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Gerakios F, Yarnall AJ, Bate G, Wright L, Davis D, Stephan BCM, Robinson L, Brayne C, Stebbins G, Taylor JP, Burn DJ, Allan LM, Richardson SJ, Lawson RA. Delirium is more common and associated with worse outcomes in Parkinson's disease compared to older adult controls: results of two prospective longitudinal cohort studies. Age Ageing 2024; 53:afae046. [PMID: 38497236 PMCID: PMC10945294 DOI: 10.1093/ageing/afae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Inpatient prevalence of Parkinson's disease (PD) delirium varies widely across the literature. Delirium in general older populations is associated with adverse outcomes, such as increased mortality, dementia, and institutionalisation. However, to date there are no comprehensive prospective studies in PD delirium. This study aimed to determine delirium prevalence in hospitalised PD participants and the association with adverse outcomes, compared to a control group of older adults without PD. METHODS Participants were hospitalised inpatients from the 'Defining Delirium and its Impact in Parkinson's Disease' and the 'Delirium and Cognitive Impact in Dementia' studies comprising 121 PD participants and 199 older adult controls. Delirium was diagnosed prospectively using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Outcomes were determined by medical note reviews and/or home visits 12 months post hospital discharge. RESULTS Delirium was identified in 66.9% of PD participants compared to 38.7% of controls (p < 0.001). In PD participants only, delirium was associated with a significantly higher risk of mortality (HR = 3.3 (95% confidence interval [CI] = 1.3-8.6), p = 0.014) and institutionalisation (OR = 10.7 (95% CI = 2.1-54.6), p = 0.004) 12 months post-discharge, compared to older adult controls. However, delirium was associated with an increased risk of developing dementia 12 months post-discharge in both PD participants (OR = 6.1 (95% CI = 1.3-29.5), p = 0.024) and in controls (OR = 13.4 (95% CI = 2.5-72.6), p = 0.003). CONCLUSION Delirium is common in hospitalised PD patients, affecting two thirds of patients, and is associated with increased mortality, institutionalisation, and dementia. Further research is essential to understand how to accurately identify, prevent and manage delirium in people with PD who are in hospital.
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Affiliation(s)
- Florence Gerakios
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Gemma Bate
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Wright
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Blossom C M Stephan
- Institute of Mental Health, School of Medicine, Nottingham University, Nottingham, UK
- Dementia Centre of Excellence, EnAble Institute, Curtin University, Perth, Australia
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Carol Brayne
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Glenn Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - David J Burn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Louise M Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
| | - Sarah J Richardson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Rachael A Lawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
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Martins R, Martins S, Correia R, Pinho E, Paulo C, Silva MJ, Teixeira A, Fontes L, Lopes L, Paiva JA, Azevedo LF, Fernandes L. Occurrence and predictors of delirium in critically ill older patients: a prospective cohort study. Porto Biomed J 2023; 8:e240. [PMID: 38093793 PMCID: PMC10715770 DOI: 10.1097/j.pbj.0000000000000240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 10/17/2024] Open
Abstract
Objectives This study aims to analyze the occurrence of delirium in critically ill older patients and to identify predictors of delirium. Methods This prospective study included critically ill older patients admitted into level II units of Intensive Care Medicine Department of a University Hospital. Patients with Glasgow Coma Scale score ≤11, traumatic brain injury, terminal disease, history of psychosis, blindness/deafness, or inability to understanding/speaking Portuguese were excluded. The Confusion Assessment Method-Short Form (CAM-4) was used to assess the presence of delirium. Results The final sample (n = 105) had a median age of 80 years, most being female (56.2%), widowed (49.5%), and with complete primary education (53%). Through CAM-4, 36.2% of the patients had delirium. The delirium group was more likely to have previous cognitive decline (48.6% vs 19.6%, P = .04) and severe dependency in instrumental activities of daily living (34.3% vs 14.8%, P = .032), comparing with patients without delirium. The final multiple logistic regression model explained that patients with previous cognitive decline presented a higher risk for delirium (odds ratio: 4.663, 95% confidence Interval: 1.055-20.599, P = .042). Conclusions These findings corroborate previous studies, showing that cognitive decline is an independent predictor for delirium in older patients. This study is an important contribution for the knowledge regarding the predictors of delirium. The recognition of these factors will help to identify patients who are at high risk for this syndrome and implement early screening and prevention strategies. However, further studies with larger samples, recruited from other clinical settings as well as analyzing other potential factors for delirium, will be needed.
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Affiliation(s)
- Rita Martins
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Sónia Martins
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Raquel Correia
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Elika Pinho
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Cristiana Paulo
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Maria João Silva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Ana Teixeira
- Psychiatry Service, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Liliana Fontes
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Luís Lopes
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - José Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Luís Filipe Azevedo
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Lia Fernandes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Psychiatry Service, Centro Hospitalar Universitário São João (CHUSJ), Alameda Prof. Hernâni Monteiro, Porto, Portugal
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Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med 2023; 115:29-33. [PMID: 37391309 DOI: 10.1016/j.ejim.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 07/02/2023]
Abstract
Acutely ill patients are not infrequently referred to the hospital and admitted, when they could be diagnosed and managed in the ambulatory setting or by hospital-level care at home. Avoidable admissions are particularly regrettable when the wide spectrum of hospitalization-associated patient harm is considered. It includes acute discomfort to the patient due to multiple disturbing hospital stressors; an emotional trauma; the burden of multiple redundant tests begetting false-positive and incidental findings triggering further testing and cascades; highly prevalent adverse events and serious harm associated with medical care, such as nosocomial infections, delirium, falls, and adverse drug events; and a complex array of post-discharge complications including significant physical and functional decline; cognitive decline; flawed transitions of care; common post-discharge adverse events; and a substantial risk of readmission, restarting the vicious cycle and compromising patient well-being, safety, and outcomes. Elderly patients are especially vulnerable, but in-hospital patient harm is not limited to older adults and is associated with increased length of stay, escalating costs, and mortality. The myriad types of harm that often accompany hospital admission is often not fully appreciated. Better awareness may result in better preventive strategies, in finding alternatives to hospital admission in some cases, and may contribute towards an improved patient experience and safety when hospitalization is mandatory, and the provision of enhanced care in the vulnerable post-discharge period.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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In Situ Simulation Training for Frailty. Geriatrics (Basel) 2023; 8:geriatrics8010026. [PMID: 36826368 PMCID: PMC9957163 DOI: 10.3390/geriatrics8010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/11/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND People living with frailty account for a significant proportion of hospital inpatients and are at increased risk of adverse events during admission. The understanding of frailty remains variable among hospital staff, and there is a need for effective frailty training across multidisciplinary teams. Simulation is known to be advantageous for improving human factor skills in multidisciplinary teams. In situ simulation can increase accessibility and promote ward team learning, but its effectiveness with respect to frailty has not been explored. METHOD A single-centre, multi-fidelity, inter-professional in situ frailty simulation programme was developed. One-hour sessions were delivered weekly using frailty-based clinical scenarios. Mixed-method evaluation was used, with data collected pre- and post-session for comparison. RESULTS In total, 86 multidisciplinary participants attended 19 sessions. There were significant improvements in self-efficacy rating across 10 of 12 human factor domains and in all frailty domains (p < 0.05). The common learning themes were situational awareness, communication and teamwork. Participants commented on the value of learning within ward teams and having the opportunity to debrief. CONCLUSION In situ simulation can improve the self-efficacy of clinical and human factor skills related to frailty. The results are limited by the nature of self-reporting methods, and further studies assessing behavioural change and clinical outcomes are warranted.
