Reducing delirium after hip fracture: a randomized trial

Utilization of NIRS Monitor to Compare the Regional Cerebral Oxygen Saturation Between Dexmedetomidine and Propofol Sedation in Mechanically Ventilated Critically ill Patients with Sepsis- A Prospective Randomized Control Trial

AIM & BACKGROUND

Delirium frequently occurs in the acute phase of sepsis and is associated with increased ICU and hospital length of stay, duration of mechanical ventilation, and higher mortality rates. We utilized the Near-Infrared Spectroscopy monitor to measure and compare the regional cerebral oxygen saturation in mechanically ventilated patients of sepsis receiving either dexmedetomidine or propofol sedation and assessed the association between delirium and regional cerebral oxygen saturation.

METHODS

A single center prospective randomized control trial conducted over a period of two years, 54 patients were included, equally divided between propofol and dexmedetomidine groups. Patients received a blinded study drug, propofol (10 mg/mL) or dexmedetomidine (5 mcg/mL) via infusion pump according to randomization. Infusion rates were adjusted every 10 min based on weight-based titration tables, aiming for target sedation (RASS -2 to 0). Management components included pain monitoring using the CPOT score and delirium assessment using CAM-ICU score.

RESULTS

Dexmedetomidine group showed higher mean regional cerebral oxygen saturation as compared to propofol group (P = .036). No significant differences were found in mechanical ventilation or ICU stay durations, delirium-free days, or sedation cessation reasons. Delirium occurred in 36 patients, with lower mean regional cerebral oxygen saturation as compared to non-delirious patients.

CONCLUSION

The dexmedetomidine group had higher regional cerebral oxygen saturation compared to the propofol group. Delirious patients showed lower cerebral oxygen saturation than non-delirious patients, suggesting a link between sedation type, cerebral oxygenation, and delirium.CTRI registration: REF/2021/11/048655 N.

Efficacy of Postoperative Oral Nutritional Supplements in Geriatric Hip Fracture Patients Undergoing Total Hip Arthroplasty

Background/Objectives: Geriatric hip fracture patients have an increased risk of malnutrition. Proper nutritional supply in the perioperative period is very important for their recovery. Oral nutritional supplements (ONSs) are recommended in geriatric hip fracture patients to improve dietary intake and prevent complications. This study aimed to evaluate the efficacy of postoperative ONSs after total hip arthroplasty in geriatric hip fracture patients. Methods: A retrospective study of elderly patients who underwent total hip arthroplasty for hip fracture was conducted. Data from patients who received ONSs postoperatively until hospital discharge (ONS group, n = 69) were compared with patients who did not receive ONSs (control group, n = 168). Laboratory test results, including serum protein and albumin levels, length of hospital stay, and the incidence of postoperative medical complications of the two groups, were analyzed. Results: Preoperative serum protein and albumin levels were significantly higher in the control group (p = 0.002 and p = 0.010, respectively). However, the degree of decline for both protein and albumin levels was significantly less in the ONS group (p < 0.001 for both). Serum albumin levels were significantly higher in the ONS group at postoperative two-week follow-up (p = 0.006). The length of hospital stay was shorter in the ONS group (p < 0.001). The incidence of postoperative delirium was significantly higher in the control group (p = 0.007). Conclusions: In geriatric hip fracture patients, postoperative ONSs can improve postoperative nutritional status, shorten the length of hospital stay, and reduce the incidence of postoperative delirium.

Intranasal administration of insulin on the incidence of postoperative delirium in middle-aged patients undergoing elective on-pump cardiac surgery (INIPOD-MOPS): a prospective double-blinded randomized control study protocol

BACKGROUND

Delirium, marked by acute cognitive decline, poses a life-threatening issue among older individuals, especially after cardiac surgery, with prevalence ranging from 15 to 80%. Postoperative delirium is linked to increased morbidity and mortality. Although clinical trials suggest preventability, there is limited research on intranasal insulin (INI) for cardiac surgery-related delirium. INI has shown promise in managing cognitive disorders. It rapidly elevates brain hormone levels, enhancing memory even in non-impaired individuals. While effective in preventing delirium in gastrointestinal surgery, its impact after cardiac surgery remains understudied, especially for middle-aged patients.

METHOD

This is a prospective randomized, double-blind, single-center controlled trial. A total of 76 eligible participants scheduled for elective on-pump cardiac surgery will be enrolled and randomly assigned in a 1:1 ratio to either receive Intranasally administered insulin (INI) or intranasally administered normal saline. The primary outcome of our study is the incidence of postoperative delirium (POD). Secondary outcomes include duration of ICU, postoperative hospital length of stay, all in-hospital mortality, the change in MMSE scores pre- and post-operation, and incidence of postoperative cognitive dysfunction at 1 month, 3 months, and 6 months after operation. Moreover, we will subjectively and objectively evaluate perioperative sleep quality to investigate the potential impact of nasal insulin on the development of delirium by influencing sleep regulation.

DISCUSSION

Our study will aim to assess the impact of intranasal administration of insulin on the incidence of postoperative delirium in middle-aged patients undergoing on-pump elective cardiac surgery. If intranasal insulin proves to be more effective, it may be considered as a viable alternative for preventing postoperative delirium.

TRIAL REGISTRATION

ChiCTR ChiCTR2400081444. Registered on March 1, 2024.

Impact of a Delirium Protocol on Deliriogenic Medication Use in Hospitalized Older Veterans

Background The Southern Arizona VA Health Care System (SAVAHCS) implemented a delirium prevention and treatment protocol in 2019. Objective The primary objective of this study was to determine if the implementation of a delirium protocol influenced deliriogenic medication use in hospitalized geriatric veterans. The secondary objectives were to compare the rates of delirium diagnosis, hospital length-of-stay, and rates of newly started deliriogenic medications during admission pre- and post-protocol. Methods This study was a retrospective, secondary data analysis study. Veterans 65 years of age and older who were admitted to an inpatient medical ward at the SAVAHCS for 24 hours or more between January 1, 2018 and December 31, 2018 (pre-protocol) or January 1, 2021 and December 31, 2021 (post-protocol) were included. Patients were excluded if they had a diagnosis of alcohol or benzodiazepine withdrawal upon admission. Results A total of 5491 patients were included in this study; 2940 (53.5%) in the pre-protocol group and 2551 (46.5%) in the post-protocol group. Patients received at least one deliriogenic medication during their admission in the post-protocol group (36.2%) compared with the pre-protocol group (34.1%), but there was no statistically significant difference (P = 0.098). There were also no significant differences in the rates of documentation of delirium as a diagnosis at discharge, hospital length-of-stay, or the rates of newly started deliriogenic medications during admission between the groups. Conclusion Implementation of a delirium prevention and treatment protocol at the SAVAHCS did not significantly impact the use of deliriogenic medications in hospitalized geriatric veterans.

