A multicomponent intervention to prevent delirium in hospitalized older patients

Mobility Loss in Hospitalized Adults Predicts Poor Clinical Outcomes

BACKGROUND

The Johns Hopkins Activity and Mobility Program is a systematic approach to measure and improve patient mobility.

PURPOSE

The purpose of this study was to evaluate the relationship between mobility loss and quality outcomes.

METHODS

A retrospective cohort study design was used. Patients were categorized into 3 groups (gain, loss, no change in mobility) using the Johns Hopkins Highest Level of Mobility (JH-HLM) scores. The association between mobility loss and falls risk, in-hospital mortality, delirium, discharge to a facility, length of stay, and 30 day readmissions were assessed.

RESULTS

Those who lost mobility were more at risk of being a high fall risk, in-hospital mortality, delirium, discharging to a facility, and had 48% longer lengths of stay. There was no association between mobility loss and 30-day readmissions.

CONCLUSIONS

Loss of mobility assessed using JH-HLM scores is associated with worse patient outcomes.

Postoperative neurocognitive disorders in ambulatory surgery: a narrative review

Postoperative neurocognitive disorders (PoNCDs), such as postoperative delirium and cognitive dysfunction or decline can occur after surgery, especially in older patients. This significantly affects patient morbidity and surgical outcomes. Among various risk factors, recent studies have shown that preoperative frailty is associated with developing these conditions. Although the mechanisms underlying PoNCDs remain unclear, neuroinflammation appears to play an important role in their development. For the prevention and treatment of PoNCDs, medication modification, a balanced diet, and prehabilitation and rehabilitation programs have been suggested. The risk of developing PoNCDs is thought to be lower in ambulatory patients. However, owing to technological advancements, an increasing number of older and sicker patients are undergoing more complex surgeries and are often not closely monitored after discharge. Therefore, equal attention should be paid to all patient populations. This article presents an overview of PoNCDs and highlights issues of particular interest for ambulatory surgery.

Diagnostic Approach to the Patient with Altered Mental Status

Acute encephalopathy is a common presenting symptom in the emergency room and complicates many hospital and intensive care unit admissions. The evaluation of patients with encephalopathy poses several challenges: limited history and examination due to the patient's mental status, broad differential diagnosis of systemic and neurologic etiologies, low yield of neurodiagnostic testing due to the high base rate of systemic causes, and the importance of identifying less common neurologic causes of encephalopathy that can be life-threatening if not identified and treated. This article discusses the differential diagnosis of acute encephalopathy, presents an approach to the history and examination in a patient with encephalopathy, reviews the literature on the yield of neurodiagnostic testing in this population, and provides a diagnostic framework for the evaluation of patients with altered mental status.

A first assessment of the safe brain initiative care bundle for addressing postoperative delirium in the postanesthesia care unit

BACKGROUND

Postoperative delirium (POD) following surgery is a prevalent and distressing condition associated with adverse patient outcomes and an increased healthcare burden.

OBJECTIVES

To assess the effectiveness of the Safe Brain Initiative care bundle (SBI-CB) in reducing POD in the postanesthesia care unit (PACU).

DESIGN

A multicenter, quality-improvement initiative with retrospective analysis of collected data.

SETTING

The study was conducted in the operating rooms and postanesthesia care units (PACUs) of four hospitals across Denmark and Turkey.

PATIENTS

The convenience sample of patients were aged ≥18 years, scheduled for surgery, and could communicate verbally. Age, sex, preoperative delirium, and the American Society for Anesthesiology physical status classification were used in statistical methods to control for potential confounding influences.

INTERVENTION

The SBI-CB, 18 delirium-reducing recommendations aligned with international guidelines. The intervention included patient education, staff training, coordination meetings across centers, and a dashboard for the monitoring of outcomes in the PACU.

MAIN OUTCOME MEASURES

The primary outcome was the POD trend in the PACU during implementation months, assessed through Nu-DESC screening at up to three time points in the PACU. We also examined the length of hospital stay.

RESULTS

Data were collected from 18,697 adult patients across four hospitals. Initial POD incidence in the PACU after the first three months was 16.36% across all sites (n = 1021). POD in the PACU was observed across all age groups, with peak incidence in younger (18-35 years) and older (>75 years) patients. General anesthesia and longer surgical duration (>1 h) were identified as significant risk factors for POD in the PACU. Matched patients who experienced POD in the PACU had longer stays in hospital, with a mean increase from 35 to 69 h (p < 0.001). Implementation of the SBI-CB was associated with a decreased risk of POD in the PACU for each month of SBI-CB implementation (adjusted odds ratio 0.96, 95% confidence interval: [0.94, 0.97], p < 0.001).

CONCLUSIONS

The presented pragmatic implementation of a multidisciplinary care bundle, encompassing pre-, intra-, and postoperative measures alongside outcome monitoring, has the potential to significantly reduce the incidence of POD in the PACU. Improved patient outcomes may be achieved for general surgical departments with patient cohorts not typically considered at risk for developing POD.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT05765162.

A nomogram for predicting the risk of postoperative delirium in individuals undergoing cardiovascular surgery

BACKGROUND AND PURPOSE

Delirium is a common mental disorder after adult cardiovascular surgery. Fifteen to 23% of patients undergoing cardiovascular surgery and cardiomyopathy experience delirium, and the efficacy of treatment interventions for delirium has been consistently unsatisfactory.

METHODS

A total of 729 patients who underwent cardiovascular surgery were randomly allocated into a training set and a validation set. A nomogram was developed using a logistic regression model to predict the incidence of delirium following cardiovascular surgery. The validity of the model was assessed by determining the receiver operating characteristic (ROC) curve, calculating the area under the ROC curve (AUROC), performing a calibration plot, and executing a decision curve analysis. This model was internally validated using the bootstrap method.

RESULTS

Postoperative delirium (POD) occurred in 165 cases (22.6%) among the 729 patients. Predictors included age, transient ischemic attack, length of preoperative stay, preoperative left ventricular injection fraction and N-terminal pro-B-type natriuretic peptide level, and intraoperative infusion of dexmedetomidine and human fibrinogen. The nomogram showed sufficient differentiation and calibration (AUROC = 0.754, 95% confidence interval = 0.703-0.804). The calibration graphs showed that the predictive values of the nomogram were in agreement with the actual values. The analysis of the training and validation sets suggested that the model possessed specific clinical significance.

