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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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Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Vojdani A, Maes M. Increased IgA-mediated responses to the gut paracellular pathway and blood-brain barrier proteins predict delirium due to hip fracture in older adults. Front Neurol 2024; 15:1294689. [PMID: 38379706 PMCID: PMC10876854 DOI: 10.3389/fneur.2024.1294689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Delirium is accompanied by immune response system activation, which may, in theory, cause a breakdown of the gut barrier and blood-brain barrier (BBB). Some results suggest that the BBB is compromised in delirium, but there is no data regarding the gut barrier. This study investigates whether delirium is associated with impaired BBB and gut barriers in elderly adults undergoing hip fracture surgery. Methods We recruited 59 older adults and measured peak Delirium Rating Scale (DRS) scores 2-3 days after surgery, and assessed plasma IgG/IgA levels (using ELISA techniques) for zonulin, occludin, claudin-6, β-catenin, actin (indicating damage to the gut paracellular pathway), claudin-5 and S100B (reflecting BBB damage), bacterial cytolethal distending toxin (CDT), LPS-binding protein (LBP), lipopolysaccharides (LPS), Porphyromonas gingivalis, and Helicobacter pylori. Results Results from univariate analyses showed that delirium is linked to increased IgA responses to all the self-epitopes and antigens listed above, except for LPS. Part of the variance (between 45-48.3%) in the peak DRS score measured 2-3 days post-surgery was explained by independent effects of IgA directed to LPS and LBP (or bacterial CDT), baseline DRS scores, and previous mild stroke. Increased IgA reactivity to the paracellular pathway and BBB proteins and bacterial antigens is significantly associated with the activation of M1 macrophage, T helper-1, and 17 cytokine profiles. Conclusion Heightened bacterial translocation, disruption of the tight and adherens junctions of the gut and BBB barriers, elevated CDT and LPS load in the bloodstream, and aberrations in cell-cell interactions may be risk factors for delirium.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aristo Vojdani
- Immunosciences Lab Inc., Los Angeles, CA, United States
- Cyrex Labs LLC, Phoenix, AZ, United States
| | - Michael Maes
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
- Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria
- Research Institute, Medical University of Plovdiv, Plovdiv, Bulgaria
- Kyung Hee University, Seoul, Republic of Korea
- Cognitive Impairment and Dementia Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Bowman EML, Brummel NE, Caplan GA, Cunningham C, Evered LA, Fiest KM, Girard TD, Jackson TA, LaHue SC, Lindroth HL, Maclullich AMJ, McAuley DF, Oh ES, Oldham MA, Page VJ, Pandharipande PP, Potter KM, Sinha P, Slooter AJC, Sweeney AM, Tieges Z, Van Dellen E, Wilcox ME, Zetterberg H, Cunningham EL. Advancing specificity in delirium: The delirium subtyping initiative. Alzheimers Dement 2024; 20:183-194. [PMID: 37522255 PMCID: PMC10917010 DOI: 10.1002/alz.13419] [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: 03/30/2023] [Revised: 05/26/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology. METHODS The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts. RESULTS Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations. DISCUSSION The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes. HIGHLIGHTS Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.