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McEvoy L, Richter M, Chen T, Le A, Wilson C, Marov L, Gujraz P, Gray L, Mayahi-Neysi M, Francis N, Mai HT, He S, Chróinín DN, Frost SA. Frailty among older surgical patients and risk of hospital acquired adverse events: The South-Western Sydney frailty and nurse sensitive indicators study. J Clin Nurs 2023; 32:477-484. [PMID: 35212075 DOI: 10.1111/jocn.16259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/12/2022] [Accepted: 01/31/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND While advances in healthcare mean people are living longer, increasing frailty is a potential consequence of this. The relationship between frailty among older surgical patients and hospital acquired adverse events has not been extensively explored. We sought to describe the relationship between increasing frailty among older surgical patients and the risk of hospital acquired adverse events. METHODS We included consecutive surgical admissions among patients aged 70 years or more across the SWSLHD between January 2010 and December 2020. This study used routinely collected ICD-10-AM data, obtained from the government maintained Admitted Patient Data Collection. The relationships between cumulative frailty deficit items and risk of hospital acquired adverse events were assessed using Poisson regression modelling. This study followed the RECORD/STROBE guidelines. RESULTS During the study period, 44,721 (57% women) older adults were admitted, and 41% (25,306) were planned surgical admissions. The risk of all adverse events increased with increasing number of frailty deficit items, the highest deficit items group (4-12 deficit items) compared with the lowest deficit items group (0 or 1 deficit item): falls adjusted rate ratio (adj RR) = 15.3, (95% confidence interval (CI) 12.1, 19.42); pressure injury adj RR = 21.3 (95% CI 12.53, 36.16); delirium adj RR = 40.9 (95% CI 31.21, 53.55); pneumonia adj RR = 16.5 (95% CI 12.74, 21.27); thromboembolism adj RR = 17.3 (95% CI 4.4, 11.92); and hospital mortality adj RR = 6.2 (95% CI 5.18, 7.37). CONCLUSION The increase in number of cumulative frailty deficit items among older surgical patients was associated with a higher risk of adverse hospital events. The link offers an opportunity to clinical nursing professionals in the surgical setting, to develop and implement targeted models of care and ensure the best outcomes for frail older adults and their families.
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Affiliation(s)
| | | | | | - Ann Le
- Liverpool Hospital, Liverpool, Australia
| | - Carol Wilson
- Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Lynda Marov
- Campbelltown Hospital, Campbelltown, Australia
| | | | | | | | - Nevenka Francis
- Liverpool Hospital, Liverpool, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia.,South Western Sydney Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Ha Thi Mai
- Western Sydney University, Liverpool, Australia
| | - Steven He
- South Western Sydney Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Liverpool, Australia.,Western Sydney University, Liverpool, Australia
| | - Danielle Ní Chróinín
- Liverpool Hospital, Liverpool, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Steven A Frost
- Liverpool Hospital, Liverpool, Australia.,South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia.,South Western Sydney Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Liverpool, Australia
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Myles PS, Yeung J, Beattie WS, Ryan EG, Heritier S, McArthur CJ. Platform trials for anaesthesia and perioperative medicine: a narrative review. Br J Anaesth 2022; 130:677-686. [PMID: 36456249 DOI: 10.1016/j.bja.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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7
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Nerdal V, Gjestad E, Saltvedt I, Munthe-Kaas R, Ihle-Hansen H, Ryum T, Lydersen S, Grambaite R. The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study. BMC Neurol 2022; 22:234. [PMID: 35761180 PMCID: PMC9235162 DOI: 10.1186/s12883-022-02756-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/14/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later. METHOD As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia. RESULTS Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)). CONCLUSIONS Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.
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Affiliation(s)
- Vilde Nerdal
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
| | - Elise Gjestad
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
- Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ragnhild Munthe-Kaas
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hege Ihle-Hansen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Sandvika, Norway
| | - Truls Ryum
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ramune Grambaite
- Department of Psychology, Norwegian University of Science and Technology, Dragvoll Bygg 12, Edvard Bulls veg 1, 7491, Trondheim, Norway.
- Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.
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Grover S, Singh OP. Basics for Physicians and Psychiatrists for Effective Practice of Consultation-Liaison Psychiatry Services. Indian J Psychiatry 2022; 64:S228-S235. [PMID: 35602360 PMCID: PMC9122166 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_714_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/26/2021] [Accepted: 01/01/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - O P Singh
- West Bengal Medical Services, Kolkata, West Bengal, India E-mail:
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Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System. J Am Med Dir Assoc 2022; 23:1322-1327.e2. [PMID: 35172165 PMCID: PMC9359928 DOI: 10.1016/j.jamda.2022.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services. DESIGN Pragmatic prospective cohort study of consecutive admissions to a large health care system. SETTING AND PARTICIPANTS A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014. METHODS Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI). RESULTS Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001). CONCLUSIONS AND IMPLICATIONS This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.
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Ramírez Zuluaga LP, Ruano Restrepo MI, Osorio Bermúdez JD, Díaz Vallejo JA. Diagnosis and management of delirium in hospital oncology services. J Geriatr Oncol 2021; 13:462-468. [PMID: 34916174 DOI: 10.1016/j.jgo.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 08/06/2021] [Accepted: 11/30/2021] [Indexed: 11/28/2022]
Abstract
The diagnosis of delirium in oncologic services is a challenge; nowadays, there is very little evidence-based information available to guide the medical personnel in the diagnosis and decision taking regarding delirium in the oncologic patient. This article provides an updated review of the literature with extensive information on delirium in patients with cancer; the subject includes its definition, clinical features, precipitating and triggering factors, the frequency of delirium in oncological patients, its consequences, its treatment, and prognosis.
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Affiliation(s)
- Liliana Patricia Ramírez Zuluaga
- Internal Medicine and Geriatrics Specialist, Hospitalization Service, S.E.S. Hospital Universitario de Caldas, Manizales, Colombia; Medicine Program, Faculty of Health Sciences, Universidad de Caldas, Manizales, Colombia
| | - Mario Iván Ruano Restrepo
- Emergency Medicine Specialist, Critical Care Unit, Clínica San Marcel, Manizales, Colombia; Medicine Program, Faculty of Health Sciences, Universidad de Caldas, Manizales, Colombia
| | - Juan David Osorio Bermúdez
- Medicine Program, Faculty of Health Sciences, Universidad de Caldas, Manizales, Colombia; Semillero Huellas, Grupo de Investigación en Gerontología y Geriatría, Universidad de Caldas, Manizales, Colombia.
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Paixao L, Sun H, Hogan J, Hartnack K, Westmeijer M, Neelagiri A, Zhou DW, McClain LM, Kimchi EY, Purdon PL, Akeju O, Westover MB. ICU delirium burden predicts functional neurologic outcomes. PLoS One 2021; 16:e0259840. [PMID: 34855749 PMCID: PMC8638853 DOI: 10.1371/journal.pone.0259840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/28/2021] [Indexed: 12/13/2022] Open
Abstract
Background We investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness. Methods Prospective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge. Results Of 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038). Conclusions Delirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.
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Affiliation(s)
- Luis Paixao
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Jacob Hogan
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Katie Hartnack
- Antioch University New England, Keene, NH, United States of America
| | - Mike Westmeijer
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Anudeepthi Neelagiri
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - David W. Zhou
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States of America
| | - Lauren M. McClain
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Eyal Y. Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Patrick L. Purdon
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Oluwaseun Akeju
- Harvard Medical School, Boston, MA, United States of America
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
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12
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Nitchingham A, Milne A, Toson B, Tuch B, Agar M, Close J, Caplan G. Intranasal insulin for treatment of delirium in older hospitalised patients: study protocol for a randomised controlled trial. BMJ Open 2021; 11:e050765. [PMID: 34667006 PMCID: PMC8527126 DOI: 10.1136/bmjopen-2021-050765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Delirium is one of the most common conditions diagnosed in hospitalised older people and is associated with numerous adverse outcomes, yet there are no proven pharmacological treatments. Recent research has identified cerebral glucose hypometabolism as a pathophysiological mechanism offering a therapeutic target in delirium. Insulin, delivered via the intranasal route, acts directly on the central nervous system and has been shown to enhance cerebral metabolism and improve cognition in patients with mild cognitive impairment and dementia. This trial will determine whether intranasal insulin can reduce the duration of delirium in older hospitalised patients. METHODS AND ANALYSIS This is a prospective randomised, placebo-controlled, double-blind study with 6 months follow-up. One hundred patients aged 65 years or older presenting to hospital with delirium admitted under geriatric medicine will be recruited. Participants will be randomised to intranasal insulin detemir or placebo administered twice daily until delirium resolves, defined as Confusion Assessment Method (CAM) negative for 2 days, or discharge from hospital. The primary outcome measure will be duration of delirium using the CAM. Secondary outcome measures will include length of hospital stay, severity of delirium, adherence to treatment, hospital complications, new admission to nursing home, mortality, use of antipsychotic medications during hospital stay and cognitive and physical function at 6 months postdischarge. ETHICS AND DISSEMINATION This trial has been approved by the South Eastern Sydney Human Research and Ethics Committee. Dissemination plans include submission to a peer-reviewed journal for publication and presentation at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12618000318280.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Milne
- Rural Clinical School, Coffs Harbour Health Campus, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Barbara Toson
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, South Australia, Australia
| | - Bernard Tuch
- Department of Molecular & Translational Science, Hudson Institute, Monash University, Melbourne, Victoria, Australia
| | - Meera Agar
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jacqueline Close
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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13
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Kim H, Lee SM. Effect on Quality of Care of a Delirium Prevention Campaign for Surgical Intensive Care Nurses. J Nurs Care Qual 2021; 36:361-368. [PMID: 33394874 DOI: 10.1097/ncq.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delirium is an important issue related to mortality in patients treated in intensive care units. LOCAL PROBLEM Although there are guidelines for preventing delirium, its importance may be overlooked compared with the treatment of physical illness. METHODS A 2-step delirium prevention campaign (DPC) was implemented and its effects compared (before and after the DPC). INTERVENTIONS The DPC comprised the Confusion Assessment Method for the Intensive Care Unit and a checklist for delirium prevention. RESULTS Hospital mortality declined after the DPC, but there were no significant changes in the incidence and duration of delirium. CONCLUSIONS Nurses led the delirium preventive care intervention. Delirium prevention care may be more effective with policy approaches to progress the DPC.
