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Eeles E, Tran DD, Boyd J, Tronstad O, Teodorczuk A, Flaws D, Fraser JF, Dissanayaka N. A narrative review of the development and performance characteristics of electronic delirium-screening tools. Aust Crit Care 2024; 37:651-658. [PMID: 38102026 DOI: 10.1016/j.aucc.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Electronic delirium-screening tools are an emergent area of research. OBJECTIVE The objective of this study was to summarise the development and performance characteristics of electronic screening tools in delirium. METHODS Searches were conducted in Pubmed, Embase, and CINAHL Complete databases to identify electronic delirium-screening tools. RESULTS Five electronic delirium-screening tools were identified and reviewed. Two were designed for and tested within a medical setting, and three were applied to intensive care. Adaptive design features, such as skip function to reduce test burden, were variably integrated into instrument design. All tools were shown to have acceptable psychometric properties, but validation studies were largely incomplete. CONCLUSIONS Electronic delirium-screening tools are an exciting area of development and may offer hope for improved uptake of delirium screening.
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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, Australia; Critical Care Research Group, School of Clinical Sciences, Queensland University of Technology, Department of Mental Health, Caboolture Hospital, University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Queensland, Australia.
| | - David Duc Tran
- Critical Care Research Group, School of Clinical Sciences, Queensland University of Technology, Department of Mental Health, Caboolture Hospital, University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia
| | - Jemima Boyd
- Allied Health Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Oystein Tronstad
- Critical Care Research Group Level 3, Clinical Sciences, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrew Teodorczuk
- Critical Care Research Group, School of Clinical Sciences, Queensland University of Technology, Department of Mental Health, Caboolture Hospital, University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia
| | - Dylan Flaws
- Critical Care Research Group, School of Clinical Sciences, Queensland University of Technology, Department of Mental Health, Caboolture Hospital, University of Queensland, Faculty of Medicine, Brisbane, Queensland, Australia
| | - John F Fraser
- Critical Care Research Group Level 3, Clinical Sciences, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Nadeeka Dissanayaka
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Queensland, Australia
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2
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Zhao E, Weddell J, Gallagher R. Post-operative delirium following open heart surgery: a commentary. Eur J Cardiovasc Nurs 2024:zvae088. [PMID: 38875462 DOI: 10.1093/eurjcn/zvae088] [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: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Emma Zhao
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Johns Hopkins Dr, Camperdown, NSW 2050, Australia
- Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Victor Coppleson Building, Western Ave, Camperdown, NSW 2050, Australia
| | - Joseph Weddell
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Johns Hopkins Dr, Camperdown, NSW 2050, Australia
- Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Victor Coppleson Building, Western Ave, Camperdown, NSW 2050, Australia
| | - Robyn Gallagher
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Johns Hopkins Dr, Camperdown, NSW 2050, Australia
- Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Victor Coppleson Building, Western Ave, Camperdown, NSW 2050, Australia
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Botero L, Banks MD, Gordon EH, Bauer J, Young AM. Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients. Clin Nutr 2024; 43:1057-1064. [PMID: 38569329 DOI: 10.1016/j.clnu.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/07/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND AND AIMS Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days. METHODS A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission. RESULTS One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044). CONCLUSION This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.
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Affiliation(s)
- Liliana Botero
- School of Human Movement and Nutrition Science, The University of Queensland, Brisbane, Queensland, Australia.
| | - Merrilyn D Banks
- Department of Nutrition and Dietetics and Food Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Emily H Gordon
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Judy Bauer
- School of Human Movement and Nutrition Science, The University of Queensland, Brisbane, Queensland, Australia; Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Adrienne M Young
- Department of Nutrition and Dietetics and Food Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [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: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Infante S, Behn A, González M, Pintor L, Franco E, Araya P, Maldonado JR. Reliability and Validity of the Spanish Adaptation of the Stanford Proxy Test for Delirium in Two Clinical Spanish-Speaking Communities. J Acad Consult Liaison Psychiatry 2024; 65:136-147. [PMID: 37806639 DOI: 10.1016/j.jaclp.2023.09.004] [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: 09/21/2022] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies. OBJECTIVE It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method). METHODS The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other. RESULTS In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity. CONCLUSIONS The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version.
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Affiliation(s)
- Sanndy Infante
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile.
| | - Alex Behn
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile
| | - Matías González
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Health Service of Reloncaví, Puerto Montt, Chile
| | - Luis Pintor
- Department of Psychiatry, Hospital Clinic of Barcelona, Barcelona, Spain; School Medicine, University of Barcelona, Barcelona, Spain
| | - Eduardo Franco
- Research Department, Universidad Maria Auxiliadora, Lima, Peru
| | - Pablo Araya
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile
| | - José R Maldonado
- Division of Medical Psychiatry, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
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Deeth S, Stevens S, Bell J, Mudge A. Nutrition care for older adults with delirium: A scoping review. J Clin Nurs 2024. [PMID: 38379358 DOI: 10.1111/jocn.17069] [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: 08/07/2023] [Revised: 12/30/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
AIMS This scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group. DESIGN Scoping review. METHODS This review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered. DATA SOURCES Databases searched were CINAHL, Medline, Embase, JBI Evidence-based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023. RESULTS The database search identified 1561 articles, 186 underwent full-text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group. CONCLUSION This scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE Providing nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families. IMPACT This scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes. REPORTING METHOD This scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). PATIENT OF PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Sophie Deeth
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
- Allied Health, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sarah Stevens
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jack Bell
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
- Allied Health, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Greater Brisbane Medical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Yang L, Do Q, Zhu X, Leung JM, Sands LP. Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium. Int J Geriatr Psychiatry 2024; 39:e6049. [PMID: 38168022 DOI: 10.1002/gps.6049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). METHODS Data were from five independent study cohorts (N = 1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2 days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. RESULTS The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. CONCLUSIONS Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.
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Affiliation(s)
- Leon Yang
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Quyen Do
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Xiaofan Zhu
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Laura P Sands
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
- Center for Gerontology, Virginia Tech, Blacksburg, Virginia, US
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Bowman EML, Brummel NE, Caplan GA, Cunningham C, Evered LA, Fiest KM, Girard TD, Jackson TA, LaHue SC, Lindroth HL, Maclullich AMJ, McAuley DF, Oh ES, Oldham MA, Page VJ, Pandharipande PP, Potter KM, Sinha P, Slooter AJC, Sweeney AM, Tieges Z, Van Dellen E, Wilcox ME, Zetterberg H, Cunningham EL. Advancing specificity in delirium: The delirium subtyping initiative. Alzheimers Dement 2024; 20:183-194. [PMID: 37522255 PMCID: PMC10917010 DOI: 10.1002/alz.13419] [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: 03/30/2023] [Revised: 05/26/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology. METHODS The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts. RESULTS Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations. DISCUSSION The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes. HIGHLIGHTS Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.
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Affiliation(s)
- Emily M. L. Bowman
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Nathan E. Brummel
- The Ohio State University College of MedicineDivision of PulmonaryCritical Care, and Sleep MedicineColumbusOhioUSA
| | - Gideon A. Caplan
- Department of Geriatric MedicinePrince of Wales Hospital, Sydney, Australia University of New South WalesSydneyAustralia
| | - Colm Cunningham
- School of Biochemistry & ImmunologyTrinity Biomedical Sciences InstituteTrinity College, DublinRepublic of Ireland
| | - Lis A. Evered
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Critical CareUniversity of MelbourneMelbourneAustralia
- Department of Anaesthesia & Acute Pain MedicineSt. Vincent's HospitalMelbourneAustralia
| | - Kirsten M. Fiest
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Critical Care MedicineUniversity of Calgary and Alberta Health ServicesCalgaryAlbertaCanada
- O'Brien Institute for Public HealthUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Department of PsychiatryCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Timothy D. Girard
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Thomas A. Jackson
- Institute of Inflammation and AgeingUniversity of BirminghamBirminghamUK
| | - Sara C. LaHue
- Department of NeurologySchool of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Weill Institute for NeurosciencesDepartment of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Buck Institute for Research on AgingNovatoCaliforniaUSA
| | - Heidi L. Lindroth
- Department of NursingMayo ClinicRochesterMinnesotaUSA
- Center for Aging ResearchRegenstrief InstituteSchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Alasdair M. J. Maclullich
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
| | - Daniel F. McAuley
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Esther S. Oh
- Departments of MedicinePsychiatry and Behavioral Sciences and PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Mark A. Oldham
- Department of PsychiatryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | | | - Pratik P. Pandharipande
- Departments of Anesthesiology and SurgeryDivision of Anesthesiology Critical Care Medicine and Critical IllnessBrain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kelly M. Potter
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Pratik Sinha
- Division of Clinical and Translational ResearchWashington University School of MedicineSt. LouisMissouriUSA
| | - Arjen J. C. Slooter
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Aoife M. Sweeney
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
- School of ComputingEngineering and Built EnvironmentGlasgow Caledonian UniversityGlasgowScotland
| | - Edwin Van Dellen
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Mary Elizabeth Wilcox
- Department of Critical Care MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
| | - Henrik Zetterberg
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska Academy at the University of GothenburgMölndalSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Neurodegenerative DiseaseUCL Institute of NeurologyQueen SquareLondonUK
- UK Dementia Research Institute at UCLLondonUK
- Hong Kong Center for Neurodegenerative DiseasesClear Water BayHong KongChina
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthUniversity of Wisconsin–MadisonMadisonWisconsinUSA
| | - Emma L. Cunningham
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
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Falk A, Stenman M, Kåhlin J, Hultgren R, Nymark C. Suffering in silence - Cardiac surgery patients recalling hypoactive delirium a qualitative descriptive study. Intensive Crit Care Nurs 2023; 79:103493. [PMID: 37480700 DOI: 10.1016/j.iccn.2023.103493] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/16/2023] [Accepted: 07/09/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVES Postoperative delirium affects up to 50% of patients undergoing cardiac surgery. Delirium phenotypes are commonly divided into hyperactive and hypoactive, with hypoactive symptoms (reduced motor activity and withdrawal) often being overlooked due to their discreet character. Although the consequences of hypoactive delirium are severe, studies focusing on patients' experiences of hypoactive delirium are scarce. The aim of the study was to describe cardiac surgery patients' experiences of hypoactive delirium. RESEARCH METHODOLOGY/DESIGN We used qualitative descriptive semi-structured interviews with an inductive, latent approach. Twelve patients with hypoactive symptoms of delirium after cardiac surgery were purposefully selected. Interview data were analysed by qualitative content analysis. FINDINGS Two themes based on eight sub-themes emerged. "Dream or reality in parallel worlds" included disturbing experiences of existing in parallel realities with cognitive effects, residual nightmares, and illusions that occasionally persisted after hospital discharge. "Managing the state of hypoactive delirium" included experiences of intellectually dealing with hypoactive delirium with assumptions of causes and cures, and through interactions like communicating with others. CONCLUSION Participants experienced hypoactive delirium as extensive and long-lasting with perceptions of existing in parallel realities. The findings emphasize the need for healthcare professionals to have expertise in hypoactive delirium and its fluctuating course, as the delirium of many patients may be undetected and undiagnosed. Improving the use of screening tools for clinical practice is essential for the detection of hypoactive delirium, and a person-centred approach is needed to properly care for this group of patients. IMPLICATIONS FOR CLINICAL PRACTICE The challenges in the recognition of hypoactive delirium need to be emphasized because the syndrome is still overlooked. The use of screening tools in clinical practice is essential. A person-centred approach supports relationships between delirious patients and healthcare professionals.