Frailty Is More Predictive of Mortality than Age in Patients With Hip Fractures

OBJECTIVES

To investigate the association between the Comprehensive Geriatric Assessment-based Frailty Index and adverse outcomes in older adult patients undergoing hip fracture surgery.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENTS

All patients aged 65 or older who underwent surgical repair of a hip fracture between May 2018 and August 2020 were identified through institutional database review.

OUTCOME MEASURES AND COMPARISONS

Data including demographics, FI, injury presentation, and hospital course were collected. Patients were grouped by FI as nonfrail (FI < 0.21), frail (0.21 ≤ FI < 0.45), and severely frail (FI > 0.45). Adverse outcomes of these groups were compared using Kaplan Meier survival analysis. Risk factors for 1-year rehospitalization and 2-year mortality were evaluated using Cox hazard regression.

RESULTS

Three hundred sixteen patients were included, with 62 nonfrail, 185 frail, and 69 severely frail patients. The total population was on average 83.8 years old, predominantly white (88.0%), and majority female (69.9%) with an average FI of 0.33 (SD: 0.14). The nonfrail cohort was on average 78.8 years old, 93.6% white, and 80.7% female; the frail cohort was on average 84.5 years old, 92.4% white, and 71.9% female; and the severely frail cohort was on average 86.4 years old, 71.0% white, and 55.1% female. Rate of 1-year readmission increased with frailty level, with a rate of 38% in nonfrail patients, 55.6% in frail patients, and 74.2% in severely frail patients (P = 0.001). The same pattern was seen in 2-year mortality rates, with a rate of 2.8% in nonfrail patients, 36.7% in frail patients, and 77.5% in severely frail patients (P < 0.0001). Being classified as frail or severely frail exhibited greater association with mortality within 2 years than age, with hazard ratio of 17.81 for frail patients and 56.81 for severely frail patients compared with 1.19 per 5 years of age.

CONCLUSIONS

Increased frailty as measured by the Frailty Index is significantly associated with increased 2-year mortality and 1-year hospital readmission rates after hip fracture surgery. Degree of frailty predicts mortality more strongly than age alone. Assessing frailty with the Frailty Index can identify higher-risk surgical candidates, facilitate clinical decision making, and guide discussions about goals of care with family members, surgeons, and geriatricians.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between preoperative persistent hyperglycemia and postoperative delirium in geriatric hip fracture patients

BACKGROUND

The management of preoperative blood glucose levels in reducing the incidence of postoperative delirium (POD) remains controversial. This study aims to investigate the impact of preoperative persistent hyperglycemia on POD in geriatric patients with hip fractures.

METHODS

This retrospective cohort study analyzed medical records of patients who underwent hip fracture surgery at a tertiary medical institution between January 2013 and November 2023. Patients were categorized based on preoperative hyperglycemia (hyperglycemia defined as ≥ 6.1mmol/L), clinical classification of hyperglycemia, and percentile thresholds. Multivariate logistic regression and propensity score matching analysis (PSM) were employed to assess the association between different levels of preoperative glucose and POD. Subgroup analysis was conducted to explore potential interactions.

RESULTS

A total of 1440 patients were included in this study, with an incidence rate of POD at 19.1% (275/1440). Utilizing multiple logistic analysis, we found that patients with hyperglycemia had a 1.65-fold increased risk of experiencing POD compared to those with normal preoperative glucose levels (95% CI: 1.17-2.32). Moreover, a significant upward trend was discerned in both the strength of association and the predicted probability of POD with higher preoperative glucose levels. PSM did not alter this trend, even after meticulous adjustments for potential confounding factors. Additionally, when treating preoperative glucose levels as a continuous variable, we observed a 6% increase in the risk of POD (95% CI: 1-12%) with each 1mmol/L elevation in preoperative glucose levels.

CONCLUSIONS

There exists a clear linear dose-response relationship between preoperative blood glucose levels and the risk of POD. Higher preoperative hyperglycemia was associated with a greater risk of POD.

CLINICAL TRIAL NUMBER

NCT06473324.

Gaps in cognitive care among older patients undergoing spine surgery

INTRODUCTION

Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under-recognized. It is well established that applying delirium preventive interventions to at-risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment.

METHODS

We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications.

RESULTS

Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients.

DISCUSSION

Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence-based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication.

Delirium management in perioperative geriatric services: a narrative review of non-pharmaceutical strategies

Delirium, a common complication in elderly surgical patients, poses significant challenges in perioperative care. Perioperative geriatric services (PGS) aim at managing comorbidities, postoperative complications, and initiating early recovery of mobility to enhance elderly patients' prognosis in the perioperative period. Studies have shown that patients with preoperative cognitive disorders are at a significantly increased risk of postoperative delirium. While postoperative delirium affects up to 70% of people over 60 and 90% of people with neurodegenerative diseases, it remains underdiagnosed in many cases. Postoperative delirium can lead to functional decline, prolonged hospitalization, increased healthcare costs, cognitive impairment, and psychological malaise. This article briefly summarizes the literature on delirium, its risk factors, and its non-pharmaceutical management strategies within the perioperative period. It highlights the importance of integrating cognitive and psychological assessments into perioperative care protocols to provide baseline data, improve patient outcomes, reduce hospital stays, and minimize complications associated with delirium. By embracing evidence-based delirium management protocols, healthcare professionals can better identify and manage delirium, ultimately improving the quality of care for elderly surgical patients, which would also benefit healthcare staff and healthcare institutions.