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Affiliation(s)
- Heejeong Kim
- Seoul St. Mary's Hospital (Ms Kim), and Department of Nursing, College of Nursing (Dr Lee), The Catholic University of Korea, Seoul, Republic of Korea
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14
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. The validation of the Czech version of the Delirium Observation Scale and the Nursing Delirium Screening Scale for delirium screening in patients with locomotive apparatus trauma. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2021.12.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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Manni B, Federzoni L, Zucchi P, Mussi C, Inzitari M, Carda CA, Fabbo A, Morandi A. Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic. Aging Clin Exp Res 2021; 33:2243-2250. [PMID: 33211247 DOI: 10.1007/s40520-020-01753-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic. METHODS A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6 months following the delirium episode. RESULTS Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management. CONCLUSIONS This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.
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Affiliation(s)
- Barbara Manni
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Lucia Federzoni
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Patrizia Zucchi
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Chiara Mussi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Inzitari
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain
| | - Cristina Arnal Carda
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain
| | - Andrea Fabbo
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Alessandro Morandi
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain.
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Hospital Ancelle, Via Aselli 14, 26100, Cremona, Italy.
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16
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Eeles E, Huang L, Dakin L, Ling C, Dunn E, Fraser J, Dissanayaka NN. Development and validation of an aetiology in delirium diagnostic support tool. Age Ageing 2021; 50:1402-1405. [PMID: 33301574 DOI: 10.1093/ageing/afaa269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 10/15/2020] [Accepted: 11/06/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND recognition of the multifactorial causes of delirium represents a clinical challenge. OBJECTIVES to develop and show proof of principle of a diagnostic support tool (DST) for identification of causes of delirium. METHODS stage 1-development of the aetiology in delirium-diagnostic support tool (AiD-DST); stage 2-validation of the AiD-DST against reference standard diagnosis, based on clinical assessment from two independent consultant geriatricians. RESULTS a series of eight steps AiD-DST were formulated by an expert group to identify possible causes of delirium. Forty inpatients admitted to a general medical unit with a consultant physician/geriatrician diagnosis of delirium were recruited, consented and reviewed against the AiD-DST. Mean age was 85.1 (standard deviation 7.9) years and 26 (65%) of participants were female. Participants had multiple chronic co-morbidities [median Charlson Comorbidity Index 7; interquartile range (IQR 6-9)] and median number of medications was 8 (IQR 6-11.75). Median number of causes of delirium detected on AiD-DST was 3 (IQR 3-4) versus 5 (IQR 3-6) using the reference standard diagnosis, with sensitivity of 88.8% (95% confidence interval, 81.6-93.9%) and specificity of 71.8% (63-79.5%). CONCLUSIONS the aetiology in delirium DST shows promise in the identification of cause(s) in delirium.
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Affiliation(s)
- Eamonn Eeles
- Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Northside Clinical School, School of Medicine, University of Queensland, Brisbane, Australia
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Huang
- Department of Medicine, Logan Hospital, Brisbane, Queensland, Australia
| | - Lucy Dakin
- Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Northside Clinical School, School of Medicine, University of Queensland, Brisbane, Australia
| | - Carolina Ling
- Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Northside Clinical School, School of Medicine, University of Queensland, Brisbane, Australia
| | - Erin Dunn
- Allied Health, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jon Fraser
- Metro North IT, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Nadeeka N Dissanayaka
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Neurology, Royal Brisbane & Women’s Hospital, Herston Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
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17
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Meagher D, Williams OA, O'Connell H, Leonard M, Cullen W, Dunne CP, Mulligan O, Adamis D. A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients. Aging Ment Health 2021; 25:879-888. [PMID: 32091236 DOI: 10.1080/13607863.2020.1727849] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.
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Affiliation(s)
- David Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Olugbenga Alaba Williams
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Henry O'Connell
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of General Practice, School of Medicine, University College Dublin, Dublin, Ireland
| | - Maeve Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Walter Cullen
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of General Practice, School of Medicine, University College Dublin, Dublin, Ireland
| | - Colum P Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Dimitrios Adamis
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Sligo Mental Health Services, Sligo, Ireland
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18
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Reynish E, Hapca S, Walesby R, Pusram A, Bu F, Burton JK, Cvoro V, Galloway J, Ebbesen Laidlaw H, Latimer M, McDermott S, Rutherford AC, Wilcock G, Donnan P, Guthrie B. Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.
Objective
This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.
Design
For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.
Data sources
Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.
Results
In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.
Limitations
A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.
Conclusions
Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.
Future work
Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.
Study registration
This study is registered as PROSPERO CRD42015024492.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emma Reynish
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Simona Hapca
- School of Medicine, University of Dundee, Dundee, UK
| | - Rebecca Walesby
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Angela Pusram
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Feifei Bu
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Jennifer K Burton
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Vera Cvoro
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - James Galloway
- Health Informatics Centre, University of Dundee, Dundee, UK
| | | | - Marion Latimer
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | | | - Gordon Wilcock
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
| | - Peter Donnan
- School of Medicine, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- School of Medicine, University of Dundee, Dundee, UK
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19
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Hu KM, Brown RM. Resuscitation of the Critically Ill Older Adult. Emerg Med Clin North Am 2021; 39:273-286. [PMID: 33863459 DOI: 10.1016/j.emc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Robert M Brown
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA 24014, USA
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20
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Rawle MJ, McCue L, Sampson EL, Davis D, Vickerstaff V. Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study. Drugs Aging 2021; 38:233-242. [PMID: 33415708 PMCID: PMC7914229 DOI: 10.1007/s40266-020-00827-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population. OBJECTIVES Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients. METHODS We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality. RESULTS The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship. CONCLUSIONS ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.
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Affiliation(s)
- Mark James Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- Whipps Cross University Hospital, London, UK
| | - Laura McCue
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Research Department of Primary Care and Population Health, UCL, London, UK
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21
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Young J, Green J, Godfrey M, Smith J, Cheater F, Hulme C, Collinson M, Hartley S, Anwar S, Fletcher M, Santorelli G, Meads D, Hurst K, Siddiqi N, Brooker D, Teale E, Brown A, Forster A, Farrin A, Inouye S. The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Delirium is a distressing, common and serious condition in older people in hospital. Evidence suggests that it could be prevented in about one-third of patients using multicomponent interventions targeting delirium risk factors, but these interventions are not yet routinely available in the NHS.
Objective
The objective was to improve delirium prevention for older people admitted to the NHS.
