Delirium in acute stroke

Prevalence of post-stroke delirium in acute settings: A systematic review and meta-analysis

BACKGROUND

Although post-stroke delirium is a frequent complication in acute settings and has significant long-lasting implications for patients, the prevalence of post-stroke delirium diagnosed according to gold-standard criteria remains uncertain. This highlights the importance of updating the current evidence.

OBJECTIVE

This review aims to provide a precise estimation of the prevalence of delirium in acute post-stroke settings and to explore potential differences in the reported prevalence according to the characteristics of the study and stroke survivors.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Post-stroke survivors with delirium in acute settings.

DATA SOURCES

Five English and two Chinese language databases from inception to June 2023, and the reference lists of published reviews.

METHODS

Studies reporting the prevalence of post-stroke delirium according to the Diagnostic and Statistical Manual of Mental Disorders criteria with the description of assessment method in the absence of interventions for delirium were eligible. Two reviewers independently screened searched records and extracted data from eligible studies. A meta-analysis was conducted using a random-effects model to evaluate the prevalence of post-stroke delirium, and predefined subgroup analyses, sensitivity analyses, and mixed-effects meta-regression were conducted to explore the contribution of heterogeneity.

RESULTS

Twenty-nine eligible studies involving 8839 survivors were included. In acute settings, the overall weighted prevalence of post-stroke delirium was 25 % (95 % CI, 20-30; I2, 95 %). Subgroup analyses revealed age-dependent variations in delirium prevalence, with rates of 20 %, 25 %, and 34 % for ages 60-64, 65-74, and 75-79, respectively. Delirium prevalence varied by assessment duration (7 days: 31 %, >7 days: 24 %, <7 days: 20 %). Initial screening significantly reduced reported prevalence to 15 %, compared with 30 % when no initial screening was conducted. Delirium prevalence was lower when nurses were involved in assessments (13 % vs. 29 %). No significant effects were detected for economic status, publication year, female percentage, onset-to-admission time, stroke type, and assessment frequency. Meta-regression analysis revealed that higher delirium prevalence was associated with increased survivors' age (β = 0.051; 95 % CI, -0.0002 to 0.103; P = 0.05; R2 = 13.36 %).

CONCLUSION

A high prevalence of post-stroke delirium was observed in acute settings. Nurses are required to integrate and coordinate the prevention, early detection, and management of delirium following stroke into their nursing practice, particularly for older stroke survivors. The findings necessitate the need for incorporating specialized training within nursing education to identify and manage the delirium effectively and accurately. This reinforces the pivotal role of nurses in the early detection and prevention of delirium within the acute stroke care continuum.

REGISTRATION

The protocol was registered on PROSPERO (CRD42022352097).

TWEETABLE ABSTRACT

Evidence suggests 25 % prevalence of post-stroke delirium in acute settings, with higher rates in older patients, emphasizing the need for prevention, early detection, and management in nursing practice.

Delirium prevalence, risk factors and outcomes among patients with acute stroke: A multi-centre observational study

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.

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

Objective

Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.

Method

As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.

Results

Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).

Conclusions

Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02756-5.

Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) With Medical Inpatients and Comparison With the Confusion Assessment Method Algorithm

OBJECTIVE

Delirium remains underdetected as a result of its broad constellation of symptoms and the inadequate neuropsychiatric expertise of most medical-surgical clinicians. Brief, accurate tools are needed to enhance detection.

METHODS

The authors extended validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro), originally validated in a study of inpatients with traumatic brain injury for diagnosis of delirium by nonexpert clinicians, for 200 general medical inpatients in Colombia. The three structured, quantitatively rated items in DDT-Pro represent the three core delirium domains.

RESULTS

High interrater reliability between physician and nurse (0.873) administrators, internal consistency (>0.81), and content validity were found. Compared with independent reference standard diagnosis with DSM-5 or the Delirium Rating Scale-Revised-98, the area under the receiver operating characteristic (ROC) curve (global diagnostic accuracy) range was 93.8%-96.3%. ROC analysis revealed the same cutoff score (≤6) as that for the original study, with somewhat lower sensitivities of 88.0%-90.0% and specificities of 85.3%-81.2% (independent expert physician or nurse ratings). Even when rated by a trained expert physician, the original version of the Confusion Assessment Method algorithm (CAM-A) performed moderately, with lower sensitivities (61.8%-70.0%) than the DDT-Pro (88.0%-100%) and somewhat higher specificities (84.8%-95.3% versus 67.4%-86.7%), with values depending on dementia status, reference standard, and rater type. Accuracies for the DDT-Pro and CAM-A were comparable (DDT-Pro: 83.0%-87.5% versus CAM-A: 87.5%-88.5%), although lower in the dementia subgroup, especially for CAM-A. However, these tools were significantly discordant, especially in negative cases, which suggests that they do not detect diagnosis of patients in the same way.