Can admission Braden skin score predict delirium in older adults in the intensive care unit? Results from a multicenter study

AIMS AND OBJECTIVES

To investigate whether a low Braden Skin Score (BSS), reflecting an increased risk of pressure injury, could predict the risk of delirium in older patients in the intensive care unit (ICU).

BACKGROUND

Delirium, a common acute encephalopathy syndrome in older ICU patients, is associated with prolonged hospital stay, long-term cognitive impairment and increased mortality. However, few studies have explored the relationship between BSS and delirium.

DESIGN

Multicenter cohort study.

METHODS

The study included 24,123 older adults from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and 1090 older adults from the eICU Collaborative Research Database (eICU-CRD), all of whom had a record of BSS on admission to the ICU. We used structured query language to extract relevant data from the electronic health records. Delirium, the primary outcome, was primarily diagnosed by the Confusion Assessment Method for the ICU or the Intensive Care Delirium Screening Checklist. Logistic regression models were used to validate the association between BSS and outcome. A STROBE checklist was the reporting guide for this study.

RESULTS

The median age within the MIMIC-IV and eICU-CRD databases was approximately 77 and 75 years, respectively, with 11,195 (46.4%) and 524 (48.1%) being female. The median BSS at enrollment in both databases was 15 (interquartile range: 13, 17). Multivariate logistic regression showed a negative association between BSS on ICU admission and the prevalence of delirium. Similar patterns were found in the eICU-CRD database.

CONCLUSIONS

This study found a significant negative relationship between ICU admission BSS and the prevalence of delirium in older patients.

RELEVANCE TO CLINICAL PRACTICE

The BSS, which is simple and accessible, may reflect the health and frailty of older patients. It is recommended that BSS assessment be included as an essential component of delirium management strategies for older patients in the ICU.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a retrospective cohort study, and no patients or the public were involved in the design and conduct of the study.

Risk factors and associated outcomes of postoperative delirium after open abdominal aortic aneurysm repair

OBJECTIVE

Open abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization.

METHODS

This was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival.

RESULTS

Overall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003).

CONCLUSIONS

POD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

There's No Place Like Home: Delirium as a Barrier in Geriatric Trauma

INTRODUCTION

Delirium is associated with a three-fold increase in frequency of 6-mo mortality following intensive care unit admission. Outside of mortality, it has been linked with severe morbidity including long-term cognitive decline, loss of autonomy, and increased risk of institutionalization. There is a paucity of literature regarding delirium and geriatric trauma patients. The aim of our study is to determine predictive factors of delirium in geriatric trauma patients.

METHODS

This is a retrospective review of all geriatric (>65 y) trauma patients with a documented frailty score at a Level I Trauma Center from 1/2019 to 9/2021. Univariate and multivariate logistic regressions were performed. Geriatric patients with delirium (D) and those without delirium (ND) were compared. Patients were excluded if they did not have a documented frailty score or died before admission.

RESULTS

One thousand three hundred and seventeen patients met criteria; 40 (3%) patients developed delirium. Neither age nor gender was different between the two groups. Frailty scores were not different between the two groups. Patients with documented delirium had a higher incidence of a positive drug screen on admission (85% versus 62.2%, P = 0.0034), higher median injury severity score (10 versus 9, P = 0.0088), and longer hospital (7 d versus 3 d, P < 0.001) and intensive care unit (1 d versus 0 d, P < 0.001) length of stay (LOS) than their ND counterparts. The D group had a higher frequency of benzodiazepine (47.5% versus 19.3%, P < 0.001) and narcotic use (77.5% versus 56.5%, P = 0.0085). Tethers nor bedrest orders were significantly associated with delirium. Incidence of urinary tract infection (12.5% versus 1%, P < 0.001) and restraint use (P < 0.001) were significantly associated with increased risk of delirium. Additionally, those with a diagnosis of delirium were more often discharged to a skilled nursing facility than those in the ND group (45% versus 30.8%, P = 0.0006).

CONCLUSIONS

We aimed to identify key predictive factors of delirium in our study population and found that certain factors correlated with higher frequencies of delirium in our geriatric trauma patients. Preadmission and early controlled substance use were significantly associated with delirium, as were the presence of urinary tract infection and extended intensive care unit LOS. By recognizing some of these modifiable factors, LOS may decrease while increasing the likelihood of discharge home.

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.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis

BACKGROUND

No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population.

OBJECTIVE

To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI.

METHODS

In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention.

RESULTS

Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%).

CONCLUSIONS

Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

Functional intervention following cardiac surgery to prevent postoperative delirium in older patients (FEEL WELL study)

BACKGROUND

Postoperative delirium is a common complication in patients after cardiac surgery, especially in older patients, and can manifest as a disturbance of attention and consciousness. It can lead to increased postoperative morbidity, prolonged need for care, and mortality. The presented study investigates whether the occurrence of postoperative delirium after cardiac surgery can be prevented by a multisensory stimulation. It was conducted as a prospective, randomized, controlled, non-pharmacological intervention study in the years 2021 and 2022 at the University Hospital Bonn in Germany. A total of 186 patients over 65 years with elective cardiac surgery were enrolled. Patients were randomized either to the intervention or control group. In both groups, postoperative delirium was assessed with the 3-min diagnostic interview for confusion assessment method on the first 5 days after surgery and pain was assessed using the Numeric Rating Scale. Multisensory stimulation was performed 20 min a day for the first three postoperative days in the intervention group.

RESULTS

The incidence of postoperative delirium was 22.6% in the intervention group and 49.5% in the control group (p < 0.001). Duration of postoperative delirium was significantly shorter in the intervention group (p < 0.001). Stay in the intensive care unit was significantly longer in the control group (p = 0.006). In the regression model non-intervention, high pain scores, advanced age, and prolonged mechanical ventilation were associated with postoperative delirium (p = 0.007; p = 0.032; p = 0.006; p = 0.006, respectively).

