bradford and Sheffield) over 18 months. Each patient will undergo a reference standard delirium assessment and will be randomised to assessment with either the 4AT or the CAM. At 12 weeks, outcomes (length of stay, institutionalisation and mortality) and resource utilisation will be collected by a questionnaire and via the electronic patient record. ETHICS AND DISSEMINATION Ethical approval was granted in Scotland and England. The study involves administering tests commonly used in clinical practice. The main ethical issues are the essential recruitment of people without capacity. Dissemination is planned via publication in high impact journals, presentation at conferences, social media and the website www.the4AT.com. TRIAL REGISTRATION NUMBER ISRCTN53388093; Pre-results.
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Affiliation(s)
| | | | - Mary Godfrey
- Health and Social Care, Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York, Hull York Medical School, York and Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - John Young
- Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Professor of Emergency Medicine, Department of Emergency Medicine, Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Joel Smith
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Tracy Ryan
- Old Age Liaison Psychiatry, NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L Black
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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19
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Bellelli G, Morandi A, Trabucchi M, Caironi G, Coen D, Fraticelli C, Paolillo C, Prevaldi C, Riccardi A, Cervellin G, Carabellese C, Putignano S, Maggi S, Cherubini A, Gnerre P, Fontanella A, Latronico N, Tommasino C, Corcione A, Ricevuti G, Ferrara N, De Filippi F, Ferrari A, Guarino M, Ruggieri MP, Modesti PA, Locatelli C, Hrelia P, Toscano MO, Bondi E, Tarasconi A, Ansaloni L, Perticone F. Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons. Intern Emerg Med 2018; 13:113-121. [PMID: 28741278 DOI: 10.1007/s11739-017-1705-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delirium in elderly hospitalized patients, (2) to focus the attention of health care personnel on prevention, diagnosis, and therapy of patients suffering from delirium, and (3) to make the health services research community and policy-makers more aware of the potential risks of this condition providing a reference for training activities and data collection.
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Affiliation(s)
| | | | | | - Guido Caironi
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | - Daniele Coen
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | - Ciro Paolillo
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | - Angela Riccardi
- AcEMC (Academy of Emergency Medicine and Care), Pavia, Italy
| | | | | | | | - Stefania Maggi
- EUGMS (European Union Geriatric Medicine Society), Venice Lido, Italy
| | - Antonio Cherubini
- EUGMS (European Union Geriatric Medicine Society), Venice Lido, Italy
| | - Paola Gnerre
- FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti), Rome, Italy
| | - Andrea Fontanella
- FADOI (Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti), Rome, Italy
| | - Nicola Latronico
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Concezione Tommasino
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Antonio Corcione
- SIAARTI (Società Italiana di Anestesia, Analgesia Rianimazione e Terapia Intensiva), Rome, Italy
| | - Giovanni Ricevuti
- SIGG (Società Italiana di Geriatria e Gerontologia), Florence, Italy
| | - Nicola Ferrara
- SIGG (Società Italiana di Geriatria e Gerontologia), Florence, Italy
| | | | - Alberto Ferrari
- SIGOT (Società Italiana di Geriatria Ospedale e Territorio), Rome, Italy
| | - Mario Guarino
- SIMEU (Società Italiana di Medicina di Emergenza e Urgenza), Milan, Italy
| | - Maria Pia Ruggieri
- SIMEU (Società Italiana di Medicina di Emergenza e Urgenza), Milan, Italy
| | - Pietro Amedeo Modesti
- SIMI (Società Italiana di Medicina Interna), Rome, Italy.