CONCLUSIONS

In summary, the predictive model consists of seven factors that can roughly predict the occurrence of POD in patients who undergo cardiovascular surgery.

Pharmacologic Treatment Strategies for Delirium in Hospitalized Adults: Past, Present, and Future

Despite the use of multidomain prevention strategies, delirium still frequently occurs in hospitalized adults. With delirium often associated with undesirable symptoms and deleterious outcomes, including cognitive decline, treatment is important. Risk-factor reduction and the protocolized use of multidomain, nonpharmacologic bundles remain the mainstay of delirium treatment. There is a current lack of strong evidence to suggest any pharmacologic intervention to treat delirium will help resolve it faster, reduce its symptoms (other than agitation), facilitate hospital throughput, or improve post-hospital outcomes including long-term cognitive function. With the exception of dexmedetomidine as a treatment of severe delirium-associated agitation in the ICU, current practice guidelines do not recommend the routine use of any pharmacologic intervention to treat delirium in any hospital population. Future research should focus on identifying and evaluating new pharmacologic delirium treatment interventions and addressing key challenges and gaps surrounding delirium treatment research.

A longitudinal multimodal MRI study of the visual network in postoperative delirium

Although structural and functional damage to the brain is considered to be an important neurobiological mechanism of postoperative delirium (POD), alterations in the visual cortical network related to this vulnerability have not yet been determined. In this study, we investigated the impact of alterations in the visual network (VN), as measured by structural and functional magnetic resonance imaging (MRI), on the development of POD. Thirty-six adult patients with frontal glioma who underwent elective craniotomy were recruited. The primary outcome was POD 1-7 days after surgery, as assessed by the Confusion Assessment Method. Cognition before surgery was measured by a battery of neuropsychological tests. Then, we evaluated preoperative and postoperative gray matter volume (GMV) and functional connectivity (FC) alterations by voxel-based morphometry and resting-state functional MRI (rs-fMRI) between the POD and non-POD groups. Multiple logistic regression models were used to investigate the associations between neuroimaging biomarkers and the occurrence of POD. Compared to those in the non-POD group, a decreased GMV in the fusiform gyrus (0.181 [0.018] vs. 0.207 [0.022], FDRp = 0.001) and decreased FC between the fusiform gyrus and VN (0.351 [0.153] vs. 0.610 [0.197], GFRp < 0.001) were observed preoperatively in the POD group, and increased FC between the fusiform gyrus and ventral attentional network (0.538 [0.180] vs. 0.452 [0.184], GFRp =  < 0.001) was observed postoperatively in the POD group. According to our multiple logistic regression analysis, age (Odds ratio [OR]: 1.141 [1.015 to 1.282], P = 0.03) and preoperative fusiform-VN FC (OR 0.001 [0.001 to 0.067], P = 0.01) were significantly related to risk of POD. Our findings suggested that preoperative functional disconnectivity between fusiform and VN might be highly involved in the development of POD. These findings may allow for the discovery of additional underlying mechanisms.

[Geriatric assessment goes digital-Possible applications in the emergency department setting]

The geriatric assessment is a basic requirement and a key quality parameter in geriatric care. An increasing number of older patients are presenting to emergency or central admission departments and discharge units in hospitals. For this reason, and in view of the time-critical decision-making requirements in this setting, digital applications of basic geriatric assessment data are becoming increasingly more important for the high-quality follow-up care of geriatric patients.

Delirium event and associated treatment modifications among older adults with Alzheimer's disease: An interrupted time-series analysis of Medicare data

BACKGROUND

Both Alzheimer's disease (AD) and deliriogenic medications increase the risk of delirium in older adults. This study examined the association between delirium and the subsequent monthly use of anticholinergic, sedative, and opioid medications in the 1 year after delirium in older adults with AD.

METHODS

This comparative interrupted time series analysis involved adults (aged 65 years and older) with a diagnosis of AD initiating on cholinesterase inhibitors (ChEIs) based on 2013-2017 Medicare data. Separate patient-level segmented regression models were used for each outcome to evaluate changes in the cumulative anticholinergic burden (CAB), sedative load, and opioid load after the delirium/index event using a 12-month baseline and follow-up period among patients who had a delirium event and those without delirium (control group). Propensity score-based stabilized weights were utilized to balance baseline factors in the delirium and control groups.

RESULTS

The study included 80,019 older adults with AD with incident ChEI use; 17.11% had delirium. There was an immediate decline in monthly CAB after the delirium event (mean estimate -0.86, p-value: 0.01) compared to the control group. A similar decline was observed when examining the sedative load (-0.06, p-value: 0.002) after the delirium event. However, there was no decline in opioid load (-0.50, p-value: 0.18). In the long term, CAB (0.13; p-value: <0.0001), sedative load (0.01; p-value: <0.001), and opioid load (0.07; p-value: 0.006) increased over the 1-year post-delirium period in the delirium group compared to those without delirium.

CONCLUSION

This study found the burden of deliriogenic medications over the 1-year follow-up showed increasing trends in older adults with AD, even though there was some level shift in CAB and sedative load after the delirium event.

Routine cognitive screening for older people undergoing major elective surgery: Benefits, risks and costs

Cognitive impairment and older age are major risk factors for postoperative delirium. Professional societies have advocated preoperative screening to identify at-risk individuals for implementation of interventions, which have moderate effectiveness in preventing delirium. However, it remains unclear from the guidelines whether screening should be completed routinely for all older individuals or targeted, and also which specific screening tool is preferred. In addition, the responsibility for screening remains undesignated in the guidelines provided. We reviewed the benefits and risks of routine screening. We also performed a cost-benefit analysis of routine screening (versus no screening). Furthermore, we summarised the sensitivities and specificities of commonly used screening tools and reviewed evolving screening tools that may have an increasing role in future practice. We concluded that routine screening is useful and appears to be cost-effective for reducing postoperative delirium, with a cost-benefit ratio of 2.89 (adjusted ratio of 2.34), and has additional advantages over other approaches such as targeted screening or routine intervention.