CONCLUSIONS

Results of the study imply that a multisensory stimulation done on the first 3 days after planned cardiac surgery can reduce the incidence and duration of postoperative delirium in older patients. Influence of the treatment on the incidence of delirium in other patient groups, the length of stay in the intensive care unit, and patients´ postoperative pain should be confirmed in further clinical studies.

TRIAL REGISTRATION

DRKS, DRKS00026909. Registered 28 October 2021, Retrospectively registered, https://drks.de/search/de/trial/DRKS00026909 .

Poorer outcomes in patients with early postoperative delirium: 120-day follow-up of the Delirium Reduction by Analgesia Management in Hip Fracture (DRAM-HF) study

OBJECTIVES

The Delirium Reduction by Analgesia Management-Hip Fracture (DRAM-HF) model of care, which incorporated a multicomponent intervention focussing on perioperative analgesia and medication optimisation, was associated with reduced Day 3 postoperative delirium (POD) amongst hip fracture patients. We investigated whether this effect was seen at 120 days postoperatively.

METHODS

We assessed 120-day outcomes in all patients who were included in the DRAM-HF study, by telephone, supplemented by electronic medical records, to include death (primary outcome), residential aged care facility (RACF) residence, patient/carer-reported frailty, hospital readmission and new dementia diagnosis.

RESULTS

Amongst 300 patients (mean age 81.1, 70% female, none lost to follow-up), by 120 days, 8% (n = 24) had died; 25% of survivors (n = 68/276) were RACF residents. Twenty-two per cent were readmitted (n = 61/281). A new dementia diagnosis was reported by 6% (n = 17/281). Intervention status in the DRAM-HF trial (intervention/control) was not associated with death by 120 days (OR 0.83, 95% CI 0.36-1.93, p = 0.67) or other outcomes assessed. POD was independently associated with 120-day death (aOR 3.3, 95% CI 1.2-9.2, p = 0.02), RACF residence (aOR 2.2, 95% CI 1.1-4.7, p = 0.03) and patient/carer-reported frailty (aOR 5.6, 95% CI 1.0-30.7, p = 0.05), but not readmission (p = 0.21) or new diagnosis of dementia (p = 0.08).

CONCLUSIONS

In this cohort, while the DRAM-HF bundle of care did not influence 120-day outcomes, patients who experienced POD had poorer clinical outcomes 120-day postfracture. Given that delirium was associated with death, RACF residence and frailty, models of care which have the potential to reduce POD may have benefits beyond the acute admission, and further investigation is needed.

The effect of anesthetic depth on postoperative delirium in older adults: a systematic review and meta-analysis

BACKGROUND

Postoperative delirium (POD) is an important complication for older patients and recent randomised controlled trials have showed a conflicting result of the effect of deep and light anesthesia.

METHODS

We included randomised controlled trials including older adults that evaluated the effect of anesthetic depth on postoperative delirium from PubMed, Embase, Web of Science and Cochrane Library. We considered deep anesthesia as observer's assessment of the alertness/ sedation scale (OAA/S) of 0-2 or targeted bispectral (BIS) < 45 and the light anesthesia was considered OAA/S 3-5 or targeted BIS > 50. The primary outcome was incidence of POD within 7 days after surgery. And the secondary outcomes were mortality and cognitive function 3 months or more after surgery. The quality of evidence was assessed via the grading of recommendations assessment, development, and evaluation approach.

RESULTS

We included 6 studies represented 7736 patients aged 60 years and older. We observed that the deep anesthesia would not increase incidence of POD when compared with the light anesthesia when 4 related studies were pooled (OR, 1.40; 95% CI, 0.63-3.08, P = 0.41, I2 = 82%, low certainty). And no significant was found in mortality (OR, 1.12; 95% CI, 0.93-1.35, P = 0.23, I2 = 0%, high certainty) and cognitive function (OR, 1.13; 95% CI, 0.67-1.91, P = 0.64, I2 = 13%, high certainty) 3 months or more after surgery between deep anesthesia and light anesthesia.

CONCLUSIONS

Low-quality evidence suggests that light general anesthesia was not associated with lower POD incidence than deep general anesthesia. And High-quality evidence showed that anesthetic depth did not affect the long-term mortality and cognitive function.

SYSTEMATIC REVIEW REGISTRATION

CRD42022300829 (PROSPERO).

Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients.

DESIGN

A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022.

SETTING

Postoperative assessments.

PATIENTS

Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded.

MEASUREMENTS

Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI.

MAIN RESULTS

Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00).

CONCLUSIONS

Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.

Indoor falls and number of previous falls are independent risk factors for long-term mortality after a hip fracture

BACKGROUND

Hip fractures are almost always the result of a fall. Causes and circumstances of falls may differ between frail and vigorous patients.

AIM

To describe the circumstances of falls causing hip fractures, number of falls during the previous year, and their association with long-term mortality.

PATIENTS AND METHODS

The study is a retrospective review conducted in a tertiary university hospital serving a population of 425,000 inhabitants in Barcelona. All patients admitted with hip fractures with medical records describing the circumstances and number of previous falls were included. The number of falls in the previous 12 months was recorded, including the one causing the fracture. The circumstances of the index fall were dichotomized according to whether it was from the patient's own height or above; day or night; indoors or outdoors, due to intrinsic or extrinsic causes. Cumulative mortality was recorded for almost 5 years after hip fracture.

RESULTS

Indoor falls were strongly associated with shorter survival. Falling more than once in the previous year was also a risk factor for long-term mortality (hazard ratio 1.461, p < 0.001 and hazard ratio 1.035, p = 0.008 respectively).

CONCLUSION

Indoor falls and falling more than once in the previous year are long-term risk factors for mortality after hip fractures. It is always essential to take a careful patient history on admission to determine the number of falls and their circumstances, and special care should be taken to reduce mortality in patients at high risk.