CONCLUSIONS

The DDT-Pro had high validity and reliability in provisional delirium diagnosis by physicians and nonexpert clinicians, although further validation is warranted before widespread use can be recommended.

Post-stroke delirium risk factors, signs and symptoms of onset and outcomes as perceived by expert nurses: A focus group study

BACKGROUND

Higher rates of delirium have been reported among patients with acute stroke. However, poorly modifiable risk factors have been documented to date while sign and symptoms capable of early detecting its onset and outcomes in this specific population have been largely neglected. The aim of this study was to emerge nurses' clinical knowledge and experiences regarding post-stroke delirium (a) risk factors, (b) signs and symptoms of delirium onset, and (c) outcomes.

METHOD

A qualitative study based upon focus groups have been performed on 2019 and here reported according to the COnsolidated criteria for REporting Qualitative research. A purposeful sample of 28 nurses was invited to participate in focus groups at two Italian hospitals, and 20 participated. A semi-structured question guide was developed; all focus groups were audio recorded and then transcribed verbatim. Two researchers independently analysed, coded and categorised the findings according to the main research question. A member checking with ten nurses was also performed to ensure rigour.

RESULTS

Four risk factors emerged (a) at the individual level; (b) associated with previous (e.g., dementia) and the current clinical condition (stroke), (c) associated with the nursing care delivered, and (d) associated with the hospital environment. In their daily practice, nurses suspect the onset of delirium when some motor, verbal or multidimensional signs and symptoms occur. The delirium episodes affect outcomes at the individual, family, and at the system levels.

CONCLUSIONS

In a field of research in need of study, we have involved expert nurses who shared their tacit knowledge to gain insights regarding risk factors, early signs and symptoms of delirium and its outcomes to address future directions of this research field.

Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19

BACKGROUND AND AIMS

Cerebral infarction in COVID-19 patients might be associated with a hypercoagulable state related to a systemic inflammatory response. Its diagnosis might be challenging. We present two critically ill patients with COVID-19 who presented acutely altered mental status as the main manifestation of multiple strokes.

METHODS

Clinical presentation and diagnostic work-up of the patients.

RESULTS

Two patients in their sixties were hospitalized with a bilateral pneumonia COVID-19. They developed respiratory failure and were admitted to ICU for mechanical ventilation and intense medical treatment. They were started on low-molecular-weight heparin since admission. Their laboratory results showed lymphopenia and increased levels of C-reactive protein and D-dimer. Case 1 developed hypofibrinogenemia and presented several cutaneous lesions with biopsy features of thrombotic vasculopathy. Case 2 was performed a CT pulmonary angiogram at ICU showing a bilateral pulmonary embolism. When waking up, both patients were conscious but with a remarkable global altered mental status without focal neurological deficits. A brain MRI revealed multiple acute bilateral ischemic lesions with areas of hemorrhagic transformation in both patients (case 1: affecting the left frontal and temporal lobes and both occipital lobes; case 2: affecting both frontal and left occipital lobes). Cardioembolic source and acquired antiphospholipid syndrome were ruled out. COVID-19-associated coagulopathy was suspected as the possible main etiology of the strokes.

CONCLUSION

Acutely altered mental status might be the main manifestation of multiple brain infarctions in critically ill COVID-19 patients. It should be specially considered in those with suspected COVID-19-associated coagulopathy. Full-dose anticoagulation and clinical-radiological monitoring might reduce their neurological consequences.

Night-time confusion in an elderly woman post-stroke

For patients with acute ischaemic stroke, faster recanalisation improves the chances of a disability-free life and a quick discharge from the hospital. Hospital discharge, certainly after suffering a major life-changing event such as a stroke, is a complex and vulnerable phase in the patient's journey. Elderly are particularly vulnerable to the stressors caused by hospitalisation. Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events. At the same time, elderly generally prefer living in their own homes and should be discharged from the hospital and return home as quickly as possible. Both premature and delayed discharge are potential threats to patient well-being. We present a 90-year-old patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital and discuss the transition process from hospital to home.