Disparities in Delirium across the Continuum of Care and Associations with Social Determinants of Health

Disparities exist in the identification, treatment, and management of delirium. These disparities can be most holistically and comprehensively understood by using a social-ecological model-which acknowledges multilevel impacts including individual, interpersonal, organizational, community, and policy-level factors-as well as a social determinant of health framework, that considers nonmedical factors that influence health outcomes. This narrative review leverages both frameworks to identify and discuss existing literature pertaining to the intersection of these social risk factors and delirium, focusing specifically on disparities due to racial and/or ethnic identity, language ability, and socioeconomic differences. We also look at disparities and the potential role of these social risk factors throughout the continuum of care, including prehospitalization, hospitalization, and posthospitalization factors. Understanding and analyzing the role of these inequities is critical to ensuring better health outcomes for patients at risk of and/or with delirium.

Real-World Adherence to a Delirium Screening Test Administered by Nurses and Medical Staff during Routine Patient Care

Delirium is often the first symptom of incipient acute illness or complications and must therefore be detected promptly. Nevertheless, routine screening for delirium in acute care hospital wards is often inadequate. We recently implemented a simple, user-friendly delirium screening test (RMA) that can be administered during ward rounds and routine nursing care. The test was found to be non-inferior to 4AT in terms of sensitivity and specificity. However, the dominant factors to take into account when assessing the performance of a test added to the routine work of busy acute care hospital wards are ease of administration, real-life amenability and the ability of the staff to adhere to testing requirements. In this study, we evaluated the prevalence of daily RMA tests that were not administered as scheduled and the impact of these omissions on the overall real-world performance of RMA. Using point-in-time assessments of 4AT by an external rater, we found that complete RMA was administered in 88.8% of the days. Physicians omitted significantly more tests than nurses, but their results were more specific for delirium. Omissions reduced the sensitivity and specificity of RMA for delirium (compared to 4AT) from 90.7% to 81.7%, and from 99.2% to 87.8%, respectively. Ideally, the number of omitted RMA tests should be minimized. However, if over 85% of the daily quota of complete tests are administered, the sensitivity and specificity of RMA for diagnosing delirium as soon as it appears remain at acceptable levels.

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.

Management of delirium in acute stroke patients: a position paper by the Austrian Stroke Society on prevention, diagnosis, and treatment

Delirium is a common complication in acute stroke patients, occurring in 15-35% of all stroke unit admissions and is associated with prolonged hospital stay and a poor post-stroke prognosis. Managing delirium in acute stroke patients necessitates an intensive and multiprofessional therapeutic approach, placing a significant burden on healthcare staff. However, dedicated practical recommendations for delirium management developed for the population of acute stroke patients are lacking. For this purpose, the Austrian Stroke Society, in cooperation with the Austrian Society of Neurology, the Austrian Society of Neurorehabilitation, and the Austrian Society of Psychiatry, Psychotherapy, and Psychosomatics has formulated an evidence-based position paper addressing the management of delirium in acute stroke patients. The paper outlines practical recommendations on the three pillars of care in stroke patients with delirium: (a) Key aspects of delirium prevention including stroke-specific delirium risk factors and delirium prediction scores are described. Moreover, a non-pharmacological delirium prevention bundle is presented. (b) The paper provides recommendations on timing and frequency of delirium screening to ensure early diagnosis of delirium in acute stroke patients. Moreover, it reports on the use of different delirium screening tools in stroke populations. (c) An overview of non-pharmacological and pharmacological treatment strategies in patients with delirium and acute stroke is presented and summarized as key recommendation statements.

Prediction of Post-Operative Delirium in Older Adults from Preoperative Cognition and Alpha Power from Resting-State EEG

Postoperative Delirium (POD) is the most common complication following surgery among older adults, and has been consistently associated with increased mortality and morbidity, cognitive decline, and loss of independence, as well as markedly increased health-care costs. The development of new tools to identify individuals at high risk for POD could guide clinical decision-making and enable targeted interventions to potentially decrease delirium incidence and POD-related complications. In this study, we used machine learning techniques to evaluate whether baseline (pre-operative) cognitive function and resting-state electroencephalography could be used to identify patients at risk for POD. Pre-operative resting-state EEGs and the Montreal Cognitive Assessment (MoCA) were collected from 85 patients (age = 73 ± 6.4 years) undergoing elective surgery, 12 of whom subsequently developed POD. The model with the highest f1-score for predicting delirium, a linear-discriminant analysis (LDA) model incorporating MoCA scores and occipital alpha-band EEG features, was subsequently validated in an independent, prospective cohort of 51 older adults (age ≥ 60) undergoing elective surgery, 6 of whom developed POD. The LDA-based model, with a total of 7 features, was able to predict POD with area under the receiver operating characteristic curve, specificity and accuracy all >90%, and sensitivity > 80%, in the validation cohort. Notably, models incorporating both resting-state EEG and MoCA scores outperformed those including either EEG or MoCA alone. While requiring prospective validation in larger cohorts, these results suggest that prediction of POD with high accuracy may be feasible in clinical settings using simple and widely available clinical tools.

Highlights

Predict postoperative delirium using pre-operative EEG alpha power and MoCA scores.Prediction performance improves over cognitive assessment alone.ROC-AUC, specificity, accuracy >90%, and sensitivity > 80%, in a validation cohort.Abnormalities in baseline EEG are a risk factor for postoperative delirium.

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.

Delirium prevalence and delirium literacy across Italian hospital wards: a secondary analysis of data from the World Delirium Awareness Day 2023

PURPOSE

Delirium, a common medical emergency among hospitalized patients, requires effective detection and management protocols. This study aims to evaluate the delirium point prevalence and its management across Italian hospitals, categorized by delirium literacy levels. Additionally, it seeks to identify prevailing barriers and future priorities in delirium practice and research.

