Delirium Prevention and Treatment

Incidence and risk factors of postoperative delirium in elderly surgical patients 2023

Postoperative delirium has the potential to impact individuals of all age groups, with a significant emphasis on the elderly population. Its presence leads to an increase in surgical morbidity and mortality rates, as well as a notable prolongation of hospital stays. However, there is a lack of research regarding the prevalence, risk factors, and implications of postoperative delirium in developing nations like Ethiopia, which affects both patients and healthcare institutions. An observational study was conducted at hospitals in the South Gondar Zone to diagnose postoperative delirium in the Post-Anesthesia Care Unit (PACU) using the Nursing Delirium Screening Scale. Both bivariable and multivariable logistic regression techniques were employed to analyze the association between independent factors and postoperative delirium. The strength of the association was indicated by the odds ratio with a 95% confidence interval (CI). Any p-values below 0.05 were considered statistically significant. The incidence of postoperative delirium was determined to be 41%. In the multivariate logistic regression analysis, several factors were identified as significantly associated with postoperative delirium. These factors include an age of 75 or older (AOR, 11.24; 95% CI, 4.74-26.65), ASA-PS IV (AOR, 3.25; 95% CI, 1.81-5.85), severe functional impairment of activities of daily living (AOR, 3.29; 95% CI, 1.06-10.20), premedication with benzodiazepine (AOR, 4.61; 95% CI, 2.48-8.57), intraoperative estimated blood loss exceeding 1000 ml (AOR, 2.74; 95% CI, 1.50-4.98), and intraoperative ketamine use (AOR, 3.84; 95% CI, 2.21-6.68). Additionally, postoperative delirium was found to significantly prolong the duration of stay in the post-anesthesia care unit (PACU) and the length of hospital stay (p-value < 0.05). Patients aged 75 or older, ASA-PS IV, experiencing severe functional impairment of ADL, patients premedicated with benzodiazepine, patients with intraoperative estimated blood loss exceeding 1000 ml, and intraoperative ketamine use were identified as risk factors for post-operative delirium.

Diagnostic test accuracy of assessment tools for detecting delirium in patients with acute stroke: commentary of a systematic review

Delirium is a common presentation after acute stroke. Post-stroke delirium is related to poor recovery, higher rates of mortality, falls, and longer hospital stays. Delirium can lead to challenging behaviour such as anger, aggression, and confusion. As such, it is important to identify delirium promptly for early management and to reduce the negative impact on post-stroke recovery and outcomes. An important aspect of identifying delirium depends on the use of efficient, easy to use and validated assessment tools. A wide range of tools are available, although it is not known how accurately they can identify post-stroke delirium. This article critically appraises a systematic review which identified delirium screening tools for patients with acute stroke, and summarised their accuracy.

Delirium REduction after administration of melatonin in acute ischemic stroke (DREAMS): A propensity score-matched analysis

BACKGROUND AND PURPOSE

Poststroke delirium (PSD) comprises a common and severe complication after stroke. However, treatment options for PSD remain insufficient. We investigated whether prophylactic melatonin supplementation may be associated with reduced risk for PSD.

METHODS

Consecutive patients admitted to the Tübingen University Stroke Unit, Tübingen, Germany, with acute ischemic stroke (AIS), who underwent standard care between August 2017 and December 2017, and patients who additionally received prophylactic melatonin (2 mg per day at night) within 24 h of symptom onset between August 2018 and December 2018 were included. Primary outcomes were (i) PSD prevalence in AIS patients and (ii) PSD risk and PSD-free survival in patients with cerebral infarction who underwent melatonin supplementation compared to propensity score-matched (PSM) controls. Secondary outcomes included time of PSD onset and PSD duration.

RESULTS

Out of 465 (81.2%) patients with cerebral infarction and 108 (18.8%) transient ischemic attack (TIA) patients, 152 (26.5%) developed PSD (median time to onset [IQR]: 16 [8-32] h; duration 24 [8-40] h). Higher age, cerebral infarction rather than TIA, and higher National Institutes of Health Stroke Scale score and aphasia on admission were significant predictors of PSD. After PSM (164 melatonin-treated patients with cerebral infarction versus 164 matched controls), 42 (25.6%) melatonin-treated patients developed PSD versus 60 (36.6%) controls (odds ratio, 0.597; 95% confidence interval, 0.372-0.958; p = 0.032). PSD-free survival differed significantly between groups (p = 0.027), favoring melatonin-treated patients. In patients with PSD, no between-group differences in the time of PSD onset and PSD duration were noted.

