Delirium masquerading as depression

Reflections on dexmedetomidine as an optimum therapy for emergence delirium in the elderly with emergency abdominal surgery

Emergence delirium (ED) is a common complication in elderly patients in post post-anesthesia care units (PACU), To our knowledge, there is currently no specific treatment for ED in the elderly, especially for patients combined with vital organs dysfunction. This article described an elderly patient with ED was successfully treated with dexmedetomidine. Although dexmedetomidine has been widely used in recent years, there are few articles on the administration of dexmedetomidine in PACU. The purpose of this paper is to review the literature and analyze related hazardous factors for ED in the elderly with complications of emergency abdominal surgery and angiocardiopathy, and to further confirm and explain the effectiveness and validation of dexmedetomidine as a rescue therapy in PACU. Finally, we look forward to more samples being collected to persuasively prove our opinion in this case.

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients

Purpose

The aim of this study is to establish the prevalence, associated factors, and clinical impact of delirium in newly referred palliative care patients and the percentage of delirium diagnoses missed by primary medical teams.

Methods

Newly referred palliative care patients were evaluated and were reviewed for possible associated factors of delirium. Univariable and multivariable analysis were used to identify associated factors. Median overall survival and survival curves were analyzed. The percentage of missed diagnosis in IPD patients was identified.

Results

We included 350 palliative care patients. Nearly all patients had cancer diagnosis (96.6%). The overall prevalence of delirium was 44.0%. The independent associated factors of delirium were age ≥ 63 years (adjusted odds ratio [aOR], 7.0; 95% CI, 2.2–22.9), palliative performance scale ≤ 20% (aOR, 54.5; 95% CI, 13.1–228.0), brain metastasis (aOR, 15.6; 95% CI, 3.7–66.7), urinary tract infection (aOR, 18.8; 95% CI, 4.7–75.5), sepsis (aOR, 59.0; 95% CI, 4.4–797.8), hyponatremia (aOR, 8.8; 95% CI, 2.6–29.8), and hypercalcemia (not applicable). Interestingly, opioids and benzodiazepines were not associated with delirium. Delirious patients had significantly shorter survival (median survival 11 days). Delirium diagnoses were missed for 76.1%.

Conclusion

Nearly half of the palliative care patients had delirium, which was associated with noticeably short survivals. We identified the independent factors associated with the delirium. Despite having a remarkably high prevalence rate and being a well-known poor prognostic factor, there was still a very high rate of missed delirium diagnoses. Effective, routine, delirium screening of palliative care patients needs to be emphasized.

Psychiatric Care in a Novel Federal COVID-19 Treatment Center: Development of a Consultation-Liaison Psychiatry Service at the Javits New York Medical Station

At the outset of the 2019 coronavirus disease (COVID-19) pandemic, New York City faced the highest burden of COVID-19 cases in the United States. In response, the U.S. Federal Government deployed medical providers from various uniformed services to treat patients with COVID-19 at the Jacob Javits Convention Center in New York City. There quickly arose a need for psychiatric services for patients with COVID-19 and psychological support for medical staff. Psychiatrists were tasked with establishing a consult-liaison psychiatry service in this unique environment. The authors detail the establishment of a novel consultation-liaison psychiatry service in a large convention center and explore lessons learned from this experience with the aim to empower uniformed psychiatrists to prepare for and deliver patient-focused care in pandemic settings.

Delirium screening tools validated in the context of palliative care: A systematic review

BACKGROUND

Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review.

AIM

To systematically review studies that validate delirium screening tools conducted in palliative care settings.

DESIGN

Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed.

DATA SOURCES

Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded.

RESULTS

Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias.

CONCLUSIONS

The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.

Development and Evaluation of Clinical Practice Guideline for Delirium in Long-Term Care

Delirium is highly prevalent and leads to several bad outcomes for older long-term care (LTC) residents. For a more successful translation of delirium knowledge, Clinical Practice Guidelines (CPGs) tailored to LTC should be developed and applied based on the understanding of the barriers to implementation. This study was conducted to develop a CPG for delirium in LTC and to determine the barriers perceived by healthcare professionals related to the implementation of the CPG. We followed a structured, evidence- and theory-based procedure during the development process. After a systematic search, quality appraisal, and selection for eligible up-to-date CPGs for delirium, the recommendations applicable to the LTC were drafted, evaluated, and confirmed by an external group of experts. To evaluate the barriers to guideline uptake from the users' perspectives, semi-structured interviews were conducted which resulted in four major themes: (1) a lack of resources, (2) a tendency to follow mindlines rather than guidelines, (3) passive attitudes, and (4) misunderstanding delirium care in LTC. To minimize adverse prognoses through prompt delirium care, the implementation of a CPG with an approach that comprehensively considers various barriers at the system, practice, healthcare professional, and patients/family levels is necessary.