METHODS

We analyzed data from World Delirium Awareness Day (WDAD) on March 15th, 2023, collected by participating clinicians in Italian hospitals. High delirium literacy (HL) was determined based on the use of validated delirium assessment tools and the presence of a written protocol for delirium management. Conversely, low delirium literacy (LL) was determined by meeting only one or neither of these criteria.

RESULTS

Fifty-eight hospital wards participated in the survey, with 25 (43.1%) classified as HL. The overall reported point prevalence of delirium was found to be approximately 10%. Notably, the reported prevalence was twice as high in the HL group compared to the LL group. Despite minimal differences compared to the other group, the HL group demonstrated greater adherence to appropriate delirium management strategies, encompassing both non-pharmacological and pharmacological strategies. Critical gaps in delirium care emerged, including suboptimal management practices, barriers to implementing evidence-based strategies, and insufficient awareness and training among professionals.

CONCLUSION

The study highlights the suboptimal identification and management of delirium among Italian hospitals, emphasizing the necessity of enhancing awareness and implementing evidence-based strategies. Addressing these shortcomings is crucial for optimizing delirium care, improving patient outcomes, and mitigating the burden of delirium in hospital settings.

Association between antidepressant use and delirium in older adults: an analysis of the World Health Organization's global pharmacovigilance database

BACKGROUND

Psychoactive drugs frequently cause delirium adverse events in older adults. However, few data on the relationship between antidepressants and delirium are available. Here, we investigated the association between antidepressant prescription and pharmacovigilance reports of delirium in older adults.

METHODS

Using the World Health Organization's VigiBase® global pharmacovigilance database from 1967 to 2022, we performed a disproportionality analysis in order to probe the putative associations between each antidepressant class (non-selective monoamine reuptake inhibitors (NSMRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), alpha-2-adrenergic receptor antagonists, and other antidepressants) and reports of delirium in people aged 65 or over. We calculated the reporting odds ratios (r-OR) and their 95% confidence interval ([95%CI]) with logistic regression models before and after adjustment for confounding factors. Secondary analyses were performed for each drug and within each class by age group (65-74, and 75 and over). We also studied the reports of concomitant delirium and hyponatremia.

RESULTS

Our main analysis included 87,524 cases of delirium. After adjustment for confounders, a significant association was found between delirium and all antidepressant classes other than SNRIs. Intraclass disparities were found for the association between the most frequently prescribed antidepressants and reports of delirium. An elevated risk of reports of concomitant delirium and hyponatremia was found for SSRIs (4.46 [4.01-4.96]), SNRIs (1.25 [1.07-1.46]), MAOIs (1.72 [1.41-2.09]), and the "other antidepressants" class (1.47 [1.30-1.65]).

CONCLUSIONS

There was a significant association between reports of delirium and antidepressant classes (other than SNRIs). However, this association varied from one drug to another within a given antidepressant class. Moreover, this association could not always be explained by antidepressant-induced hyponatremia.

Delirium diagnostic tools in the postoperative setting: A scoping review protocol

BACKGROUND

Delirium is an acute and fluctuating disturbance in attention, awareness, and cognition, commonly observed in hospital settings, particularly among older adults, critically ill and surgical patients. Delirium poses significant challenges in patient care, leading to increased morbidity, mortality, prolonged hospital stays, and functional decline.

AIM

The aim of this review is to map existing evidence on delirium diagnostic tools suitable for use in patients treated surgically due to hip fracture, to inform clinical practice and enhance patient care protocols in the postoperative setting.

METHOD

We will conduct a scoping review on delirium diagnostic tools used for adult patients in the postoperative setting according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Eligibility criteria encompass all languages, publications dates, and study designs, with exception of case-reports. We will systematically search multiple databases and include unpublished trials, ensuring a comprehensive review based on a predefined protocol.

RESULTS

Results will be presented descriptively, with supplementary tables and graphs. Studies will be grouped by design, surgical specialties, and diagnostic tools to identify potential variations.

CONCLUSION

This scoping review will provide an overview of existing delirium diagnostic tools used in the postoperative setting and highlight knowledge-gaps to support future research. Due to the large number of patients affected by postoperative delirium, evidence mapping is much needed to facilitate evidence-based practice.

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.

The role of anesthesia in peri‑operative neurocognitive disorders: Molecular mechanisms and preventive strategies

Peri-operative neurocognitive disorders (PNDs) include postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). Children and the elderly are the two populations most vulnerable to the development of POD and POCD, which results in both high morbidity and mortality. There are many factors, including neuroinflammation and oxidative stress, that are associated with POD and POCD. General anesthesia is a major risk factor of PNDs. However, the molecular mechanisms of PNDs are poorly understood. Dexmedetomidine (DEX) is a useful sedative agent with analgesic properties, which significantly improves POCD in elderly patients. In this review, the current understanding of anesthesia in PNDs and the protective effects of DEX are summarized, and the underlying mechanisms are further discussed.

Screening for Delirium During Pediatric Brain Injury Rehabilitation

OBJECTIVE

To assess feasibility of routine delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) in children admitted for rehabilitation with acquired brain injury (ABI), report on the prevalence of positive delirium screens in this population, and explore longitudinal trends in CAPD scores and their association with rehabilitation outcomes.

DESIGN

Retrospective study.

SETTING

Pediatric inpatient rehabilitation unit.

PARTICIPANTS

144 children (median 10.8 years) with ABI (N=144).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percent compliance with twice daily delirium screening; prevalence of positive delirium screens; trajectories in CAPD scores and their relation with FIM for Children (WeeFIM) scores.

RESULTS

Screening was feasible (mean 75% compliance for each of 144 children). Of 16,136 delirium screens, 29% were positive. 62% of children had ≥1 positive screen. Four primary patterns of CAPD trajectories were identified: Static Encephalopathy (10%), Episodic Delirium (10%), Improving (32%), and No Delirium (48%). Validity of these trajectories was demonstrated through association with WeeFIM and CALS outcomes. Younger age at admission was associated with positive delirium screens, and rehabilitation length of stay was significantly longer for the Improving group.

CONCLUSIONS

Delirium occurs frequently in children with ABI during inpatient rehabilitation. Routine delirium screening provides clinically relevant information including the potential to facilitate early detection and intervention for medical complications. Longitudinal ratings of delirium symptoms may also have a role in developing a standardized definition for Post Traumatic Confusional State (PTCS) stage of recovery in children.