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Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, L1:00, Anna Steckséns gata 53, SE-171 76 Stockholm, Sweden; Perioperative Medicine and Intensive Care Function E7:67, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, L1:00, Anna Steckséns gata 53, SE-171 76 Stockholm, Sweden; Perioperative Medicine and Intensive Care Function E7:67, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function E7:67, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Biomedicum, Solnavägen 9, SE-171 65 Solna, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, L1:00, Anna Steckséns gata 53, SE-171 76 Stockholm, Sweden; Department of Vascular Surgery, C9:27, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, SE-141 52 Huddinge, Sweden; Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
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10
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Chotai S, Chen JW, Turer R, Smith C, Kelly PD, Bhamidipati A, Davis P, McCarthy JT, Bendfeldt GA, Peyton MB, Dennis BM, Terry DP, Guillamondegui O, Yengo-Kahn AM. Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury. Neurosurgery 2023; 93:1425-1431. [PMID: 37326424 DOI: 10.1227/neu.0000000000002562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.
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Affiliation(s)
- Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Robert Turer
- Department of Emergency Medicine, University of Texas Southwestern, Dallas , Texas , USA
| | - Candice Smith
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | | | - Philip Davis
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Jack T McCarthy
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | | | - Mary B Peyton
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Bradley M Dennis
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Douglas P Terry
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Oscar Guillamondegui
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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11
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Wang J, Niu S, Wu Y. Effect of the clinical decision assessment system on clinical outcomes of delirium in hospitalized older adults: study protocol for a pair-matched, parallel, cluster randomized controlled superiority trial. Trials 2023; 24:581. [PMID: 37697324 PMCID: PMC10494451 DOI: 10.1186/s13063-023-07607-3] [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: 06/07/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Prompt recognition of delirium is the first key step in its proper management. A previous study has demonstrated that nurses' delirium screening using the usual paper version assessment tool has no effect on clinical outcomes. Clinical decision assessment systems have been demonstrated to improve patients' adherence and clinical outcomes. Therefore, We developed a clinical decision assessment system (3D-DST) based on the usual paper version (3-min diagnostic interview for CAM-defined delirium), which was developed for assessing delirium in older adults with high usability and accuracy. However, no high quality evidence exists on the effectiveness of a 3D-DST in improving outcomes of older adults compared to the usual paper version. METHODS A pair-matched, open-label, parallel, cluster randomized controlled superiority trial following the SPIRIT checklist. Older patients aged 65 years or older admitted to four medical wards of a geriatric hospital will be invited to participate in the study. Prior to the study, delirium prevention and treatment interventions will be delivered to nurses in both the intervention and control groups. The nurses in the intervention group will perform routine delirium assessments on the included older patients with 3D-DST, while the nurses in the control group will perform daily delirium assessments with the usual paper version. Enrolled patients will be assessed twice daily for delirium by a nurse researcher using 3D-DST. The primary outcome is delirium duration. The secondary outcomes are delirium severity, incidence of delirium, length of stay, in-hospital mortality, adherence to delirium assessment, prevention, and treatment of medical staff. DISCUSSION This study will incorporate the 3D-DST into clinical practice for delirium assessment. If our study will demonstrate that 3D-DST will improve adherence with delirium assessment and clinical outcomes in older patients, it will provide important evidence for the management of delirium in the future. TRIAL REGISTRATION Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402. https://www.chictr.org.cn/showproj.aspx?proj=47127 . PROTOCOL VERSION 1, 29/7/22.
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Affiliation(s)
- Jiamin Wang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 102488, China
- School of Nursing, Capital Medical University, 10 You-an-Men Wai Xi-Tou-Tiao, Fengtai District, Beijing, 100069, China
| | - Sen Niu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Ying Wu
- School of Nursing, Capital Medical University, 10 You-an-Men Wai Xi-Tou-Tiao, Fengtai District, Beijing, 100069, China.
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12
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Martinez FE, Tee R, Poulter AL, Jordan L, Bell L, Balogh ZJ. Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused. J Clin Med 2023; 12:5671. [PMID: 37685738 PMCID: PMC10488395 DOI: 10.3390/jcm12175671] [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: 08/04/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.
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Affiliation(s)
- F. Eduardo Martinez
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Rebecca Tee
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Amber-Louise Poulter
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Leah Jordan
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Liam Bell
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Zsolt J. Balogh
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Traumatology, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW 2305, Australia
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13
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Weiss Y, Zac L, Refaeli E, Ben-Yishai S, Zegerman A, Cohen B, Matot I. Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study). Ann Surg 2023; 278:59-64. [PMID: 35913053 DOI: 10.1097/sla.0000000000005657] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium. BACKGROUND Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years. METHODS Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes. RESULTS Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days]. CONCLUSIONS One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.
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Affiliation(s)
- Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Lilach Zac
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Einat Refaeli
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shimon Ben-Yishai
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Alexander Zegerman
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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14
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Gong XY, Hou DJ, Yang J, He JL, Cai MJ, Wang W, Lu XY, Gao J. Incidence of delirium after non-cardiac surgery in the Chinese elderly population: a systematic review and meta-analysis. Front Aging Neurosci 2023; 15:1188967. [PMID: 37455941 PMCID: PMC10346854 DOI: 10.3389/fnagi.2023.1188967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background POD places a heavy burden on the healthcare system as the number of elderly people undergoing surgery is increasing annually because of the aging population. As a large country with a severely aging population, China's elderly population has reached 267 million. There has been no summary analysis of the pooled incidence of POD in the elderly Chinese population. Methods Systematic search databases included PubMed, Web of Science, EMBASE, Cochrane Library Databases, China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), WanFang Database, and Chinese Science and Technology Periodicals (VIP). The retrieval time ranged from the database's establishment to February 8, 2023. The pooled incidence of delirium after non-cardiac surgery was calculated using a random effects model. Meta-regression, subgroup, and sensitivity analyses were used to explore the source of heterogeneity. Results A total of 52 studies met the inclusion criteria, involving 18,410 participants. The pooled incidence of delirium after non-cardiac surgery in the elderly Chinese population was 18.6% (95% CI: 16.4-20.8%). The meta-regression results revealed anesthesia method and year of publication as a source of heterogeneity. In the subgroup analysis, the gender subgroup revealed a POD incidence of 19.6% (95% CI: 16.9-22.3%) in males and 18.3% (95% CI: 15.7-20.9%) in females. The year of publication subgroup analysis revealed a POD incidence of 20.3% (95% CI: 17.4-23.3%) after 2018 and 14.6 (95% CI: 11.6-17.6%) in 2018 and before. In the subgroup of surgical types, the incidence of hip fracture surgery POD was 20.7% (95% CI: 17.6-24.3%), the incidence of non-cardiac surgery POD was 18.4% (95% CI: 11.8-25.1%), the incidence of orthopedic surgery POD was 16.6% (95% CI: 11.8-21.5%), the incidence of abdominal neoplasms surgery POD was 14.3% (95% CI: 7.6-21.1%); the incidence of abdominal surgery POD was 13.9% (95% CI: 6.4-21.4%). The anesthesia methods subgroup revealed a POD incidence of 21.5% (95% CI: 17.9-25.1%) for general anesthesia, 15.0% (95% CI: 10.6-19.3%) for intraspinal anesthesia, and 8.3% (95% CI: 10.6-19.3%) for regional anesthesia. The measurement tool subgroup revealed a POD incidence of 19.3% (95% CI: 16.7-21.9%) with CAM and 16.8% (95% CI: 12.6-21.0%) with DSM. The sample size subgroup revealed a POD incidence of 19.4% (95% CI: 16.8-22.1%) for patients ≤ 500 and 15.3% (95% CI: 11.0-19.7%) for patients > 500. The sensitivity analysis suggested that the pooled incidence of postoperative delirium in this study was stable. Conclusion Our systematic review of the incidence of delirium after non-cardiac surgery in elderly Chinese patients revealed a high incidence of postoperative delirium. Except for cardiac surgery, the incidence of postoperative delirium was higher for hip fracture surgery than for other types of surgery. However, this finding must be further explored in future large-sample studies. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42023397883.