Delirium

Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called acute brain failure, acute brain dysfunction, or altered mental status. All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.

Managing delirium in terminally ill patients: perspective of palliative care nurse specialists

Delirium occurs frequently at end of life. Palliative care clinical nurse specialists (CNSs) are involved in community palliative care provision. Many patients prefer being cared for at home, yet managing delirium in this setting presents unique challenges, potentially resulting in emergency hospital or hospice admission. We examined the experiences and practice of palliative care CNSs managing delirium in the community; 10 interviews were undertaken. Data were analysed using the framework approach. Challenges to delirium management in the community included limited time with patients, reliance on families and access to medications. Assessment tools were not used routinely; time limited visits and inconsistent retesting were perceived barriers. Management approaches differed depending on CNSs' previous delirium education. Strategies to prevent delirium were not used. Community delirium management presents challenges; support surrounding these could be beneficial. Routine assessment tool use and delirium prevention strategies should be included in further education and research.

Trajectory of severity of postoperative delirium symptoms and its prospective association with cognitive function in patients with gastric cancer: results from a prospective observational study

PURPOSE

Delirium is a common neurocognitive complication in cancer. Despite this, the studies examining the trajectory of the severity of delirium symptoms and its impact on health outcome in gastric cancer is rather limited. This study examined the trajectory of delirium symptom severity (DSS) following resection surgery for gastric cancer and its prospective association with cognitive function.

METHODS

A three-wave prospective observational study was conducted with 242 gastric cancer patients admitted for resection surgery at a teaching hospital in South Korea from May 2016 to November 2017. DSS was assessed by the clinical staff before and 1, 2, 3, and 7 days after surgery using the Delirium Rating Scale-Revised-98. A survey including the Functional Assessment of Cancer Therapy-Cognitive Scale (FACT-Cog) and Mini-Mental State Examination (MMSE) was administered before surgery (T0), 7 days after (T1), and 3 to 6 months after surgery (T2).

RESULTS

Out of 242 participants, 48.8% (118) completed the survey at all three time points, 43.4% (105) did so for two time points, and 7.9% (19) for one time point. No cases of full delirium were observed over four postoperative time points. Latent growth curve modeling analyses indicated that DSS declined over 3 days after surgery. Age and anesthesia time were positively associated with the initial level of DSS. A medication history for memory complaints was related to a slower recovery from delirium symptoms. While the use of propofol as an anesthetic agent was associated with lower initial DSS, it predicted a slower recovery from DSS. A higher initial DSS predicted a lower T1 MMSE score.

CONCLUSIONS

Severity of postoperative delirium symptoms predicts a short-term and objective cognitive function post-surgery. Monitoring and timely treatment of postoperative delirium symptoms is needed to diminish cognitive consequences in gastric cancer patients.

Relational ethics of delirium care: Findings from a hospice ethnography

Delirium, a common syndrome in terminally ill people, presents specific challenges to a good death in end-of-life care. This paper examines the relational engagement between hospice nurses and their patients in a context of end-of-life delirium. Ethnographic fieldwork spanning 15 months was conducted at a freestanding residential hospice in eastern Canada. A shared value system was apparent within the nursing community of hospice; patients' comfort and dignity were deemed most at stake and therefore commanded nurses' primary attention. This overarching commitment to comfort and dignity shaped all of nursing practice in this hospice, including practices related to end-of-life delirium. The findings of this study elaborate the ways in which hospice nurses interpreted and responded to the discomfort of their patients in delirium, as well as the efforts they made to understand their patients' subjective experiences and to connect with them in supportive ways. In addition to what is already known about clinical assessment and treatment of delirium in palliative care settings, the findings of this study offer points of reflection for nurses anywhere who are contending with the relational challenges that delirium presents in end-of-life care.

Delirium in a residential care facility: An exploratory study of staff knowledge

OBJECTIVE

To explore staff knowledge of delirium by eliciting meaning through descriptions of their experiences within a residential aged care facility (RACF).

METHODS

Six staff from one RACF in Australia participated in this qualitative study. Semi-structured individual interviews were conducted and analysed using Colaizzi's analytical framework.

RESULTS

The analysis revealed four themes: (i) absence of the word delirium; (ii) care based on intuition and automated actions; (iii) reliance on teamwork; and (iv) confusing delirium, depression and dementia.

