Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences

Impact of spirituality on patient memories of intensive care unit stays: A nationwide cross-sectional study

Background

Absent or delusional memories are experienced by many patients following an intensive care unit (ICU) stay. Up to 70% may have delusional or hallucinatory intrusive memories, which may persist long term. This study aims to investigate how spiritual health (SH) impacts ICU patients' memories and quality of communication (QoC) between patients and physicians (PP) or nurses (PN).

Methods

This cross-sectional study was conducted across the country on ICU patients discharged from 45 medical centers in 31 provinces of Iran, to evaluate the direct and indirect effects of SH and ICU characteristics on patients' memory. Two valid and standard ICU memory tools (ICU-MT) and SH questionnaires were administered to patients 1 day post-ICU discharge used.

Results

No significant direct effect of SH scores on ICU-MT items was observed. No significant correlation was observed between PP-QoC and PN-QoC variables and primary items of the ICU-MT. Female sex positively correlated with the development of delusional memories (odds ratio [OR]: 1.730, 95% confidence interval [CI]: 1.025-2.915, P < 0.05). Subjects admitted to the medical ICU were less likely to remember being in the ICU (OR: 0.398, 95% CI: 0.159-0.996, P < 0.05), and were less likely to report intrusive memories from their time in the hospital or events that led to their admission (OR: 0.19, 95% CI: 0.086-0.419, P < 0.001).

Conclusions

The results of this study indicate that the spiritual health indirectly increased coping with intrusive memories, however, no direct effect was observed on ICU-MT items. The quality of communication between patients and physicians and nurses significantly mediated development of intrusive memories.

[End-of-Life Dreams and Visions]

End-of-Life Dreams and Visions Abstract: End-of life dreams and visions (ELDVs) or so-called death bed phenomena are transcendent experiences at the end of life that can be visual, auditory and/or kinesthetic, and often include visions of (deceased) loved ones, close friends or perceptions of places, travels, bright lights, or music. ELDVs typically occur weeks to hours prior to death and may comfort the dying and prepare spiritually for the end of life. Such experiences are frequently reported by dying individuals, the prevalence varying between 30 and 80%, but in the clinical context ELDVs are usually neglected, but interpreted and treated as pathological changes in the brain that result in, and from, delirium. This article tries to enlighten the occurrence, the contents and meanings of ELDVs in dying persons as opposed to delirium and night dreams using findings from the literature and from clinical observations. Implications of these conclusions for palliative care and the therapeutic relevance of ELDVs when taking care of dying individuals and their loved ones will also be discussed.

A review of key strategies to address the shortage of analgesics and sedatives in pediatric intensive care

IMPORTANCE

Targeted analgosedation is a challenge in critically ill children, and this challenge becomes even more significant with drug shortages.

OBSERVATIONS

Published guidelines inform the provision of analgosedation in critically ill children. This review provides insights into general approaches using these guidelines during drug shortages in Pediatric Intensive Care Units as well as strategies to optimize both pharmacological and non-pharmacological approaches in these situations.

CONCLUSIONS AND RELEVANCE

Considering that drug shortages are a recurrent worldwide problem, this review may guide managing these drugs in critically ill children in situations of scarcity, such as in pandemics or disasters.

[Delirium Management in Palliative Care]

Delirium Management in Palliative Care Abstract. Delirium is one of the most common neuropsychiatric complications in patients with advanced incurable disease. End-of-life delirium is common but is often overlooked, undiagnosed or incorrectly diagnosed/untreated. Delirium should also be treated in a palliative situation - as far as possible - because persistent delirious states increase the patient's fragility, limit physical functionality and shorten the lifespan. In addition, acute states of confusion trigger high levels of distress in affected patients and their relatives, impair the quality of life and a dignified dying process. While hallucinations and visions at the end of life are interpreted as delirium in medicine and treated as such, this phenomenon is interpreted by philosophical and theological hermeneutics as a resource that can help patients and their relatives to reconcile with past life events and to deal with the process of dying. However, the occurrence of end-of-life visions as opposed to delirium has not yet been studied very much and requires more detailed exploration.