Transplantation-Associated Altered Mentation and Encephalopathy: A New Classification for Acute Neurocognitive Changes Associated with Hematopoietic Cell Transplantation from the ASTCT Committee on Practice Guidelines

Acute encephalopathy, manifesting clinically as delirium, is a common but often unrecognized complication of hematopoietic cell transplantation (HCT). Delirium can occur in patients of any age and is observed after autologous or allogeneic HCT. Although delirium has been studied primarily during initial HCT hospitalizations in recipients of myeloablative conditioning, recent investigations have identified delirium later post-transplantation and in recipients of reduced-intensity conditioning. Acute encephalopathy can be driven by infectious complications, medications, tissue damage, and/or organ dysfunction. Altered consciousness, either mild or profound, is often its only clinical manifestation. Identifying delirium is essential to overall HCT care, because patients who experience delirium have longer hospitalization and recovery times and are at risk for other poor post-HCT outcomes. Given the critical nature of this common complication and the ongoing expansion of HCT for more vulnerable populations, the American Society of Transplantation and Cellular Therapy (ASTCT) recommends intensifying research into post-HCT cognitive changes and establishing standardized definitions that encompass the full spectrum of altered consciousness for clinical care purposes and to provide benchmark endpoints for future research studies. To capture a range of acute neurocognitive changes specifically found in HCT patients (often referred to as acute encephalopathy), the ASTCT proposes a new diagnosis, transplantation-associated altered mentation and encephalopathy (TAME). The TAME diagnosis includes HCT patients who meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for delirium and those with acute neurocognitive changes who do not meet all the DSM-5 criteria for delirium (subsyndromal delirium). Early TAME is defined as occurring during conditioning or ≤100 days post-HCT, whereas late TAME occurs >100 days post-HCT in patients with additional HCT-related complications. This manuscript establishes clear diagnostic criteria and discusses factors that can potentially impact the development of TAME, as well as the workup and management of TAME.

In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization

Importance

Older adults who are hospitalized for COVID-19 are at risk of delirium. Little is known about the association of in-hospital delirium with functional and cognitive outcomes among older adults who have survived a COVID-19 hospitalization.

Objective

To evaluate the association of delirium with functional disability and cognitive impairment over the 6 months after discharge among older adults hospitalized with COVID-19.

Design, Setting, and Participants

This prospective cohort study involved patients aged 60 years or older who were hospitalized with COVID-19 between June 18, 2020, and June 30, 2021, at 5 hospitals in a major tertiary care system in the US. Follow-up occurred through January 11, 2022. Data analysis was performed from December 2022 to February 2024.

Exposure

Delirium during the COVID-19 hospitalization was assessed using the Chart-based Delirium Identification Instrument (CHART-DEL) and CHART-DEL-ICU.

Main Outcomes and Measures

Primary outcomes were disability in 15 functional activities and the presence of cognitive impairment (defined as Montreal Cognitive Assessment score <22) at 1, 3, and 6 months after hospital discharge. The associations of in-hospital delirium with functional disability and cognitive impairment were evaluated using zero-inflated negative binominal and logistic regression models, respectively, with adjustment for age, month of follow-up, and baseline (before COVID-19) measures of the respective outcome.

Results

The cohort included 311 older adults (mean [SD] age, 71.3 [8.5] years; 163 female [52.4%]) who survived COVID-19 hospitalization. In the functional disability sample of 311 participants, 49 participants (15.8%) experienced in-hospital delirium. In the cognition sample of 271 participants, 31 (11.4%) experienced in-hospital delirium. In-hospital delirium was associated with both increased functional disability (rate ratio, 1.32; 95% CI, 1.05-1.66) and increased cognitive impairment (odds ratio, 2.48; 95% CI, 1.38-4.82) over the 6 months after discharge from the COVID-19 hospitalization.

Conclusions and Relevance

In this cohort study of 311 hospitalized older adults with COVID-19, in-hospital delirium was associated with increased functional disability and cognitive impairment over the 6 months following discharge. Older survivors of a COVID-19 hospitalization who experience in-hospital delirium should be assessed for disability and cognitive impairment during postdischarge follow-up.

Using Artificial Intelligence to predict outcomes of operatively managed neck of femur fractures

Aims/Background Patients with neck of femur fractures present a tremendous public health problem that leads to a high incidence of death and dysfunction. An essential factor is the postoperative length of stay, which heavily impacts hospital costs and the quality of care. As an extension of traditional statistical methods, machine learning (ML) provides the possibility of accurately predicting the length of hospital stay. This review assesses how machine learning can effectively use healthcare data to predict the outcomes of patients with operatively managed neck of femurs. Methods A narrative literature review on the use of Artificial Intelligence to predict outcomes in the neck of femurs was undertaken to understand the field and critical considerations of its application. The papers and any relevant references were scrutinised using the specific inclusion and exclusion criteria to produce papers that were used in the analysis. Results Thirteen papers were used in the analysis. The critical themes recognised the different models, the 'backbox' conundrum, predictor identification, validation methodology and the need to improve efficiency and quality of care. Through reviewing the themes in this paper, current issues, and potential avenues of advancing the field are explored. Conclusions This review has demonstrated that the use of machine learning in Orthopaedic pathways is in its infancy. Further work is needed to leverage this technology effectively to improve outcomes.

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.

Resilience, Survival, and Functional Independence in Older Adults Facing Critical Illness

BACKGROUND

Older adults surviving critical illness often experience new or worsening functional impairments. Modifiable positive psychological constructs such as resilience may mitigate post-intensive care morbidity.

RESEARCH QUESTION

Is pre-ICU resilience associated with: (1) post-ICU survival; (2) the drop in functional independence during the ICU stay; or (3) the trend in predicted independence before vs after the ICU stay?