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | | | | | - Marco Otto Toscano
- CNI-SPDC (Coordinamento Nazionale Servizi Psichiatrici di Diagnosi e Cura), Bergamo, Italy
| | - Emi Bondi
- CNI-SPDC (Coordinamento Nazionale Servizi Psichiatrici di Diagnosi e Cura), Bergamo, Italy
| | | | - Luca Ansaloni
- WSES (World Society of Emergency Surgery), Bologna, Italy
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20
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Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Reddy SV, Irkal JN, Srinivasamurthy A. Postoperative delirium in elderly citizens and current practice. J Anaesthesiol Clin Pharmacol 2017; 33:291-299. [PMID: 29109625 PMCID: PMC5672535 DOI: 10.4103/joacp.joacp_180_16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Postoperative delirium (POD) represents an acute brain dysfunction in the postsurgical period. Perioperative physicians caring for the older adults are familiar with the care of dysfunction of organs such as lungs, heart, liver, or kidney in the perioperative setting, but they are less familiar with management of brain dysfunction. As early detection and prompt treatment of inciting factors are utmost important to prevent or minimize the deleterious outcomes of delirium. The purpose of this review is to prepare perioperative physicians with a set of current clinical practice recommendations to provide optimal perioperative care of older adults, with a special focus on specific perioperative interventions that have been shown to prevent POD. On literature search in EMBASE, CINAHL, and PUBMED between January 2000 and September 2015 using search words delirium, POD, acute postoperative confusion, and brain dysfunction resulted in 9710 articles. Among them, 73 articles were chosen for review, in addition, National Institute for Health and Clinical Excellence guidelines, American Geriatric Society guidelines, hospital elderly life program-confusion assessment method training manual, New York geriatric nursing protocols, World Health Organization's International Classification of Diseases, 10th Revision classification of mental disorders, Food and Drug Administration requests boxed warnings on older class of antipsychotic drugs 2008 and delirium in Miller's text book of anesthesia were reviewed and relevant information presented in this article.
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Affiliation(s)
- Siddareddygari Velayudha Reddy
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
| | - Jawaharlal Narayanasa Irkal
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
| | - Ananthapuram Srinivasamurthy
- Department of Anaesthesiology and Critical Care, Navodaya Medical College and Research Center, Raichur, Karnataka, India
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22
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FitzGerald JM. The role of predictive coding in the pathogenesis of delirium. Med Hypotheses 2017; 103:71-77. [PMID: 28571816 DOI: 10.1016/j.mehy.2017.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 03/20/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
Delirium and dementia represent an emerging global crisis in healthcare. Attempts have been made to identify the pathognomonic feature that would make delirium stand out from dementia but unfortunately the global neural dysfunction of both disorders has made the establishment of a direct measurement difficult. Modern conceptualisations of delirium have been influenced by the assessment tools used to assess, detect, and analyse its complex and transient nature. Recent publication of the DSM-V criteria for delirium has marginally altered the previous DSM-IV criteria with a focus upon inattention with vague terms such as consciousness downplayed. Such an alteration has been found to be restrictive and thus impact upon delirium case identification. Although these findings are approximating the empirical state of delirium as measured by validated instruments, a more refined neuroscientifically informed phenomenological framework is required in order to enhance the theoretical understanding of delirium assessment and resolve these challenges. One such application is the predictive coding (PC) model, also known as the hierarchical Bayesian inference model, to interpreting delirium pathophysiology. Therefore, the aims of this paper are to 1) propose the hypothesis that delirium pathophysiology can be explained in terms of the PC model, 2) support this hypothesis by applying this model to current methods of assessing delirium phenomenology, particularly attention, and 3) outline a future programme of research to test many of the parameters of this application.
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Affiliation(s)
- J M FitzGerald
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds Teaching Hospital Trust NHS, UK.
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Li H, Zhang L, Shi M, Yang S, Li S, Gao S. Impact of Dexmedetomidine on Pediatric Agitation in the Postanesthesia Care Unit. J Perianesth Nurs 2017; 33:53-57. [PMID: 29362047 DOI: 10.1016/j.jopan.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/14/2016] [Accepted: 03/05/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to investigate the impacts of dexmedetomidine (DEX) on agitation in the postanesthesia care unit (PACU) for pediatric patients undergoing tonsillectomy. DESIGN Eighty-two pediatric patients with elective tonsillectomy were randomly divided into the DEX group (group D) and the control group (group C). All patients' surgery in the two study groups were completed under tracheal cannula-based general anesthesia. Group D was infused 0.2 mcg/kg/hour DEX. The operation time, extubation time, PACU time, number of cases with nausea and vomiting, hemodynamic changes, and doses of rescue fentanyl, as well as every 10-minute observational pain scoring, and emergence agitation score in PACU, of the two groups were recorded. METHODS Chi-square and Fischer exact tests were applied for categorical variables. FINDINGS The maximum observational pain scoring and emergence agitation score of group D at 0, 10, and 20 minutes in PACU were significantly lower than group C (P < .01); the rescue doses of fentanyl and incidence of severe agitation in PACU in group D were significantly reduced than group C (P < .01). Group D showed significantly less cases with nausea and vomiting than group C (P < .05). CONCLUSIONS Low-dose DEX could significantly reduce the delirium and agitation in the PACU stage of pediatric tonsillectomy, and there were no untoward hemodynamic events in this study of 80 patients.