The Effect of Dexmedetomidine on the Mini-Cog Score and High-Mobility Group Box 1 Levels in Elderly Patients with Postoperative Neurocognitive Disorders Undergoing Orthopedic Surgery

Dexmedetomidine prevents postoperative cognitive dysfunction by inhibiting high-mobility group box 1 (HMGB1), which acts as an inflammatory marker. This study investigated the HMGB1 levels and the cognitive function using a Mini-Cog© score in elderly patients undergoing orthopedic surgery with dexmedetomidine infusion. In total, 128 patients aged ≥ 65 years were analyzed. The patients received saline in the control group and dexmedetomidine in the dexmedetomidine group until the end of surgery. Blood sampling and the Mini-Cog© test were performed before the surgery and on postoperative days 1 and 3. The primary outcomes were the effect of dexmedetomidine on the HMGB1 levels and the Mini-Cog© score in terms of postoperative cognitive function. The Mini-Cog© score over time differed significantly between the groups (p = 0.008), with an increase in the dexmedetomidine group. The postoperative HMGB1 levels increased over time in both groups; however, there was no significant difference between the groups (p = 0.969). The probability of perioperative neurocognitive disorders decreased by 0.48 times as the Mini-Cog© score on postoperative day 3 increased by 1 point. Intraoperative dexmedetomidine has shown an increase in the postoperative Mini-Cog© score. Thus, the Mini-Cog© score is a potential tool for evaluating cognitive function in elderly patients.

Delirium and neuropsychological recovery among emergency general surgery survivors (DANE): study protocol for a randomized controlled trial and collaborative care intervention

BACKGROUND

Delirium is a complex neuropsychiatric syndrome which consists of acute and varying changes in cognition and consciousness. Patients who develop delirium are at increased risk for a constellation of physical, cognitive, and psychological disabilities long after the delirium has ended. Collaborative care models integrating primary and specialty care in order to address patients with complex biopsychosocial needs have been demonstrated to improve outcomes in patients with chronic diseases. The purpose of this study is to evaluate the ability of a collaborative care model on the neuropsychologic recovery of delirium survivors following emergency surgery.

METHODS

This protocol describes a multicenter (eight hospitals in three states) randomized controlled trial in which 528 patients who develop delirium following emergency surgery will be randomized to either a collaborative care model or usual care. The efficacy of the collaborative care model on cognitive, physical, and psychological recovery in these delirium survivors will then be evaluated over 18 months.

DISCUSSION

This will be among the first randomized clinical trials in postoperative delirium survivors evaluating an intervention designed to mitigate the downstream effects of delirium and improve the neuropsychologic recovery after surgery. We hope that the results of this study will add to and inform strategies to improve postoperative recovery in this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05373017. Registered on May 12, 2022.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

OBJECTIVES

To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes.

METHODS

An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use.

RESULTS

Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001).

CONCLUSIONS

A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Diagnosing delirium in perioperative and intensive care medicine

PURPOSE OF REVIEW

This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent findings to guide clinicians and researchers in choosing the most appropriate tools.

RECENT FINDINGS

The incidence of delirium in hospitalized patients ranges from 5% to over 50%, depending on the population of patients studied. Failure to diagnose delirium in a timely manner is associated with serious adverse outcomes, including death and institutionalization. Valid assessment tests are needed for delirium detection, as early identification and treatment of delirium may help to prevent complications. Currently, there are more than 30 available instruments, which have been developed to assist with the screening and diagnosis of delirium. However, these tools vary greatly in sensitivity, specificity, and administration time, and their overabundance challenges the selection of specific tool as well as direct comparisons and interpretation of results across studies.

SUMMARY

Overlooking or misdiagnosing delirium may result in poor patient outcomes. Familiarizing healthcare workers with the variety of delirium assessments and selecting the most appropriate tool to their needs is an important step toward improving awareness and recognition of delirium.

Delirium and Neuropsychological Recovery among Emergency General Surgery Survivors (DANE): study protocol for a randomized controlled trial and collaborative care intervention

Background: Delirium is a complex neuropsychiatric syndrome which consists of acute and varying changes in cognition and consciousness. Patients who develop delirium are at increased risk for a constellation of physical, cognitive, and psychological disability long after the delirium has ended. Collaborative care models integrating primary and specialty care in order to address patients with complex biopsychosocial needs has been demonstrated to improve outcomes in patients with chronic diseases. The purpose of this study is to evaluate the ability of a collaborative care model on the neuropsychologic recovery of delirium survivors following emergency surgery. Methods: This protocol describes a multicenter (eight hospitals in three states) randomized controlled trial in which 528 patients who develop delirium following emergency surgery will be randomized to either a collaborative care model or usual care. The efficacy of the collaborative care model on cognitive, physical, and psychological recovery in this delirium survivors will then be evaluated over eighteen months. Discussion: This will be among the first randomized clinical trials in postoperative delirium survivors evaluating an intervention designed to mitigate the downstream effects of delirium and improve the neuropsychologic recovery after surgery. We hope that the results of this study will add to and inform strategies to improve postoperative recovery in this patient group. Trial registration: NCT05373017 (clinicaltrials.gov).

Managing Geriatric Patients with Falls and Fractures

Orthopedic fractures in adults 65 and older are common and can lead to functional decline and increased morbidity and mortality. Falls are often the precipitating event for fractures in this population, linked to common aging physiology with increasing comorbid conditions and advancing frailty. Managing falls and orthopedic fractures in the geriatric population is complex, requiring a systematic and collaborative approach spearheaded by a multidisciplinary team focused on improving patient outcomes.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Does melatonin administration reduce the incidence of postoperative delirium in adults? Systematic review and meta-analysis

Postoperative delirium (POD) is common. It is associated with increased morbidity and mortality. Many cases may be preventable and melatonin offers promise as a preventative agent.

OBJECTIVE

This systematic review provides an up-to-date synthesis of the evidence on the effect of melatonin in preventing POD.

DESIGN

A systematic search of randomised controlled trials of melatonin in POD was run across multiple databases (EMBASE, MEDLINE, CINAHL, PsycINFO) and a clinical trials registry (ClinicalTrials.org) (1 January 1990 to 5 April 2022). Studies examining the effects of melatonin on POD incidence in adults are included. Risk of bias was assessed using the Cochrane risk of bias 2 tool.

OUTCOME MEASURES

The primary outcome is POD incidence. Secondary outcomes are POD duration and length of hospital stay. Data synthesis was undertaken using a random-effects meta-analysis and presented using forest plots. A summary of methodology and outcome measures in included studies is also presented.