STUDY DESIGN AND METHODS

This retrospective cohort study was performed by using Medicare-linked Health and Retirement Study surveys from 2006 to 2018. Older adults aged ≥ 65 years admitted to an ICU were included. Resilience was calculated prior to ICU admission. The resilience measure was defined from the Simplified Resilience Score, which was previously adapted and validated for the Health and Retirement Study. Resilience was scored by using the Leave-Behind survey normalized to a scale from 0 (lowest resilience) to 12 (highest resilience). Outcomes were survival and probability of functional independence. Survival was modeled by using Gompertz models and independence using joint survival models adjusting for sociodemographic and clinical variables. Average marginal effects were estimated to determine independence probabilities.

RESULTS

Across 3,409 patients aged ≥ 65 years old admitted to ICUs, preexisting frailty (30.5%) and cognitive impairment (24.3%) were common. Most patients were previously independent (82.7%). Mechanical ventilation occurred in 14.8% and sepsis in 43.2%. Those in the highest resilience group (vs lowest resilience) had a lower risk of post-ICU mortality (adjusted hazard ratio, 0.81; 95% CI, 0.70-0.94). Higher resilience was associated with greater likelihood of post-ICU functional independence (estimated probability of functional independence 5 years after ICU discharge in highest-to-lowest resilience groups (adjusted hazard ratio [95% CI]): 0.53 (0.33-0.74), 0.47 (0.26-0.68), 0.49 (0.28-0.70), and 0.36 (0.17-0.55); P < .01. Resilience was not associated with a difference in the drop in independence during the ICU stay or a difference in the pre-ICU vs post-ICU trend in predicted independence .

INTERPRETATION

ICU survivors with higher resilience had increased rates of survival and functional independence, although the slope of functional decline before vs after the ICU stay did not differ according to resilience group.

Chest trauma clinical practice guideline protects against delirium in patients with rib fractures

Introduction

Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been implemented, including effective pain management, pulmonary hygiene, and early walking. Vancouver General Hospital, a level 1 trauma center in British Columbia, Canada, developed a comprehensive multidisciplinary chest trauma clinical practice guideline (CTCPG) to optimize the management of patients with rib fractures. This prospective cohort study aimed to assess the impact of the CTCPG on pain management interventions and patient outcomes.

Methods

The study involved patients admitted between January 1, 2021 and December 31, 2021 (post-CTCPG cohort) and a historical control group admitted between November 1, 2018 and December 31, 2019 (pre-CTCPG cohort). Patient data were collected from patient charts and the British Columbia Trauma Registry, including demographics, injury characteristics, pain management interventions, and relevant outcomes.

Results

Implementation of the CTCPG resulted in an increased use of multimodal pain therapy (99.4% vs 96.1%; p=0.03) and a significant reduction in the incidence of delirium in the post-CTCPG cohort (OR 0.43, 95% CI 0.21 to 0.80, p=0.0099). There were no significant differences in hospital length of stay, ICU (intensive care unit) days, non-invasive positive pressure ventilation requirement, ventilator days, pneumonia incidence, or mortality between the two cohorts.

Discussion

Adoption of a CTCPG improved chest trauma management by enhancing pain management and reducing the incidence of delirium. Further research, including multicenter studies, is warranted to validate these findings and explore additional potential benefits of the CTCPG in the management of chest trauma patients.

Level of evidence

IIb.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Emergency nurses' and physicians' perceptions and self-assessed competence in providing care to older patients

AIM

This study examined emergency nurses' and physicians' perceptions and self-assessed competence in caring for older patients.

METHODS

Data were analyzed using a mixed methods approach and quantitative data were supplemented with qualitative responses. There were 451 nurses and physicians working at the two examined emergency departments, with 125 of them responding to the survey; the response rate was 27.7 %.

RESULTS

Physicians and nurses felt that acutely ill older patients are a responsibility of emergency services. Nurses were more critical than physicians (p = 0.000) of the failure to recognize older patients as a special group at the emergency department. Over half (51.8 %) of the physicians and 29.0 % of the nurses (p = 0.027) felt that older patients' special needs had been considered during facility planning. Nurses and physicians described the problems related to multimorbidity and aging relatively similarly. Both expressed a need for more knowledge in geriatrics and gerontology.

CONCLUSION

Future facility planning and care processes at the emergency department should better consider the specific needs of older patients. The results also emphasize a need to more effectively prioritize competence and educational needs of emergency staff and recognize caring for older patients as a specific competence area in the emergency department.

Enhancing healthcare access for an older population: The age-friendly emergency department

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

Interventions to prevent and treat delirium: An umbrella review of randomized controlled trials

Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.

Sustained delirium reduction in an inpatient neuroscience unit

BACKGROUND

Delirium is described as acute brain dysfunction that often fluctuates throughout the day and is highly prevalent in hospitalized adults. Delirium negatively affects patient outcomes with consequences including decreased cognitive functioning and increased mortality and healthcare costs. Furthermore, neurological patients are at increased risk for developing delirium due to their underlying diagnoses.

PURPOSE

The purpose of this evidence-based practice project was to evaluate the long-term impact of nursing education and use of trained volunteers to prevent the development of delirium in an inpatient neuroscience unit.

IMPLEMENTATION PLAN

This was a pre-post designed evidence-based practice project to educate and prioritize nursing care interventions for delirium prevention compared to a delirium management framework. The interventions included delirium education for nurses and nursing assistants along with the development of a specialized volunteer program to implement non-pharmacological, multi-component delirium prevention interventions. Long-term sustainment and enculturation occurred over the subsequent year.

OUTCOMES

The baseline data collection period included 2520 patients. The intervention period included 4515 patients, with both groups being similar in age, race, gender, and length of stay. The total number of patients with a discharge diagnosis of delirium decreased from 29.2% to 19.8% (p < .001). Fewer patients in the intervention group were discharged to a skilled nursing facility (p < .001) and other post-acute facility (p = .008), along with more patients being discharged to home care (p < .001).

LINKING EVIDENCE TO ACTION

This evidence-based practice project demonstrates long-term sustained reduction of delirium in the neuroscience population. Despite the challenges during the COVID-19 pandemic, delirium prevention strategies were found to be effective in decreasing the rate at which patients develop delirium.

Frailty as an upstream target for intervention: A unifying approach to intervening in the trajectories of health, function, and disease in late life

This editorial comments on the article by Deiner et al. in this issue.

