Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study

Effect of remimazolam versus propofol anesthesia on postoperative delirium in neurovascular surgery: study protocol for a randomized controlled, non-inferiority trial

BACKGROUND

Remimazolam is a short-acting benzodiazepine newly approved for the induction and maintenance of general anesthesia. Remimazolam emerges as an ideal drug for the neurosurgical population due to its rapid emergence, enabling early neurological assessment, and its ability to maintain perfusion pressure, which is crucial for preventing cerebral ischemia. However, the use of benzodiazepine has been associated with an increased risk of postoperative delirium (POD). There is currently limited evidence about the relationship between remimazolam-based total intravenous anesthesia (TIVA) and POD.

METHODS

In this double-blind, randomized, non-inferiority trial, we plan to include 696 adult patients with American Society of Anesthesiologists physical status class I to III, undergoing elective neurovascular surgery under general anesthesia. After informed consent, the patients will be randomized to receive either remimazolam or propofol-based TIVA with a 1:1 ratio. The primary outcome is the incidence of POD within 5 days after surgery. Secondary outcomes include subtypes, number of positive assessments and severity of POD, emergence agitation, intraoperative awareness and undesirable patient movement, intraoperative hypotension, and postoperative cognitive function. The data will be analyzed in modified intention to treat.

DISCUSSION

This trial will evaluate the effect of remimazolam on the development of POD compared to propofol anesthesia. The results of this trial will provide evidence regarding the choice of optimal anesthetics to minimize the risk of POD in neurosurgical patients.

TRIAL REGISTRATION

The study protocol was prospectively registered at the Clinical trials ( https://clinicaltrials.gov , NCT06115031, principal investigator: Jiseon Jeong; date of first registration: November 2, 2023, before the recruitment of the first participant.

The 4AT scale for rapid detection of delirium in emergency department triage

Aims

To assess the diagnostic accuracy and time impact of the 4AT scale in emergency department triage.

Methods

A Prospective diagnostic accuracy study was carried out. People aged ≥65 years presenting to the emergency department from 1 November 2021 to 30 June 2022 were included. Nurses opportunistically screened eligible patients using the 4AT scale during triage according to the Manchester Triage System Francesc de Borja Hospital emergency department, Gandía (Spain). Accuracy was compared with medical diagnosis of delirium. Time (seconds) spent in triage with and without screening was assessed.

Results

The study included 370 patients (55.1% men, mean age 81.8 years), of whom 58.4% (n = 216) were screened. A final diagnosis of delirium was made in 41.4% of those screened. The most frequently used presentational flow charts and discriminators were 'behaving strangely' (15%) and 'rapid onset' (33.3%). The highest accuracy was obtained for a score of 3 points or more (sensitivity 85.1%; specificity 66.9%; positive predictive value 52.8%; negative predictive value 71.7%). No significant differences were found in the time spent in triage according to the performance of screening.

Conclusion

A score of 3 points or more on the 4AT scale enables rapid detection of delirium in emergency department triage, without consuming more time than conventional triage.

Access to primary eye care for people living with dementia: a call to action for primary care practitioners to 'think vision'

Access to allied health services offers significant benefits for people living with dementia, yet access is currently fragmented and inconsistent. The 2023-2024 budget allocated AU$445million to further enable general practice-led, multidisciplinary teams, with integrated care located within practices, including employment of allied health professionals. Such team care models are recognised by The Royal Australian College of General Practitioners as vital to delivery of high-quality care for older adults. They are especially relevant for over 250,000 Australians who live with dementia in the community. However, not all allied health professionals are currently based within general practices. Future, sustainable general practice-led models of multidisciplinary care that connect patients with external allied health providers could be considered for a comprehensive and collaborative approach to care. Our focus is on people living with dementia, who are at greater risk of preventable vision impairment. Poor vision and/or ocular health can be detected and managed through regular eye examinations, which are predominantly delivered by community-based optometrists in Australia, in a primary care capacity. However, people living with dementia are also less likely to have regular eye examinations. In this paper, we highlight the value of ensuring access to primary eye care services as part of post-diagnosis dementia care. We illustrate the important role of primary care practitioners in building and sustaining connections with allied health professions, like optometry, through effective referral and interprofessional communication systems. This can help break down access barriers to dementia-friendly eye care, through promoting the importance of regular eye tests for people living with dementia.

