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Ditzel FL, Hut SCA, van den Boogaard M, Boonstra M, Leijten FSS, Wils EJ, van Nesselrooij T, Kromkamp M, Rood PJT, Röder C, Bouvy PF, Coesmans M, Osse RJ, Pop-Purceleanu M, van Dellen E, Krulder JWM, Milisen K, Faaij R, Vondeling AM, Kamper AM, van Munster BC, de Jonghe A, Winters MAM, van der Ploeg J, van der Zwaag S, Koek DHL, Drenth-van Maanen CAC, Beishuizen A, van den Bos DM, Cahn W, Schuit E, Slooter AJC. DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study. Am J Geriatr Psychiatry 2024; 32:1093-1104. [PMID: 38171949 DOI: 10.1016/j.jagp.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs). DESIGN Prospective cross-sectional study. SETTING Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals. PARTICIPANTS 494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious. MEASUREMENTS DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets. METHODS Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus. RESULTS DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity. CONCLUSIONS DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.
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Affiliation(s)
- Fienke L Ditzel
- Department of Intensive Care Medicine and UMC Utrecht Brain Center (FLD, SCAH, MB, DMB, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Suzanne C A Hut
- Department of Intensive Care Medicine and UMC Utrecht Brain Center (FLD, SCAH, MB, DMB, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine (MB, PJTR), Radboud university medical center, Nijmegen, the Netherlands
| | - Michel Boonstra
- Department of Intensive Care Medicine and UMC Utrecht Brain Center (FLD, SCAH, MB, DMB, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans S S Leijten
- Department of Clinical Neurophysiology and UMC Utrecht Brain Center (FSSL), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care (E-JW), Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Tim van Nesselrooij
- Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marjan Kromkamp
- Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Paul J T Rood
- Department of Intensive Care Medicine (MB, PJTR), Radboud university medical center, Nijmegen, the Netherlands; HAN University of Applied Sciences (PJTR), School of Health Studies, Research Department of Emergency and Critical Care, Nijmegen, the Netherlands
| | - Christian Röder
- Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Paul F Bouvy
- Department of Psychiatry (PFB, MC, RJO), Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michiel Coesmans
- Department of Psychiatry (PFB, MC, RJO), Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert Jan Osse
- Department of Psychiatry (PFB, MC, RJO), Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Monica Pop-Purceleanu
- Department of Psychiatry (MP-P), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edwin van Dellen
- Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology (ED, AJCS), UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Jaap W M Krulder
- Department of Geriatrics (JWMK), Franciscus Gasthuis&Vlietland, Rotterdam, the Netherlands
| | - Koen Milisen
- Department of Public Health and Primary Care (KM), Academic Center for Nursing and Midwifery, Katholieke Univerisiteit Leuven - University of Leuven, Leuven, Belgium; Department of Geriatric Medicine (KM), University Hospitals Leuven, Leuven, Belgium
| | - Richard Faaij
- Department of Geriatrics (RF, AMV), Diakonessenhuis, Utrecht, the Netherlands
| | - Ariël M Vondeling
- Department of Geriatrics (RF, AMV), Diakonessenhuis, Utrecht, the Netherlands
| | - Ad M Kamper
- Department of Geriatrics (AK, MAMW, JP, SZ), Isala, Zwolle, the Netherlands
| | - Barbara C van Munster
- Department of Internal Medicine/Geriatrics (BCM), University Center of Geriatric Medicine, University Medical Center of Groningen, Groningen, the Netherlands; Alzheimer Center Groningen (BCM), Groningen, the Netherlands
| | | | - Marian A M Winters
- Department of Geriatrics (AK, MAMW, JP, SZ), Isala, Zwolle, the Netherlands
| | | | | | - Dineke H L Koek
- Department of Geriatrics (DHLK, CACDM), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Clara A C Drenth-van Maanen
- Department of Geriatrics (DHLK, CACDM), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine (AB), Medical Spectrum Twente, Enschede, the Netherlands
| | - Deirdre M van den Bos
- Department of Intensive Care Medicine and UMC Utrecht Brain Center (FLD, SCAH, MB, DMB, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wiepke Cahn
- Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care (ES), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center (FLD, SCAH, MB, DMB, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Psychiatry and UMC Utrecht Brain Center (TN, MK, CR, ED, WC, AJCS), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology (ED, AJCS), UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Oldham MA, Heinrich T, Luccarelli J. Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System. J Acad Consult Liaison Psychiatry 2024; 65:302-312. [PMID: 38503671 PMCID: PMC11179982 DOI: 10.1016/j.jaclp.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/21/2024]
Abstract
Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
| | - Thomas Heinrich
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI; Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [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: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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Dayton K, Hudson M, Lindroth H. Stopping Delirium Using the Awake-and-Walking Intensive Care Unit Approach: True Mastery of Critical Thinking and the ABCDEF Bundle. AACN Adv Crit Care 2023; 34:359-366. [PMID: 38033207 PMCID: PMC11019856 DOI: 10.4037/aacnacc2023159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Kali Dayton