Design
Project 1 comprised case studies employing qualitative methods (observation, interviews, workshops) in three NHS hospitals to develop the Prevention of Delirium system of care. Project 2 comprised case studies using mixed methods in five NHS hospitals to test the Prevention of Delirium implementation, feasibility and acceptability, and to modify the Prevention of Delirium system of care. Project 3 comprised a multicentre, cluster randomised, controlled, pragmatic feasibility study in eight hospitals, with embedded economic evaluation, to investigate the potential clinical effectiveness and cost-effectiveness of the Prevention of Delirium system of care, compared with standard care, among older patients admitted to hospital for emergency care. The primary objectives related to gathering information to design a definitive trial. Criteria for progression to a definitive trial were as follows: a minimum of six wards (75%) completing the Prevention of Delirium manual milestone checklist and an overall recruitment rate of at least 10% of the potential recruitment pool.
Setting
This study was set in NHS general hospitals.
Participants
In project 1, participants were staff, volunteers, and patient and carer representatives. In project 2, participants were staff, volunteers, patients and carers. In project 3, participants were older patients admitted to elderly care and orthopaedic trauma wards.
Intervention
The developed intervention (i.e. the Prevention of Delirium system of care).
Main outcome measures
For the feasibility study (project 3), the primary outcome measure was the Confusion Assessment Method. The secondary outcome measures were the Nottingham Extended Activities of Daily Living scale, the Clinical Anxiety Scale and the Geriatric Depression Scale Short Form.
Results
Project 1: understanding of delirium prevention was poor. Drawing on evidence, and working with ward teams, we developed the Prevention of Delirium system of care, which targeted 10 delirium risk factors. This multicomponent intervention incorporated systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Project 2: five out of six wards implemented or partially implemented the Prevention of Delirium intervention. A prominent role for hospital volunteers was intended, but most wards were unable to recruit or sustain the numbers needed. We identified four conditions necessary to implement and deliver the Prevention of Delirium intervention: (1) commitment of senior nurse, (2) a named person to drive implementation forward, (3) dedicated time (1 day per week) of an experienced nurse to lead implementation and (4) adequate ward staffing levels. Overall, the intervention was acceptable to staff, volunteers, patients and carers, and did not increase nursing staff workload. In the light of these findings, the Prevention of Delirium system of care was modified for use in project 3. Project 3: 16 wards in eight hospitals (two wards per hospital) were recruited. Out of 4449 patients screened, 3274 (73.6%) were eligible and 713 were registered, resulting in a recruitment rate of 16.0%. Thirty-three (4.6%) participants withdrew. The screened and registered participants were similar, but some between-treatment group imbalances were noted among those registered to the trial. All eight wards allocated to the intervention group completed the Prevention of Delirium manual milestone checklist and delivered the Prevention of Delirium intervention (median time 18.6 weeks for implementation). Overall, fidelity to the intervention was assessed as being high in two wards, medium in five wards and low in one ward. Of the expected 5645 Confusion Assessment Method delirium assessments, 5065 (89.7%) were completed during the first 10 days of admission. The rates of return of the patient-reported questionnaire booklets were 98.0% at baseline, 81.8% at 30 days and 70.5% at 3 months. The return rate of the EuroQol-5 Dimensions questionnaire was 98.6% at baseline, 77.5% at 1 month and 65.3% at 3 months (94–98% fully completed). The completion rate of the resource use questionnaire was lower (48.7%). The number of people with new-onset delirium at 10 days was 24 (7.0%) in the Prevention of Delirium group and 33 (8.9%) in the control group. Multilevel logistic regression analysis showed that participants in the Prevention of Delirium group had non-significant lower odds of developing delirium (odds ratio 0.68, 95% confidence interval 0.37 to 1.26; p = 0.2225). The average cost of the Prevention of Delirium intervention was estimated as £10.98 per patient and the mean costs for the Prevention of Delirium and usual-care groups were £5332 and £4412, respectively, with negligible between-group differences in quality-adjusted life-years. There was conflicting evidence from the trial- and model-based analyses relating to the cost-effectiveness of the Prevention of Delirium intervention. Given this, and in view of issues with the data (e.g. high levels of missingness), the results from the economic evaluation are highly uncertain. The criteria for continuation to a future definitive randomised controlled trial were met. Such a trial would need to recruit 5200 patients in 26 hospital clusters (200 patients per cluster).
Conclusions
The Prevention of Delirium system of care was successfully developed, and a multicentre feasibility study showed that the intervention is capable of implementation and delivery in routine care, with acceptable intervention fidelity and preliminary estimate of effectiveness.
Limitations
A prominent role for volunteers was originally intended in the Prevention of Delirium system of care, but only three of the eight wards allocated to the trial intervention group involved volunteers.
Future work
The findings indicate that a definitive multicentre evaluation of the Prevention of Delirium system of care should be designed and conducted to obtain robust estimates of clinical effectiveness and cost-effectiveness.
Trial registration
Current Controlled Trials ISRCTN28213290 (project 1), ISRCTN65924234 (project 2) and ISRCTN01187372 (project 3).
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Young
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - John Green
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Mary Godfrey
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Jane Smith
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Francine Cheater
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Suzanne Hartley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Shamaila Anwar
- National Institute for Health Research Clinical Research Network, Huddersfield, UK
| | - Marie Fletcher
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | | | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, York, UK
| | - Dawn Brooker
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Elizabeth Teale
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Alex Brown
- Elderly and Intermediate Care Service, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anne Forster
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sharon Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Boston, MA, USA
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22
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Sohrevardi SM, Nasab FS, Mirjalili MR, Bagherniya M, Tafti AD, Jarrahzadeh MH, Azarpazhooh MR, Saeidmanesh M, Banach M, Jamialahmadi T, Sahebkar A. Effect of atorvastatin on delirium status of patients in the intensive care unit: a randomized controlled trial. Arch Med Sci 2021; 17:1423-1428. [PMID: 34522273 PMCID: PMC8425261 DOI: 10.5114/aoms.2019.89330] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/29/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Delirium is one of the most prevalent complications in intensive care unit (ICU) patients, which is related to worse clinical outcomes including a longer ICU stay, longer duration of mechanical ventilation, higher mortality rates and increased risk of cognitive impairment. Observational studies have suggested that statins might have a positive effect on delirium status of hospitalized patients. To date, there has been no trial assessing the effect of atorvastatin on delirium status in critically ill patients. Thus, the aim of the current study was to determine the efficacy of atorvastatin on delirium status of patients in the ICU. METHODS In this randomized, double-blind and controlled trial, a total of 90 patients in the general ICU who had delirium for at least 2 days were randomly divided into atorvastatin (40 mg/day) (n = 40) and control (n = 50) groups. Delirium status of the patients was determined twice a day at 10:00 a.m. and 18:00 p.m. using the Richmond Agitation-Sedation Scale (RASS). RESULTS Administration 40 mg/day of atorvastatin significantly reduced the mean RASS score and increased delirium-free days at both morning and afternoon time points compared to the control group (p < 0.05). CONCLUSIONS Administration of atorvastatin had a significant positive effect on delirium status in patients admitted to the ICU.
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Affiliation(s)
- Seyed Mojtaba Sohrevardi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Stroke Prevention & Atherosclerosis Research Centre, University of Western Ontario, Canada
| | - Fatemeh Shojaei Nasab
- Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shahid Sadoughi University of Medical Silences, Yazd, Iran
| | - Mohammad Reza Mirjalili
- Department of Anesthesia and Intensive Care Medicine, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Bagherniya
- Department of Community Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arefeh Dehghani Tafti
- Department of Biostatistics and Epidemiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Jarrahzadeh
- Department of Anesthesia and Intensive Care Medicine, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahmoud Reza Azarpazhooh
- Department of Clinical Neurological Sciences, University of Western Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, Canada
| | | | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland
- Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Tannaz Jamialahmadi
- Halal Research Center of IRI, FDA, Tehran, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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23
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Affiliation(s)
- Sarah T Pendlebury
- Departments of Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital and Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK., Professor Sarah Pendlebury is supported by the NIHR Oxford Biomedical Research Centre
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24
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Efraim NT, Zikrin E, Shacham D, Katz D, Makulin E, Barski L, Zeller L, Bartal C, Freud T, Lebedinski S, Press Y. Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes. Front Med (Lausanne) 2020; 7:581069. [PMID: 33195329 PMCID: PMC7604336 DOI: 10.3389/fmed.2020.581069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an “any symptoms of delirium” group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.