RESULTS

Eleven studies, with 1244 patients from a range of surgical specialties were included. Seven studies used melatonin, in variable doses, and four used ramelteon. Eight different diagnostic tools were used to diagnose POD. Time points for assessment also varied. Six studies were assessed as low risk of bias and five as some concern. The combined OR of developing POD in the melatonin groups versus control was 0.41 (95% CI 0.21 to 0.80, p=0.01).

CONCLUSION

This review found that melatonin may reduce the incidence of POD in adults undergoing surgery. However, included studies displayed inconsistency in their methodology and outcome reporting. Further work to determine the optimum regime for melatonin administration, along with consensus of how best to evaluate results, would be beneficial.

PROSPERO REGISTRATION NUMBER

CRD42021285019.

Quality contract 'prevention of postoperative delirium in the care of elderly patients' study protocol: a non-randomised, pre-post, monocentric, prospective trial

INTRODUCTION

Postoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a 'quality contract' (QC) as a new instrument to improve healthcare in Germany. One of the four areas for improvement of in-patient care is the 'Prevention of POD in the care of elderly patients' (QC-POD), as a means to reduce the risk of developing POD and its complications.The Institute for Quality Assurance and Transparency in Health Care identified gaps in the in-patient care of elderly patients related to the prevention, screening and treatment of POD, as required by consensus-based and evidence-based delirium guidelines. This paper introduces the QC-POD protocol, which aims to implement these guidelines into the clinical routine. There is an urgent need for well-structured, standardised and interdisciplinary pathways that enable the reliable screening and treatment of POD. Along with effective preventive measures, these concepts have a considerable potential to improve the care of elderly patients.

METHODS AND ANALYSIS

The QC-POD study is a non-randomised, pre-post, monocentric, prospective trial with an interventional concept following a baseline control period. The QC-POD trial was initiated on 1 April 2020 between Charité-Universitätsmedizin Berlin and the German health insurance company BARMER and will end on 30 June 2023.

INCLUSION CRITERIA

patients 70 years of age or older that are scheduled for a surgical procedure requiring anaesthesia and insurance with the QC partner (BARMER). Exclusion criteria included patients with a language barrier, moribund patients and those unwilling or unable to provide informed consent. The QC-POD protocol provides perioperative intervention at least two times per day, with delirium screening and non-pharmacological preventive measures.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/054/20). The results will be published in a peer-reviewed scientific journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04355195.

Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management

Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.

Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol

INTRODUCTION

The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture.

METHODS

A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05.

RESULTS

One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272).

CONCLUSION

The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.

The high-risk hip fracture patient and the palliative care consult : A retrospective study to investigate risks of complications and the utility of a palliative care consult in hip fracture patients undergoing surgical fixation

We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications and is associated with a delay to surgery in the high-risk patient population that it served.

PURPOSE

The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR).

METHODS

Retrospective cohort at a Level I academic trauma center.

RESULTS

Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13-4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43-15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34-6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0-1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3-3.9, p = .005), renal failure (OR 3.1, CI 1.1-9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2-5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4-15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4-22.7, p = .017).

CONCLUSIONS

Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.

The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit

Objective

The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties.

Methods

We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins.

Results

Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2.

Conclusion

The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as prognostic predictors for delirium in critically ill patients: a systematic review and meta-analysis

INTRODUCTION

In this systematic review and meta-analysis, we aim to analyze the current literature to evaluate neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) values among critically ill patients who develop delirium as compared to those who do not.

METHODS

PubMed, Web of Science, and Scopus were used to conduct a systematic search for relevant publications published before June 12, 2022. The Newcastle-Ottawa scale was used for quality assessment. Because a significant level of heterogeneity was found, we used the random-effects model to generate pooled effects.

RESULTS

Twenty-four studies including 11,579 critically ill patients, of whom 2439 were diagnosed with delirium, were included in our meta-analysis. Compared with the non-delirious group, the delirious group's NLR levels were significantly higher (WMD = 2.14; CI 95% = 1.48-2.80, p < 0.01). In the subgroup analysis according to the type of critical condition, the NLR levels in patients of delirious group were significantly more than those of non-delirious group in studies on POD, PSD and PCD (WMD = 1.14, CI 95% = 0.38-1.91, p < 0.01, WMD = 1.38, CI 95% = 1.04-1.72, p < 0.001, and WMD = 4.22, CI 95% = 3.47-4.98, p < 0.001, respectively). However, compared with the non-delirious group, the delirious group's PLR levels were not significantly different (WMD = 1.74; CI 95% = -12.39-15.86, p = 0.80).

CONCLUSION

Our findings support NLR to be a promising biomarker that can be readily integrated into clinical settings to aid in the prediction and prevention of delirium.

Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes

Purpose

The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery.

Patients and Methods

A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria.

Results

The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)).

Conclusion

Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.

Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies

Postoperative delirium (POD) is an acute alteration of mental state, characterized by reduced awareness and attention, occurring up to five postoperative days after recovery from anesthesia. Several original studies and reviews have identified possible perioperative POD risk factors; however, there is no comprehensive review of the preoperative risk factors in patients diagnosed with POD using only validated diagnostic scales. The aim of this systematic review was to report the preoperative risk factors associated with an increased incidence of POD in patients undergoing non-cardiac and non-brain surgery. The reviewed studies included original research papers that used at least one validated diagnostic scale to identify POD occurrence for more than 24 h. A total of 6475 references were retrieved from the database search, with only 260 of them being suitable for further review. Out of the 260 reviewed studies, only 165 that used a validated POD scale reported one or more preoperative risk factors. Forty-one risk factors were identified, with various levels of statistical significance. The extracted risk factors could serve as a preoperative POD risk assessment workup. Future studies dedicated to the further evaluation of the specific preoperative risk factors' contributions to POD could help with the development of a weighted screening tool.

Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review

INTRODUCTION

Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS.

METHOD

This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed.

RESULTS

There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months.

CONCLUSIONS

Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.