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Affiliation(s)
- Emily M. L. Bowman
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Nathan E. Brummel
- The Ohio State University College of MedicineDivision of PulmonaryCritical Care, and Sleep MedicineColumbusOhioUSA
| | - Gideon A. Caplan
- Department of Geriatric MedicinePrince of Wales Hospital, Sydney, Australia University of New South WalesSydneyAustralia
| | - Colm Cunningham
- School of Biochemistry & ImmunologyTrinity Biomedical Sciences InstituteTrinity College, DublinRepublic of Ireland
| | - Lis A. Evered
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Critical CareUniversity of MelbourneMelbourneAustralia
- Department of Anaesthesia & Acute Pain MedicineSt. Vincent's HospitalMelbourneAustralia
| | - Kirsten M. Fiest
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Critical Care MedicineUniversity of Calgary and Alberta Health ServicesCalgaryAlbertaCanada
- O'Brien Institute for Public HealthUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Department of PsychiatryCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Timothy D. Girard
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Thomas A. Jackson
- Institute of Inflammation and AgeingUniversity of BirminghamBirminghamUK
| | - Sara C. LaHue
- Department of NeurologySchool of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Weill Institute for NeurosciencesDepartment of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Buck Institute for Research on AgingNovatoCaliforniaUSA
| | - Heidi L. Lindroth
- Department of NursingMayo ClinicRochesterMinnesotaUSA
- Center for Aging ResearchRegenstrief InstituteSchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Alasdair M. J. Maclullich
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
| | - Daniel F. McAuley
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Esther S. Oh
- Departments of MedicinePsychiatry and Behavioral Sciences and PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Mark A. Oldham
- Department of PsychiatryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | | | - Pratik P. Pandharipande
- Departments of Anesthesiology and SurgeryDivision of Anesthesiology Critical Care Medicine and Critical IllnessBrain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kelly M. Potter
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Pratik Sinha
- Division of Clinical and Translational ResearchWashington University School of MedicineSt. LouisMissouriUSA
| | - Arjen J. C. Slooter
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Aoife M. Sweeney
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
- School of ComputingEngineering and Built EnvironmentGlasgow Caledonian UniversityGlasgowScotland
| | - Edwin Van Dellen
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Mary Elizabeth Wilcox
- Department of Critical Care MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
| | - Henrik Zetterberg
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska Academy at the University of GothenburgMölndalSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Neurodegenerative DiseaseUCL Institute of NeurologyQueen SquareLondonUK
- UK Dementia Research Institute at UCLLondonUK
- Hong Kong Center for Neurodegenerative DiseasesClear Water BayHong KongChina
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthUniversity of Wisconsin–MadisonMadisonWisconsinUSA
| | - Emma L. Cunningham
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
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Wiredu K, O’Connor S, Naseem H, Brauer BL, Kettenbach AN, Frost HR, Shaefi S, Gerber SA. Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium. Proteomics Clin Appl 2023; 17:e2200066. [PMID: 36567636 PMCID: PMC10290728 DOI: 10.1002/prca.202200066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/02/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Delirium presents a significant healthcare burden. It complicates post-operative care in up to 50% of cardiac surgical patients with worse outcomes, longer hospital stays and higher cost of care. Moreover, the nature of delirium following cardiac surgery with cardiopulmonary bypass (CPB) remains unclear, the underlying pathobiology is poorly understood, status quo diagnostic methods are subjective, and diagnostic biomarkers are currently lacking. OBJECTIVE To identify diagnostic biomarkers of delirium and for insights into possible neuronal pathomechanisms. EXPERIMENTAL DESIGN Comparative proteomic analyses were performed on plasma samples from a nested matched cohort of patients who underwent cardiac surgery. Validation by targeted proteomics was performed in an independent set of samples. Biomarkers were assessed for biological functions and diagnostic accuracy. RESULTS Forty-seven percent of subjects demonstrated delirium. Of 3803 proteins identified from patient samples by multiplexed quantitative proteomics, 16 were identified as signatures of exposure to CPB, and 11 biomarkers distinguished delirium cases from non-cases (AuROC = 93%). Notable among these biomarkers are C-reactive protein, serum amyloid A-1 and cathepsin-B. CONCLUSIONS AND CLINICAL RELEVANCE The interplay of systemic and central inflammatory markers sheds new light on delirium pathogenesis. This work suggests that accurate identification of cases may be achievable using panels of biomarkers.