Detecting delirium in patients with acute stroke: a systematic review of test accuracy

BACKGROUND

Patients with acute stroke are particularly vulnerable to delirium episodes. Although delirium detection is important, no evidence-based recommendations have been established to date on how these patients should be routinely screened for delirium or which tool should be used for this purpose in this population. Therefore, the aim of this study was to identify delirium screening tools for patients with acute stroke and to summarise their accuracy.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of Medline, CINAHL and Scopus databases was performed to include: (a) diagnostic test accuracy studies; (b) evaluating tools detecting delirium among patients with acute stroke; (c) written in English; (d) published up to September 2018. The included studies were assessed in their quality by using the Quality Assessment of Diagnostic Accuracy Studies-2.

RESULTS

A total of four studies have been performed to date in the field with a variable quality for the methodology used and documentation of the accuracy of mainly two tools, as (1) the 4-Assessment Test for delirium (4AT), reporting a range of sensitivity from 90.2 to 100% and a specificity from 64.5 to 86%; and (2) the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) showing a sensitivity of 76% (95% Confidence of Interval [CI] 55-91) and a specificity of 98% (95%CI 93-100). Other tools have been studied as: The Abbreviated Mental Test-10, the Abbreviated Mental Test short form, the Clock Drawing Test, the Cognitive Examination derived from the National Institutes of Health Stroke Scale and the Glasgow Coma Scale. Moreover, the use of a single question-namely, 'Does this patient have cognitive issues?' as answered by the multidisciplinary team-has been subjected to a validation process.

CONCLUSIONS

To date a few primary studies have been published to test the accuracy of tools in their ability to detect post-stroke delirium; among those available, the 4AT and the CAM-ICU tools have been mostly studied. Research has just started to add evidence to the challenge of detecting and usefully assessing newly-acquired delirium among stroke patients: therefore, more studies are needed to improve the knowledge and allow a robust selection of the most useful tool to use in this population.

Delirium in patients with ischaemic and haemorrhagic stroke: findings from a scoping review

BACKGROUND

Delirium is a complex syndrome characterised by disturbances in attention and awareness, associated with alterations in cognitive functions, which can emerge in a time frame of hours or days and tend to fluctuate in severity over time. Delirium is a clinical manifestation of the brain's vulnerability and diminished resilience to insult. Stroke patients are particularly vulnerable to delirium episodes.

AIMS

The aim of this study was to map: (a) studies focused on ischaemic or haemorrhagic post-stroke delirium; (b) factors that have been investigated as being possibly associated with post-stroke delirium; and (c) outcomes that have been studied to date.

METHODS

A scoping review was performed. Medline, CINAHL, Cochrane Database of Systematic Reviews, PsycINFO and Scopus databases were searched. Eligible studies were those: (a) exploring any variable regarding delirium in patients with stroke; (b) involving adults; (c) as primary studies; (d) written in English; and (e) published before April 2017.

RESULTS

To date 25 studies have been published, mainly prospective or cohort studies. The most commonly studied predisposing factors have been the older age, gender, aetiology of the stroke and its location, and the presence of previous cognitive decline/dementia. The most studied precipitating factors to date have been pneumonia, urinary tract infections and symptoms of neglect. Functional dependence, length of inhospital stays, post-stroke cognitive impairments or dementia, short and long-term mortality have been the most studied post-stroke delirium outcomes.

CONCLUSIONS

Studies across different clinical settings, also at the international level, including more female patients and a wider range of ages should be designed in order to improve the evidence available to develop specific clinical guidelines. Standardised frameworks of research addressing the great variability of methods and measures used in the field should be established at the international level by clinicians and researchers' experts in the field.

Disruption of the ascending arousal system and cortical attention networks in post-stroke delirium and spatial neglect

Delirium is an acute attention and cognitive dysfunction, adversely affecting functional outcomes and mortality. As many as half of hospitalized right brain stroke survivors may develop delirium. Further, about 50% of right stroke patients experience spatial neglect, impairing safety and recovery. In this review we explore the brain mechanisms, which may explain the high incidence of delirium and spatial neglect after right-brain stroke. We suggest that brain networks for spatial attention and arousal, composed of ascending projections from the midbrain nuclei and integrating dorsal and ventral cortical and limbic components, may underlie impairments in delirium and spatial neglect. We propose that lateralized deficits in spatial neglect may arise because cortical and limbic components of these functional networks are disproportionally impaired by right-brain strokes, and that spatial neglect may lower the threshold for developing delirium. An improved understanding of the brain basis of delirium and spatial neglect could provide a critical biomarker for initiating preventive care in stroke patients at high risk of hospital morbidity and loss of independence.