A retrospective analysis of the incidence of postoperative delirium and the importance of database selection for its definition

BACKGROUND

Postoperative delirium (POD) is a common complication after major surgery, resulting in various adverse reactions. However, incidence and risk factors associated with POD after shoulder arthroplasty (SA) have not been well studied using a large-scale national database.

METHODS

A retrospective database analysis was performed based on the Nationwide Inpatient Sample (NIS) from 2005 to 2014, the largest fully paid hospital care database in the United States. Patients undergoing SA were included. The patient's demographics, comorbidities, length of stay (LOS), total costs, type of insurance, type of hospital, in-hospital mortality, and medical and surgical perioperative complications were assessed.

RESULTS

A total of 115,147 SA patients were obtained from the NIS database. The general incidence of delirium after SA was 0.89%, peaking in 2010. Patients with delirium after SA had more comorbidities, prolonged LOS, increased hospitalization costs, and higher in-hospital mortality (P < 0.0001). These patients were associated with medical complications during hospitalization, including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, urinary tract infection, sepsis, continuous invasive mechanical ventilation, blood transfusion, and overall perioperative complications. Risk factors associated with POD include advanced age, neurological disease, depression, psychosis, fluid and electrolyte disturbances, and renal failure. Protective factors include elective hospital admissions and private insurance.

CONCLUSION

The incidence of delirium after SA is relatively low. Delirium after SA was associated with increased comorbidities, LOS, overall costs, Medicare coverage, mortality, and perioperative complications. Studying risk factors for POD can help ensure appropriate management and mitigate its consequences. Meanwhile, we found some limitations of this type of research and the need to establish a country-based POD database, including further clearly defining the diagnostic criteria for POD, investigating risk factors and continuing to collect data after discharge (30 days or more), so as to further improve patient preoperative optimization and management.

Physiotherapists´ experiences with older adults´ rehabilitation trajectory after hip fracture: A qualitative study in Western Norway

BACKGROUND

Norway reports the highest prevalence of hip fractures in the world. Physiotherapists play a key-role in rehabilitation.

PURPOSE

To explore physiotherapists' experiences with rehabilitation trajectories of older adults after hip fracture across levels of care in Norway.

METHODS

A case-study design combined interviews and group-discussions with 22 physiotherapists in four hospitals and 12 primary health care settings in urban and rural municipalities in 2016 and 2018. A thematic content analysis was applied.

RESULTS

The physiotherapists viewed the rehabilitation trajectory after hip fracture as fragmented and poorly suited for patients with complex needs. Early hospital discharge, multiple transfers and insufficient staffing, put patients at risk of not receiving adequate services. Most at risk were patients with cognitive impairment. The physiotherapists' role and influence during the patients' rehabilitation course varied, depending on the health-care level. They viewed that current reforms and structural conditions limited the quality of geriatric care and the prioritization of patients with dementia, who risked getting no rehabilitation at all.

CONCLUSION

An orthogeriatric, person-centered approach to rehabilitation after hip fracture seems beneficial. A focus on cognitive impairment is needed requiring investment and professional skills' development. Political, economic, and organizational interventions should secure that, geriatric patients receive necessary rehabilitation services.

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs

BACKGROUND

Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs.

METHODS

Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration).

RESULTS

All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group.

CONCLUSIONS

A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

Association of preoperative prognostic nutritional index with risk of postoperative delirium: A systematic review and meta-analysis

Study objective

To assess the association between prognostic nutritional index (PNI) and risk of postoperative delirium (POD) in adult patients.

Methods

MEDLINE, Google scholar, EMBASE, and Cochrane library databases were searched from inception till April 2022. The primary outcome was the association between PNI and the risk of POD, while the secondary outcomes were correlations of other prognostic factors with POD risk. The correlation between PNI and the incidence of POD was assessed with three approaches: Difference in preoperative PNI between POD and non-POD groups (Model 1) as well as the association of PNI as a continuous parameter (Model 2) or as a binary variable (i.e., low vs. high using a PNI cut-off value of 50) (Model 3) with POD risk.

Results

Analysis of nine observational studies published from 2010 to 2021 recruiting 3,743 patients showed a POD incidence of 6.4-35%. Our meta-analysis demonstrated a lower PNI among patients in the POD group (MD: -3.78, 95% CI: -4.85 to -2.71, p < 0.0001, I ² = 54.2%) compared to the non-POD group (Model 1). Pooled results revealed a negative association between PNI and POD risk for both Model 2 (OR: 0.91, 95% CI: 0.86-0.97, p = 0.002, I ² = 71%) and Model 3 (OR: 1.68, 95% CI: 1.26-2.23, p < 0.0001, I ² = 0%). Besides, while our results supported an age-dependent increase in POD risk, other factors including body-mass index, surgical time, health status, hypertension, diabetes mellitus, and male gender were non-significant predictors of POD.

Conclusion

Our results demonstrated a negative association between PNI and POD, which warrant further large-scale studies for validation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022323809.

Improving the Prevention, Detection, and Management of Delirium in Adult Inpatients; an Interprofessional Consultative Team Pilot Project

Delirium is a common, often preventable fluctuating state of cognition associated with increased morbidity and mortality. This report describes the implementation of an interprofessional consultative Delirium Team formed to improve the prevention, detection, and management of delirium in a community hospital. Team members consulted refered inpatients with delirium to establish a care plan and provide recommendations for pharmacological and non-pharmacological management. The team also offered delirium-related education to unit staff, patients, and caregivers. Consultations were initially completed by the team Nurse Practitioner or Occupational Therapist, and complex patients were discussed with the team Geriatrician and Psychiatrist at rounds to optimize specialist input. Of the 160 patients managed by the team over the 8-month study period, two-thirds of referred patients did not require specialist consultation for their delirium management. Strategies most often recommended by experts for managing delirium were related to medical management, social/cognitive engagement, and functional mobility. Two-thirds of all recommendations made by the team were implemented. Barriers and facilitators to implementation and improving unit staff adherence are further described. The consultative Delirium Team is a promising model that should be further explored for managing an aging population in a capacity-limited medical system.