Delirium is associated with an increased morbidity and in-hospital mortality in cancer patients: Results from a prospective cohort study

OBJECTIVE

Delirium is a frequent complication in advanced cancer patients, among whom it is frequently underdiagnosed and inadequately treated. To date, evidence on risk factors and the prognostic impact of delirium on outcomes remains sparse in this patient population.

METHOD

In this prospective observational cohort study at a single tertiary-care center, 1,350 cancer patients were enrolled. Simple and multiple logistic regression models were utilized to identify associations between predisposing and precipitating factors and delirium. Cox proportional-hazards models were used to estimate the effect of delirium on death rate.

RESULTS

In our patient cohort, the prevalence of delirium was 34.3%. Delirium was associated inter alia with prolonged hospitalization, a doubling of care requirements, increased healthcare costs, increased need for institutionalization (OR 3.22), and increased mortality (OR 8.78). Predisposing factors for delirium were impaired activity (OR 10.82), frailty (OR 4.75); hearing (OR 2.23) and visual impairment (OR 1.89), chronic pneumonitis (OR 2.62), hypertension (OR 1.46), and renal insufficiency (OR 1.82). Precipitating factors were acute renal failure (OR 7.50), pressure sores (OR 3.78), pain (OR 2.86), and cystitis (OR 1.32). On multivariate Cox regression, delirium increased the mortality risk sixfold (HR 5.66). Age ≥ 65 years and comorbidities further doubled the mortality risk of delirious patients (HR 1.77; HR 2.05).

SIGNIFICANCE OF RESULTS

Delirium is common in cancer patients and associated with increased morbidity and mortality. Systematically categorizing predisposing and precipitating factors might yield new strategies for preventing and managing delirium in cancer patients.

Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients

Objectives

Patients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.

Methods

In this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.

Results

In 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).

Significance of results

The results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.

White Matter Lesions as Brain Frailty and Age are Risk Factors for Surgical Clipping of Unruptured Intracranial Aneurysms in the Elderly

INTRODUCTION

We aimed to identify the risk factors for surgical treatment of unruptured intracranial aneurysms (UIAs) in individuals aged >60 years, particularly focusing on white matter lesions (WMLs).

MATERIAL AND METHODS

We investigated a total of 214 patients with UIAs. The patient group comprised 53 males and 151 females with an average age of 68.2 years. UIA size ranged from 2.7 to 26 (mean: 7.3) mm. The primary endpoint of the study was patient prognosis evaluated at the time of discharge using the modified Rankin Scale. We examined the risk factors for poor outcome and WMLs using magnetic resonance imaging.

RESULTS

Poor outcome was observed in 23 (10.7%) patients. Significant correlations were observed between poor outcome and UIA size (P < 0.0001), UIAs located posteriorly (P = 0.0204), UIA thrombosis (P = 0.0002), and presence of WMLs (P < 0.0001) in univariate regression analysis. However, no significant correlations were noted between poor outcome and age (P = 0.1438). Multivariate logistic regression analyses showed significant correlations between poor outcome and UIA size (P < 0.0001), presence of WMLs (P = 0.001). Severe WMLs based on the Fazekas classification was correlated to age (P < 0.0001) and atherosclerosis (P = 0.0001). Severe WMLs were associated with ischemia (P < 0.001) and epilepsy (P = 0.0502) as well as length of hospitalization (P < 0.0001).

CONCLUSION

Severe WMLs are risk factors for surgical treatment of UIAs in the elderly. Surgical indications must be considered and caution should be taken when managing patients with severe WMLs.

Prospective, multi-centric benchmark study assessing delirium: prevalence, incidence and its correlates in hospitalized elderly Lebanese patients

BACKGROUND

With the increase in the proportion of elderly Lebanese patients, little is known about delirium's prevalence, incidence and correlated factors.