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Affiliation(s)
- Kwame Wiredu
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Anesthesia, Critical Care and Pain Medicine, Mass General Hospital, Boston MA
- Department of Anaesthesia, Harvard Medical School, Boston MA
| | - Sean O’Connor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Heba Naseem
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Brooke L. Brauer
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Arminja N. Kettenbach
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Hildreth R. Frost
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Shahzad Shaefi
- Department of Anaesthesia, Harvard Medical School, Boston MA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Scott A. Gerber
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
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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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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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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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Smith RJ, Lachner C, Singh VP, Trivedi S, Khatua B, Cartin-Ceba R. Cytokine profiles in intensive care unit delirium. Acute Crit Care 2022; 37:415-428. [PMID: 35791660 PMCID: PMC9475146 DOI: 10.4266/acc.2021.01508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background Neuroinflammation causing disruption of the blood-brain barrier and immune cell extravasation into the brain parenchyma may cause delirium; however, knowledge of the exact pathophysiologic mechanism remains incomplete. The purpose of our study was to determine whether cytokine profiles differ depending on whether delirium occurs in the setting of sepsis, coronavirus disease 2019 (COVID-19), or recent surgery. Methods This prospective observational cohort study involved 119 critically ill patients admitted to a multidisciplinary intensive care unit (ICU) during 2019 and 2020. Delirium was identified using the validated confusion assessment method for the ICU. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. Serums samples were collected within 12 hours of ICU admission and cytokine levels were measured. Results: The following proinflammatory cytokines were elevated in our delirium population: tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-18, C-C motif ligand (CCL) 2, CCL3, C-X-C motif chemokine ligand (CXCL)1, CXCL10, IL-8, IL-1 receptor antagonist, and IL-10. Analysis of relative cytokine levels in those patients that developed delirium in the setting of sepsis, COVID-19, and recent surgery showed elevations of CCL2, CXCL10, and TNF-α in both the sepsis and COVID-19 group in comparison to the postsurgical population. In the postsurgical group, granulocyte colony-stimulating factor was elevated and CXCL10 was decreased relative to the opposing groups. Conclusions We identify several cytokines and precipitating factors known to be associated with delirium. However, our study suggests that the cytokine profile associated with delirium is variable and contingent upon delirium precipitating factors.
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10
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Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Maes M. Delirium due to hip fracture is associated with activated immune-inflammatory pathways and a reduction in negative immunoregulatory mechanisms. BMC Psychiatry 2022; 22:369. [PMID: 35641947 PMCID: PMC9158285 DOI: 10.1186/s12888-022-04021-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The objectives of this study were to delineate whether delirium in older adults is associated with activation of the immune-inflammatory response system (IRS) as indicated by activation of M1, T helper (Th)1, and Th17 profiles, and/or by reduced activities of the compensatory immunoregulatory system (CIRS), including Th2 and T regulatory profiles. METHODS We recruited 65 older adult patients with a low energy impact hip fracture who underwent hip fracture operation. The CAM-ICU and the Delirium Rating Scale, Revised-98-Thai version (DRS-R-98) were assessed pre-operatively and 1, 2 and 3 days after surgery. Blood samples (day 1 and 2) post-surgery were assayed for cytokines/chemokines using a MultiPlex assay and the neutrophil/lymphocyte ratio. RESULTS We found that delirium and/or the DRS-R-98 score were associated with IRS activation as indicated by activated M1, Th1, Th17 and T cell growth profiles and by attenuated CIRS functions. The most important IRS biomarkers were CXCL8, interleukin (IL)-6, and tumor necrosis factor-α, and the most important CIRS biomarkers were IL-4 and soluble IL-1 receptor antagonist. We found that 42.5% of the variance in the actual changes in the DRS-R-98 score (averaged from day 1 to day 3) was explained by T cell growth factors, baseline DRS-R-98 scores and age. An increase in the NLR reflects overall IRS, M1, Th1, Th17, and Th2 activation. CONCLUSIONS Post-hip surgery delirium is associated with activated IRS pathways and appears especially in patients with lowered CIRS functions.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Yanin Thipakorn
- grid.7922.e0000 0001 0244 7875Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- grid.7922.e0000 0001 0244 7875Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- grid.7922.e0000 0001 0244 7875Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria. .,IMPACT Strategic Research Center, Deakin University, Geelong, Australia.