Association between Malnutrition and Delirium in Older Chronic Kidney Disease Patients Admitted to Intensive Care Units: A Data Linkage Study

BACKGROUND

Independently, malnutrition and delirium in older hospitalised adults is prevalent. However, there is limited evidence on the association between these two conditions in older hospitalised adults with chronic kidney disease (CKD).

OBJECTIVES

To determine the association between malnutrition and delirium in older CKD patients admitted to intensive care units (ICU).

METHODS

This data linkage study utilised administrative data from New South Wales (NSW) hospitals in Australia between 2017 and 2020.Admitted patient data was linked with Cause of Death Unit Record File, and NSW Registry of Deaths (RBD). The study population comprised all CKD patients aged 65 and over admitted to ICUs. Descriptive statistics were used to summarise patient characteristics. Binary logistic tested for association between malnutrition and delirium.

RESULTS

The study population included 748 CKD patients with a total 948 admissions in the study period. The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) was used to code for all outcomes and comorbidities. The incidence of delirium was 15.5% (n=141) and malnutrition was recorded in 11.3% (n=103) across all admissions. The adjusted odds ratio (OR) of a delirium diagnosis was 2.07 (95% CI: 1.27-3.39) for CKD patients that were malnourished compared to non-malnourished CKD patients.

CONCLUSIONS

This study showed a significant association between delirium and malnutrition in older CKD patients admitted to ICU. Management of malnutrition could be critical in reducing the risk of delirium in older hospitalized patients with CKD. Additionally, more education and awareness around delirium and its association with malnutrition are needed in clinical practice.

Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review

Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan

OBJECTIVES

Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment.

DESIGN

Retrospective, cross-sectional, observational study.

SETTING

Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020.

PARTICIPANTS

Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10^th Revision codes or antipsychotic prescriptions.

OUTCOME MEASURES

Total medical costs during hospitalisation were compared between the groups using a generalised linear model.

RESULTS

The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia.

CONCLUSIONS

Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge

Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.

Impact of early mobilization on the duration of delirium in elderly hospitalized patients: A retrospective cohort pilot study

Development of delirium during hospitalization impairs the activities of daily living in elderly hospitalized patients. In clinical practice, early mobilization from bed is recommended to reduce delirium incidence and hospitalization stay. However, the effects of early mobilization on elderly inpatients with delirium have not been established yet. The aim of this study was to investigate the association between early mobilization and the duration of delirium in elderly inpatients with delirium. This retrospective cohort pilot study examined 45 participants (23 males, 22 females; mean age: 84.5 ± 6.6 years), who developed delirium during hospitalization. Of the participants, 28 were surgically treated and 17 were non-surgically treated. We classified early or delayed mobilization based on the median number of days until the start of mobilization and compared after propensity score matching to adjust for baseline characteristics. Additionally, we examined the correlation between the number of days until the start of mobilization and the duration of delirium. The duration of delirium was significantly shorter in the early mobilization group, particularly in terms of sitting on the bed and wheelchair use than that in the delayed mobilization group {median: 4.0 [interquartile range (IQR): 2.0-6.0] vs 8.0 [IQR: 7.0-14.5] days, P = .013; median: 3.0 [IQR: 2.0-5.5] vs 11.0 [IQR: 7.5-14.5] days, P = .004, respectively}. Moreover, the duration of delirium significantly positively moderate correlated with the time until the start of sitting on the bed and wheelchair use (Spearman r = 0.527; P = .012, Spearman r = 0.630; P = .002, respectively). The results of this study suggest that early mobilization from sitting on the bed or wheelchair use after hospitalization or surgery may shorten the duration of delirium. Because the sample size of this pilot study is small, careful interpretation is needed, and further research is warranted.

Platform trials for anaesthesia and perioperative medicine: a narrative review

Large randomised trials provide the most reliable evidence of effectiveness of new treatments in clinical practice. However, the time and resources required to complete such trials can be daunting. An overarching clinical trial platform focused on a single condition or type of surgery, aiming to compare several treatments, with an option to stop any or add in new treatment options, can provide greater efficiency. This has the potential to accelerate knowledge acquisition and identify effective, ineffective, or harmful treatments faster. The master protocol of the platform defines the study population(s) and standardised procedures. Ineffective or harmful treatments can be discarded or study drug dose modified during the life cycle of the trial. Other adaptive elements that can be modified include eligibility criteria, required sample size for any comparison(s), randomisation assignment ratio, and the addition of other promising treatment options. There are excellent opportunities for anaesthetists to establish platform trials in perioperative medicine. Platform trials are highly efficient, with the potential to provide quicker answers to important clinical questions that lead to improved patient care.

New onset delirium prediction using machine learning and long short-term memory (LSTM) in electronic health record

OBJECTIVE

To develop and test an accurate deep learning model for predicting new onset delirium in hospitalized adult patients.

METHODS

Using electronic health record (EHR) data extracted from a large academic medical center, we developed a model combining long short-term memory (LSTM) and machine learning to predict new onset delirium and compared its performance with machine-learning-only models (logistic regression, random forest, support vector machine, neural network, and LightGBM). The labels of models were confusion assessment method (CAM) assessments. We evaluated models on a hold-out dataset. We calculated Shapley additive explanations (SHAP) measures to gauge the feature impact on the model.

RESULTS

A total of 331 489 CAM assessments with 896 features from 34 035 patients were included. The LightGBM model achieved the best performance (AUC 0.927 [0.924, 0.929] and F1 0.626 [0.618, 0.634]) among the machine learning models. When combined with the LSTM model, the final model's performance improved significantly (P = .001) with AUC 0.952 [0.950, 0.955] and F1 0.759 [0.755, 0.765]. The precision value of the combined model improved from 0.497 to 0.751 with a fixed recall of 0.8. Using the mean absolute SHAP values, we identified the top 20 features, including age, heart rate, Richmond Agitation-Sedation Scale score, Morse fall risk score, pulse, respiratory rate, and level of care.

CONCLUSION

Leveraging LSTM to capture temporal trends and combining it with the LightGBM model can significantly improve the prediction of new onset delirium, providing an algorithmic basis for the subsequent development of clinical decision support tools for proactive delirium interventions.