CONCLUSIONS

Patients prophylactically treated with melatonin within 24 h of AIS onset had lower risk for PSD than patients undergoing standard care. Prospective randomized trials are warranted to corroborate these findings.

Statistical analysis plan for the Prophylactic Melatonin for Delirium in Intensive Care (ProMEDIC): a randomised controlled trial

Rationale

Delirium is defined as acute organic brain dysfunction characterised by inattention and disturbance of cognition. It is common in the intensive care unit and is associated with poorer outcomes. Good quality sleep is important in the prevention and management of delirium. Melatonin is a natural hormone secreted by the pineal gland which helps in the regulation of the sleep-wake cycle. It is possible that melatonin supplementation in intensive care improves sleep and prevents delirium.

Methods and design

The ‘Prophylactic Melatonin for Delirium in Intensive Care’ study is a multi-centre, randomised, double-blinded, placebo-controlled trial. The primary objective of this study is to determine whether melatonin given prophylactically decreases delirium in critically ill patients. A total of 850 ICU patients have been randomised (1:1) to receive either melatonin or a placebo. Participants were monitored twice daily for symptoms of delirium.

Results

This paper and the attached additional files describe the statistical analysis plan (SAP) for the trial. The SAP has been developed and submitted for publication before the database has been locked and before the treatment allocation has been unblinded. The SAP contains details of analyses to be undertaken, which will be reported in the primary and secondary publications.

Discussion

The SAP details the analyses that will be done to avoid bias coming from knowledge of the results in advance. This trial will determine whether prophylactic melatonin administered to intensive care unit patients helps decrease the rate and the severity of delirium.

Trial registration

Australian and New Zealand Clinical Trial Registry (ANZCTR) ACTRN1261600043647, registration date: 06 April 2016. WHO Trial Number – U1111-1175-1814

Efficacy of Low-Dose Prophylactic Quetiapine on Delirium Prevention in Critically Ill Patients: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

Purpose: To evaluate the efficacy of short-term low-dose quetiapine for delirium prevention in critically ill patients. Methods: In this prospective, a single-center, randomized, double-blind, placebo-controlled trial, adult patients who were admitted from July 2015 to July 2017 to a medical intensive care unit (ICU) of a tertiary teaching hospital affiliated to Seoul National University were included. Quetiapine (12.5 mg or 25 mg oral at night; N = 16) or placebo (N = 21) was administered according to randomization until ICU discharge or the 10th ICU day. The primary endpoint was the incidence of delirium within the first 10 ICU days. Secondary endpoints included the rate of positive Confusion Assessment Method for the ICU (CAM-ICU) (the number of positive CAM-ICU counts/the number of total CAM-ICU counts), delirium duration, successful extubation, and overall mortality. Result: The incidence of delirium during the 10 days after ICU admission was 46.7% (7/15) in the quetiapine group and 55.0% (11/20) in the placebo group (p = 0.442). In the quetiapine group, the rate of positive CAM-ICU was significantly lower than in the placebo group (14.4% vs. 37.4%, p = 0.048), delirium duration during the study period was significantly shorter (0.28 day vs. 1.83 days, p = 0.018), and more patients in the quetiapine than in the placebo group were weaned from mechanical ventilation successfully (84.6% vs. 47.1%, p = 0.040). Conclusions: Our study suggests that prophylactic use of low-dose quetiapine could be helpful for preventing delirium in critically ill patients. A further large-scale prospective study is needed.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

Preoperative Risk Factors for Subsyndromal Delirium in Older Adults Who Undergo Joint Replacement Surgery

BACKGROUND

Older adults with subsyndromal delirium have similar risks for adverse outcomes following joint replacement surgery as those who suffer from delirium.

PURPOSE

This study examined relationships among subsyndromal delirium and select preoperative risk factors in older adults following major orthopaedic surgery.