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Affiliation(s)
- Xiao-Yan Gong
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Dong-Jiang Hou
- School of Medicine and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Yang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jia-li He
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ming-Jin Cai
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Wei Wang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xian-Ying Lu
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Gao
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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15
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Huang JW, Yang YF, Gao XS, Xu ZH. A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial. J Orthop Surg Res 2023; 18:441. [PMID: 37337260 DOI: 10.1186/s13018-023-03930-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery. METHODS Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score. RESULTS There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups. CONCLUSIONS A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery. TRIAL REGISTRATION ChiCTR2200055281.
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Affiliation(s)
- Jian-Wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Yun-Fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China.
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Zhong-He Xu
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
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16
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Pouw MA, Calf AH, Georg RR, de Rooij SE, Ter Maaten JC, van Munster BC. Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting. Aging Clin Exp Res 2023:10.1007/s40520-023-02447-2. [PMID: 37285074 PMCID: PMC10363057 DOI: 10.1007/s40520-023-02447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.
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Affiliation(s)
- Maaike A Pouw
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Agneta H Calf
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Rita R Georg
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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17
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Ehrlich AL, Owodunni OP, Mostales JC, Qin CX, Hadvani PJ, Sirisegaram L, Bettick D, Gearhart SL. Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway. Ann Surg 2023; 277:e1254-e1261. [PMID: 35837966 DOI: 10.1097/sla.0000000000005567] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine geriatric-specific outcomes following implementation of a multispecialty geriatric surgical pathway (GSP). BACKGROUND In 2018, we implemented a GSP in accordance with the proposed 32 standards of American College of Surgeons' Geriatric Surgery Verification Program. METHODS This observational study combined data from the electronic health record system (EHR) and ACS-National Surgery Quality Improvement Program (NSQIP) to identify patients ≥65 years undergoing inpatient procedures from 2016 to 2020. GSP patients (2018-2020) were identified by preoperative high-risk screening. Frailty was measured with the modified frailty index. Surgical procedures were ranked according to the operative stress score (1-5). Loss of independence (LOI), length of stay, major complications (CD II-IV), and 30-day all-cause unplanned readmissions were measured in the pre/postpatient populations and by propensity score matching of patients by operative procedure and frailty. RESULTS A total of 533 (300 pre-GSP, 233 GSP) patients similar by demographics (age and race) and clinical profile (frailty) were included. On multivariable analysis, GSP patients showed decreased risk for LOI [odds ratio (OR) 0.26 (0.23, 0.29) P <0.001] and major complications [OR: 0.63 (0.50, 0.78) P <0.001]. Propensity matching demonstrated similar findings. Examining frail patients alone, GSP showed decreased risk for LOI [OR: 0.30 (0.25, 0.37) P <0.001], major complications [OR: 0.31 (0.24, 0.40) P <0.001], and was independently associated with a reduction in length of stay [incidence rate ratios: 0.97 (0.96, 0.98), P <0.001]. CONCLUSIONS In our diverse patient population, implementation of a GSP led to improved geriatric-specific surgical outcomes. Future studies to examine pathway compliance would promote the identification of further interventions.
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Affiliation(s)
- April L Ehrlich
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Oluwafemi P Owodunni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Joshua C Mostales
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Xu Qin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Priyanka J Hadvani
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
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18
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Liu Y, Li Z, Li Y, Ge N, Yue J. Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients. Front Psychol 2023; 14:1166392. [PMID: 37251016 PMCID: PMC10214704 DOI: 10.3389/fpsyg.2023.1166392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium. Methods The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). Result Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70). Conclusion UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.
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Affiliation(s)
- Yadong Liu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Zhenzhen Li
- Health Management Center, General Practice Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Li
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Ning Ge
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
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Ma R, Zhao J, Li C, Qin Y, Yan J, Wang Y, Yu Z, Zhang Y, Zhao Y, Huang B, Sun S, Ning X. Diagnostic accuracy of the 3-minute diagnostic interview for confusion assessment method-defined delirium in delirium detection: a systematic review and meta-analysis. Age Ageing 2023; 52:afad074. [PMID: 37211364 DOI: 10.1093/ageing/afad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND Delirium is a common complication clinically and is associated with the poor outcomes, yet it is frequently unrecognised and readily disregarded. Although the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM) has been used in a variety of care settings, a comprehensive evaluation of its accuracy in all available care settings has not been performed. OBJECTIVE This study aimed to evaluate the diagnostic test accuracy of the 3D-CAM in delirium detection through a systematic review and meta-analysis. METHODS We systematically searched PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL (EBSCO) and ClinicalTrials.gov published from inception to 10 July 2022. The quality assessment of the diagnostic accuracy studies-2 tool was applied to evaluate methodological quality. A bivariate random effects model was used to pool sensitivity and specificity. RESULTS Seven studies with 1,350 participants and 2,499 assessments were included, which were carried out in general medical wards, intensive care units, internal medical wards, surgical wards, recovery rooms and post-anaesthesia care units. The prevalence of delirium ranged from 9.1% to 25%. The pooled sensitivity and specificity were 0.92 (95% confidence interval [CI] 0.87-0.95) and 0.95 (95% CI 0.92-0.97), respectively. The pooled positive likelihood ratio was 18.6 (95% CI 12.2-28.2), the negative likelihood ratio was 0.09 (95% CI 0.06-0.14) and the diagnostic odds ratio was 211 (95% CI 128-349). Moreover, the area under the curve was 0.97 (95% CI 0.95-0.98). CONCLUSIONS The 3D-CAM has good diagnostic accuracy for delirium detection in different care settings. Further analyses illustrated that it had comparable diagnostic accuracy in older adults and patients with dementia or known baseline cognitive impairment. In conclusion, the 3D-CAM is recommended for clinical delirium detection.
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Affiliation(s)
- Rui Ma
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jin Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Cui Li
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yunlong Qin
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jipeng Yan
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuwei Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zixian Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yumeng Zhang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yueru Zhao
- Medicine School of Xi'an Jiaotong University, Xi'an, China
| | - Boyong Huang
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaoxuan Ning
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Freeman H, Martin RC, Whittington C, Zhang Y, Osborne JD, O'Leary T, Vickers JK, Flood KL, Skains RM, Markland AD, Buford TW, Brown CJ, Kennedy RE. Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults. J Am Med Dir Assoc 2023; 24:533-540.e9. [PMID: 36931323 PMCID: PMC10370492 DOI: 10.1016/j.jamda.2023.02.006] [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: 05/08/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults. DESIGN Retrospective cross-sectional study. SETTING AND PARTICIPANTS General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019. METHODS Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD. RESULTS One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001). CONCLUSIONS AND IMPLICATIONS Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.
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Affiliation(s)
- Hyun Freeman
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Caroline Whittington
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yue Zhang
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John D Osborne
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tobias O'Leary
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jasmine K Vickers
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kellie L Flood
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, AL, USA
| | - Thomas W Buford
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cynthia J Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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21
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Mallick A, Biffi A. Diagnostic and Management Strategies for Common Neurobehavioral and Psychiatric Disturbances Among Patients with Cognitive Impairment and the Dementias. Clin Geriatr Med 2023; 39:161-175. [PMID: 36404029 DOI: 10.1016/j.cger.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Neurobehavioral and neuropsychiatric symptoms are highly prevalent among individuals diagnosed with cognitive impairment or dementia and impact the quality of life for patients and caregivers alike. Diagnosis and management of these conditions (including primarily depression, anxiety, apathy, psychosis, agitation, and aggression) is crucial to optimal patient care outcomes in clinical practice. The present article provides a practical review of diagnostic approaches and management strategies for behavioral and neuropsychiatric disorders arising in patients with cognitive impairment, up to and including dementia.
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Affiliation(s)
- Akashleena Mallick
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Henry and Allison McCance Center for Brain Health, 100 Cambridge Street, Room 2054, Boston, MA 02144, USA
| | - Alessandro Biffi
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Henry and Allison McCance Center for Brain Health, 100 Cambridge Street, Room 2054, Boston, MA 02144, USA.