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11
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Oldham MA. Delirium disorder: Unity in diversity. Gen Hosp Psychiatry 2022; 74:32-38. [PMID: 34875568 DOI: 10.1016/j.genhosppsych.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing them through the model of delirium disorder. METHOD This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets. RESULTS Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies. CONCLUSIONS Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
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12
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Cartin-Ceba R, Smith R, Lachner C, Singh V. Intensive care unit delirium in patients with severe COVID-19: A prospective observational cohort study. Int J Crit Illn Inj Sci 2022; 12:61-69. [PMID: 35845128 PMCID: PMC9285129 DOI: 10.4103/ijciis.ijciis_93_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/02/2021] [Accepted: 12/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Delirium is common in patients with severe coronavirus disease-19 (COVID-19). The purpose of our study was to determine whether severe COVID-19 is an independent risk factor for the development of delirium in patients treated in the intensive care unit (ICU). Methods: This prospective observational cohort study involved 162 critically ill patients admitted to a multidisciplinary ICU during 2019 and 2020. A validated screening tool was used to diagnose delirium. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. After univariate analysis, a multivariate logistic regression analysis was performed to determine independent risk factors associated with the development of delirium. Results: In our study population, 50 (31%) patients developed delirium. A total of 39 (24.1%) tested positive for COVID-19. Initial analysis showed COVID-19 to be more prevalent in those patients that developed delirium (40% vs. 17%; P = 0.003). Multivariate analysis showed opioid use (odds ratio [OR]: 24 [95% confidence intervals (CI): 16–27]; P ≤ 0.001), benzodiazepine use (OR: 23 [95% CI: 16–63] P = 0.001), and estimated mortality based on acute physiology and chronic health evaluation IV score (OR: 1.04 [95% CI: 1.01–1.07] P = 0.002) to be independently associated with delirium development. COVID-19 (OR: 1.44 [95% CI: 0.13–10.6]; P = 0.7) was not found to be associated with delirium. Conclusion: Delirium is prevalent in critically ill patients admitted to the ICU, including those with COVID-19. However, after adjustment for important covariates, we found in this cohort that COVID-19 was not an independent risk factor for delirium.
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13
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Thisayakorn P, Tangwongchai S, Tantavisut S, Thipakorn Y, Sukhanonsawat S, Wongwarawipat T, Sirivichayakul S, Maes M. Immune, Blood Cell, and Blood Gas Biomarkers of Delirium in Elderly Individuals with Hip Fracture Surgery. Dement Geriatr Cogn Disord 2021; 50:161-169. [PMID: 34350874 DOI: 10.1159/000517510] [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] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative delirium in elderly people with hip fracture is associated with various adverse clinical outcomes. Nevertheless, the pathophysiological processes underpinning delirium have remained elusive. OBJECTIVES The aim of this study was to explore the associations between delirium and its features and immune-inflammatory and blood gas biomarkers. METHODS In this prospective study, we examined 65 patients who underwent a hip fracture surgery and assessed the Confusion Assessment Method for the Intensive Care Unit, Richmond Agitation-Sedation Scale (RASS), and Delirium Rating Scale Revised-98 (DRS-R-98) before and during 4 days after the surgery. Complete blood count and venous blood gas markers were obtained at the same time points. RESULTS Delirium was observed in 19 patients and was accompanied by significantly increased pO2, number of white blood cells, neutrophil percentage, and neutrophil/lymphocyte ratio, and lower mean platelet volume (MPV) after adjusting for age, central nervous system (CNS) disease, blood loss during surgery, sleep disorders, and body mass index. The severity of delirium was associated with lowered number of platelets and MPV. Psychomotor disorders were associated with lower bicarbonate levels. The requirement of physical restraint of the patients was predicted by increased percentages of neutrophils and lymphocytes. Prior CNS disease was together with these biomarkers a significant predictor of delirium and severity of delirium. CONCLUSION Delirium and psychomotor disorders following hip fracture and surgery may be caused by immune-inflammatory and oxidative stress pathways probably attributable to an aseptic inflammatory process.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Siree Sukhanonsawat