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De J, Wand APF. Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients. THE GERONTOLOGIST 2015; 55:1079-99. [DOI: 10.1093/geront/gnv100] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/04/2015] [Indexed: 11/14/2022] Open
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Bellelli G, Nobili A, Annoni G, Morandi A, Djade CD, Meagher DJ, Maclullich AMJ, Davis D, Mazzone A, Tettamanti M, Mannucci PM. Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards. Eur J Intern Med 2015; 26:696-704. [PMID: 26333532 DOI: 10.1016/j.ejim.2015.08.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/05/2015] [Accepted: 08/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric disorder, triggered by medical precipitants causes. Study aims were to describe the prevalence and impact on in-hospital mortality of delirium identified through ICD-9 codes as well as evidence of neurocognitive deficits demonstrated in a population of older patients admitted to acute medical wards. METHODS This was a prospective cohort multicenter study of 2521 older patients enrolled in the "Registro Politerapie SIMI (REPOSI)" during the years 2010 and 2012. The diagnosis of delirium was obtained by ICD-9 codes. Cognitive function was evaluated with the Short Blessed Test (SBT) and single SBT items were used as measures of deficits in attention, orientation and memory. Combination of deficits in SBT items was used as a proxy for delirium. Logistic regression was used to evaluate the association with in-hospital mortality of delirium and combined deficits in SBT items. RESULTS Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates. CONCLUSIONS The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.
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Affiliation(s)
- G Bellelli
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy.
| | - A Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - G Annoni
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | - A Morandi
- Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - C D Djade
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - D J Meagher
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - A M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom; Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, United Kingdom
| | - D Davis
- MRC Unit for Lifelong Health and Ageing, University College London, United Kingdom
| | - A Mazzone
- Department of Health Sciences, University of Milano Bicocca, Italy
| | - M Tettamanti
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - P M Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
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Vahedian Azimi A, Ebadi A, Ahmadi F, Saadat S. Delirium in Prolonged Hospitalized Patients in the Intensive Care Unit. Trauma Mon 2015; 20:e17874. [PMID: 26290854 PMCID: PMC4538727 DOI: 10.5812/traumamon.17874] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/13/2014] [Accepted: 04/30/2014] [Indexed: 01/08/2023] Open
Abstract
Background: Prolonged hospitalization in the intensive care unit (ICU) can impose long-term psychological effects on patients. One of the most significant psychological effects from prolonged hospitalization is delirium. Objectives: The aim of this study was to assess the effect of prolonged hospitalization of patients and subsequent delirium in the intensive care unit. Patients and Methods: This conventional content analysis study was conducted in the General Intensive Care Unit of the Shariati Hospital of Tehran University of Medical Sciences, from the beginning of 2013 to 2014. All prolonged hospitalized patients and their families were eligible participants. From the 34 eligible patients and 63 family members, the final numbers of actual patients and family members were 9 and 16, respectively. Several semi-structured interviews were conducted face-to-face with patients and their families in a private room and data were gathered. Results: Two main themes from two different perspectives emerged, 'patients' perspectives' (experiences during ICU hospitalization) and 'family members' perspectives' (supportive-communicational experiences). The main results of this study focused on delirium, Patients' findings were described as pleasant and unpleasant, factual and delusional experiences. Conclusions: Family members are valuable components in the therapeutic process of delirium. Effective use of family members in the delirium caring process can be considered to be one of the key non-medical nursing components in the therapeutic process.