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22
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Ma X, Chu H, Han K, Shao Q, Yu Y, Jia S, Wang D, Wang Z, Zhou Y. Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:646-660. [PMID: 36419366 DOI: 10.1111/jgs.18104] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 11/25/2022]
Abstract
AIMS To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). METHODS We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. RESULTS A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73). CONCLUSIONS POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.
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Affiliation(s)
- Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Huijun Chu
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuo Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dunliang Wang
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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23
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Beckwith N, Probert J, Rosenbaum BL, Bains A, Angelucci VC, Morfin Rodriguez AE, London S, Zollman JW, Soto Ordoñez A, Kontos N, Smith FA, Celano CM, Beach SR. Demographic Features, Physical Examination Findings, and Medication Use in Hospitalized, Delirious Patients With and Without COVID-19 Infection: A Retrospective Study. J Acad Consult Liaison Psychiatry 2023; 64:35-44. [PMID: 35948255 PMCID: PMC9357932 DOI: 10.1016/j.jaclp.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Delirium is common in the setting of infection with severe acute respiratory syndrome coronavirus 2. Anecdotal evidence and case reports suggest that patients with delirium in the setting of Coronavirus 2019 (COVID-19) may exhibit specific features, including increased tone, abulia, and alogia. OBJECTIVE To determine whether differences exist in sociodemographic and medical characteristics, physical examination findings, and medication use in delirious patients with and without COVID-19 infection referred for psychiatric consultation. METHODS We undertook an exploratory, retrospective chart review of 486 patients seen by the psychiatry consultation service at a tertiary care hospital from March 10 to May 15, 2020. Delirious patients were diagnosed via clinical examination by a psychiatric consultant, and these patients were stratified by COVID-19 infection status. The strata were described and compared using bivariate analyses across sociodemographic, historical, objective, and treatment-related variables. RESULTS A total of 109 patients were diagnosed with delirium during the study period. Thirty-six were COVID-19+. Median age was 63 years and did not differ between groups. COVID-19+ patients with delirium were more likely to present from nursing facilities (39% vs 11%; Fisher's exact test; P = 0.001) and have a history of schizophrenia (11% vs 0%; Fisher's exact test; P = 0.011). Myoclonus (28% vs 4%; P = 0.002), hypertonia (36% vs 10%; P = 0.003), withdrawal (36% vs 15%; P = 0.011), akinesia (19% vs 6%; P = 0.034), abulia (19% vs 3%; P = 0.004), and alogia (25% vs 8%; P = 0.012) were more common in COVID-19+ patients. COVID-19+ delirious patients were significantly more likely to have received ketamine (28% vs 7%; P = 0.006), alpha-adrenergic agents besides dexmedetomidine (36% vs 14%; P = 0.014), and enteral antipsychotics (92% vs 66%; P = 0.007) at some point. CONCLUSIONS Patients with COVID-19 delirium referred for psychiatric consultation are more likely to reside in nursing facilities and have a history of schizophrenia than delirious patients without COVID-19. Patients with delirium in the setting of COVID-19 may exhibit features consistent with akinetic mutism. Psychiatrists must assess for such features, as they may influence management choices and the risk of side effects with agents commonly used in the setting of delirium.
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Affiliation(s)
- Noor Beckwith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Julia Probert
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Blake L Rosenbaum
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Ashika Bains
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Victoria C Angelucci
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Alejandra E Morfin Rodriguez
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Stephanie London
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Joshua W Zollman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Andrea Soto Ordoñez
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Felicia A Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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24
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Winarto H, Habiburrahman M, Anggraeni TD, Nuryanto KH, Julianti RA, Purwoto G, Andrijono A. The Utility of Pre-Treatment Inflammation Markers as Associative Factors to the Adverse Outcomes of Vulvar Cancer: A Study on Staging, Nodal Involvement, and Metastasis Models. J Clin Med 2022; 12:jcm12010096. [PMID: 36614896 PMCID: PMC9821387 DOI: 10.3390/jcm12010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Given the role of inflammation in carcinogenesis, this study investigated the utility of pre-treatment inflammatory markers as associative indicators for advanced-stage disease, lymph node metastasis (LNM), and distant metastasis (DM) in vulvar cancer (VC). METHODS A cross-sectional study was conducted on 86 women with VC in a single centre in Jakarta, Indonesia. The laboratory data was based on C-reactive protein (CRP), procalcitonin, the erythrocyte sedimentation rate (ESR) and fourteen derived, recorded and calculated ratios: leukocyte-to-platelet (LPR), neutrophil-to-lymphocyte (NLR), derived neutrophil-to-lymphocyte (dNLR), neutrophil-to-monocyte (NMR), platelet-to-monocyte (PLR), lymphocyte-to-monocyte (LMR), basophil-to-monocyte (BLR), systemic immune-inflammation index (SII), body mass index, albumin, and NLR (BAN) score, haemoglobin-to-platelet (HPR), prognostic nutritional index (PNI), modified Glasgow Prognostic Score (mGPS), CRP-to-albumin, and CRP-to-procalcitonin. The optimal cut-off for each marker was determined using receiver operating characteristic (ROC) curve analysis, and their diagnostic indicator performances were assessed. The utility of these ratios as associative factors for three endpoints was further evaluated in multivariate regression models. RESULTS Investigated inflammatory markers exhibited specific performances for individual adverse outcomes, proving a fair to excellent ability in case finding and screening. After adjustment, the BAN score ≤ 334.89 (OR 9.20, p = 0.001) and ESR ≥ 104 (OR 4.18, p = 0.048) become two advanced-stage associative factors with AUC: 0.769. LNM was solely determined by higher NLR ≥ 2.83 (OR 4.15, p = 0.014) with AUC: 0.615. Meanwhile, BLR ≥ 0.035 (OR 5.67, p = 0.001) and ESR ≥ 84 (OR 6.01, p = 0.003) were contributing factors for DM, with AUC: 0.765. CONCLUSIONS Inflammatory markers are crucial for identifying the deleterious outcomes of VC. Accordingly, yielded models require external validation.
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Affiliation(s)
- Hariyono Winarto
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Correspondence: (H.W.); (M.H.); Tel.: +62-21-3914806 (H.W.); +62-21-31930373 (M.H.)
| | - Muhammad Habiburrahman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
- Correspondence: (H.W.); (M.H.); Tel.: +62-21-3914806 (H.W.); +62-21-31930373 (M.H.)
| | - Tricia Dewi Anggraeni
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
| | - Kartiwa Hadi Nuryanto
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
| | - Renny Anggia Julianti
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
| | - Gatot Purwoto
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
| | - Andrijono Andrijono
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia
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25
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Spiller TR, Tufan E, Petry H, Böttger S, Fuchs S, Duek O, Ben-Zion Z, Korem N, Harpaz-Rotem I, von Känel R, Ernst J. Delirium screening in an acute care setting with a machine learning classifier based on routinely collected nursing data: A model development study. J Psychiatr Res 2022; 156:194-199. [PMID: 36252349 DOI: 10.1016/j.jpsychires.2022.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 12/12/2022]
Abstract
Delirium screening in acute care settings is a resource intensive process with frequent deviations from screening protocols. A predictive model relying only on daily collected nursing data for delirium screening could expand the populations covered by such screening programs. Here, we present the results of the development and validation of a series of machine-learning based delirium prediction models. For this purpose, we used data of all patients 18 years or older which were hospitalized for more than a day between January 1, 2014, and December 31, 2018, at a single tertiary teaching hospital in Zurich, Switzerland. A total of 48,840 patients met inclusion criteria. 18,873 (38.6%) were excluded due to missing data. Mean age (SD) of the included 29,967 patients was 71.1 (12.2) years and 12,231 (40.8%) were women. Delirium was assessed with the Delirium Observation Scale (DOS) with a total score of 3 or greater indicating that a patient is at risk for delirium. Additional measures included structured data collected for nursing process planning and demographic characteristics. The performance of the machine learning models was assessed using the area under the receiver operating characteristic curve (AUC). The training set consisted of 21,147 patients (mean age 71.1 (12.1) years; 8,630 (40.8%) women|) including 233,024 observations with 16,167 (6.9%) positive DOS screens. The test set comprised 8,820 patients (median age 71.1 (12.4) years; 3,601 (40.8%) women) with 91,026 observations with 5,445 (6.0%) positive DOS screens. Overall, the gradient boosting machine model performed best with an AUC of 0.933 (95% CI, 0.929 - 0.936). In conclusion, machine learning models based only on structured nursing data can reliably predict patients at risk for delirium in an acute care setting. Prediction models, using existing data collection processes, could reduce the resources required for delirium screening procedures in clinical practice.