PREDICTORS FOR POST- STROKE DELIRIUM OUTCOME

BACKGROUND

There have been only a small number of studies that have evaluated the outcome of post-stroke delirium.

OBJECTIVES

To evaluate the effects of gender, age, stroke localization, delirium severity, previous illnesses, associated medical complications on delirium outcome as well as, to determine effects of delirium on cognitive functioning one year after stroke.

PATIENTS AND METHODS

Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glazgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State.

RESULTS

Patients who developed post-stroke delirium had significantly more complications (p = 0.0005). Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The strongest predictor of outcome was age, mean age ≥ 65 years with a odds ratio (OR) 4.9. Cox's regression survival was conducted to assess the impact of multiple factors on survival. The accompanying medical complications were the strongest predictor of respondents poore outcome with Hazard-risk 3.3. Cognitive assessments including Mini Mental State score have showen that post-stroke delirium patients had significant cognitive impairment, three (p = 0.0005), six months (p = 0.0005) and one year (p = 0.0005) after stroke, compared to patients without delirium.

CONCLUSION

Patient gender, age, localization of stroke, severity of delirium, chronic diseases and emerging complications significantly affect the outcome of post- stroke delirium. Delirium significantly reduced cognitive functioning of after stroke patients.

Delirium in Acute Stroke: A Review

Background

Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation.

Summary of review

Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke.

Conclusion

This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.

Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes

OBJECTIVE

To identify risk factors, circumstances, and outcomes for individuals with acute ischemic stroke (AIS) chameleons (AIS-C) arriving in the emergency department of a university hospital.

METHODS

We retrospectively reviewed all patients with AIS from the prospectively constructed Acute Stroke Registry and Analysis of Lausanne during 8.25 years. AIS-C were defined as a failure to suspect stroke or as incorrect exclusion of stroke diagnosis. They were compared with patients diagnosed correctly at the time of admission.

RESULTS

Forty-seven of 2,200 AIS were missed (2.1%). These AIS-C were either very mild or very severe strokes. Multivariate analysis showed a younger age in patients with AIS-C (odds ratio [OR] per year 0.98, p < 0.01), less prestroke statin treatment (OR 0.29, p = 0.04), and lower diastolic admission blood pressure (OR 0.98 p = 0.04). They showed less eye deviation (OR 0.21, p = 0.04) and more cerebellar strokes (OR 3.78, p < 0.01). AIS-C were misdiagnosed as other neurologic (42.6% of cases) or nonneurologic (17.0%) disease, as unexplained decreased level of consciousness (21.3%), and as concomitantly present disease (19.1%). At 12 months, patients with AIS-C had less favorable outcomes (adjusted OR 0.21, p < 0.01) and higher mortality (adjusted OR 4.37, p < 0.01).

CONCLUSIONS

AIS are missed in patients with younger age with a lower cerebrovascular risk profile and may be masked by other acute conditions. Patients with chameleons present more often with milder strokes or coma, fewer focal signs and cerebellar strokes, and have higher disability and mortality rates at 12 months. These findings may be used to raise awareness in emergency departments to recognize and treat such patients appropriately.

The prevalence and clinical manifestations of delirium in sub-Saharan Africa: a systematic review with inferences

BACKGROUND

In high-income countries with ageing populations, delirium is most prevalent in older adults and in palliative and intensive care settings. The prevalence and aetiology of delirium are likely to differ in low income countries, including sub-Saharan Africa (SSA), due to different population demographics, disease burden and exposure to pathogens. We reviewed published literature relating to the prevalence, clinical features and underlying causes of delirium in SSA and compare this with that published in high-income countries in order to identify knowledge and clinical service gaps, and priorities for further research.

METHODS

We performed a narrative review by comprehensively searching the following databases: Medline, PsychInfo, Embase and PubMed. Studies published between January 1 1975 and December 31 2013 in all languages, including the terms 'delirium', 'acute brain syndrome', 'organic brain syndrome', or 'acute confusion' originating from SSA were included. In addition, reference lists of included articles and online databases of African medical literature were hand-searched. We also included case series and case reports due to paucity of published studies.

RESULTS

We identified a total of 46 relevant studies. Delirium was the main focus of only one cross-sectional study, whereas most included delirium in studies on neuropsychiatric conditions. Only two studies reported prevalence in older adults. Most studies reported very low (<2%) delirium prevalence, whereas delirium in psychiatric inpatient and outpatient settings was higher than expected (18.2%-29.9%). Descriptive studies of 'bouffee delirante' from psychiatry settings were often describing delirium. Infection and HIV seropositivity were common associations of delirium throughout these studies. There were no studies of intensive, critical or surgical care settings or of management strategies.