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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14
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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15
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Sepulveda E, Adamis D, Franco JG, Meagher D, Aranda S, Vilella E. The complex interaction of genetics and delirium: a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci 2021; 271:929-939. [PMID: 33779822 DOI: 10.1007/s00406-021-01255-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 03/16/2021] [Indexed: 02/06/2023]
Abstract
The objective is to understand genetic predisposition to delirium. Following PRISMA guidelines, we undertook a systematic review of studies involving delirium and genetics in the databases of Pubmed, Scopus, Cochrane Library and PsycINFO, and performed a meta-analysis when appropriate. We evaluated 111 articles, of which 25 were finally included in the analysis. The studies were assessed by two independent researchers for methodological quality using the Downs and Black Tool and for genetic analysis quality. We performed a meta-analysis of 10 studies of the Apolipoprotein E (APOE) gene, obtaining no association with the presence of delirium (LOR 0.18, 95% CI - 0.10-0.47, p = 0.21). Notably, only 5 out of 25 articles met established criteria for genetic studies (good quality) and 6 were of moderate quality. Seven studies found an association with APOE4, the dopamine transporter gene SCL6A3, dopamine receptor 2 gene, glucocorticoid receptor, melatonin receptor and mitochondrial DNA haplotypes. One genome-wide association study found two suggestive long intergenic non-coding RNA genes. Five studies found no association with catechol-o-methyltransferase, melatonin receptor or several interleukins genes. The studies were heterogenous in establishing the presence of delirium. Future studies with large samples should further specify the delirium phenotype and deepen our understanding of interactions between genes and other biological factors.
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Affiliation(s)
- Esteban Sepulveda
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, C/Institut Pere Mata, S/N, 43206, Reus, Spain. .,Universitat Rovira i Virgili, Tarragona, Spain.
| | | | - Jose G Franco
- Grupo de Investigación en Psiquiatría de Enlace, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - David Meagher
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Selena Aranda
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, C/Institut Pere Mata, S/N, 43206, Reus, Spain.,Universitat Rovira i Virgili, Tarragona, Spain
| | - Elisabet Vilella
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, C/Institut Pere Mata, S/N, 43206, Reus, Spain.,Universitat Rovira i Virgili, Tarragona, Spain
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16
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Stokholm J, Birkmose LKH, Ahmed AABO, Csillag C, Kjær TW, Christensen T. Changes in autonomic tone during delirium in acute stroke patients assessed by pupillometry and skin conductance. J Neurol Sci 2021; 428:117582. [PMID: 34284172 DOI: 10.1016/j.jns.2021.117582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
Delirium is a common complication in acute ischemic stroke, possibly caused by alterations in the regulation of the sympathetic autonomic nervous system. We investigated whether such an association could be demonstrated with two easy-to-use measurement techniques: Measurement of palmar skin conductance level (SCL) and pupillometry measuring the dilation velocity in the pupillary light reflex (PLRdil.vel.). The cohort study included 64 patients admitted with acute ischemic stroke. During the study period (median 4.1 days, interquartile range 2.1 days) patients were assessed for delirium once daily as well as with measurements of SCL and PLRdil.vel up to twice daily. SCL and PLRdil.vel. during delirium were lower than without delirium present. For SCL the unadjusted difference was -40.8% (95% CI (-55.1 to -22.0), P value <.001) and for PLRdil.vel the unadjusted difference was -0.22 mm/s (95% CI (-0.42 to -0.01), P value = .041). The results demonstrate changes in sympathetic autonomic nervous system regulation during delirium in acute stroke patients.