METHODS

Delirium assessments of a sample of 62 adults 65 years of age or older were completed on postoperative Days 1, 2, and 3 following joint replacement surgery. Data were analyzed for relationships among delirium symptoms and the following preoperative risk factors: increased comorbidity burden, cognitive impairment, fall history, and preoperative fasting time.

RESULTS

Postoperative subsyndromal delirium occurred in 68% of study participants. A recent fall history and a longer preoperative fasting time were associated with delirium symptoms (p ≤ .05).

CONCLUSIONS

Older adults with a recent history of falls within the past 6 months or a longer duration of preoperative fasting time may be at higher risk for delirium symptoms following joint replacement surgery.

Prophylactic Melatonin for Delirium in Intensive Care (Pro-MEDIC): study protocol for a randomised controlled trial

BACKGROUND

Delirium is an acute state of brain dysfunction characterised by fluctuating inattention and cognitive disturbances, usually due to illness. It occurs commonly in the intensive care unit (ICU), and it is associated with greater morbidity and mortality. It is likely that disturbances of sleep and of the day-night cycle play a significant role. Melatonin is a naturally occurring, safe and cheap hormone that can be administered to improve sleep. The main aim of this trial will be to determine whether prophylactic melatonin administered to critically ill adults, when compared with placebo, decreases the rate of delirium.

METHODS

This trial will be a multi-centre, randomised, placebo-controlled study conducted in closed ICUs in Australia. Our aim is to enrol 850 adult patients with an expected ICU length of stay (LOS) of 72 h or more. Eligible patients for whom there is consent will be randomised to receive melatonin 4 mg enterally or placebo in a 1:1 ratio according to a computer-generated randomisation list, stratified by site. The study drug will be indistinguishable from placebo. Patients, doctors, nurses, investigators and statisticians will be blinded. Melatonin or placebo will be administered once per day at 21:00 until ICU discharge or 14 days after enrolment, whichever occurs first. Trained staff will assess patients twice daily to determine the presence or absence of delirium using the Confusion Assessment Method for the ICU score. Data will also be collected on demographics, the overall prevalence of delirium, duration and severity of delirium, sleep quality, participation in physiotherapy sessions, ICU and hospital LOS, morbidity and mortality, and healthcare costs. A subgroup of 100 patients will undergo polysomnographic testing to further evaluate the quality of sleep.

DISCUSSION

Delirium is a significant issue in ICU because of its frequency and associated poorer outcomes. This trial will be the largest evaluation of melatonin as a prophylactic agent to prevent delirium in the critically ill population. This study will also provide one of the largest series of polysomnographic testing done in ICU.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry (ANZCTR) number: ACTRN12616000436471 . Registered on 20 December 2015.

Validation of the Danish version of the Critical Care Pain Observation Tool

BACKGROUND

Assessing pain in critically ill patients is a challenge even in an intensive care unit (ICU) with a no sedation protocol. The aim of this study was to validate the Danish version of the pain assessment method; Critical Care Pain Observation Tool (CPOT) in an ICU with a no sedation protocol.

METHODS

Seventy patients were included in this study. The patients were observed during a non-nociceptive procedure (wash of an arm) and a nociceptive procedure (turning). Patients were observed before, during, and 15 min after the two interventions (six assessments). Two observers participated in the data collection and CPOT scores were blinded to each other. Calculations of interrater reliability, criterion validity and discriminant validity were performed to validate the Danish version of CPOT.

RESULTS

The results indicated a good correlation between the two raters (all scores > 0.9 and P < 0.05). About 48 (68.6%) of the included patients were able to self-report pain. We found a significantly higher mean CPOT score at the nociceptive procedure than at rest or the non-nociceptive procedure (P < 0.05). No correlation was found between CPOT scores and physiological indicators. Patients self-reported pain and CPOT showed a significant correlation (P < 0.05). A CPOT score of ≥ 3 correlated with patients' self-reported pain (ROC AUC 0.83).

CONCLUSION

The Danish version of CPOT can be used to assess pain in critically ill patients, also when the ICU has a no sedation protocol. CPOT scores showed a good interrater reliability and correlates well with patient's self-reported pain.