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Affiliation(s)
- Amir Vahedian Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Abbas Ebadi, Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, P.O. Box: 19575-174, Tehran, IR Iran. Tel: +98-9122149019, Fax: +98-2126127237, E-mail:
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
| | - Soheil Saadat
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, Deiner S, Fick D, Hutchison L, Johanning J, Katlic M, Kempton J, Kennedy M, Kimchi E, Ko C, Leung J, Mattison M, Mohanty S, Nana A, Needham D, Neufeld K, Richter H. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Coll Surg 2015; 220:136-48.e1. [DOI: 10.1016/j.jamcollsurg.2014.10.019] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 12/17/2022]
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Tieges Z, Brown LJE, MacLullich AMJ. Objective assessment of attention in delirium: a narrative review. Int J Geriatr Psychiatry 2014; 29:1185-97. [PMID: 24760756 DOI: 10.1002/gps.4131] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 03/26/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Inattention is a core feature of delirium, and valid assessment of attention is central to diagnosis. Methods of measuring attention in delirium can be divided into two broad categories: (i) objective neuropsychological testing; and (ii) subjective grading of behaviour during interview and clinical examination. Here, we review and critically evaluate studies of objective neuropsychological testing of attention in delirium. We examine the implications of these studies for delirium detection and monitoring in clinical practice and research, and how these studies inform understanding of the nature of attentional deficits in delirium. METHODS Searches of MEDLINE and ISI Web of Knowledge databases were performed to identify studies in which objective tests of attention had been administered to patients with delirium, who had been diagnosed using DSM or ICD criteria. RESULTS Sixteen publications were identified. The attention tests administered in these studies were grouped into the following categories: measures of attention span, vigilance tests, other pen-and-paper tests (e.g. Trail Making Test) and computerised tests of speeded reaction, vigilance and sustained attention. Patients with delirium showed deficits on all tasks, although most tasks were not considered pure measures of attention. Five papers provided data on differential diagnosis from dementia. Cancellation tests, spatial span tests and computerised tests of sustained attention discriminated delirium from dementia. Five studies presented reliability or validity statistics. CONCLUSIONS The existing evidence base on objective assessment of attention in delirium is small. Objective testing of attention is underdeveloped but shows considerable promise in clinical practice and research.
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Affiliation(s)
- Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK; Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
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O'Regan NA, Ryan DJ, Boland E, Connolly W, McGlade C, Leonard M, Clare J, Eustace JA, Meagher D, Timmons S. Attention! A good bedside test for delirium? J Neurol Neurosurg Psychiatry 2014; 85:1122-31. [PMID: 24569688 PMCID: PMC4173985 DOI: 10.1136/jnnp-2013-307053] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'. METHODS We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method. RESULTS 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity. CONCLUSIONS Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.
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Affiliation(s)
- Niamh A O'Regan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Daniel J Ryan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | | | - Ciara McGlade
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University of Limerick, Limerick, Ireland
| | - Josie Clare
- Department of Geriatric Medicine, Waterford Regional Hospital, Waterford, Ireland
| | - Joseph A Eustace
- HRB Clinical Research Facility at UCC, University College Cork, Cork, Ireland
| | - David Meagher
- Department of Psychiatry, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gallagher TK, McErlean S, O'Farrell A, Hoti E, Maguire D, Traynor OJ, Conlon KC, Geoghegan JG. Incidence and risk factors of delirium in patients post pancreaticoduodenectomy. HPB (Oxford) 2014; 16:864-9. [PMID: 24750484 PMCID: PMC4159461 DOI: 10.1111/hpb.12266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative delirium is an important and common complication of major abdominal surgery characterized by acute confusion with fluctuating consciousness. The aim of this study was to establish the incidence of post-operative delirium in patients undergoing a pancreaticoduodenectomy and to determine the risk factors for its development. METHODS From a prospectively maintained database, a retrospective cohort analysis was performed of 50 consecutive patients who underwent a pancreaticoduodenectomy at the National Surgical Centre for Pancreatic Cancer in St. Vincent's University Hospital, Dublin and whose entire post-operative stay was in this institution, between July 2011 and December 2012. Two independent medical practitioners assessed all data and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder (DSM), fourth edition. Univariate and multivariate analyses were performed. RESULTS Seven patients (14%) developed post-operative delirium. The median onset was on the second post-operative day. Older age was predictive of an increased risk of delirium post-operatively. Those who developed delirium had a significantly increased length of stay (LOS) as well as a significantly increased risk of developing at least a grade 3 complication (Clavien-Dindo classification). CONCLUSION This study demonstrates that post-operative delirium is associated with a more complicated recovery after a pancreaticoduodenectomy and that older age is independently predictive of its development. Focused screening may allow targeted preventative strategies to be used in the peri-operative period to reduce complications and costs associated with delirium.