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Affiliation(s)
- Nirit Tzur Efraim
- Department of Psychiatry, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeniya Zikrin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - David Shacham
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Dori Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Evgeni Makulin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine F, Soroka Medical Center, Beer-Sheva, Israel
| | - Lior Zeller
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine C, Soroka Medical Center, Beer-Sheva, Israel
| | - Carmi Bartal
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine E, Soroka Medical Center, Beer-Sheva, Israel
| | - Tamar Freud
- Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Svetlana Lebedinski
- Clinical Pharmacy Services, Pharmacy Department, Clalit Health Services, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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25
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Morandi A, Inzitari M, Udina C, Gual N, Mota M, Tassistro E, Andreano A, Cherubini A, Gentile S, Mossello E, Marengoni A, Olivé A, Riba F, Ruiz D, de Jaime E, Bellelli G. Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study. J Am Med Dir Assoc 2020; 22:1162-1167.e3. [PMID: 33160873 DOI: 10.1016/j.jamda.2020.09.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/16/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. DESIGN Cross-sectional study nested in the 2017 "Delirium Day" project. SETTING AND PARTICIPANTS Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. METHODS Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). RESULTS A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). CONCLUSIONS AND IMPLICATIONS Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy; REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain.
| | - Marco Inzitari
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Udina
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Neus Gual
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Miriam Mota
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Anita Andreano
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA Ancona, Italy
| | - Simona Gentile
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Enrico Mossello
- University of Florence, Carreggi University Hospital, Florence, Italy
| | - Alessandra Marengoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Anna Olivé
- Hospital Mare de Déu de la Mercè, Barcelona, Spain
| | - Francesc Riba
- Hospital de la Santa Creu, Jesus-Tortors, Tarragona, Spain
| | - Domingo Ruiz
- Fundació Althaia, Manresa, Spain; Universitat de Vic-Universitat Central de Catalunya, Barcelona, Spain
| | - Elisabet de Jaime
- Geriatrics Department, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Giuseppe Bellelli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy; Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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26
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Morandi A, Di Santo SG, Zambon A, Mazzone A, Cherubini A, Mossello E, Bo M, Marengoni A, Bianchetti A, Cappa S, Fimognari F, Antonelli Incalzi R, Gareri P, Perticone F, Campanini M, Penco I, Montorsi M, Di Bari M, Trabucchi M, Bellelli G. Delirium, Dementia, and In-Hospital Mortality: The Results From the Italian Delirium Day 2016, A National Multicenter Study. J Gerontol A Biol Sci Med Sci 2020; 74:910-916. [PMID: 29982365 DOI: 10.1093/gerona/gly154] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/26/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is little evidence about the prevalence of cognitive disorders and their effect on in-hospital mortality in large multicenter studies. The objectives of the 2016th edition of the "Italian Delirium Day," a large multicenter study on in-hospital older patients, were to assess (i) the point prevalence of cognitive impairment/no dementia, dementia, delirium, and delirium superimposed on dementia and (ii) the effect of these conditions on in-hospital mortality. METHODS This multicenter study and included 2,037 older patients (aged ≥65 years) admitted to acute medical and surgical wards across 205 acute hospitals. The four cognitive disorders groups were defined with a structured approach including the four AT and the presence of a documented diagnosis of dementia. The outcome measure was in-hospital mortality, as reported by the researchers involved in the study in each center. RESULTS The mean age was 81.17 ± 7.7 years. Overall, 893 patients (43.8%) had neither delirium nor dementia nor cognitive impairment, 483 (23.7%) had cognitive impairment/no dementia, 230 (11.3%) dementia alone, 187 (9.2%) delirium alone, and 244 (12.0%) delirium superimposed on dementia. Overall, 99 (4.8%) patients died. Participants with delirium alone (odds ratio 2.56; 95% confidence interval: 1.29-5.09) and those with delirium superimposed on dementia (odds ratio 2.60; 95% confidence interval: 1.39-4.85) had higher mortality risk compared with the reference group of patients with "no cognitive impairment." CONCLUSIONS Delirium and delirium superimposed on dementia were highly prevalent among older hospitalized patients and significantly increased in-hospital mortality. Clinicians should systematically assess these conditions and recognize them as markers of critical conditions and predictors of imminent death.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | - Antonella Zambon
- School of Medicine and Surgery, University of Milano-Bicocca, Italy
| | | | - Antonio Cherubini
- Geriatria, Accettazione Geriatrica, Centro di ricerca per l'invecchiamento, IRCCS-INRCA, Ancona, Italy
| | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | | | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Stefano Cappa
- Italian Society of Neurology for Dementia (SINDEM), Roma, Italy
| | - Filippo Fimognari
- Italian Society of Hospital's and Community Geriatrics (SIGOT), Roma, Italy
| | - Raffaele Antonelli Incalzi
- Department of Geriatrics, Campus Bio-Medico University of Roma, Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Roma, Italy
| | - Pietro Gareri
- Center for Cognitive Diseases and Dementias, Catanzaro, Italy.,Extrahospital Geriatric Association (AGE), Roma, Italy
| | | | - Mauro Campanini
- Federazione Italiana delle Associazioni Dirigenti Ospedalieri Internisti (FADOI), Società Italiana di Cure Palliative, Roma, Italy
| | | | - Marco Montorsi
- Department of General and Digestive Surgery, Humanitas University and Research Hospital, Roma, Italy.,Tor Vergata, Roma University, Italy
| | - Mauro Di Bari
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Italy.,Geriatric Unit, San Gerardo Hospital, Monza, Italy
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27
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Gual N, García-Salmones M, Brítez L, Crespo N, Udina C, Pérez LM, Inzitari M. The role of physical exercise and rehabilitation in delirium. Eur Geriatr Med 2020; 11:83-93. [PMID: 32297245 PMCID: PMC7224129 DOI: 10.1007/s41999-020-00290-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/15/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research. METHODS In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other. RESULTS This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function. CONCLUSION The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.
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Affiliation(s)
- N Gual
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain. .,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M García-Salmones
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - L Brítez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - N Crespo
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - C Udina
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L M Pérez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - M Inzitari
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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28
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Eagles D, Otal D, Wilding L, Sinha S, Thiruganasambandamoorthy V, Wells GA, Stiell IG. Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients. Am J Emerg Med 2020; 38:2545-2551. [PMID: 31937444 DOI: 10.1016/j.ajem.2019.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/07/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians. METHODS We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement. RESULTS Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67. DISCUSSION This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Damanjot Otal
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
| | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Samir Sinha
- Departments of Medicine and Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, Department of Medicine and Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Chia J, Eeles EM, Tattam K, Yerkovich S. Outcomes for patients with delirium receiving hospital‐in‐the‐home treatment: An Australian perspective. Australas J Ageing 2020; 39:e215-e219. [DOI: 10.1111/ajag.12768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/13/2019] [Accepted: 12/15/2019] [Indexed: 01/11/2023]
Affiliation(s)
- June Chia
- Internal Medicine Services The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine The University of Queensland Brisbane Queensland Australia
| | - Eamonn Michael Eeles
- Internal Medicine Services The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine The University of Queensland Brisbane Queensland Australia
| | - Kym Tattam
- Community and Oral Health Brisbane Queensland Australia
| | - Stephanie Yerkovich
- School of Clinical Medicine The University of Queensland Brisbane Queensland Australia
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Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC Med 2019; 17:229. [PMID: 31837711 PMCID: PMC6911703 DOI: 10.1186/s12916-019-1458-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Delirium is a common severe neuropsychiatric condition secondary to physical illness, which predominantly affects older adults in hospital. Prior to this study, the UK point prevalence of delirium was unknown. We set out to ascertain the point prevalence of delirium across UK hospitals and how this relates to adverse outcomes. METHODS We conducted a prospective observational study across 45 UK acute care hospitals. Older adults aged 65 years and older were screened and assessed for evidence of delirium on World Delirium Awareness Day (14th March 2018). We included patients admitted within the previous 48 h, excluding critical care admissions. RESULTS The point prevalence of Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) delirium diagnosis was 14.7% (222/1507). Delirium presence was associated with higher Clinical Frailty Scale (CFS): CFS 4-6 (frail) (OR 4.80, CI 2.63-8.74), 7-9 (very frail) (OR 9.33, CI 4.79-18.17), compared to 1-3 (fit). However, higher CFS was associated with reduced delirium recognition (7-9 compared to 1-3; OR 0.16, CI 0.04-0.77). In multivariable analyses, delirium was associated with increased length of stay (+ 3.45 days, CI 1.75-5.07) and increased mortality (OR 2.43, CI 1.44-4.09) at 1 month. Screening for delirium was associated with an increased chance of recognition (OR 5.47, CI 2.67-11.21). CONCLUSIONS Delirium is prevalent in older adults in UK hospitals but remains under-recognised. Frailty is strongly associated with the development of delirium, but delirium is less likely to be recognised in frail patients. The presence of delirium is associated with increased mortality and length of stay at one month. A national programme to increase screening has the potential to improve recognition.