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Affiliation(s)
- Tobias R Spiller
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - Ege Tufan
- German Institute for Literature, Leipzig University, Leipzig, Germany
| | - Heidi Petry
- University of Zurich (UZH), Zurich, Switzerland; Center of Clinical Nursing Science, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Sönke Böttger
- University of Zurich (UZH), Zurich, Switzerland; Department of Gastroenterology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland; Psychiatric University Hospital Zurich (PUK), Zurich, Switzerland
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ziv Ben-Zion
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Nachshon Korem
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ilan Harpaz-Rotem
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, USA; Department of Psychology, Yale University, New Haven, CT, USA
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland
| | - Jutta Ernst
- University of Zurich (UZH), Zurich, Switzerland; Center of Clinical Nursing Science, University Hospital Zurich (USZ), Zurich, Switzerland
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David-Bercholz J, Acker L, Caceres AI, Wu PY, Goenka S, Franklin NO, Rodriguiz RM, Wetsel WC, Devinney M, Wright MC, Zetterberg H, Yang T, Berger M, Terrando N. Conserved YKL-40 changes in mice and humans after postoperative delirium. Brain Behav Immun Health 2022; 26:100555. [PMID: 36457825 PMCID: PMC9706140 DOI: 10.1016/j.bbih.2022.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Delirium is a common postoperative neurologic complication among older adults. Despite its prevalence (14%-50%) and likely association with inflammation, the exact mechanisms that underpin postoperative delirium are unclear. This project aimed to characterize systemic and central nervous system (CNS) inflammatory changes following surgery in mice and humans. Matched plasma and cerebrospinal fluid (CSF) samples from the "Investigating Neuroinflammation Underlying Postoperative Brain Connectivity Changes, Postoperative Cognitive Dysfunction, Delirium in Older Adults" (INTUIT; NCT03273335) study were compared to murine endpoints. Delirium-like behavior was evaluated in aged mice using the 5-Choice Serial Reaction Time Test (5-CSRTT). Using a well established orthopedic surgical model in the FosTRAP reporter mouse we detected neuronal changes in the prefrontal cortex, an area implicated in attention, but notably not in the hippocampus. In aged mice, plasma interleukin-6 (IL-6), chitinase-3-like protein 1 (YKL-40), and neurofilament light chain (NfL) levels increased after orthopedic surgery, but hippocampal YKL-40 expression was decreased. Given the growing evidence for a YKL-40 role in delirium and other neurodegenerative conditions, we assayed human plasma and CSF samples. Plasma YKL-40 levels were similarly increased after surgery, with a trend toward a greater postoperative plasma YKL-40 increase in patients with delirium. However, YKL-40 levels in CSF decreased following surgery, which paralleled the findings in the mouse brain. Finally, we confirmed changes in the blood-brain barrier (BBB) as early as 9 h after surgery in mice, which warrants more detailed and acute evaluations of BBB integrity following surgery in humans. Together, these results provide a nuanced understanding of neuroimmune interactions underlying postoperative delirium in mice and humans, and highlight translational biomarkers to test potential cellular targets and mechanisms.
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Key Words
- 4-OHT, 4-hydroxytamoxifen
- 5-CSRTT, 5-Choice Serial Reaction Time Test
- AD, Alzheimer’s disease
- Aging
- Attention
- BBB, blood-brain barrier
- Biomarkers
- CAM, Confusion AssessmentMethod
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Delirium
- ELISA, enzyme-linked immunosorbent assay
- GFAP, glial fibrillary acidic protein
- IHC, immunohistochemistry
- IL-6, interleukin-6
- MMSE, mini-mental status exam
- NfL, neurofilament light chain
- PBS, phosphate-buffered saline
- PFA, paraformaldehyde
- PLC, prelimbic cortex
- ROI, regions of interest
- SIMOA, single molecule array
- Surgery
- TRAP, Targeted Recombination in Active Populations
- YKL-40
- YKL-40, chitinase-3-like protein 1
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Affiliation(s)
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Ana I. Caceres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Pau Yen Wu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Saanvi Goenka
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Nathan O. Franklin
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - Ramona M. Rodriguiz
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - William C. Wetsel
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
- Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
| | - Michael Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Ting Yang
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Immunology, Duke University Medical Center, Durham, NC, United States
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Mansutti I, Saiani L, Cargnelutti D, Petrucco S, Giannina V, Di Domenico C, Passadore P, Palese A. Delirium prevalence, risk factors and outcomes among patients with acute stroke: A multi-centre observational study. JOURNAL OF VASCULAR NURSING 2022; 40:172-180. [PMID: 36435600 DOI: 10.1016/j.jvn.2022.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delirium is a frequent and serious acute neuropsychiatric syndrome leading to worse prognosis including mortality. Patients with ischaemic and/or haemorrhagic stroke are vulnerable to delirium. However, predisposing and precipitating factors have not been fully discovered to date, leaving this area of practice under-represented in available guidelines. AIMS To describe the prevalence, associated factors and main in-hospital outcomes of post-stroke delirium. METHODS A multi-centre observational study was conducted from 2019 to 2020 and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data were collected in stroke units located in two large hospitals in the North-East region of Italy. Consecutive adult patients with ischaemic and/or haemorrhagic stroke with a Glasgow Coma Scale > 5, who were willing to participate, were included. Data at admission, during the in-hospital stay and at discharge were collected by trained nurses, not involved in the care of patients, with (a) validated tools, (b) direct observation, and (c) access of patients' records. RESULTS A total of 78 patients were enrolled (mean 73.1 years; 59% male), and 70.5% of them had suffered an ischaemic stroke. The mean National Institutes of Health Stroke Scale (NIHSS) at admission was 8.2 ± 7.0. A total of 34.6% of patients developed post-stroke delirium; the onset was mainly on the first day of admission (70.4%) and the condition lasted for an average of 3.7 days (SD 2.6). In the multivariate logistic regression, 64.1% of the delirium variance was explained by the NIHSS scores (RR 1.259, 95%CI 1.035-1.533; p = 0.022). Patients with post-stroke delirium reported higher functional dependence at discharge and the need for more delaying of hospital care to be admitted in rehabilitation units. CONCLUSIONS At admission, higher scores in the NIHSS evaluation might suggest which patients are at an increased risk of delirium. Avoiding interventions that could potentially increase this risk, together with continuous surveillance, become imperative for nurses who are constantly and closely present by their patients' side, in order to prevent this serious complication.
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Affiliation(s)
- Irene Mansutti
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Luisa Saiani
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
| | - Daniela Cargnelutti
- Department of Neurosciences, Stroke Unit/Neurology, Udine University Hospital, Italy.
| | - Stefania Petrucco
- Department of Neurosciences, Stroke Unit/Neurology, Udine University Hospital, Italy.
| | - Viera Giannina
- Department of Medical Sciences, University of Udine, Italy.
| | | | - Paolo Passadore
- Department of Neurosciences, Stroke Unit/Neurology, Pordenone Hospital, Italy.
| | - Alvisa Palese
- Department of Medical Sciences, University of Udine, Italy.
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Reynolds CF, Jeste DV, Sachdev PS, Blazer DG. Mental health care for older adults: recent advances and new directions in clinical practice and research. World Psychiatry 2022; 21:336-363. [PMID: 36073714 PMCID: PMC9453913 DOI: 10.1002/wps.20996] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The world's population is aging, bringing about an ever-greater burden of mental disorders in older adults. Given multimorbidities, the mental health care of these people and their family caregivers is labor-intensive. At the same time, ageism is a big problem for older people, with and without mental disorders. Positive elements of aging, such as resilience, wisdom and prosocial behaviors, need to be highlighted and promoted, both to combat stigma and to help protect and improve mental health in older adults. The positive psychiatry of aging is not an oxymoron, but a scientific construct strongly informed by research evidence. We champion a broader concept of geriatric psychiatry - one that encompasses health as well as illness. In the present paper, we address these issues in the context of four disorders that are the greatest source of years lived with disability: neurocognitive disorders, major depression, schizophrenia, and substance use disorders. We emphasize the need for implementation of multidisciplinary team care, with comprehensive assessment, clinical management, intensive outreach, and coordination of mental, physical and social health services. We also underscore the need for further research into moderators and mediators of treatment response variability. Because optimal care of older adults with mental disorders is both patient-focused and family-centered, we call for further research into enhancing the well-being of family caregivers. To optimize both the safety and efficacy of pharmacotherapy, further attention to metabolic, cardiovascular and neurological tolerability is much needed, together with further development and testing of medications that reduce the risk for suicide. At the same time, we also address positive aging and normal cognitive aging, both as an antidote to ageism and as a catalyst for change in the way we think about aging per se and late-life mental disorders more specifically. It is in this context that we provide directions for future clinical care and research.
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Affiliation(s)
| | - Dilip V. Jeste
- Department of PsychiatryUniversity of California San DiegoLa JollaCAUSA
| | | | - Dan G. Blazer
- Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamNCUSA
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Muzzana C, Mantovan F, Huber MK, Trevisani K, Niederbacher S, Kugler A, Ausserhofer D. Delirium in elderly postoperative patients: A prospective cohort study. Nurs Open 2022; 9:2461-2472. [PMID: 35716398 PMCID: PMC9374408 DOI: 10.1002/nop2.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN Prospective cohort study. METHODS Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.