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Affiliation(s)
- Tom K Gallagher
- Correspondence, Tom K. Gallagher, Department of Hepatobiliary & Pancreatic Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland. Tel: +44 781 606 5765. Fax: +353 1 2837724. E-mail:
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Leonard MM, Nekolaichuk C, Meagher DJ, Barnes C, Gaudreau JD, Watanabe S, Agar M, Bush SH, Lawlor PG. Practical assessment of delirium in palliative care. J Pain Symptom Manage 2014; 48:176-90. [PMID: 24766745 DOI: 10.1016/j.jpainsymman.2013.10.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 10/25/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging. OBJECTIVES This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings. METHODS In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care. RESULTS Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes. CONCLUSION Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.
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Affiliation(s)
| | - Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Alberta, Canada; Tertiary Palliative Care Unit, Covenant Health, Grey Nuns Hospital, Edmonton, Alberta, Canada
| | - David J Meagher
- University of Limerick, Limerick, Ireland; Department of Adult Psychiatry, Limerick Regional Hospital, Limerick, Ireland
| | - Christopher Barnes
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-David Gaudreau
- Centre de recherche du CHU de Québec and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada
| | - Sharon Watanabe
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Alberta, Canada; Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Meera Agar
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Shirley H Bush
- Bruyère and Ottawa Hospital Research Institutes, Ottawa, Ontario, Canada; Division of Palliative Care, Departments of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Bruyère and Ottawa Hospital Research Institutes, Ottawa, Ontario, Canada; Division of Palliative Care, Departments of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Bellelli G, Morandi A, Davis DHJ, Mazzola P, Turco R, Gentile S, Ryan T, Cash H, Guerini F, Torpilliesi T, Del Santo F, Trabucchi M, Annoni G, MacLullich AMJ. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014; 43:496-502. [PMID: 24590568 PMCID: PMC4066613 DOI: 10.1093/ageing/afu021] [Citation(s) in RCA: 423] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 10/30/2013] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE to evaluate the performance of the 4 'A's Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice. DESIGN : prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments. SETTING : an acute geriatrics ward and a department of rehabilitation. PARTICIPANTS two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months. MEASUREMENTS in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium. RESULTS patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia. CONCLUSIONS the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.
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Affiliation(s)
- Giuseppe Bellelli
- Department of Health Sciences, University of Milano-Bicocca and S. Gerardo Hospital, Geriatric Clinic, Monza, Italy Geriatric Research Group, via Romanino 1, Brescia, Italy
| | - Alessandro Morandi
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Daniel H J Davis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Paolo Mazzola
- Department of Health Sciences, University of Milano-Bicocca and S. Gerardo Hospital, Geriatric Clinic, Monza, Italy
| | - Renato Turco
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Simona Gentile
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Tracy Ryan
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, UK
| | - Helen Cash
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, UK
| | - Fabio Guerini
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Tiziana Torpilliesi
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Francesco Del Santo
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Rehabilitation and Aged Care, Ancelle Della Carità Hospital, Cremona, Italy
| | - Marco Trabucchi
- Geriatric Research Group, via Romanino 1, Brescia, Italy Department of Medicine, University of Roma Tor Vergata, Roma, Italy
| | - Giorgio Annoni
- Department of Health Sciences, University of Milano-Bicocca and S. Gerardo Hospital, Geriatric Clinic, Monza, Italy
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, UK
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Abstract
Delirium is a common, severe and acute neuropsychiatric syndrome that affects mainly older patients. Delirium is a well-recognised complication of trauma and is important as it is associated with an increase in mortality as well as cognitive and functional decline, increased length of hospital stay and increased risk of institutionalisation on discharge. Recognition and management is challenging and the psychological impact for patients and relatives devastating. This review discusses the current understanding of delirium with specific reference to trauma patients.
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Affiliation(s)
- S Eliza Griffiths
- Queen Elizabeth Hospital Birmingham, Queen Elizabeth Medical Centre, UK
| | - U Tandon
- Queen Elizabeth Hospital Birmingham, Queen Elizabeth Medical Centre, UK
| | - J Treml
- Queen Elizabeth Hospital Birmingham, Queen Elizabeth Medical Centre, UK
| | - TA Jackson
- School of Immunity and Infection, University of Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
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O'Hanlon S, O'Regan N, Maclullich AMJ, Cullen W, Dunne C, Exton C, Meagher D. Improving delirium care through early intervention: from bench to bedside to boardroom. J Neurol Neurosurg Psychiatry 2014; 85:207-13. [PMID: 23355807 DOI: 10.1136/jnnp-2012-304334] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.