A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units

OBJECTIVE

The objective of this review is to examine the effectiveness, implementation, and costs of multifaceted care approaches, including care bundles, for the prevention and mitigation of delirium in patients hospitalized in intensive care units (ICUs).

DATA SOURCES

A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted utilizing PubMed, EMBASE, and CINAHL. Searches were limited to studies published in English from January 1, 1988, to March 31, 2014. Randomized controlled trials and comparative studies of multifaceted care approaches with the reduction of delirium in ICU patients as an outcome and evaluations of the implementation or cost-effectiveness of these interventions were included.

DATA EXTRACTION

Data on study methods including design, cohort size, interventions, and outcomes were abstracted, reviewed, and summarized. Given the variability in study design, populations, and interventions, a qualitative review of findings was conducted.

DATA SYNTHESIS

In all, 14 studies met our inclusion criteria: 6 examined outcomes, 5 examined implementation, 2 examined outcomes and implementation, and 1 examined cost-effectiveness. The majority of studies indicated that multifaceted care approaches were associated with improved patient outcomes including reduced incidence and duration of delirium. Additionally, improvements in functional status and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates were observed. Implementation strategies included structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams. The cost-effectiveness analysis indicated an average reduction of $1000 in hospital costs for patients treated with a multifaceted care approach.

CONCLUSION

Although multifaceted care approaches may reduce delirium and improve patient outcomes, greater improvements may be achieved by deploying a comprehensive bundle of care practices including awakening and breathing trials, delirium monitoring and treatment, and early mobility. Further research to address this knowledge gap is essential to providing best care for ICU patients.

An analysis of patient safety incident reports describing injuries to staff working in critical care in the North West of England between 2009 and 2013

BACKGROUND

Critical care environments are potentially high-risk areas for staff harm due to procedural demand and increased incidence of delirium/dependence. The principal types of harm and temporal trends have not yet been quantified.

METHODS

Retrospective analysis of a multicentre dataset prospectively collected over a five-year period. All patient safety incidents reported to a regional network project were analysed; those recorded as staff harm were extracted, quantified and assessed by thematic analysis to identify key areas of harm, temporal trends and incident rates.

RESULTS

Staff harm accounted for 7% of all reported patient safety incidents over the study period. Incident rates remained static, ranging annually from 2.6 to 3.7 episodes/1000 patient days. Assaults on staff accounted for the highest proportional contribution on thematic analysis, which was a consistent annual finding. Sharps injuries and manual handling incidents were also notable contributions. Temporal trends for each theme remained static over the study period implying limited reduction in staff harm despite implementation of national guidance and local initiatives.

CONCLUSION

Staff harm is a consistent issue for those working in critical care. Assaults on staff appear to be the highest contributor on thematic analysis. These data imply significant reduction in harm can still be achieved and can be used to design and implement interventional measures.

Intensive care unit delirium

Intensive care unit (ICU) delirium is widespread and occurs in 20% to 80% of patients. It can be assessed with ICU-validated scoring tools. The most commonly used tools include the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist. Since ICU delirium is associated with increased morbidity and mortality, it is imperative that risk factors are identified and prevented. Risk factors include predisposing factors such as history of alcohol abuse, dementia, or hypertension and precipitating factors such as immobilization, oversedation, higher severity of illness, and use of certain psychoactive medications such as benzodiazepines. Pharmacologic treatment with atypical antipsychotics may be used to reduce the duration of delirium if prevention is not successful. However, because of the adverse effects associated with these treatments, close monitoring for side effects is warranted.

The Distinct Role of Palliative Care in the Surgical Intensive Care Unit

Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. Palliative care enhances the SICU team’s ability to recognize pain and distress; establish the patient’s wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation. Educational opportunities to improve end-of-life management skills are outlined. It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU. Palliative care can provide a significant, “value added” contribution to the care of seriously ill SICU patients.

Impact of a delirium screening tool and multifaceted education on nurses' knowledge of delirium and ability to evaluate it correctly

BACKGROUND

The impact of using a validated delirium screening tool and different levels of education on surgical-trauma intensive care unit (STICU) nurses' knowledge about delirium is unclear.

OBJECTIVES

To measure the impact of using the Intensive Care Delirium Screening Checklist (ICDSC), with or without a multi-faceted education program, on STICU nurses' knowledge and perceptions of delirium and their ability to evaluate it correctly.