CONCLUSIONS

We currently know very little about the prevalence, presentation and aetiology of delirium in developing countries. This knowledge gap should be tackled with some urgency, in order to address questions of screening, diagnosis, prevention and management in this setting.

Intracranial cause of delirium: computed tomography yield and predictive factors

BACKGROUND

Computed tomography (CT) of the brain in delirium investigation has a low yield of identifiable causes. We sought to identify the best clinical predictors of an intracranial cause of delirium.

METHODS

We performed a case-control study of patients admitted to a delirium unit. Clinical factors of patients with positive findings on scans were compared with those without demonstrated causes. The main outcome measure was intracranial abnormalities accountable for the cause of delirium.

RESULTS

During 18 months, there were 300 admissions to the unit. Mean age of patients was 86.6 years. Among 200 patients who proceeded to CT scanning, only 29 demonstrated intracranial pathology accountable for the cause of delirium, with a yield of 14.5%. There were 13 patients with ischaemic stroke, seven with subdural haemorrhage and nine with intracerebral haemorrhage. In multivariate analysis, new neurological deficits (adjusted odds ratio (OR) 18.17, 95% confidence interval (CI) 5.99-55.15), recent falls history (adjusted OR 5.58, 95% CI 1.90-16.42) and decline in conscious level (adjusted OR 4.58, 95% CI 1.33-15.79) were predictors of clinically meaningful radiological findings. Twenty-six of the 29 patients with scans had these three predictors with a sensitivity of 89.7% (95% CI 78.6-100%).

CONCLUSION

We identified a history of recent fall as a new independent predictor for clinically relevant intracranial pathology in delirious patients, besides new neurological deficits and decline in conscious state. A flow chart incorporating CT head scanning as part of delirium investigation is proposed.

Evaluation of patients with delirium in the emergency department

OBJECTIVE

Delirium is a neuropsychiatric syndrome characterized by acute onset and a fluctuating course of globally altered mental status. It has been reported that the frequency of delirium among patients hospitalized with any disorder ranges from 2 to 30%. However, in the literature, few studies have evaluated the frequency of delirium in hospitalized patients, including those older than 65 years. According to our knowledge, this is the first study on adult patients in all age groups in an emergency department. We aimed to classify delirium according to its etiological causes and to compare the age groups for frequency and these causes.

MATERIAL AND METHODS

Forty-three patients were included in the study; they had been diagnosed with delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV in an emergency department from December 2002 to December 2003. The patients were divided into two groups (group I: age <65 years, group II: age ≥65 years). Following a detailed history, each patient underwent a physical and neurological examination. Additionally, the Mini-Mental State Examination was administered. Radiological and hematological examinations were conducted on all patients who had indications for such testing.

RESULTS

Of the patients with delirium, 18 were female and 25 were male. Mean age was 61.18 years (range 18 to 90 years). Of the 43 patients, 21 were in group I and 22 were in group II. The most common causes of delirium were metabolic disorders. There was no significant difference between group I and II for the frequency or etiological causes of delirium.

CONCLUSION

In emergency departments, all patients with delirium should be evaluated for etiological factors, especially metabolic disorders, as treatment of the underlying cause is essential in delirium.

Incidence of post-stroke delirium and 1-year outcome

INTRODUCTION

Post-stroke delirium is not uncommon, and is associated with poorer outcome, higher mortality, longer hospital stay and greater risk of post-stroke dementia. We aim to identify the incidence of post-stroke delirium, risk factors for its development and 1-year outcome.

METHOD

Consecutive patients aged >50 years admitted to the acute stroke unit were recruited. Baseline demographic data, types of stroke, location of infarct, etiology of stroke, premorbid cognitive impairment, living arrangement, comorbidity, drug history and biochemical parameters were collected. Delirium was screened by the Confusion Assessment Method. Outcome data included length of stay, mortality, functional mobility, and placement on discharge 6 months and 12 months post-stroke.