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Affiliation(s)
- Chiara Muzzana
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | - Franco Mantovan
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy.,Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
| | | | - Katia Trevisani
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | | | - Alexander Kugler
- Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
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30
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Burke A, Gupta A, Houchens N. Quality and Safety in the Literature: September 2022. BMJ Qual Saf 2022; 31:689-694. [PMID: 35981736 DOI: 10.1136/bmjqs-2022-015160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Anna Burke
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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31
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Elsayem AF, Warneke CL, Reyes-Gibby CC, Buffardi LJ, Sadaf H, Chaftari PS, Brock PA, Page VD, Viets-Upchurch J, Lipe D, Alagappan K. "Triple Threat" Conditions Predict Mortality Among Patients With Advanced Cancer Who Present to the Emergency Department. J Emerg Med 2022; 63:355-362. [DOI: 10.1016/j.jemermed.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/19/2022] [Accepted: 05/09/2022] [Indexed: 11/12/2022]
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32
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Rollo E, Brunetti V, Scala I, Callea A, Marotta J, Vollono C, Frisullo G, Broccolini A, Calabresi P, Della Marca G. Impact of delirium on the outcome of stroke: a prospective, observational, cohort study. J Neurol 2022; 269:6467-6475. [PMID: 35945396 PMCID: PMC9618551 DOI: 10.1007/s00415-022-11309-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 11/06/2022]
Abstract
Introduction Delirium is an acute fluctuating disorder of attention and awareness, which often complicates the clinical course of several conditions, including acute stroke. The aim of the present study was to determine whether delirium occurrence impacts the outcome of patients with acute stroke. Methods The study design is single center, prospective, observational. We consecutively enrolled patients admitted to the stroke unit from April to October 2020. Inclusion criteria were age ≥ 18 years and diagnosis of acute stroke. Exclusion criteria were stroke mimics, coma, and terminal conditions. All patients were screened for delirium upon admission, within 72 h, and whenever symptoms suggesting delirium occurred by means of the Confusion Assessment Method for Intensive Care Unit and the Richmond Agitation Sedation Scale. Outcomes were evaluated with the 90-days modified Rankin Scale (mRS) by telephone interview. Results The final study cohort consisted of 103 patients (62 men; median age 75 years, interquartile range 63–81). Thirty-one patients (30%) developed delirium. In the multivariate ordinal logistic regression, patients with delirium had higher mRS scores at 3 months (DLR + : mRS = 4 (3–6); DLR–: mRS = 1 (1–3); adjusted odds ratio = 4.83; CI = 1.88–12.35; p = 0.006). Delirium was a risk factor for death (mRS = 6) in the univariate logistic regression (OR 4.5, CI = 1.44–14.07; p = 0.010), but not in the adjusted analysis (OR 3.45; CI = 0.66–17.95; p = 0.142). Survival time during 90-days follow-up was shorter in the delirium group (Log Rank χ2 3.89; p = 0.048). Conclusion Delirium negatively impacts the prognosis of patients with acute stroke. Patients with post-stroke delirium have a worse functional outcome and a shorter survival.
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Affiliation(s)
- Eleonora Rollo
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Neurosciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Valerio Brunetti
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Irene Scala
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Callea
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jessica Marotta
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neuroriabilitazione ad Alta Intensità, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Catello Vollono
- UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Aldobrando Broccolini
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Paolo Calabresi
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giacomo Della Marca
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Neurologia, Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Gold C, Ray E, Christianson D, Park B, Kournoutas IA, Kahn TA, Perez EA, Berger JI, Sander K, Igram CA, Pugely A, Olinger CR, Carnahan R, Chen PF, Mueller R, Hitchon P, Howard MA, Banks M, Sanders RD, Woodroffe RW. Risk factors for delirium in elderly patients after lumbar spinal fusion. Clin Neurol Neurosurg 2022; 219:107318. [PMID: 35750022 DOI: 10.1016/j.clineuro.2022.107318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. PATIENTS AND METHODS A retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. RESULTS Of the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). CONCLUSION Risk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.
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Affiliation(s)
- Colin Gold
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - David Christianson
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Brian Park
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | - Taimur A Kahn
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli A Perez
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Joel I Berger
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Katie Sander
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cassim A Igram
- Department of Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Andrew Pugely
- Department of Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Catherine R Olinger
- Department of Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Pei-Fu Chen
- Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Rashmi Mueller
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Patrick Hitchon
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Matthew Banks
- Department of Anesthesiology University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Specialty of Anaesthetics, University of Sydney, Sydney, Australia; Department of Anaesthetics & Institute of Academic Surgery, Royal Prince Alfred Hospital, Australia
| | - Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Wang F, Tang X, Wang J, Liu S, Wu X, Dong R, Lin X, Wang B, Bi Y. Potential Value of Serum Uric Acid in the Identification of Postoperative Delirium in Geriatric Patients Undergoing Knee Replacement. Front Aging Neurosci 2022; 14:909738. [PMID: 35912084 PMCID: PMC9329914 DOI: 10.3389/fnagi.2022.909738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives The relationship between preoperative serum uric acid (SUA) and cerebrospinal fluid (CSF) Alzheimer-related biomarkers were investigated to determine whether high SUA is a potential risk factor for postoperative delirium (POD) and to evaluate its predictive efficacy. Methods The participants were selected from the Perioperative Neurocognitive Disorder Risk Factor and Prognosis (PNDRFAP) study and the Perioperative Neurocognitive Disorder and Biomarker Lifestyle (PNDABLE) study. The logistic regression equation was used to analyze the risk factors and protective factors of POD. The interaction term (SUA × Sex) was introduced into the linear model to explore the potential modification effects of sex on the identified correlations. We analyzed the mediating effects of Alzheimer-related biomarkers. Finally, we constructed the receiver operating characteristic (ROC) curve and the nomogram model to evaluate the efficacy of SUA and Alzheimer-related biomarkers in predicting POD. Results Patients with POD had elevated SUA level (PNDRFAP: p = 0.002, PNDABLE: p < 0.001). Preoperative SUA level was positively correlated with CSF phosphorylated tau (P-tau) (p = 0.027) and β-amyloid42 (Aβ42)/P-tau (p = 0.023). Interaction analysis did not find any modification effect of sex. The relationship between SUA and POD was partially mediated by CSF P-tau (15.3%). ROC curve showed that the model combining SUA and Alzheimer-related biomarkers had better performance in predicting POD [area under the curve (AUC) = 0.880; p < 0.001], and the predictive model is accurate. Conclusions High SUA may enhance CSF P-tau level, thus increasing the risk of POD, and the model combining SUA and Alzheimer-related biomarkers can accurately predict the occurrence of POD.
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Affiliation(s)
- Fei Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xinhui Tang
- Department of Anesthesiology, Dalian Medical University, Dalian, China
| | - Jiahan Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Siyv Liu
- Department of Anesthesiology, Weifang Medical College, Weifang, China
| | - Xiaoyue Wu
- Department of Anesthesiology, Dalian Medical University, Dalian, China
| | - Rui Dong
- Department of Anesthesiology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, China
| | - Xu Lin
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
- Xu Lin
| | - Bin Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
- Bin Wang
| | - Yanlin Bi
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
- *Correspondence: Yanlin Bi
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Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:1225-1235. [PMID: 34981431 DOI: 10.1007/s40520-021-02057-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU. AIM To examine the diagnostic accuracy of delirium screening tools used in the PACU. METHODS A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool. RESULTS A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU. CONCLUSION Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.
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Early Recognition, Prevention, and Management of Delirium in the Acute Care Setting. CLIN NURSE SPEC 2022. [DOI: 10.1097/nur.0000000000000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nurse-Driven Assessment, Prevention, and Management of Delirium on an Acute Inpatient Neurology Unit. J Nurs Care Qual 2022; 37:334-341. [PMID: 35486389 DOI: 10.1097/ncq.0000000000000628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delirium commonly affects hospitalized patients and is associated with increased hospital length of stay, discharge to skilled care, cost, morbidity, and mortality. LOCAL PROBLEM At our organization, there was no formal delirium assessment performed by the nursing staff outside of the intensive care unit. METHODS Assessment of nurses' knowledge about delirium, a nurse-driven delirium screening protocol, and patient education were implemented on an adult inpatient neurology unit. Knowledge change, protocol implementation, and patient-level outcomes were assessed. INTERVENTIONS Staff nurse delirium education and a nurse-driven delirium screening protocol were implemented. RESULTS No change in nursing knowledge occurred pre/postintervention. Falls, falls with injury, and restraint and sitter usage decreased. Changes in length of stay varied over the intervention period. The trend to discharge to home increased, while the trend to discharge to skilled nursing care decreased. CONCLUSIONS Formal delirium screening protocols may add organizational value by positively impacting patient outcomes.
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Warren AM, Grossmann M, Hoermann R, Zajac JD, Russell N. Tolvaptan versus fluid restriction in acutely hospitalised patients with moderate-profound hyponatraemia (TVFR-HypoNa): design and implementation of an open-label randomised trial. Trials 2022; 23:335. [PMID: 35449020 PMCID: PMC9028077 DOI: 10.1186/s13063-022-06237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background Current hyponatraemia guidelines are divided on the use of tolvaptan in hospitalised patients with moderate to severe hyponatraemia, due to an uncertain risk-benefit ratio. We will conduct a randomised trial to test the hypothesis that early use of tolvaptan improves the rate of serum sodium correction and clinical outcomes compared with current standard first-line therapy, restriction of fluid intake, without increasing the risk of serum sodium overcorrection. Methods We will enrol hospitalised patients with euvolaemic or hypervolaemic hyponatraemia and serum sodium of 115–130 mmol/L at Austin Health, a tertiary care centre in Melbourne, Australia. Participants will be randomised 1:1 to receive either tolvaptan (initial dose 7.5 mg) or fluid restriction (initial limit 1000 ml per 24 h), with titration of therapy based on serum sodium response according to a pre-determined protocol over a 72-h intervention period. The primary endpoint will be the between-group change in serum sodium over time, from study day 1 to day 4. Secondary endpoints include serum sodium increment in the first 24 and 48 h, proportion of participants with normalised serum sodium, length of hospital stay, requirement for serum sodium re-lowering with intravenous dextrose or desmopressin, cognitive and functional measures (Confusion Assessment Method Short form, Timed Up and Go test, hyponatraemia symptom questionnaire), 30-day readmission rate, treatment satisfaction score and serum sodium 30 days after discharge. The trial will be overseen by an independent Data Safety Monitoring Board. Serum sodium will be monitored every 6–12 h throughout the study period, with pre-specified thresholds for commencing intravenous 5% dextrose if serum sodium rise targets are exceeded. Discussion We seek to inform future international guidelines with high-quality data regarding the utility and safety of tolvaptan compared to standard therapy fluid restriction in patients with moderate-severe hyponatraemia in hospital. If tolvaptan use in this patient group is endorsed by our findings, we will have established an evidence-based framework for tolvaptan initiation and monitoring to guide its use. Trial registration Australia and New Zealand Clinical Trials Registry ACTRN12619001683123. Registered on December 2 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06237-5.