METHODS

The knowledge and perceptions of subject nurses about delirium, and agreement between the independent assessments of delirium by the subject nurse and by a validated judge (who always used the ICDSC), were compared across 3 phases. Phase 1: No delirium screening tool and no education. Phase 2: ICDSC and minimal education (ie, ICDSC validation study only). Phase 3: ICDSC and multifaceted education (ie, pharmacist-led didactic lecture, Web-based module, and nurse-led bedside training).

RESULTS

Nurses' knowledge (mean [SD] score out of 10 points) was similar (P = .08) in phase 1 (6.1 [1.4]) and phase 2 (6.5 [1.4]) but was greater (P = .001) in phase 3 (8.2 [1.4]). Agreement between nurses and the validated judge in the assessment of delirium increased from phase 1 (κ = 0.40) to phase 2 (κ = 0.62) to phase 3 (κ = 0.74). Nurses perceived use of the ICDSC as improving their ability to recognize delirium.

CONCLUSIONS

Use of a multifaceted education program improves both nurses' knowledge about delirium and their perceptions about its recognition. Implementation of the ICDSC improves the ability of STICU nurses to evaluate delirium correctly.

Delirium in older adults

Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis, and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and nonpharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and nonpharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research.

Current Perceptions and Practices Surrounding the Recognition and Treatment of Delirium in the Intensive Care Unit: A Survey of 250 Critical Care Pharmacists from Eight States

Background:

Pharmacists are key members of the intensive care unit (ICU) team; however, few data exist regarding their clinical role, perceptions, and current practices in recognizing and managing delirium.

Objective:

To describe current practices and perceptions of ICU pharmacists regarding delirium recognition and treatment relative to current recommendations.

Methods:

A self-administered survey was distributed to 457 pharmacists in 8 states who are members of the Society of Critical Care Medicine or the American College of Clinical Pharmacy and who spend 25% or more of their time providing clinical ICU pharmacy services.

Results:

A total of 250 (55%) pharmacists responded. A delirium screening tool was routinely used by few (7%) pharmacists. Lack of time (34%) and the belief that screening is a nursing role (24%) were key barriers to pharmacist screenings. Most (85%) said that delirium should be pharmacologically managed; 66% responded that 2 or more medications should be used. The treatments of first choice included Haloperidol (76%), an atypical antipsychotic (14%), or a benzodiazepine (10%). Frequently used treatments were Haloperidol (87%), quetiapine (59%), and lorazepam (47%). Haloperidol was perceived by many (42%) to have 1 or more randomized trials supporting its use for delirium and Food and Drug Administration approval for this indication (34%). Haloperidol was most often administered on a scheduled basis (62%), intravenously (92%), and al a daily dose of 5–10 mg (58%). While the QTc interval was frequently measured at least once per shift using an electrocardiogram strip (64%), it was not routinely measured in 20% of ICUs, and 60% continued haloperidol when the QTc exceeded 500 msec.

Conclusions:

Current practices and perceptions surrounding recognition and treatment of delirium in patients in the ICU by the critical care pharmacists surveyed are heterogeneous. Antipsychotics are frequently recommended by pharmacists for delirium treatment, despite a lack of rigorous evidence to support their use. While pharmacists are ideally suited to lead delirium recognition efforts and provide treatment recommendations in this area, these roles need further elucidation. The optimal pedagogical strategy to support these efforts remains unclear, and the potential impact of pharmacists’ efforts on patients’ outcomes is unknown.

Impact of quetiapine on resolution of individual delirium symptoms in critically ill patients with delirium: a post-hoc analysis of a double-blind, randomized, placebo-controlled study

INTRODUCTION

We hypothesized that delirium symptoms may respond differently to antipsychotic therapy. The purpose of this paper was to retrospectively compare duration and time to first resolution of individual delirium symptoms from the database of a randomized, double-blind, placebo-controlled study comparing quetiapine (Q) or placebo (P), both with haloperidol rescue, for critically ill patients with delirium.