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Affiliation(s)
- Jannik Stokholm
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark.
| | - Lars Kristian Hebsgaard Birkmose
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Abd Al Bari Omar Ahmed
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Claudio Csillag
- Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark; Psychiatric Outpatient Clinic, Mental Health Centre North Zealand, Dyrehavevej 48, 3400 Hillerød, Denmark
| | - Troels Wesenberg Kjær
- Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark; Center for Neurophysiology, Department of Neurology, Zealand University Hospital, Vestermarksvej 11, 4000 Roskilde, Denmark
| | - Thomas Christensen
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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17
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Via-Clavero G, Frade-Mera MJ, Alonso-Crespo D, Castanera-Duro A, Gil-Castillejos D, Vallés-Fructuoso O, Rodríguez-Mondéjar JJ, López-López C, Robleda G, Acevedo-Nuevo M. Future lines of research on pain care, sedation, restraints and delirium in the critically ill patient. ENFERMERIA INTENSIVA 2021; 32:57-61. [PMID: 34099265 DOI: 10.1016/j.enfie.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- G Via-Clavero
- Enfermera Clínica, Área del Paciente Crítico, Hospital Universitari de Bellvitge, Profesora Asociada, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Grup de Recerca Infermera (GRIN-IDIBELL), Spain.
| | - M J Frade-Mera
- Enfermera Clínica, Área del Paciente Crítico, Hospital Universitario 12 de Octubre, Profesora Asociada, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Spain
| | - D Alonso-Crespo
- Enfermero, Unidad de Cuidados Intensivos, Área Sanitaria de Vigo, Hospital Álvaro Cunqueiro SERGAS-UVigo, Translational Neuroscience Group-CIBERSAM, Galicia Sur, Instituto de Investigación Sanitaria (IIS Galicia Sur), Spain
| | - A Castanera-Duro
- Enfermero Clínico, Área del paciente crítico, Hospital Universitario de Girona Dr. Josep Trueta, Profesor Asociado departamento de Enfermería Universitat de Girona (UdG), Spain
| | - D Gil-Castillejos
- Enfermera Clínica, Área de Críticos, Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - O Vallés-Fructuoso
- Enfermera, Unidad de Cuidados Intensivos, Hospital Vall d'Hebrón, Barcelona, Spain
| | - J J Rodríguez-Mondéjar
- Enfermero en UME-2 Alcantarilla, Gerencia de Urgencias y Emergencias Sanitarias 061 Región de Murcia, Servicio Murciano de Salud, Profesor asociado en la Facultad de Enfermería de la Universidad de Murcia, Campus Mare Nostrum, Miembro del grupo de investigación ENFERAVAN en el IMIB-Arrixaca, Spain
| | - C López-López
- Enfermera, Departamento de Cuidados Intensivos, Hospital Universitario 12 de Octubre, Madrid, Investigadora, Grupo de Investigación en Cuidados (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Profesora Asociada, Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Spain
| | - G Robleda
- Campus docente Fundación Privada Sant Joan de Déu, Escuela de Enfermería, Universidad de Barcelona, Centro Cochrane Iberoamericano, Spain
| | - M Acevedo-Nuevo
- Enfermera, Organización Nacional de Trasplantes, Grupo de Investigación en Enfermería y Cuidados de Salud - Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Spain
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18
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Via-Clavero G, Frade-Mera MJ, Alonso-Crespo D, Castanera-Duro A, Gil-Castillejos D, Vallés-Fructuoso O, Rodríguez-Mondéjar JJ, López-López C, Robleda G, Acevedo-Nuevo M. Future lines of research on pain care, sedation, restraints and delirium in the critically ill patient. ENFERMERIA INTENSIVA 2021; 32:57-61. [PMID: 33966878 DOI: 10.1016/j.enfi.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/14/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Gemma Via-Clavero
- Enfermera Clínica, Área del Paciente Crítico. Hospital Universitari de Bellvitge. Profesora Asociada. Escuela de Enfermería. Facultad de Medicina y Ciencias de la Salud. Universitat de Barcelona. Grup de Recerca Infermera (GRIN-IDIBELL).