CONCLUSION

Delirium was absent from clinical discourse in the RACF. Although participants concluded that delirium was common, lack of knowledge led to under-assessment. Findings emphasise the need for staff education, informed assessment and clinical guidelines to better support staff care for residents.

Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents

OBJECTIVE

This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States.

METHOD

Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity.

CONCLUSION

This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.

Risk-benefit analysis of antidepressant drug treatment in the elderly

Depression in the elderly is a significant health issue that has the potential to seriously affect physical and emotional well-being. Therefore, the treatment of geriatric depression is necessary. Antidepressant treatment in older depressed patients is efficacious, but differences in the effectiveness of different classes of antidepressants have not been demonstrated. However, differences in tolerability profile are most recognizable in the elderly. With ageing, a series of changes occur in the elderly that modify both the pharmacokinetics and pharmacodynamics of antidepressants and may influence the efficacy, tolerability and safety of treatment in the elderly. Comorbidities require the use of other drugs, which increases the possibility of drug-drug interactions. Given these aspects, individualized therapy for each elderly patient is needed to achieve acceptable risk-benefit ratio. Effective treatment of depression in the elderly, which may require combined pharmacological with psychosocial treatment, can decrease both morbidity and mortality; it also may lead to reduced demands on family members and on health-care and social services.

Practical assessment of delirium in palliative care

CONTEXT

Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging.

OBJECTIVES

This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings.

METHODS

In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care.

RESULTS

Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes.

CONCLUSION

Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.

Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes

CONTEXT

Delirium often presents difficult diagnostic and classification challenges in palliative care settings.

OBJECTIVES

To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review.

RESULTS

We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness.

CONCLUSION

Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.

Documentation of delirium in the VA electronic health record

Background

Delirium is a life-threatening, clinical syndrome common among the elderly and hospitalized patients. Delirium is under-recognized and misdiagnosed, complicating efforts to study the epidemiology and construct appropriate decision support to improve patient care. This study was primarily conducted to realize how providers documented confirmed cases of delirium in electronic health records as a preliminary step for using computerized methods to identify patients with delirium from electronic health records.

Methods

The Mental Health Consult (MHC) team reported cases of delirium to the study team during a 6-month study period (December 1, 2009 - May 31, 2010). A chart extraction tool was developed to abstract documentation of diagnosis, signs and symptoms and known risk factors of delirium. A nurse practitioner, and a clinical pharmacist independently reviewed clinical notes during each patients hospital stay to determine if delirium and or sign and symptoms of delirium were documented.

Results

The MHC team reported 25 cases of delirium. When excluding MHC team notes, delirium was documented for 5 of the 25 patients (one reported case in a physician’s note, four in discharge summaries). Delirium was ICD-9 Coded for 7 of the 25 cases. Signs and symptoms associated with delirium were characterized in 8 physician notes, 11 discharge summaries, and 14 nursing notes, accounting for 16 of the 25 cases with identified delirium.

Conclusions

Documentation of delirium is highly inconsistent even with a confirmed diagnosis. Hence, efforts to use existing data to precisely estimate the prevalence of delirium or to conduct epidemiological studies based on medical records will be challenging.

How do palliative medicine specialists conceptualize depression? Findings from a qualitative in-depth interview study

BACKGROUND AND OBJECTIVE

Different professional conceptualizations of depression may complicate the clinical approach to depression in the palliative care setting. This study aimed to explore and characterize how palliative medicine specialists conceptualize depression.

METHODS

Palliative medicine specialists (i.e., consultants/attending physicians in palliative medicine) practicing in Australia were recruited. Participants were purposively sampled. Individual semi-structured, in-depth interviews were conducted to explore their conceptualizations of depression. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

RESULTS

Four main themes were identified in relation to the conceptualization of depression: (1) depression is a varied concept--it was variously considered as abnormal, a medical problem, an emotional experience, a social product, and an action-oriented construct; (2) depression has unclear boundaries, with differentiation between depression and sadness being especially challenging; (3) depression is different in the palliative care setting--it was seen as more understandable, and distinct from depression that predates life-limiting illnesses; and (4) depression is a challenging issue.

CONCLUSIONS

Depression is conceptualized by palliative medicine specialists in divergent, ontologically heterogeneous and ill-defined ways. A unitary concept of depression was not evident in this study. The concepts of depression need to be actively debated and refined in clinical practice, medical education, and research in order for more sophisticated and consistent models to be developed. The distinction of de novo depression from recurrent or persistent forms of depression also warrants further study.