- Kali Dayton is ICU Sedation and Mobility Consultant, Dayton ICU Consulting, Washington
| | - Mark Hudson
- Mark Hudson is an ICU survivor and patient advocate for improved ICU care; podcaster of the ICU Life and Recovery podcast; and a student at the School of Psychology and Counselling, The Open University, Milton Keynes, United Kingdom
| | - Heidi Lindroth
- Heidi Lindroth is a clinician-nurse scientist, Department of Nursing, Mayo Clinic, 200 1st St SW, Mayo Clinic, Rochester, MN, 55902 ; and an affiliate scientist, Center for Innovation and Implementation Science and the Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, Indianapolis, Indiana
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Oldham MA, Weber MT. The phenotype of delirium based on a close reading of diagnostic criteria. Int J Geriatr Psychiatry 2023; 38:e6046. [PMID: 38146182 PMCID: PMC10763520 DOI: 10.1002/gps.6046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/14/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE Although delirium is well known to acute care clinicians, the features required for its diagnosis and how to understand and operationalize them remain sticking points in the field. To clarify the delirium phenotype, we present a close reading of past and current sets of delirium diagnostic criteria. METHODS We first differentiate the delirium syndrome (i.e., features evaluated at bedside) from additional criteria required for diagnosis. Next, we align related features across diagnostic systems and examine them in context to determine intent. Where criteria are ambiguous, we review common delirium instruments to illustrate how they have been interpreted. RESULTS An acute disturbance in attention is universally attested across diagnostic systems. A second core feature denotes confusion and has been included across systems as disturbance in awareness, impaired consciousness, and thought disorganization. This feature may be better understood as a disturbance in thought clarity and operationalized in terms of neuropsychological domains thereby clearly linking it to global neurocognitive disturbance. Altered level of activity describes a third core feature, including motor and sleep/wake cycle disturbances. Excluding stupor (wherein mental content cannot be assessed due to reduced arousal) from delirium, as in DSM-5-TR, is appropriate for a psychiatric diagnosis, but the brain injury exclusion in ICD-11 is unjustified. CONCLUSIONS The delirium phenotype involves a disturbance in attention, qualitative thought clarity, and quantitative activity level, including in relation to expected sleep/wake cycles. Future diagnostic systems should include a severity threshold and specify that delirium diagnosis refers to a 24-h period.
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Affiliation(s)
- Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center
| | - Miriam T. Weber
- Department of Neurology, Department of Obstetrics and Gynecology, University of Rochester Medical Center
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Oldham MA, Crone CC, Rosenthal LJ. Response to Commentary Titled "Conflation of Delirium and Coma as Acute Encephalopathy". J Acad Consult Liaison Psychiatry 2023; 64:412-413. [PMID: 37474247 PMCID: PMC10372725 DOI: 10.1016/j.jaclp.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
| | - Catherine C Crone
- Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine, Washington, DC
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
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8
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Oldham MA, Slooter AJC, Ely EW, Crone C, Maldonado JR, Rosenthal LJ. An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes. J Acad Consult Liaison Psychiatry 2023; 64:248-261. [PMID: 35840003 PMCID: PMC9839895 DOI: 10.1016/j.jaclp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 07/04/2022] [Indexed: 01/17/2023]
Abstract
An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education Clinical Center (GRECC), TN Valley Veterans Affairs Medical Center, Nashville, TN
| | - Cathy Crone
- Inova Health System, Behavioral Health, Falls Church, VA; George Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Washington, DC
| | - José R Maldonado
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, CA
| | - Lisa J Rosenthal
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
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Bowman EML, Cardwell C, McAuley DF, McGuinness B, Passmore AP, Beverland D, Zetterberg H, Schott JM, Cunningham EL. Factors influencing resilience to postoperative delirium in adults undergoing elective orthopaedic surgery. Br J Surg 2022; 109:908-911. [PMID: 35707934 PMCID: PMC10364747 DOI: 10.1093/bjs/znac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/15/2022] [Accepted: 05/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Christopher Cardwell
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | - Bernadette McGuinness
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Anthony P Passmore
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - David Beverland
- Outcomes Assessment Unit, Musgrave Park Hospital, Belfast Trust, Belfast, UK
| | - Henrik Zetterberg
- UK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Emma L Cunningham
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Connecting Acute and Chronic Neurocognitive Impairment: Commentary on Post-Operative Delirium and Its Relationship with Biomarkers of Dementia: A Meta-analysis. Int Psychogeriatr 2022; 34:323-325. [PMID: 35538872 DOI: 10.1017/s104161022200028x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Follow the money: The widening coding disparity between acute encephalopathy and delirium. J Acad Consult Liaison Psychiatry 2022; 63:423-425. [DOI: 10.1016/j.jaclp.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 10/19/2022]
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