Successful aging after elective surgery II: Study cohort description

BACKGROUND

The Successful Aging after Elective Surgery (SAGES) II Study was designed to examine the relationship between delirium and Alzheimer's disease and related dementias (AD/ADRD), by capturing novel fluid biomarkers, neuroimaging markers, and neurophysiological measurements. The goal of this paper is to provide the first complete description of the enrolled cohort, which details the baseline characteristics and data completion. We also describe the study modifications necessitated by the COVID-19 pandemic, and lay the foundation for future work using this cohort.

METHODS

SAGES II is a prospective observational cohort study of community-dwelling adults age 65 and older undergoing major non-cardiac surgery. Participants were assessed preoperatively, throughout hospitalization, and at 1, 2, 6, 12, and 18 months following discharge to assess cognitive and physical functioning. Since participants were enrolled throughout the COVID-19 pandemic, procedural modifications were designed to reduce missing data and allow for high data quality.

RESULTS

About 420 participants were enrolled with a mean (standard deviation) age of 73.4 (5.6) years, including 14% minority participants. Eighty-eight percent of participants had either total knee or hip replacements; the most common surgery was total knee replacement with 210 participants (50%). Despite the challenges posed by the COVID-19 pandemic, which required the use of novel procedures such as video assessments, there were minimal missing interviews during hospitalization and up to 1-month follow-up; nearly 90% of enrolled participants completed interviews through 6-month follow-up.

CONCLUSION

While there are many longitudinal studies of older adults, this study is unique in measuring health outcomes following surgery, along with risk factors for delirium through the application of novel biomarkers-including fluid (plasma and cerebrospinal fluid), imaging, and electrophysiological markers. This paper is the first to describe the characteristics of this unique cohort and the data collected, enabling future work using this novel and important resource.

Long-term recovery after critical illness in older adults

PURPOSE OF REVIEW

The population is aging, and recent epidemiologic work reveals that an increasing number of older adults are presenting to the ICU with preexisting geriatric syndromes. In this update, we discuss recent literature pertaining to the long-term recovery of older ICU patients and highlight gaps in current knowledge.

RECENT FINDINGS

A recent longitudinal study demonstrated that the incidence of frailty, disability, and multimorbidity among older ICU patients is rising; these geriatric syndromes have all previously been shown to impact long-term recovery. Recent studies have demonstrated the impact of social factors in long-term outcomes after critical illness; for example, social isolation was recently shown to be associated with disability and mortality among older adults in the year after critical illness. Socioeconomic disadvantage is associated with higher rates of dementia and disability following critical illness impacting recovery, and further studies are necessary to better understand factors influencing this disparity. The COVID-19 pandemic disproportionately impacted older adults, resulting in worse outcomes and increased rates of functional decline and social isolation. In considering how to best facilitate recovery for older ICU survivors, transitional care programs may address the unique needs of older adults and help them adapt to new disability if recovery has not been achieved.

SUMMARY

Recent work demonstrates increasing trends of geriatric syndromes in the ICU, all of which are known to confer increased vulnerability among critically ill older adults and decrease the likelihood of post-ICU recovery. Risk factors are now known to extend beyond geriatric syndromes and include social risk factors and structural inequity. Strategies to improve post-ICU recovery must be viewed with a lens across the continuum of care, with post-ICU recovery programs targeted to the unique needs of older adults.

Falls in Senior Adults Part II: Management, Treatment, Prevention, and Therapy Plans

In this follow up to our Falls in Senior Adults Part I article,1 we address further management of falls after fall risk has been identified. This review will focus on the current literature on the treatment, therapy plans, and prevention of falls in senior adults.

Delirium and Clusters of Older Patients Affected by Multimorbidity in Acute Hospitals

OBJECTIVES

Delirium is commonly seen in older adults with multimorbidity, during a hospitalization, resulting from the interplay between predisposing factors such as advanced age, frailty, and dementia, and a series of precipitating factors. The association between delirium and specific multimorbidity is largely unexplored so far although of potential key relevance for targeted interventions. The aim of the study was to check for a potential association of multimorbidity with delirium in a large cohort of older patients hospitalized for an acute medical or surgical condition.