| | - María Jesús Frade-Mera
- Enfermera Clínica, Área del Paciente Crítico. Hospital Universitario 12 de Octubre. Profesora Asociada. Facultad de Enfermería, Fisioterapia y Podología. Universidad Complutense de Madrid
| | - David Alonso-Crespo
- Enfermero, Unidad de Cuidados Intensivos. Área Sanitaria de Vigo. Hospital Álvaro Cunqueiro SERGAS-UVigo. Translational Neuroscience Group-CIBERSAM, Galicia Sur. Instituto de Investigación Sanitaria (IIS Galicia Sur)
| | - Aaron Castanera-Duro
- Enfermero Clínico. Área del paciente crítico. Hospital Universitario de Girona Dr. Josep Trueta. Profesor Asociado departamento de Enfermería Universitat de Girona (UdG)
| | - Diana Gil-Castillejos
- Enfermera Clínica, Área de Críticos. Servicio de Medicina Intensiva. Hospital Universitari Joan XXIII, Tarragona
| | | | - Juan José Rodríguez-Mondéjar
- Enfermero en UME-2 Alcantarilla. Gerencia de Urgencias y Emergencias Sanitarias 061 Región de Murcia. Servicio Murciano de Salud. Profesor asociado en la Facultad de Enfermería de la Universidad de Murcia. Campus Mare Nostrum. Miembro del grupo de investigación ENFERAVAN en el IMIB-Arrixaca
| | - Candelas López-López
- Enfermera, Departamento de Cuidados Intensivos, Hospital Universitario 12 de Octubre, Madrid. Investigadora, Grupo de Investigación en Cuidados (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid. Profesora Asociada, Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid
| | - Gemma Robleda
- Campus docente Fundación Privada Sant Joan de Déu. Escuela de Enfermería, Universidad de Barcelona. Centro Cochrane Iberoamericano
| | - María Acevedo-Nuevo
- Enfermera, Organización Nacional de Trasplantes. Grupo de Investigación en Enfermería y Cuidados de Salud - Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA)
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19
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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Oh ES, Leoutsakos JM, Rosenberg PB, Pletnikova AM, Khanuja HS, Sterling RS, Oni JK, Sieber FE, Fedarko NS, Akhlaghi N, Neufeld KJ. Effects of Ramelteon on the Prevention of Postoperative Delirium in Older Patients Undergoing Orthopedic Surgery: The RECOVER Randomized Controlled Trial. Am J Geriatr Psychiatry 2021; 29:90-100. [PMID: 32532654 PMCID: PMC8809889 DOI: 10.1016/j.jagp.2020.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Postoperative delirium, associated with negative consequences including longer hospital stays and worse cognitive and physical outcomes, is frequently accompanied by sleep-wake disturbance. Our objective was to evaluate the efficacy and short-term safety of ramelteon, a melatonin receptor agonist, for the prevention of postoperative delirium in older patients undergoing orthopedic surgery. DESIGN A quadruple-masked randomized placebo-controlled trial (Clinical Trials.gov NCT02324153) conducted from March 2017 to June 2019. SETTING Tertiary academic medical center. PARTICIPANTS Patients aged 65 years or older, undergoing elective primary or revision hip or knee replacement. INTERVENTION Ramelteon (8 mg) or placebo MEASUREMENTS: Eighty participants were randomized to an oral gel cap of ramelteon or placebo for 3 consecutive nights starting the night before surgery. Trained research staff conducted delirium assessments for 3 consecutive days starting on postoperative day (POD) 0, after recovery from anesthesia, and on to POD2. A delirium diagnosis was based upon DSM-5 criteria determined by expert panel consensus. RESULTS Of 80 participants, five withdrew consent (one placebo, four ramelteon) and four were excluded (four ramelteon) after randomization. Delirium incidence during the 2 days following surgery was 7% (5 of 71) with no difference between the ramelteon versus placebo: 9% (3 of 33) and 5% (2 of 38), respectively. The adjusted odds ratio for postoperative delirium as a function of assignment to the ramelteon treatment arm was 1.28 (95% confidence interval: 0.21-7.93; z-value 0.27; p-value = 0.79). Adverse events were similar between the two groups. CONCLUSION In older patients undergoing elective primary or revision hip or knee replacement, ramelteon was not efficacious in preventing postoperative delirium.