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. MAIN BODY The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). SHORT CONCLUSION In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy.
- Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
- Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy
- University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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Çınar F, Eti Aslan F. Evaluation of Postoperative Delirium: Validity and Reliability of the Nursing Delirium Screening Scale in the Turkish Language. Dement Geriatr Cogn Dis Extra 2019; 9:362-373. [PMID: 31911787 PMCID: PMC6940440 DOI: 10.1159/000501903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Postoperative delirium is the most well-known form of postoperative cognitive impairment in all patient groups, especially in the elderly. Delirium is a syndrome that causes serious consequences, increasing mortality and morbidity rates and extending the length of hospital stay. The aim of this study was to evaluate the validity and reliability of the Turkish version of the Nursing Delirium Screening Scale (Nu-DESC). METHOD One hundred twelve patients who were hospitalized for a surgical operation in the orthopedics, neurosurgery, and general surgery clinic of a state hospital for 3 months were evaluated concurrently (and independently for delirium). Patients were observed by clinical nurses 3 times over a 24-h period. The presence of delirium was diagnosed by 2 neurologists according to DSM-IV criteria. Student's t test, the χ2 test, and the Mann-Whitney U test were used, and construct validity, intrascale factor analysis, interrater reliability, and specificity and sensitivity (ROC) analyses were performed for descriptive analysis. SPSS 25.0 and MedCalc18.6 were used for statistical analysis. RESULTS Delirium was detected in 28 patients according to the Nu-DESC. The ICC (intraclass correlation) is 0.97 in the 95% confidence interval from 0.96 to 0.98 for agreement between nurses and neurologists for the total Nu-DESC score. Weighted κ rates were between 0.78 and 0.92. In the ROC analysis of the Nu-DESC scale, the optimum cutoff value calculated for the 1,344 observations and 112 patients was determined as >1 according to the maximum sensitivity and the specific situation. Sensitivity at the cut-off point was 92.27; specificity was determined as 92.72. The Youden index was found to be J = 0.845 (0 < J = 0.845 < 1). CONCLUSION We believe that Turkish translation of Nu-DESC is valid and reliable for clinicians, nurses, and researchers and will contribute to delirium studies.
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Affiliation(s)
- Fadime Çınar
- Sabahattin Zaim University, Faculty of Health Sciences, Istanbul, Turkey
| | - Fatma Eti Aslan
- Bahçeşehir University, Faculty of Health Sciences, Istanbul, Turkey
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Delirium risk in non-surgical patients: systematic review of predictive tools. Arch Gerontol Geriatr 2019; 83:292-302. [PMID: 31136886 DOI: 10.1016/j.archger.2019.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/09/2019] [Accepted: 05/14/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Delirium is a common, serious condition associated with poor hospital outcomes. Guidelines recommend screening for delirium risk to target diagnostic and/or prevention strategies. This study critically reviews multicomponent delirium risk prediction tools in adult non-surgical inpatients. STUDY DESIGN Systematic review of studies incorporating at least two clinical factors in a multicomponent tool predicting risk of delirium during hospital admission. Derivation and validation studies were included. Study design, risk factors and tool performance were extracted and tabulated, and study quality was assessed by CHARMS criteria. DATA SOURCES PubMed, Embase, PsycINFO, and Cumulative Index to Nursing Health Literature (CINAHL) to 11th March 2018. DATA SYNTHESIS 22 derivation studies enrolling 38,874 participants (9 with a validation component) and 4 additional validation studies were identified, from a range of ward types. All studies had at least moderate risk of bias. Older age and cognitive, functional and sensory impairment were important predisposing factors. Precipitating risk factors included infection, illness severity, renal and electrolyte disturbances. Tools mostly did not differentiate between predisposing and precipitating risk factors mathematically or conceptually Most tools showed fair to good discrimination, and identified more than half of older inpatients at risk. CONCLUSIONS Several validated delirium risk prediction tools can identify patients at increased risk of delirium, but do not provide clear advice for clinical application. Most recommended cut-points are sensitive but have low specificity. Implementation studies demonstrating how risk screening can better direct clinical interventions in specific clinical settings are needed to define the potential value of these tools.
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Choutko-Joaquim S, Tacchini-Jacquier N, Pralong D'Alessio G, Verloo H. Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department. Dement Geriatr Cogn Dis Extra 2019; 9:236-249. [PMID: 31303870 PMCID: PMC6600030 DOI: 10.1159/000499707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/17/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium. AIM To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland. METHOD A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver. RESULTS The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference. CONCLUSION Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.
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Affiliation(s)
| | | | | | - Henk Verloo
- School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Sion, Switzerland
- Consultant of Valais Hospital, Sion, Switzerland
- Scientific collaborator of the service of Old Age psychiatry, University Hospital Lausanne, Cery, Prilly, Switzerland
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Mueller C, Soysal P, Rongve A, Isik AT, Thompson T, Maggi S, Smith L, Basso C, Stewart R, Ballard C, O'Brien JT, Aarsland D, Stubbs B, Veronese N. Survival time and differences between dementia with Lewy bodies and Alzheimer's disease following diagnosis: A meta-analysis of longitudinal studies. Ageing Res Rev 2019; 50:72-80. [PMID: 30625375 DOI: 10.1016/j.arr.2019.01.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/26/2018] [Accepted: 01/04/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To synthesize the evidence across longitudinal studies comparing survival in dementia with Lewy bodies (DLB) and Alzheimer's disease (AD). METHODS We conducted a systematic review and meta-analysis of studies comparing survival in clinically diagnosed DLB to AD. Longitudinal cohort studies were identified through a systematic search of major electronic databases from inception to May 2018. A random effects meta-analysis was performed to calculate survival time and relative risk of death. RESULTS Overall, 11 studies were identified including 22,952 patients with dementia: 2029 with DLB (mean diagnosis age 76.3; 47% female) compared with 20,923 with AD (mean diagnosis age 77.2; 65.1% female). Average survival time in DLB from diagnosis was 4.11 years (SD ± 4.10) and in AD 5.66 (SD ± 5.32) years, equating to a 1.60 (95% CI: -2.44 to -0.77) years shorter survival in DLB (p < 0.01). Relative risk of death was increased by 1.35 (95%CI: 1.17-1.55) in DLB compared to AD (p < 0.01). Differences in survival were not explained by follow-up time, age at diagnosis, gender, or cognitive score. CONCLUSIONS There is consistent evidence for higher and earlier mortality in DLB compared to AD. This is important for all stakeholders and underlines the importance of expanding research into DLB.