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Affiliation(s)
- Annabelle M Warren
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia. .,Department of Endocrinology, The Austin Hospital, Melbourne, Victoria, Australia.
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Rudolf Hoermann
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeffrey D Zajac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Nicholas Russell
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Endocrinology, The Austin Hospital, Melbourne, Victoria, Australia
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van Lieshout C, Schuit E, Hermes C, Kerrigan M, Frederix GWJ. Hospitalisation costs and health related quality of life in delirious patients: a scoping review. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 169:28-38. [PMID: 35288063 DOI: 10.1016/j.zefq.2022.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Delirium is a common condition of a global disturbance of cognition, triggered by underlying diseases. The objective of this study is to review the current evidence in the literature on direct healthcare costs and health-related quality of life (HRQOL) associated with delirium. METHODS A systematic search was conducted in PubMed and Embase for relevant studies published between January 1, 2010 and November 4, 2021. Studies for inclusion reported estimates on healthcare costs or HRQOL, adjusted for relevant confounding factors. RESULTS Fourteen studies on healthcare costs and eleven studies on HRQOL were included. Delirium resulted in (adjusted) increased costs ranging from $1,532 to $22,269 depending on included cost categories, the country and the type of hospital department. Increased length of stay for delirious patients ranged from 2.5 days to 10.4 days and had the largest contribution to overall, direct incremental costs. Heterogeneity was observed in HRQOL outcomes. CONCLUSION The analysis indicates that the presence of a delirium episode may lead to increased costs of hospitalisation. Changes in HRQOL due to delirium are not well demonstrated and more research is needed to determine the effect of delirium on HRQOL.
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Affiliation(s)
- Chris van Lieshout
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands.
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands
| | - Carsten Hermes
- CCRN, Business economist (IHK), Co-founder of the German Delirium Network e.V., Bonn, Germany
| | | | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands
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Ahmed N, Kuo YH. Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data. Injury 2022; 53:1469-1476. [PMID: 35144810 DOI: 10.1016/j.injury.2022.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study. HYPOTHESIS Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients. METHODS The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created. RESULTS Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78-0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%. CONCLUSION Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States; Hackensack Meridian School of Medicine, Nutley, NJ, United States.
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, United States
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Weldingh NM, Mellingsæter MR, Hegna BW, Benth JS, Einvik G, Juliebø V, Thommessen B, Kirkevold M. Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a controlled clinical trial design. BMC Geriatr 2022; 22:266. [PMID: 35361136 PMCID: PMC8974092 DOI: 10.1186/s12877-022-02949-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards. Methods This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 ‘A’s Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR). Results Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote “dementia-friendly” care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality. Conclusions A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention. Trial registration The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021.
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Affiliation(s)
- N M Weldingh
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B W Hegna
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway
| | - J Saltyte Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - G Einvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pulmonary Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - V Juliebø
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - M Kirkevold
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.,Faculty of Medicine, Department of Nursing Science, University of Oslo, Institute of Health and Society, Oslo, Norway
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Awada HN, Steinthorsdottir KJ, Schultz NA, Hillingsø JG, Larsen PN, Jans Ø, Kehlet H, Aasvang EK. High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy. Acta Anaesthesiol Scand 2022; 66:696-703. [PMID: 35325467 PMCID: PMC9320957 DOI: 10.1111/aas.14057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD. METHODS This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward. RESULTS Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group. CONCLUSIONS The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.
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Affiliation(s)
- Hussein Nasser Awada
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Kristin Julia Steinthorsdottir
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Nicolai A. Schultz
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Jens G. Hillingsø
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Peter Nørgaard Larsen
- Department of Gastrointestinal Surgery and Transplantation Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Øivind Jans
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Surgical Pathophysiology Unit Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Eske Kvanner Aasvang
- Department of Anesthesiology Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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Albanese AM, Ramazani N, Greene N, Bruse L. Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment. Geriatr Orthop Surg Rehabil 2022; 13:21514593211058947. [PMID: 35282299 PMCID: PMC8915233 DOI: 10.1177/21514593211058947] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a serious complication occurring in 4–53.3%
of geriatric patients undergoing surgeries for hip fracture. Incidence of
hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in
2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected
to increase, POD is also anticipated to increase. Signficance Postoperative delirium remains the most common complication of emergency hip
fracture surgery leading to high morbidity and mortality rates despite
significant research conducted regarding this topic. This study reviews
literature from 1990 to 2021 regarding POD in geriatric hip fracture
management. Results Potentially modifiable and non-modifiable risk factors for developing POD
include, but are not limited to, male gender, older age, multiple
comorbidities, specific comorbidities (dementia, cognitive impairment,
diabetes, vision impairment, and abnormal blood pressure), low BMI,
preoperative malnutrition, low albumin, low hematocrit, blunted preoperative
cytokines, emergency surgery, time to admission and surgery, preoperative
medical treatment, polypharmacy, delirium-inducing medications, fever,
anesthesia time, and sedation depth and type. Although the pathophysiology
remains unclear, the leading theories suggest neurotransmitter imbalance,
inflammation, and electrolyte or metabolic derangements as the underlying
cause of POD. POD is associated with increased length of hospital stay,
cost, morbidity, and mortality. Prevention and early recognition are key
factors in managing POD. Methods to reduce POD include utilizing
interdisciplinary teams, educational programs for healthcare professionals,
reducing narcotic use, avoiding delirium-inducing medications, and
multimodal pain control. Conclusion While POD is a known complication after hip fracture surgery, further
exploration in prevention is needed. Early identification of risk factors is
imperative to prevent POD in geriatric patients. Early prevention will
enhance delivery of health care both pre- and post-operatively leading to
the best possible surgical outcome and better quality of life after hip
fracture treatment.
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Affiliation(s)
- Anita M Albanese
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Noyan Ramazani
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Natasha Greene
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Laura Bruse
- Adjunct Clinical Assistant Professor Community Faculty, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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Wiegand TLT, Rémi J, Dimitriadis K. Electroencephalography in delirium assessment: a scoping review. BMC Neurol 2022; 22:86. [PMID: 35277128 PMCID: PMC8915483 DOI: 10.1186/s12883-022-02557-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Background Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments. Methods We therefore conducted a scoping review on EEG findings in delirium. One thousand two hundred thirty-six articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis. Results EEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive. Conclusion Future studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02557-w.
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The detection of delirium in admitted oncology patients: a scoping review. Eur Geriatr Med 2022; 13:33-51. [PMID: 35032322 PMCID: PMC8860783 DOI: 10.1007/s41999-021-00586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
Aim To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting. Findings Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias. Message In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1. Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1.
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Ren Y, Zhang Y, Luo J, Liao W, Cheng X, Zhan J. Research progress on risk factors of delirium in burn patients: A narrative review. Front Psychiatry 2022; 13:989218. [PMID: 36405924 PMCID: PMC9666388 DOI: 10.3389/fpsyt.2022.989218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu Zhang
- Medical Innovation Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Hasegawa T, Seo T, Kubota Y, Sudo T, Yokota K, Miyazaki N, Muranaka A, Hirano S, Yamauchi A, Nagashima K, Iyo M, Sakai I. Reliability and validity of the Japanese version of the 4A's Test for delirium screening in the elderly patient. Asian J Psychiatr 2022; 67:102918. [PMID: 34798384 DOI: 10.1016/j.ajp.2021.102918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 12/15/2022]
Abstract
Although many screening tools for delirium are available, delirium is still occasionally overlooked or misdiagnosed. One of the reasons for this is the lack of brief screening tools that do not require specialized training to use. The 4 'A's test (the 4AT) is a validated screening tool for delirium that can be administered in a very short time without specialized training. Herein, we evaluated the reliability and validity of the Japanese version of the 4AT (the 4AT-J). A total of 150 patients aged ≥ 65 years were enrolled. Their demographics and clinical characteristics were obtained within 24 hr of their hospitalization. On each patient's high-risk day of developing delirium, the 4AT-J was administered by a nurse, and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-Ⅴ) and the Japanese version of Delirium Rating Scale-Revised-98 (DRS-98-J) were administered by a psychiatrist. Our analyses revealed that when a cut-off score of 4, the 4AT-J showed high sensitivity and specificity. The Cronbach's α-coefficient was similar to that of the original version. A receiver operating curve analysis showed sufficient power of the 4AT-J to discriminate delirium. The 4AT-J showed adequate reliability and validity for delirium screening in elderly patients.