METHODS

Data for 10 delirium symptoms from the eight-domain, intensive care delirium screening checklist (ICDSC) previously collected every 12 hours were extracted for 29 study patients. Data between the Q and P groups were compared using a cut-off P-value of ≤ 0.10 for this exploratory study.

RESULTS

Baseline ICDSC scores (5 (4 to 7) (Q) vs 5 (4 to 6)) (median, interquartile range (IQR)) and % of patients with each ICDSC symptom were similar in the two groups (all P > 0.10). Among patients with the delirium symptom at baseline, use of Q may lead to a shorter time (days) to first resolution of symptom fluctuation (4 (Q) vs. 14, P = 0.004), inattention (3 vs. 8, P = .10) and disorientation (2 vs. 10, P = 0.10) but a longer time to first resolution of agitation (3 vs. 1, P = 0.04) and hyperactivity (5 vs. 1, P = 0.07). Among all patients, Q-treated patients tended to spend a smaller percent of time with inattention (47 (0 to 67) vs. 78 (43 to 100), P = 0.025), hallucinations (0 (0 to 17) vs. 28 (0 to 43), P = 0.10) and symptom fluctuation (47 (19 to 67) vs. 89 (33 to 00), P = 0.04] and there was a trend for Q-treated patients to spend a greater percent of time at an appropriate level of consciousness (26% (13 to 63%) vs. 14% (0 to 33%), P = 0.17].

CONCLUSIONS

Our exploratory analysis suggests that quetiapine may resolve several intensive care unit (ICU) delirium symptoms faster than the placebo. Individual symptom resolution appears to differ in association with the pharmacologic intervention (that is, P vs Q, both with as needed haloperidol). Future studies evaluating antipsychotics in ICU patients with delirium should measure duration and resolution of individual delirium symptoms and their relation to long-term outcomes.

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role?

Delirium affects up to 80% of critically ill patients, worsens outcomes, and is frequently treated with antipsychotics despite uncertainty regarding their efficacy and safety. We identified published, English-language, randomized, controlled studies evaluating antipsychotics in ICU patients either with delirium or at risk for developing delirium. In 105 mechanically ventilated patients, the number of days spent alive without delirium or coma was similar between haloperidol (median, 14.0 days; interquartile range [IQR], 6.0-18.0 days) or ziprasidone (median, 15.0 days; IQR, 9.1-18.0 days) prophylaxis, and placebo (median, 12.5 days; IQR, 1.2-17.2 days) groups (p=0.66). Treating delirium with quetiapine, compared to placebo, in 36 ICU patients was associated with a quicker resolution of delirium (median for quetiapine, 1.0 days; IQR, 0.5-3.0 days/median for placebo, 4.5 days; IQR, 2.0-7.0 days [p=0.001]). In a third study, a similar decrease over time in delirium severity was noted between fixed-dose oral olanzapine and oral haloperidol in patients with delirium. None of the studies identified serious safety concerns with administering the antipsychotics that were studied. Published prospective, randomized clinical trials evaluating antipsychotic therapy for preventing or treating delirium in the ICU are few in number. The conclusions that can be drawn from them are limited by their heterogeneity, inconsistency in incorporating non-antipsychotic strategies known to reduce delirium or in maintaining patients in an arousable state, their size, the lack of ICU and non-ICU clinical outcomes evaluated, and the lack of placebo arms. A research framework for future evaluation of the use of antipsychotic therapy in the critically ill is proposed.

The impact of frailty in the elderly on the outcome of surgery in the aged

As the population continues to age, we will continue to encounter issues involving aging and the elderly. Despite these issues, knowledge is expanding and evolving with new solutions to ongoing problems. Mechanistically, frailty at its root is a symptom of growing old, with cascades and circuitous feedback between organ systems at all levels. Clinically, frailty is as equally dynamic and its multifactorial nature represents a unique challenge to the surgical community and warrants the integration of geriatric assessment into clinical practice. Integration within clinical practice includes using an interdisciplinary approach, where surgeons work with anesthesiologists, geriatricians, nursing, rehabilitation, nutritionists, and other support staff to provide holistic assessment, efficient delivery, and higher quality of care. This in hand, recognition of frailty can occur in a timely fashion to initiate treatment, decreasing the risk of morbidity and mortality for improved surgical outcomes.