AIMS

To identify the prevalence, incidence and factors associated with overall and incident delirium in hospitalized elderly Lebanese patients.

METHODS

A convenient sample was recruited from three university hospitals affiliated to the Lebanese university faculty of medical sciences. We included patients aged more than 65 years. Baseline factors were examined upon presentation and the confusion assessment method (CAM) was used to detect prevalent delirium upon admission or within the first 48 h. Enrolled patients were then assessed every other day to detect incident delirium cases.

RESULTS

Among the 230 patients included, delirium prevalence was 17% and incidence 8.7%. We found that a history of falls (odds ratio (OR) = 5.12; p = 0.001), immobilization (OR = 7.33; p = 0.035), polypharmacy (OR = 5.07; p = 0.026) along with tachycardia (OR = 6.94; p = 0.03) and severe anemia (OR = 12.5; p = 0.005) upon admission were significant factors associated with overall delirium (incident and prevalent delirium cases). Whereas, living alone was significantly associated with lower odds for overall delirium (OR = 0.03; p = 0.02). Moreover, current smoking (OR = 14; p = 0.02), low oxygen saturation (OR = 9.6; p = 0.008) and severe anemia (OR = 8.4; p = 0.013) upon admission remained significantly associated with higher odds for incident delirium along with urine catheter placement (OR = 7.8; p = 0.015).

CONCLUSION

Secondary to the burden of delirium and its impact on mortality among elderly population, trying to understand and adjust modifiable factors would promote more appropriate prevention strategies.

Predisposing and precipitating risk factors for delirium in palliative care patients

Objective

Delirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.

Method

In this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.

Results

The prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).

Significance of results

Our study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.

The sensitivity of the human thirst response to changes in plasma osmolality: a systematic review

BACKGROUND

Dehydration is highly prevalent and is associated with adverse cardiovascular and renal events. Clinical assessment of dehydration lacks sensitivity. Perhaps a patient's thirst can provide an accurate guide to fluid therapy. This systematic review examines the sensitivity of thirst in responding to changes in plasma osmolality in participants of any age with no condition directly effecting their sense of thirst.

METHODS

Medline and EMBASE were searched up to June 2017. Inclusion criteria were all studies reporting the plasma osmolality threshold for the sensation of thirst.

RESULTS

A total of 12 trials were included that assessed thirst intensity on a visual analogue scale, as a function of plasma osmolality (pOsm), and employed linear regression to define the thirst threshold. This included 167 participants, both healthy controls and those with a range of pathologies, with a mean age of 41 (20-78) years.The value ±95% CI for the pOsm threshold for thirst sensation was found to be 285.23 ± 1.29 mOsm/kg. Above this threshold, thirst intensity as a function of pOsm had a mean ± SEM slope of 0.54 ± 0.07 cm/mOsm/kg. The mean ± 95% CI vasopressin release threshold was very similar to that of thirst, being 284.3 ± 0.71 mOsm/kg.Heterogeneity across studies can be accounted for by subtle variation in experimental protocol and data handling.

CONCLUSION

The thresholds for thirst activation and vasopressin release lie in the middle of the normal range of plasma osmolality. Thirst increases linearly as pOsm rises. Thus, osmotically balanced fluid administered as per a patient's sensation of thirst should result in a plasma osmolality within the normal range. This work received no funding.

The confused oncologic patient: a rational clinical approach

PURPOSE OF REVIEW

The purpose of this review is to provide a practical clinical approach to confusion in the patient with cancer. Confusion in the cancer population has a broader differential diagnosis than in the general medical population. The clinician must consider the usual differential diagnoses as well as causes unique to the cancer patient including direct complications from the cancer and indirect complications related to cancer treatment.

RECENT FINDINGS

In the recent age of precision medicine, the oncologist now utilizes the genomic profile of both the patient and the tumor to provide advanced biologic therapies including targeted anticancer drugs, antiangiogenic agents, and immunotherapy. Such advances carry with them an emerging pattern of neurotoxicity which, although less well described in the literature, is now an important consideration to the clinical approach to confusion in cancer patients.