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Affiliation(s)
- Shane O'Hanlon
- Graduate Entry Medical School, , University of Limerick, Ireland
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Neerland BE, Watne LO, Wyller TB. [Delirium in elderly patients]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1596-600. [PMID: 23970274 DOI: 10.4045/tidsskr.12.1327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Delirium, «acute confusional state», is a frequent and serious complication of acute illness, particularly in the elderly. The strain on the patient, the next of kin and the health service is considerable. The purpose of the article is to provide healthcare personnel who deal with delirium with updated information about the condition. METHOD The article is based on a literature search in PubMed combined with articles from the author's own archives and own clinical experience. RESULTS Delirium is a serious acute medical condition that is often overlooked in the elderly. The prevalence is estimated to be between 11% and 42% for elderly patients on medical wards and close to 50% in patients with hip fractures. The prevalence is probably also high in nursing homes, but this is less well surveyed. Advanced age and dementia are the most important risk factors. Traumas, infections, stroke and metabolic disturbances are the most common triggering factors. The pathophysiology is poorly surveyed and the possibilities for drug treatment are few and are little studied. Delirium is associated with increased risk of dementia, loss of function and mortality. Short-term use of low-dosage antipsychotics is the first-line choice, but is contraindicated for patients with Parkinsonian symptoms. INTERPRETATION Detection and treatment of triggering causes must have high priority in case of delirium. Non-drug interventions are most important to prevent and treat the condition.
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Maclullich AMJ, Anand A, Davis DHJ, Jackson T, Barugh AJ, Hall RJ, Ferguson KJ, Meagher DJ, Cunningham C. New horizons in the pathogenesis, assessment and management of delirium. Age Ageing 2013; 42:667-74. [PMID: 24067500 PMCID: PMC3809721 DOI: 10.1093/ageing/aft148] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.
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Affiliation(s)
- Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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Smith T, Hameed Y, Cross J, Sahota O, Fox C. Assessment of people with cognitive impairment and hip fracture: a systematic review and meta-analysis. Arch Gerontol Geriatr 2013; 57:117-26. [PMID: 23680535 DOI: 10.1016/j.archger.2013.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/26/2013] [Accepted: 04/18/2013] [Indexed: 01/12/2023]
Abstract
This study systematically assesses the literature pertaining to the diagnostic test accuracy of assessment instruments to evaluate patients following hip fracture surgery who present with cognitive impairment. A systematic review and meta-analysis was performed. Studies assessing the reliability, validity, sensitivity or specificity of assessment tools for patients following hip fracture who were cognitively impaired were included. An assessment of published (MEDLINE, EMBASE, CINHAL, AMED, Cochrane library, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials, the UK National Research Register Archive) databases were undertaken. Methodological quality of the literature was assessed using the QUADAS-2 appraisal tool. Nine studies including 690 participants, with a mean age of 82.1 years were included. The literature demonstrated a high risk of bias for study methodology, but low risk of bias for applicability. Two assessment domains were recognized: pain and delirium. For pain, the Facial Action Coding System (FACS) and DOLOPLUS-2 tools possessed strong inter-rater reliability and internal consistency, with the FACS demonstrating concurrent validity with other pain scales. For delirium, the Delirium Rating Scale-Revisited-98 (DRS-R-98) demonstrated high inter-rater reliability and sensitivity and specificity, with the NEECHAM Confusion Scale possessing high internal consistency. To conclude, there is a paucity of literature assessing the reliability, validity and diagnostic test accuracy of instruments to assess people with cognitive impairment following hip fracture surgery. Based on the current available data, delirium may be best assessed using the NEECHAM Confusion Scale or DRS-R-98. Pain is most accurately evaluated using the FACS.
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Affiliation(s)
- Toby Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
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Gregoretti C, Pelosi P. Delirium in the hospital setting: Do not let our patients “going off the ploughed track”. Best Pract Res Clin Anaesthesiol 2012; 26:265-6. [DOI: 10.1016/j.bpa.2012.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 08/08/2012] [Indexed: 10/27/2022]
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