DESIGN

This is a cross-sectional study nested in the 2017 Delirium Day project.

SETTING AND PARTICIPANTS

The study includes 1829 hospitalized patients (age: 81.8, SD: 5.5). Of them, 419 (22.9%) had delirium.

METHODS

Sociodemographic and medical history were collected. The 4AT was used to assess the presence of delirium. The Charlson Comorbidity index was used to assess multimorbidity.

RESULTS

The results identified neurosensorial multimorbidity as the most prevalent, including patients with dementia, cerebrovascular diseases, and sensory impairments. In light of the highest co-occurrence of 3 neurosensorial chronic conditions, we could hypothesize that a baseline altered brain functional and neural connectivity might determine the vulnerability signature for incipient overall system disruption in presence of acute insults.

CONCLUSIONS AND IMPLICATIONS

Eventually, our findings moved a step forward in supporting the key importance of routine screening for sensory impairments and cognitive status of older patients for the highest risk of in-hospital delirium. In fact, preventive interventions could be particularly relevant and effective in preventing delirium in such vulnerable populations and might help refining this early diagnosis.

Development and validation of a delirium risk assessment tool in older patients admitted to the Emergency Department Observation Unit

BACKGROUND

Delirium is frequent though undetected in older patients admitted to the Emergency Department (ED).

AIMS

To develop and validate a delirium risk assessment tool for older persons admitted to the ED Observation Unit (OU).

METHODS

We used data from two samples of 65 + year-old patients, one admitted to the ED of Brescia Hospital (n = 257) and one to the ED of Desio Hospital (n = 107), Italy. Data from Brescia were used as training sample, those collected in Desio as testing one. Delirium was assessed using the 4AT and patients' characteristic were retrieved from medical charts. Variables found to be associated with delirium in the training sample were tested for the creation of a delirium risk assessment tool. The resulting tool's performances were assessed in the testing subsample.

RESULTS

Of all possible scores tested, the combination with the highest discriminative ability in the training sample included: age ≥ 75 years, dementia diagnosis, chronic use of neuroleptics, and hearing impairment. The delirium score exhibited an AUC of 0.874 and 0.893 in the training and testing samples, respectively. For a 1-point increase in the score, the odds of delirium increased more than twice in both samples.

DISCUSSION

We propose a delirium risk assessing tool that includes variables that can be easily collected at ED admission and that can be calculated rapidly.

CONCLUSION

A risk assessment tool could help improving delirium detection in older persons referring to ED.

The relationship between frailty and delirium: insights from the 2017 Delirium Day study

BACKGROUND

although frailty and delirium are among the most frequent and burdensome geriatric syndromes, little is known about their association and impact on short-term mortality.

OBJECTIVE

to examine, in hospitalized older persons, whether frailty is associated with delirium, and whether these two conditions, alone or in combination, affect these patients' 30-day survival.

DESIGN

observational study nested in the Delirium Day project, with 30-day follow-up.

SETTING

acute medical wards (n = 118) and rehabilitation wards (n = 46) in Italy.

SUBJECTS

a total of 2,065 individuals aged 65+ years hospitalized in acute medical (1,484 patients, 71.9%) or rehabilitation (581 patients, 28.1%) wards.

METHODS

a 25-item Frailty Index (FI) was created. Delirium was assessed using the 4AT test. Vital status was ascertained at 30 days.

RESULTS

overall, 469 (22.7%) patients experienced delirium on the index day and 82 (4.0%) died during follow-up. After adjustment for potential confounders, each FI score increase of 0.1 significantly increased the odds of delirium (odds ratio, OR: 1.66 [95% CI: 1.45-1.90]), with no difference between the acute (OR: 1.65 [95% CI: 1.41-1.93]) and rehabilitation ward patients (OR: 1.71 [95% CI: 1.27-2.30]). The risk of dying during follow-up also increased significantly for every FI increase of 0.1 in the overall population (OR: 1.65 [95% CI: 1.33-2.05]) and in the acute medical ward patients (OR: 1.61 [95% CI: 1.28-2.04]), but not in the rehabilitation patients. Delirium was not significantly associated with 30-day mortality in either hospital setting.

CONCLUSIONS

in hospitalized older patients, frailty is associated with delirium and with an increased risk of short-term mortality.