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

Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients

BACKGROUND

Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients.

METHODS

Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established.

RESULTS

POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively.

CONCLUSION

The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.

Individuals Who Developed Delirium While Enrolled in the Hospital Elder Life Program: An Exploratory Study

Delirium prevention in hospitalized older adults is important due to delirium's high prevalence and negative impact on outcomes. Today, there are evidence-based programs with well-documented effectiveness aimed at preventing delirium, such as the Hospital Elder Life Program (HELP); however, approximately 4% to 5% of patients develop delirium regardless of implemented prevention interventions. It remains unknown why some patients develop delirium. The current retrospective exploratory chart review analyzed 98 records for clinical risk factors and outcomes of patients who developed delirium while enrolled in the HELP. On admission, immobility (86.7%) was the most common risk factor. Patients developed delirium approximately 70 hours after admission. Average length of stay was 8 days. Approximately one half (44.9%) of patients died within 1 year. Immobility (97.7% vs. 77.8%, p = 0.005) and renal disease (52.3% vs. 24.1%, p = 0.008) were more often found in patients who died. This study identifies risk factors that seem to require heightened attention during hospitalization to prevent the negative outcomes associated with delirium in older adults. [Journal of Gerontological Nursing, 49(5), 19-29.].

Longitudinal validation of an electronic health record delirium prediction model applied at admission in COVID-19 patients

OBJECTIVE

To validate a previously published machine learning model of delirium risk in hospitalized patients with coronavirus disease 2019 (COVID-19).

METHOD

Using data from six hospitals across two academic medical networks covering care occurring after initial model development, we calculated the predicted risk of delirium using a previously developed risk model applied to diagnostic, medication, laboratory, and other clinical features available in the electronic health record (EHR) at time of hospital admission. We evaluated the accuracy of these predictions against subsequent delirium diagnoses during that admission.

RESULTS

Of the 5102 patients in this cohort, 716 (14%) developed delirium. The model's risk predictions produced a c-index of 0.75 (95% CI, 0.73-0.77) with 27.7% of cases occurring in the top decile of predicted risk scores. Model calibration was diminished compared to the initial COVID-19 wave.

CONCLUSION

This EHR delirium risk prediction model, developed during the initial surge of COVID-19 patients, produced consistent discrimination over subsequent larger waves; however, with changing cohort composition and delirium occurrence rates, model calibration decreased. These results underscore the importance of calibration, and the challenge of developing risk models for clinical contexts where standard of care and clinical populations may shift.

Real-world evidence of age-independent electroconvulsive therapy efficacy: A retrospective cohort study

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders and approved for use in adolescents and adults, but it is unclear whether efficacy or cognitive side effect burden differs with age or if effectiveness in usual clinical practice matches that in prospective studies. We examined the effects of ECT on depression and cognition in a large clinical cohort.

METHODS

A retrospective cohort study of patients ages 16 and older receiving ECT between 2011 and 2020 and who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and after treatment #10.

RESULTS

Among 1698 patients, ECT was associated with a decrease in depression symptoms (QIDS reduction from 17.1 ± 4.9 to 10.1 ± 5.2) and improvement in self-reported mental health (BASIS-24 scores improved from 1.92 ± 0.55 to 1.17 ± 0.60). There was a reduction in MoCA scores from 25.8 ± 3.1 to 25.4 ± 3.1. In multivariate models, age was not associated with a differential QIDS or BASIS-24 response, but older age was associated with a lesser reduction in MoCA.

CONCLUSION

Among 1698 patients aged 16 and older, ECT was associated with improvement in depression and overall self-reported mental health, with a slight decrease in cognition. Age was not associated with changes in efficacy, but older age was associated with a lesser cognitive change as measured by the MoCA. These results provide normative data of real-world effectiveness of ECT, and add further support to its utility in patients with severe psychiatric illness.