SUMMARY

Confusion is the most common neurologic complication in cancer and is associated with significant morbidity, mortality, and prolonged hospital stays resulting in increased healthcare costs. Early recognition and treatment of delirium is essential to improve clinical outcomes.

Environmental and Clinical Risk Factors for Delirium in a Neurosurgical Center: A Prospective Study

BACKGROUND

Few reports of delirium-related risk factors have focused on environmental risk factors and clinical risk factors, such as white matter signal abnormalities on magnetic resonance imaging fluid attenuated inversion recovery images.

METHODS

We prospectively enrolled 253 patients admitted to our neurosurgical center between December 2014 and June 2015 and analyzed 220 patients (100 male patients; mean age, 64.1 years; age range, 17-92 years). An Intensive Care Delirium Screening Checklist score ≥4 points indicated delirium. We evaluated patient factors consisting of baseline characteristics and related factors, such as white matter lesions (WMLs), as well as the surrounding environment.

RESULTS

Delirium occurred in 29/220 cases (13.2%). Regarding baseline characteristics, there were significant statistical correlations between delirium and age (P = 0.0187), Hasegawa Dementia Scale-Revised score (P = 0.0022) on admission, and WMLs (P < 0.0001). WMLs were related to age (P < 0.0001) and atherosclerotic disease (P = 0.004). Regarding related factors, there were significant statistical correlations between delirium and stay in a neurosurgical care unit (P = 0.0245). Multivariate logistic regression analyses showed statistically significant correlations of delirium with WMLs (P < 0.0001) and surrounding patients with delirium (P = 0.026).

CONCLUSIONS

WMLs in patients and the surrounding environment are risk factors for delirium in a neurosurgical center. To prevent delirium, clinicians must recognize risk factors, such as high-grade WMLs, and manage environmental factors.

Risk Factors for Delirium After Spinal Surgery: A Meta-Analysis

OBJECTIVE

Postoperative delirium can occur following various types of surgeries. The specific risk factors for delirium following spinal surgery have not been systematically evaluated. The aim of this study is to conduct a meta-analysis of the risk factors for delirium after spinal surgery.

METHODS

PubMed, EMBASE, the Cochrane Library, and Science Citation Index were searched from inception to October 2014 for original research studies. Relevant studies on patients with delirium following spinal surgery were included if they identified at least 1 risk factor as being associated with delirium. The Newcastle-Ottawa Scale (NOS) was used for the study quality assessment, and the pooled odds ratios (ORs) were used for determining the risk factors.

RESULTS

Six articles met the inclusion criteria. Twenty-four risk factors in the multivariate analyses and 22 factors in the univariate analyses were significantly associated with delirium following spinal surgery. In the pooled analyses, age >65 years (OR: 6.13; 95% confidence interval [CI]: 5.75, 6.54); female sex (OR: 1.21; 95% CI: 1.15, 1.28); number of medications (mean difference [MD]: 1.36; 95% CI: 0.73, 2.00); low preoperative hematocrit (MD: -1.67; 95% CI: -2.97, -0.38) and albumin (MD: -0.33; 95% CI: -0.53, -0.13); duration of surgery (MD: 35.79; 95% CI: 1.42, 70.16); intraoperative blood loss (MD: 124.44; 95% CI: 100.03, 148.85); low postoperative hematocrit (MD: -2.58; 95% CI: -3.70, -1.46), hemoglobin (MD: -1.10; 95% CI: -1.86, -0.35), and sodium (MD: -2.97; 95% CI: -5.42, -0.51); and postoperative fever (OR: 4.52; 95% CI: 2.94, 6.95) were significantly associated with delirium.

CONCLUSIONS

Several risk factors were consistently associated with delirium following spinal surgery, which can be used to identify high-risk patients. Recognizing these patients is important for physicians to develop preventive strategies to reduce postoperative delirium and its negative consequences.