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Affiliation(s)
- Christoph Mueller
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; South London and Maudsley NHS Foundation Trust, London, UK.
| | - Pinar Soysal
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; Department of Geriatric Medicine, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey
| | - Arvid Rongve
- University of Bergen, Department of Clinical Medicine, Bergen, Norway; Department of Research and Innovation, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway
| | - Ahmet Turan Isik
- Unit for Aging Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Trevor Thompson
- Faculty of Education and Health, University of Greenwich, London, UK
| | - Stefania Maggi
- National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy
| | - Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | | | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Clive Ballard
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; University of Exeter Medical School, Exeter, UK
| | - John T O'Brien
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Dag Aarsland
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Brendon Stubbs
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy; Azienda Zero, Veneto Region, Venice, Italy
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Pendlebury ST. Delirium screening in older patients. Age Ageing 2018; 47:635-637. [PMID: 30010699 DOI: 10.1093/ageing/afy103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 01/23/2023] Open
Affiliation(s)
- Sarah T Pendlebury
- Departments of General (Internal) Medicine and Geratology, John Radcliffe hospital, Oxford, UK
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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Monaro S, West S, Pinkova J, Gullick J. The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation. J Clin Nurs 2018; 27:3530-3543. [PMID: 29776002 DOI: 10.1111/jocn.14536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/10/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023]
Abstract
AIMS AND OBJECTIVES To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI). BACKGROUND CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning. DESIGN Longitudinal qualitative study using Heideggerian phenomenology. METHODS Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed. RESULTS Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity). CONCLUSIONS Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy. RELEVANCE TO CLINICAL PRACTICE A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Sandra West
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Janice Gullick
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
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Eeles E, Gunn H, Sutt AL, Pinsker D, Flaws D, Jarrett P, Lye I, Fraser JF. e-Screening revolution: A novel approach to developing a delirium screening tool in the intensive care unit. Australas J Ageing 2018; 37:147-150. [PMID: 29602189 DOI: 10.1111/ajag.12525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Delirium is common in the intensive care unit (ICU), often affecting older patients. A bedside electronic tool has the potential to revolutionise delirium screening. Our group describe a novel approach to the design and development of delirium screening questions for the express purpose of use within an electronic device. Preliminary results are presented. METHODS Our group designed a series of tests which targeted the clinical criteria for delirium according to Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) criteria against predefined requirements, including applicability to older patients. RESULTS Candidate questions, including tests of attention and awareness, were devised and then refined by an expert multidisciplinary group, including geriatricians. A scoring scheme was constructed, with testing to failure an indicator of delirium. The device was tested in healthy controls, aged 20-80 years, who were recorded as being without delirium. CONCLUSION e-Screening for delirium requires a novel approach to instrument design but may revolutionise recognition of delirium in ICU.
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Affiliation(s)
- Eamonn Eeles
- Northside Clinical School, The Prince Charles Hospital, University of Queensland, Brisbane, Queensland, Australia.,Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Hayley Gunn
- Speech Pathology Department, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Queensland, Australia
| | - Anna-Liisa Sutt
- Speech Pathology Department, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Queensland, Australia
| | - Donna Pinsker
- Neuropsychology Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Dylan Flaws
- Department of Psychiatry, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Paul Jarrett
- Critical Care Research Group, Brisbane, Queensland, Australia.,The Adult Intensive Care Unit, Brisbane, Queensland, Australia
| | - India Lye
- Critical Care Research Group, Brisbane, Queensland, Australia.,The Adult Intensive Care Unit, Brisbane, Queensland, Australia
| | - John F Fraser
- Northside Clinical School, The Prince Charles Hospital, University of Queensland, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Queensland, Australia.,Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
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40
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Davis D, Richardson S, Hornby J, Bowden H, Hoffmann K, Weston-Clarke M, Green F, Chaturvedi N, Hughes A, Kuh D, Sampson E, Mizoguchi R, Cheah KL, Romain M, Sinha A, Jenkin R, Brayne C, MacLullich A. The delirium and population health informatics cohort study protocol: ascertaining the determinants and outcomes from delirium in a whole population. BMC Geriatr 2018; 18:45. [PMID: 29426299 PMCID: PMC5807842 DOI: 10.1186/s12877-018-0742-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/05/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Delirium affects 25% of older inpatients and is associated with long-term cognitive impairment and future dementia. However, no population studies have systematically ascertained cognitive function before, cognitive deficits during, and cognitive impairment after delirium. Therefore, there is a need to address the following question: does delirium, and its features (including severity, duration, and presumed aetiologies), predict long-term cognitive impairment, independent of cognitive impairment at baseline? METHODS The Delirium and Population Health Informatics Cohort (DELPHIC) study is an observational population-based cohort study based in the London Borough of Camden. It is recruiting 2000 individuals aged ≥70 years and prospectively following them for two years, including daily ascertainment of all inpatient episodes for delirium. Daily inpatient assessments include the Memorial Delirium Assessment Scale, the Observational Scale for Level of Arousal, and the Hierarchical Assessment of Balance and Mobility. Data on delirium aetiology is also collected. The primary outcome is the change in the modified Telephone Interview for Cognitive Status at two years. DISCUSSION DELPHIC is the first population sample to assess older persons before, during and after hospitalisation. The cumulative incidence of delirium in the general population aged ≥70 will be described. DELPHIC offers the opportunity to quantify the impact of delirium on cognitive and functional outcomes. Overall, DELPHIC will provide a real-time public health observatory whereby information from primary, secondary, intermediate and social care can be integrated to understand how acute illness is linked to health and social care outcomes.
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Affiliation(s)
- Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Joanne Hornby
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Helen Bowden
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | - Fenella Green
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Alun Hughes
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | | | | | - Abhi Sinha
- Royal Free London NHS Foundation Trust, London, UK
- Central and North West London NHS Foundation Trust, London, UK
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41
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Schrijver EJM, de Vries OJ, van de Ven PM, Bet PM, Kamper AM, Diepeveen SHA, van Marum RJ, van Strien AM, Anten S, Lagaay AM, Boelaarts L, Bloemers FW, Kramer MHH, Nanayakkara PWB. Haloperidol versus placebo for delirium prevention in acutely hospitalised older at risk patients: a multi-centre double-blind randomised controlled clinical trial. Age Ageing 2018; 47:48-55. [PMID: 28985255 DOI: 10.1093/ageing/afx124] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background because the few randomised placebo-controlled trials investigating the potential role for prophylactic haloperidol in delirium prevention have focused on specific surgical populations, we investigated its efficacy and safety in acutely hospitalised older patients. Methods this multi-centre, double-blind, stratified, block randomised, placebo-controlled trial was conducted at six Dutch hospitals. Patients age ≥70 years, acutely admitted through the emergency department for general medicine or surgical specialties and at risk for delirium were randomised (n = 245) to haloperidol or placebo 1 mg orally twice-daily (maximum of 14 doses) on top of standard nonpharmacological prevention strategies. The primary outcome was delirium incidence. Other endpoints included delirium severity and duration, drug safety and clinical outcomes. Results intention-to-treat analysis included 242 participants (calculated sample size n = 390, statistical power of current sample 59%) allocated to haloperidol (n = 118) or placebo (n = 124). In the haloperidol and placebo group, delirium incidence was 19.5 versus 14.5% (OR 1.43, 95% CI 0.72 to 2.78); median (IQR) delirium duration 4 (2, 5) versus 3 (1, 6) days (P = 0.366); maximum DRS-R-98 score 16 (9.8, 19.5) versus 10 (5.5, 22.5) (P = 0.549; 53.7% missing data); hospital LOS 7 (4, 10.3) versus 7 (5, 11.8) days (P = 0.343); 3-month mortality 9.9 versus 12.5% (OR 0.77, 95% CI 0.34 to 1.75), respectively. No treatment-limiting side effects were noted. Conclusions prophylactic low-dose oral haloperidol did not reduce delirium incidence in acutely hospitalised older patients. Therefore, prophylactic use of haloperidol in this population is not recommended.
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Affiliation(s)
- Edmée J M Schrijver
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Oscar J de Vries
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis (OLVG Hospital), Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, The Netherlands
| | - Ad M Kamper
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | | | - Rob J van Marum
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Astrid M van Strien
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Anne M Lagaay
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Boelaarts
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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Dostovic Z, Smajlovic D, Ibrahimagic OC, Dostovic A. Mortality and Functional Disability of Poststroke Delirium. Mater Sociomed 2018; 30:95-97. [PMID: 30061796 PMCID: PMC6029905 DOI: 10.5455/msm.2018.30.95-97] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Small number of studies have evaluated the mortality and the degree of functional disability of post-stroke delirium, and our aim was to determine that. Patients and Methods Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glasgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results Delirious patients had a significantly higher mortality (p = 0.0005). As opposed to the type of stroke mortality was higher after ischemic (p = 0.0005). The patients without delirium had significantly better cumulative survival during the first year after stroke (p = 0.0005). Delirious patients aged ≥65 years had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). In relation to the type of stroke delirious patients with ischemic had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). Delirious patients had a greater degree of functional impairment at discharge (p = 0.01), three (p = 0.01), six months (p = 0.01) and one year (p = 0.01) after stroke. Conclusion Delirious patients have a significantly higher mortality, lower cumulative survival and a greater degree of functional disability in the first year after stroke.