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Affiliation(s)
- Esther S Oh
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pathology (ESO), Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing (ESO, KJN), Baltimore, MD.
| | - Jeannie-Marie Leoutsakos
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul B Rosenberg
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra M Pletnikova
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harpal S Khanuja
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert S Sterling
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julius K Oni
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frederick E Sieber
- Departments of Anesthesiology and Critical Care Medicine (FES), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Neal S Fedarko
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Narjes Akhlaghi
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karin J Neufeld
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing (ESO, KJN), Baltimore, MD
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21
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 414] [Impact Index Per Article: 103.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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Oldham MA, Holloway RG. Delirium disorder. Neurology 2020; 95:173-178. [DOI: 10.1212/wnl.0000000000009949] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
ObjectiveAs the US population ages and with no definitive delirium treatments on the horizon, the delirium epidemic is on course to expand over the coming decades. Recognizing the import of this condition, a recent position statement from 10 medical societies—among whom the American Academy of Neurology was represented—issued recommendations on preferred nomenclature of delirium and acute encephalopathy: it concluded by preferring both terms. Urgently needed is an integrated model that addresses the near-total segregation of these separate bodies of literature, ideally one that offers an interdisciplinary framework to bring these 2 terms and those who use them together.MethodsWe review the historical forces that have led these terms to diverge and consider the unique benefits of each approach as well as their liabilities when considered in isolation. We then explore the potential implications of integrating these concepts and propose a hybrid model to capitalize on the strengths of both the model of delirium and that of acute encephalopathy.ResultsThe model we propose—delirium disorder—builds on the recommendations of this recent position statement and provides a unifying framework designed to have clinical utility and interdisciplinary appeal. It also broadens the translational landscape by identifying 4 distinct treatment targets: underlying causes, procognitive factors, delirium (phenotype alone), and neurophysiologic targets.ConclusionsThis person-centered model aims to integrate delirium and acute encephalopathy within a single framework and shared nomenclature. It is hoped that this model aids in harmonizing research efforts and advancing clinical practice.
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Affiliation(s)
- Christian S Guay
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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24
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Abstract
Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.
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Affiliation(s)
- Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Building 10, Level 3, 235 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Shirley H Bush
- The Ottawa Hospital, General Campus, 501 Smyth Road, Box 206, Ottawa, ON K1H 8L6, Canada; Bruyère Research Institute, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada; Ottawa Hospital Research Institute, 053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; Palliative Care, Bruyère Continuing Care, The Ottawa Hospital, 43, Bruyère Street, Ottawa, Ontario K1N 5C8, Canada
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Oldham MA. Refining Postoperative Delirium: The Case of a Gene × Protein Interaction. Am J Geriatr Psychiatry 2019; 27:9-11. [PMID: 30477914 DOI: 10.1016/j.jagp.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Mark A Oldham
- School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY.
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Unraveling Delirium: Where to Start: Top Down Versus Bottom Up? Am J Geriatr Psychiatry 2018; 26:925-926. [PMID: 30146000 DOI: 10.1016/j.jagp.2018.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/23/2022]
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