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Affiliation(s)
- Tadashi Hasegawa
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan.
| | - Tomomi Seo
- Department of Nursing, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Yoko Kubota
- Department of Nursing, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Tomoko Sudo
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Kumi Yokota
- Department of Rehabilitation Medicine, Chiba University Hospital, 1-8-1 Inohana Chuou-ku, Chiba-shi, Chiba 260-8677, Japan
| | - Nao Miyazaki
- Kokorono-mori Clinic, 1-16-1 Yatsu, Narashino-shi, Chiba 275-0026, Japan
| | - Akira Muranaka
- Oyumino Central Hospital, 6-49-9 Oyumino-minami, Midori-ku, Chiba-shi, Chiba 266-0033, Japan
| | - Shigeki Hirano
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Atsushi Yamauchi
- Chiba Rosai Hospital, 2-16 Tatsumidai-Higashi, Ichihara-shi, Chiba 290-0003, Japan
| | - Kengo Nagashima
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8670, Japan
| | - Ikuko Sakai
- Interprofessional Education Research Center, Graduate School of Nursing, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba-shi, Chiba 260-8672, Japan
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García-Grimshaw M, Chiquete E, Jiménez-Ruiz A, Vidal-Mayo JDJ, Grajeda-González SL, Vargas-Martínez MDLÁ, Toapanta-Yanchapaxi LN, Valdés-Ferrer SI, Chávez-Martínez OA, Marché-Fernández OA, Jiménez-Ávila AI, Cantú-Brito C, Flores-Silva FD. Delirium and Associated Factors in a Cohort of Hospitalized Patients With Coronavirus Disease 2019. J Acad Consult Liaison Psychiatry 2022; 63:3-13. [PMID: 34242847 PMCID: PMC8259046 DOI: 10.1016/j.jaclp.2021.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/10/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the number of patients requiring treatment in an intensive care unit or invasive mechanical ventilation worldwide. Delirium is a well-known neuropsychiatric complication of patients with acute respiratory diseases, representing the most frequent clinical expression of acute brain dysfunction in critically ill patients, especially in those undergoing invasive mechanical ventilation. Among hospitalized patients with COVID-19, delirium incidence ranges from 11% to 80%, depending on the studied population and hospital setting. OBJECTIVE To determine risk factors for the development of delirium in hospitalized patients with COVID-19 pneumonia. METHODS We retrospectively studied consecutive hospitalized adult (≥18 y) patients with confirmed COVID-19 pneumonia from March 15 to July 15, 2020, in a tertiary-care hospital in Mexico City. Delirium was assessed by the attending physician or trained nurse, with either the Confusion Assessment Method for the Intensive Care Unit or the Confusion Assessment Method brief version, according to the appropriate diagnostic tool for each hospital setting. Consultation-liaison psychiatrists and neurologists confirmed all diagnoses. We calculated adjusted hazard ratios (aHR) with 95% confidence interval (CI) using a Cox proportional-hazards regression model. RESULTS We studied 1017 (64.2% men; median age, 54 y; interquartile range 44-64), of whom 166 (16.3%) developed delirium (hyperactive in 75.3%); 78.9% of our delirium cases were detected in patients under invasive mechanical ventilation. The median of days from admission to diagnosis was 14 (interquartile range 8-21) days. Unadjusted mortality rates between delirium and no delirium groups were similar (23.3% vs. 24.1; risk ratio 0.962, 95% CI 0.70-1.33). Age (aHR 1.02, 95% CI 1.01-1.04; P = 0.006), an initial neutrophil-to-lymphocyte ratio ≥9 (aHR 1.81, 95% CI 1.23-2.65; P = 0.003), and requirement of invasive mechanical ventilation (aHR 3.39, 95% CI 1.47-7.84; P = 0.004) were independent risk factors for in-hospital delirium development. CONCLUSIONS Delirium is a common in-hospital complication of patients with COVID-19 pneumonia, associated with disease severity; given the extensive number of active COVID-19 cases worldwide, it is essential to detect patients who are most likely to develop delirium during hospitalization. Improving its preventive measures may reduce the risk of the long-term cognitive and functional sequelae associated with this neuropsychiatric complication.
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Affiliation(s)
- Miguel García-Grimshaw
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Erwin Chiquete
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Amado Jiménez-Ruiz
- Stroke, Dementia & Heart Disease Laboratory, Western University, London, ON, Canada
| | - José de Jesús Vidal-Mayo
- Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Samara Lissete Grajeda-González
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Liz Nicole Toapanta-Yanchapaxi
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sergio Iván Valdés-Ferrer
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Center for Biomedical Science, Feinstein Institute for Medical Research, Manhasset, NY
| | - Oswaldo Alan Chávez-Martínez
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Osvaldo Alexis Marché-Fernández
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Itiel Jiménez-Ávila
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Cantú-Brito
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Daniel Flores-Silva
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Jaatinen R, Luukkaala T, Hongisto MT, Helminen H, Nuotio MS. In-Hospital Delirium as a Prognostic Factor for New Cognitive Disorder in a 1-Year Post-Hip Fracture Follow-Up. Dement Geriatr Cogn Disord 2021; 50:296-302. [PMID: 34515089 DOI: 10.1159/000518487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Older hip fracture patients are at high risk of delirium during acute hospital care. Pre-fracture dementia is known to increase the risk of in-hospital delirium. Data on the development of new cognitive disorders in patients with delirium are scarce. OBJECTIVE The objective of this study is to evaluate the prognostic significance of in-hospital delirium on the development of new cognitive disorders in a 1-year follow-up in older hip fracture patients. MATERIAL AND METHODS Data consisted of 476 hip fracture patients aged 65 years or more with no known cognitive disorder on admission. Delirium was assessed using the Confusion Assessment Method (CAM). Cognitive disorders were diagnosed following the national guidelines. Information on the new diagnoses of cognitive disorders (NDCD) at 1-year follow-up was elicited in a telephone interview and confirmed from the electronic patient files. Logistic regression analyses were conducted to examine the association of delirium with NDCDs. RESULTS Of the 476 patients, 87 (18%) had delirium during hospital stay. Patients with delirium were older, they had poorer nutritional status, lower mobility level, and more supported living arrangements than did patients without delirium. At the 1-year time point, 205 (43%) had NDCDs or were strongly suspected of this. CAM result was statistically significantly associated with development of NDCD in multivariable-adjusted analysis (odds ratio [OR] 2.29; 95% confidence interval [CI]: 1.39-3.79). Also, poor nutritional status continued to be associated with NDCDs (multivariable-adjusted OR 1.58; 95% CI: 1.03-2.43). CONCLUSION Delirium during hospitalization and poor nutritional status on admission are independent prognostic factors for development of subsequent cognitive disorders in older hip fracture patients.
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Affiliation(s)
- Roope Jaatinen
- Department of Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Division of Geriatric Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tiina Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital, Tampere, Finland.,Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Markus T Hongisto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Orthopaedics, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Heli Helminen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Maria S Nuotio
- Department of Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Division of Geriatric Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland.,Research Services and Department of Clinical Medicine, Turku University Hospital, Turku, Finland.,Turku University Hospital and University of Turku, Turku, Finland
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Detecting Incident Delirium within Routinely Collected Inpatient Rehabilitation Data: Validation of a Chart-Based Method. Neurol Int 2021; 13:701-711. [PMID: 34940753 PMCID: PMC8705493 DOI: 10.3390/neurolint13040067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/30/2021] [Accepted: 11/15/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Delirium is a brain condition associated with poor outcomes in rehabilitation. It is therefore important to assess delirium incidence in rehabilitation. Purpose: To develop and validate a chart-based method to identify incident delirium episodes within the electronic database of a Swiss rehabilitation clinic, and to identify a study population of validated incident delirium episodes for further research purposes. Design: Retrospective validation study. Settings: Routinely collected inpatient clinical data from ZURZACH Care. Participants: All patients undergoing rehabilitation at ZURZACH Care, Rehaklinik Bad Zurzach between 2015 and 2018 were included. Methods: Within the study population, we identified all rehabilitation stays for which ≥2 delirium-predictive key words (common terms used to describe delirious patients) were recorded in the medical charts. We excluded all prevalent delirium episodes and defined the remaining episodes to be potentially incident. At least two physicians independently confirmed or refuted each potential incident delirium episode by reviewing the patient charts. We calculated the positive predictive value (PPV) with 95% confidence interval (95% CI) for all potential incident delirium episodes and for specific subgroups. Results: Within 10,515 rehabilitation stays we identified 554 potential incident delirium episodes. Overall, 125 potential incident delirium episodes were confirmed by expert review. The PPV of the chart-based method varied from 0.23 (95% CI 0.19–0.26) overall to 0.69 (95% CI 0.56–0.79) in specific subgroups. Conclusions: Our chart-based method was able to capture incident delirium episodes with low to moderate accuracy. By conducting an additional expert review of the medical charts, we identified a study population of validated incident delirium episodes. Our chart-based method contributes towards an automated detection of potential incident delirium episodes that, supplemented with expert review, efficiently yields a validated population of incident delirium episodes for research purposes.
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