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Affiliation(s)
- Zikrija Dostovic
- Clinic of Neurology, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
| | - Dzevdet Smajlovic
- Clinic of Neurology, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
| | - Omer C Ibrahimagic
- Clinic of Neurology, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
| | - Adnan Dostovic
- Faculty of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
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43
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Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Current practice and opinions of hospital pharmacists regarding their role in the screening, prevention and treatment of delirium. Int J Clin Pharm 2017; 39:1194-1200. [PMID: 29038936 DOI: 10.1007/s11096-017-0547-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/06/2017] [Indexed: 11/28/2022]
Abstract
Background An interdisciplinary approach is fundamental for effective prevention and treatment of delirium. Pharmacists could play a role in identifying and resolving medication-related delirium. However, little is known about their role in delirium care. Objective The main purpose of this survey was to assess the current practice and opinions of pharmacists concerning their involvement in screening, prevention and treatment of delirium. Setting Pharmacists in public and private hospitals in Australia. Method A cross-sectional survey was conducted using a pilot tested web-based questionnaire which was distributed primarily via a link in the electronic newsletter of the Society of Hospital Pharmacists of Australia. Main outcome measure Number and proportion of respondents answering questions related to the practice and perceptions of pharmacists in delirium management. Results Responses from 106 pharmacists were included in the analysis. Most respondents believed that pharmacists could play a role in prevention (92%) and screening (62%) of patients for delirium. However, in practice only 8% of pharmacists reported that they had ever screened a patient for delirium using a validated tool and 79% indicated that pharmacists were never or rarely involved in delirium treatment. When pharmacists did make recommendations half of the respondents said that pharmacists' recommendations were frequently or always accepted by the delirium treating teams. Conclusion Hospital pharmacists are underutilised in the prevention and management of delirium. Strategies to increase their involvement in the prevention and management of delirium should be implemented.
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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44
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Tropea J, LoGiudice D, Liew D, Gorelik A, Brand C. Poorer outcomes and greater healthcare costs for hospitalised older people with dementia and delirium: a retrospective cohort study. Int J Geriatr Psychiatry 2017; 32:539-547. [PMID: 27114271 DOI: 10.1002/gps.4491] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes. METHODS Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment. RESULTS There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3; p < 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment. CONCLUSIONS Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Joanne Tropea
- Melbourne EpiCentre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Dina LoGiudice
- Department of Aged Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Danny Liew
- Melbourne EpiCentre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Alexandra Gorelik
- Melbourne EpiCentre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Caroline Brand
- Melbourne EpiCentre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
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45
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Dharmarajan K, Swami S, Gou RY, Jones RN, Inouye SK. Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality. J Am Geriatr Soc 2016; 65:1026-1033. [PMID: 28039852 DOI: 10.1111/jgs.14743] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES (1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality. DESIGN Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000. SETTING Large academic hospital. PARTICIPANTS Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only. MEASUREMENTS (1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission. RESULTS Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8-6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation. CONCLUSION Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults.
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Affiliation(s)
- Kumar Dharmarajan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Sunil Swami
- Department of Research and Development, Philips Healthcare, Baltimore, Maryland
| | - Ray Y Gou
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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46
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van Velthuijsen EL, Zwakhalen SMG, Warnier RMJ, Mulder WJ, Verhey FRJ, Kempen GIJM. Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review. Int J Geriatr Psychiatry 2016; 31:974-89. [PMID: 26898375 DOI: 10.1002/gps.4441] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 01/06/2016] [Accepted: 01/20/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Delirium is a serious and common complication among older hospitalized patients and is a predictor of many adverse outcomes. However, up to 72% of delirium incidents are unrecognized or misdiagnosed. The aim of this systematic review is to determine the validity, reliability, and feasibility of instruments for the detection of delirium in older hospitalized patients. METHODS A systematic literature search was conducted. The inclusion criteria were a mean or median age of 65+ years, the use of the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases-10 as a reference standard, and publication in English. All included studies underwent a quality assessment (QUADAS-2). RESULTS Forty-three of the 3.790 identified studies were relevant to the review, describing 28 instruments. Quality assessment resulted in 37 studies with a positive quality assessment, describing 23 instruments. Five instruments (Delirium Observation Scale (DOS), Nursing Delirium Screening Scale (Nu-DESC), Confusion Assessment Method (CAM), CAM-Intensive Care Unit (ICU), and Delirium Rating Scale-Revised-98) were described in three or more methodologically sound studies. The Delirium Observation Screening Scale (DOS) and Nu-DESC are observational instruments with good psychometric properties, but the Nu-DESC is shorter and has been validated in more languages. The CAM, CAM-ICU, and Delirium Rating Scale-Revised-98 (DRS-R-98) are instruments with both observational and interactive components. The CAM is the most widely studied and demonstrates the best psychometric properties. CONCLUSION Timely detection of delirium might reduce the negative outcomes of delirium in the long term. The Nu-DESC and CAM appear to be the most adequate instruments for detecting delirium. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Eveline L van Velthuijsen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sandra M G Zwakhalen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Ron M J Warnier
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wubbo J Mulder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frans R J Verhey
- Alzheimer Center Limburg, MHeNS School for Mental Health and NeuroScience and Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Gertrudis I J M Kempen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
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47
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Gottschalk A, Gottschalk LB, Sieber FE. In Response. Anesth Analg 2016; 122:1728-9. [PMID: 27101513 DOI: 10.1213/ane.0000000000001208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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48
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Gurunathan U, Marudhachalam K, Reynolds K. Preoperative Delirium: Not to Be Overlooked. Anesth Analg 2016; 122:1727. [PMID: 27101512 DOI: 10.1213/ane.0000000000001202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Usha Gurunathan
- Department of Anesthesia and Perfusion Services, The Prince Charles Hospital, University of Queensland, Brisbane, Australia,
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49
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Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy. .,Geriatric Unit, San Gerardo University Hospital, Monza, Italy. .,Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy.,Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy.,Tor Vergata, Rome University, Rome, Italy.,Italian Psychogeriatric Association (AIP), Brescia, Italy
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50
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Yeung J, Patel V, Champaneria R, Dretzke J. Regional versus general anaesthesia in elderly patients undergoing surgery for hip fracture: protocol for a systematic review. Syst Rev 2016; 5:66. [PMID: 27098125 PMCID: PMC4839155 DOI: 10.1186/s13643-016-0246-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/13/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND With an ageing population, the incidence of hip fractures requiring surgery is increasing. Post-operative delirium is common following hip fracture surgery. Delirium is associated with high mortality and morbidity, poor long-term functional outcomes and institutionalisation. There is some evidence to suggest that perioperative intervention, specifically the anaesthetic technique employed, may reduce the incidence of delirium in this population. The aim of this systematic review is to investigate the impact of anaesthesia type on post-operative delirium. METHOD We will conduct a systematic literature review using Embase, MEDLINE, CINAHL and the Cochrane Library (CENTRAL) bibliographic databases and the ZETOC and Web of Science websites. Authors of these trials will be invited to contribute unpublished data. PROSPERO register and clinical trial registers will also be searched to identify any ongoing reviews and trials. Eligible studies will assess the incidence of post-operative delirium in patients having regional or general anaesthesia for hip fracture surgery. The primary outcome of interest will be post-operative delirium; secondary outcomes will include mortality, measures of functional outcome, quality of life, length of hospital stay, discharge location and adverse events. Two reviewers will independently screen references identified by electronic literature searches. Two independent reviewers will extract data from studies fulfilling our inclusion criteria using a piloted data extraction form. Methodological quality and bias of included randomised controlled trials will be assessed using the 'Cochrane Collaborations tool for assessing risk of bias'; for non-randomised studies, this will be assessed using the Newcastle-Ottawa scale. Data on similar outcomes will be pooled when possible. Where possible, meta-analysis will be undertaken using Review Manager (RevMan version 5.3) software. DISCUSSION This systematic review will provide an updated evidence base with which to guide clinical practice and research for this group of challenging patients. If the anaesthetic technique employed is shown to reduce the incidence of post-operative cognition dysfunction, then this may lead to a change in evidence-based practice, influence future guidelines and support further randomised controlled trial research. There is no known effective treatment for delirium, creating the urgent need for research into delirium prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015020166.
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Affiliation(s)
- Joyce Yeung
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Vanisha Patel
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Rita Champaneria
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Janine Dretzke
- Institute of Applied Health Research Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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