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.

Managing Delirium in the Emergency Department: An Updated Narrative Review

Purpose of Review

Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs.

Recent Findings

We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record.

Summary

Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.

COVID-19 vaccination may prevent postoperative delirium in elderly patients undergoing elective non-cardiac surgery: The PNDRFAP and PNDABLE studies

Background

Postoperative delirium (POD) often occurs in elderly patients after surgery. We conducted two clinical studies to determine whether COVID-19 vaccination has a protective effect on POD and to explore the role of CSF biomarkers in this process.

Methods

We conducted two clinical studies, Perioperative Neurocognitive Disorder Risk Factor and Prognosis (PNDRFAP) and Perioperative Neurocognitive Disorder and Biomarker Lifestyle (PNDABLE), in which patients more than or equal to 65 years old who have had elective non-cardiac surgery were enrolled. The preoperative cognitive status of patients were evaluated by Mini-Mental State Examination (MMSE) one day preoperatively. Confusion Assessment Method (CAM) was used to diagnose POD. We used the mediation model to analyze the relationship between CSF biomarkers, COVID-19 vaccination and POD, as well as Dynamic Nomogram to calculate the incidence of Non-Postoperative Delirium (NPOD). The main outcome of these studies was the incidence of POD during seven days postoperatively or before discharge, which was assessed by CAM.

Results

In the final, 705 participants were enrolled in the PNDRFAP study, and 638 patients in the PNDABLE. In both studies, we found that the occurrence of POD was lower in patients who had injected COVID-19 vaccination before surgery compared with those without vaccination (PNDRFAP: 10.20 % [21/205] vs 25.80 % [129/500], P < 0.001; PNDABLE: 2.40 % [4/164] vs 34.60 % [164/474], P < 0.001). Mediation analysis showed that the protective effect of preoperative COVID-19 vaccine on POD was significantly mediated by CSF Aβ42 (proportion = 17.56 %), T-tau (proportion = 19.64 %), Aβ42/T-tau (proportion = 29.67 %), and Aβ42/P-tau (proportion = 12.26 %).

Conclusions

COVID-19 vaccine is a protective factor for POD in old patients, which is associated with CSF biomarkers.

Telenovela (Spanish Soap Opera) Interventions on Latino Health: A Scoping Review

Introduction: The use of telenovelas shows promise as a mode of education that could enhance Latino people's ability to prevent or manage different health conditions. This scoping review examined the available evidence about telenovela interventions on Latino health. Methods: A scoping review was conducted by searching five peer-reviewed databases for articles published on any date in English or Spanish. The methods of this review were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews recommendations. Results: A total of 431 articles were identified, and 22 articles published between 1999 and 2022 were included in the final scoping review. Nineteen telenovela interventions were described in the literature. Most studies included telenovela interventions without other elements (n = 15; 68%), and 91% were conducted in the U.S. (n = 20). Studies were qualitative (n = 8; 36%), quantitative (n = 8; 36%), and mixed methods (n = 6; 27%), and most telenovela interventions were developed and/or tested in Spanish (n = 10; 53%). The most common topics for the telenovela interventions were substance use/risky sexual health behaviors, cardiovascular disease, and mental health. Conclusions: This scoping review may serve to continue empirical and theoretical work on telenovela-style entertainment interventions on Latino health and future implementation in real-life settings.

Development and validation of delirium prediction models for noncardiac surgery patients

STUDY OBJECTIVE

Postoperative delirium is associated with morbidity and mortality, and its incidence varies widely. Using known predisposing and precipitating factors, we sought to develop postoperative delirium prediction models for noncardiac surgical patients.

DESIGN

Retrospective prediction model study.

SETTING

Major quaternary medical center.

PATIENTS

Our January 2016 to June 2020 training dataset included 51,677 patients of whom 2795 patients had delirium. Our July 2020 to January 2022 validation dataset included 14,438 patients of whom 912 patients had delirium.

INTERVENTIONS

None.

MEASUREMENTS

We trained and validated two static prediction models and one dynamic delirium prediction model. For the static models, we used random survival forests and traditional Cox proportional hazard models to predict postoperative delirium from preoperative variables, or from a combination of preoperative and intraoperative variables. We also used landmark modeling to dynamically predict postoperative delirium using preoperative, intraoperative, and postoperative variables before onset of delirium.

MAIN RESULTS

In the validation analyses, the static random forest model had a c-statistic of 0.81 (95% CI: 0.79, 0.82) and a Brier score of 0.04 with preoperative variables only, and a c-statistic of 0.86 (95% CI: 0.84, 0.87) and a Brier score of 0.04 when preoperative and intraoperative variables were combined. The corresponding Cox models had similar discrimination metrics with slightly better calibration. The dynamic model - using all available data, i.e., preoperative, intraoperative and postoperative data - had an overall c-index of 0.84 (95% CI: 0.83, 0.85).

CONCLUSIONS

Using preoperative and intraoperative variables, simple static models performed as well as a dynamic delirium prediction model that also included postoperative variables. Baseline predisposing factors thus appear to contribute far more to delirium after noncardiac surgery than intraoperative or postoperative variables. Improved postoperative data capture may help improve delirium prediction and should be evaluated in future studies.

The research progress of perioperative non-pharmacological interventions on postoperative cognitive dysfunction: a narrative review

Postoperative cognitive dysfunction (POCD) is a common neurological complication in elderly patients after surgery and general anesthesia. The occurrence of POCD seriously affects the postoperative recovery of patients, and leads to prolonged hospital stay, reduced quality of life, increased medical costs, and even higher mortality. There is no definite and effective drug treatment for POCD. More evidence shows that perioperative non-pharmacological intervention can improve postoperative cognitive function and reduce the incidence of POCD. Therefore, our studies summarize the current non-pharmacological interventions of POCD from the aspects of cognitive training, physical activity, transcutaneous electrical acupoint stimulation, noninvasive brain stimulation, non-pharmacological sleep improvement, music therapy, environment, and multimodal combination Interventions, to provide more data for clinical application and research.