Clinical associations of delirium in hospitalized adult patients and the role of on admission presentation

OBJECTIVE

To describe clinical associations of delirium in hospitalized patients and relationships to on admission presentation.

DESIGN

Retrospective analysis of an administrative hospitalization database 1998-2007.

SETTING

Acute care hospitalizations in the New York State (NYS).

MEASUREMENTS

Four categories of diagnosis related group (DRG) hospitalizations were extracted from a NYS administrative database: pneumonia, congestive heart failure, urinary tract/kidney infection (UTI), and lower extremity orthopedic surgery (LEOS) DRGs. These hospitalizations were examined for clinical associations with delirium coding both on and after admission.

RESULTS

Delirium was coded in 0.8% of the cohort, of which an on admission diagnosis was present in 59%. On admission delirium was strongly associated with dementia (adjusted odds ratio 0, 95%CI 5.8-6.3) and with adverse drug effects (ADEs) (adjusted odds ratio 4.6, 95%CI 4.3, 5.0). After admission delirium was even more highly associated with ADEs (adjusted odds ratio 22.2, 95%CI 20.7-23.7). The UTI DRG category had the greatest proportion of on admission delirium. However after admission delirium was more common in the LEOS DRG category. Over time, there was a greater increase in delirium proportions in the UTI DRG category, and an overall increase in coding for encephalopathy states (potential alternative delirium descriptors).

CONCLUSION

ADEs play an important role in delirium regardless of whether or not it is present on admission. While the finding that most delirium hospitalizations presented on admission suggests that delirium impacts more as a clinical admitting determinant, in-hospital prevention strategies may still have benefit in targeted settings where after admission delirium is more frequent, such as patients with LEOS.

Risk factors of delirium after cardiac surgery: a systematic review

BACKGROUND

Delirium or acute confusion is a temporary mental disorder that occurs frequently among hospitalized elderly patients, but also in younger patients a delirium can develop. Patients who undergo cardiac surgery have an increased risk of developing delirium that is associated with many negative consequences. Therefore, prevention of delirium is essential. Despite the high incidence of delirium, a paucity of data on risk factors for delirium exists.

AIM

The aim of this study was to summarize the available information concerning these risk factors.

METHODS

A literature research was performed using the PubMed, Cinahl, and Cochrane Library databases and was limited to the last 10 years.

RESULTS

Our review revealed 27 risk factors; 12 predisposing and 15 precipitating factors for delirium after cardiac surgery. The most established predisposing risk factors were atrial fibrillation, cognitive impairment, depression, history of stroke, older age, and peripheral vascular disease. The most established precipitating risk factor was a red blood cell transfusion. An abnormal albumin level was reported as the most established precipitating risk factor among blood values tested. A low cardiac output and the use of an Intra Aortic Balloon Pump or inotropic medication seem to be the most relevant risk factors associated with a postoperative delirium.

CONCLUSION

A multifactorial risk model should be applied to identify patients at an increased risk of developing delirium following elective cardiac surgery. In these patients, if possible, preventative interventions can be taken and early recognition of delirium can be realized. This could potentially decrease the incidence of delirium and negative consequences caused by a postoperative delirium.

Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit

As critically ill patients frequently receive analgesics, sedatives, and antipsychotics to optimize patient comfort and facilitate mechanical ventilation, adverse events associated with the use of these agents can affect all organ systems and result in substantial morbidity and mortality. Although many of these adverse effects are common pharmacologic manifestations of the agent, and therefore frequently reversible, others are idiosyncratic and thus unexpected. The critically ill are more susceptible to adverse drug events than nonintensive care unit patients due to the high doses and long periods for which each of these agents are often administered, the frequent use of intravenous formulations that contain adjuvants that may lead to toxicity in some instances, and the high prevalence of end-organ dysfunction that affects the pharmacokinetic and pharmacodynamic response to therapy. This paper will review the most common and serious adverse drug events reported to occur with the use of sedatives, analgesics, and antipsychotics in the intensive care unit; highlight the pharmacokinetic, pharmacodynamic, and pharmacogenetic factors that can influence analgesic, sedative, and antipsychotic response and safety in the critically ill; and identify strategies that can be used to minimize toxicity with these agents.