Intravenous infusion of dexmedetomidine during the surgery to prevent postoperative delirium and postoperative cognitive dysfunction undergoing non-cardiac surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine plays a pivotal role in mitigating postoperative delirium and cognitive dysfunction while enhancing the overall quality of life among surgical patients. Nevertheless, the influence of dexmedetomidine on such complications in various anaesthesia techniques remains inadequately explored. As such, in the present study, a meta-analysis was conducted to comprehensively evaluate its effects on postoperative delirium and cognitive dysfunction.

METHODS

A number of databases were searched for randomised controlled trials comparing intravenous dexmedetomidine to other interventions in preventing postoperative delirium and cognitive dysfunction in non-cardiac and non-neurosurgical patients. These databases included PubMed, Embase, and Cochrane Library. Statistical analysis and graphing were performed using Review Manager, STATA, the second version of the Cochrane risk-of-bias tool for randomised controlled trials, and GRADE profiler.

MAIN RESULTS

This meta-analysis comprised a total of 24 randomised controlled trials, including 20 trials assessing postoperative delirium and 6 trials assessing postoperative cognitive dysfunction. Across these 24 studies, a statistically significant positive association was observed between intravenous administration of dexmedetomidine and a reduced incidence of postoperative delirium (RR: 0.55; 95% CI 0.47 to 0.64, p < 0.00001, I2 = 2%) and postoperative cognitive dysfunction (RR: 0.60; 95% CI 0.38 to 0.96, p = 0.03, I2 = 60%). Subgroup analysis did not reveal a significant difference in the incidence of postoperative delirium between the general anaesthesia and non-general anaesthesia groups, but a significant difference was observed in the incidence of postoperative cognitive dysfunction. Nonetheless, when the data were pooled, it was evident that the utilisation of dexmedetomidine was associated with an increased incidence of hypotension (RR: 1.42; 95% CI 1.08 to 1.86, p = 0.01, I2 = 0%) and bradycardia (RR: 1.66; 95% CI 1.23 to 2.26, p = 0.001, I2 = 0%) compared with other interventions. However, there was no significantly higher occurrence of hypertension in the DEX groups (RR = 1.35, 95% CI 0.81-2.24, p = 0.25, I2 = 0%).

CONCLUSION

Compared with other interventions, intravenous dexmedetomidine infusion during non-cardiac and non-neurosurgical procedures may significantly reduce the risk of postoperative delirium and cognitive dysfunction. The results of subgroup analysis reveal a consistent preventive effect on postoperative delirium in both general and non-general anaesthesia groups. Meanwhile, continuous infusion during general anaesthesia was more effective in reducing the risk of cognitive dysfunction. Despite such findings, hypotension and bradycardia were more frequent in patients who received dexmedetomidine during surgery.

Decreasing the incidence of delirium via multi-sensory stimulation in patients receiving mechanical ventilation in the intensive care unit: A protocol for a randomized feasibility study

Introduction

Delirium is a common acute brain dysfunction syndrome in patients admitted to intensive care units (ICUs). Family engagement strategies, based on the theory of multi-sensory stimulation to ameliorate sensory deprivation in patients, may be an effective and scalable method to reduce the burden of delirium.

Methods

/design: This is a assessor-blinded, randomised controlled trial of the feasibility of multi-sensory stimulation (MS) in patients with delirium. A total of 72 mechanically ventilated patients (n = 24 in each group) admitted to the ICU will be randomised to routine non-pharmacological delirium care (control), family multi-sensory stimulation and nurse multi-sensory stimulation groups. All participants except the control group will receive multi-sensory stimulation, including visual, auditory, tactile and kinesthetic stimulation, for 5 days. Our primary aim is to determine the feasibility of the study procedure (recruitment, eligibility, retention and attrition rates, appropriateness of clinical outcome measures), feasibility, acceptability and safety of the intervention (adverse events, satisfaction and other). Our secondary objective is to assess the preliminary efficacy of the MS protocol in reducing the incidence, duration and severity of delirium. Sedation levels and delirium severity will be assessed twice daily. Enrolled participants will be followed in hospital until death, discharge or up to 28 days after treatment.

Ethics and dissemination

The current study was approved by the Ethics Review Board of Huazhong University of Science and Technology Union Shenzhen Hospital, China (KY-2023-031-01). The results of this study will be presented at scientific conferences and submitted for publication in peer-reviewed journals.

Trial registration number

ChiCTR2300071457.

Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG)

Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.

Effect of hospital elder life program on the incidence of delirium: A systematic review and meta-analysis of clinical trials

OBJECTIVE

This meta-analysis aims to investigate the effect of the Hospital Elder Life Program (HELP) on the incidence of delirium, delirium scores, length of hospital stay, and incidence of falls.

METHODS

Four databases (PubMed, Embase, Cochrane Library, and Web of Science) were searched from inception until January 18, 2024. The search specifically targeted randomized controlled trials (RCTs). Two independent researchers conducted literature screening, quality assessment, and data extraction. The meta-analysis was performed using Review Manager 5.4.1 and Stata 15.1 software.

RESULTS

The final analysis included a total of 9 RCTs with 2583 patients. The findings from the meta-analysis indicated that HELP was found to considerably reduce the incidence of delirium and the length of hospital stay when compared to the control group. Nevertheless, no statistically significant differences were observed between the two groups in terms of delirium scores and fall rates.

CONCLUSION

In this meta-analysis, HELP can effectively reduce the incidence of delirium and lead to a shorter hospital stay.

Clinical Trials for Special Populations: Children, Older Adults, and Rare Diseases

Research cannot maximize population health unless it improves health for all members of the public, including special populations such as children, older adults, and people living with rare diseases. Each of these categories require special considerations when planning and performing clinical trials, and common threads of ethical conduct of research in vulnerable populations appear throughout. In this review, definitions of each of the three categories of special population (children, older adults, and rare diseases) are discussed in terms of US research regulations, the unique challenges to conducting clinical trials for these special populations, critical ethical issues, and opportunities for innovative ways to design and operationalize clinical trials in special populations. Additional critical attention is focused on factors that influence the generalizability of study results to reduce health disparities, as well as the importance of community engagement and advocacy groups that can help to educate potential trial participants of the benefits of clinical trial participation.