RESULTS

A total of 314 patients with a mean age of 72.9 years were recruited. Of those patients, 86 (27.4%) had delirium. Age (OR 1.05), presence of acute urinary retention (OR 7.67), chest infection (OR 22), National Institutes of Health Stroke Scale (OR 1.13), total anterior circulation infarct (OR 18.8), posterior circulation infarct (OR 3.52) and pre-existing cognitive impairment (OR 2.51) were independent predictors of post-stroke delirium. Patients with delirium had more functional disability, a higher proportion went to a nursing home on discharge (62% vs 11.2%), at 6 months (60% vs 12.5%) and at 12 months (65% vs 13%), and there was higher inpatient mortality (18% vs 2.2%) and 1-year mortality (30% vs 7.4%). Hospital stay was also longer (45 vs 22 days).

CONCLUSION

Delirium is a common complication post-stroke, with treatable risk factors. It results in higher functional impairment, nursing home placement and mortality. Comprehensive geriatric assessment of older stroke patients might help to reduce the occurrence of delirium.

Post-stroke delirium in relation to dementia and long-term mortality

BACKGROUND

Delirium is a frequent post-stroke complication that compromises effective rehabilitation and has been associated with poor outcome. We aimed to investigate whether delirium is associated with increased risk of post-stroke dementia and long-term mortality once confounding is taken into account.

METHODS

The study comprised 263 consecutive acute ischemic stroke patients aged 55-85 years admitted to the emergency department of a university hospital. The cohort included three-month survivors followed up for 10 years. The diagnosis of post-stroke delirium during the first 7 days after stroke was based on the DSM-IV criteria.

FINDINGS

Of all the patients, 50 (19.0%) were diagnosed with delirium. Low education, pre-stroke cognitive decline, and severe stroke indicated by a Modified Rankin score between 3 and 5 were risk factors for post-stroke delirium, which was also associated with diagnosis of dementia at 3 months post-stroke. In the Kaplan-Meier analysis, delirium was associated with poor long-term survival (6.1 versus 9.1 years). In the stepwise Cox regression proportional hazards analysis adjusted for demographic factors and risk factors, advanced age (hazard ratio [HR] 1.08) and stroke severity (HR 1.83), but not post-stroke delirium, were associated with poor survival.

INTERPRETATION

In our well-defined cohort of post-stroke patients, acute stage delirium was diagnosed in one in five patients and associated with dementia at 3 months. Advanced age and stroke severity were related to the higher long-term mortality among patients with post-stroke delirium.

Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

OBJECTIVE

To describe the epidemiology and time spectrum of delirium using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and to validate a tool for delirium assessment in patients in the acute poststroke period.

DESIGN

A prospective observational cohort study.

SETTING

The stroke unit of a university hospital.

PATIENTS

A consecutive series of 129 patients with stroke (with infarction or intracerebral hemorrhage, 57 women and 72 men; mean age, 72.5 yrs; age range, 35-93 yrs) admitted to the stroke unit of a university hospital were evaluated for delirium incidence.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Criterion validity and overall accuracy of the Czech version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were determined using serial daily delirium assessments with CAM-ICU by a junior physician compared with delirium diagnosis by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria that began the first day after stroke onset and continued for at least 7 days. Cox regression models using time-dependent covariate analysis adjusting for age, gender, prestroke dementia, National Institutes of Stroke Health Care at admission, first-day Sequential Organ Failure Assessment, and asphasia were used to understand the relationships between delirium and clinical outcomes. An episode of delirium based on reference Diagnostic and Statistical Manual assessment was detected in 55 patients with stroke (42.6%). In 37 of these (67.3%), delirium began within the first day and in all of them within 5 days of stroke onset. A total of 1003 paired CAM-ICU/Diagnostic and Statistical Manual of Mental Disorders daily assessments were completed. Compared with the reference standard for diagnosing delirium, the CAM-ICU demonstrated a sensitivity of 76% (95% confidence interval [CI] 55% to 91%), a specificity of 98% (95% CI 93% to 100%), an overall accuracy of 94% (95% CI 88% to 97%), and high interrater reliability (κ = 0.94; 95% CI 0.83-1.0). The likelihood ratio of the CAM-ICU in the diagnosis of delirium was 47 (95% CI 27-83). Delirium was an independent predictor of increased length of hospital stay (hazard ratio 1.63; 95% CI 1.11-2.38; p = .013).

CONCLUSIONS

Poststroke delirium may frequently be detected provided that the testing algorithm is appropriate to the time profile of poststroke delirium. Early (first day after stroke onset) and serial screening for delirium is recommended. CAM-ICU is a valid instrument for the diagnosis of delirium and should be considered an aid in delirium screening and assessment in future epidemiologic and interventional studies in patients with stroke.

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Delirium in acute stroke: a predictor of subsequent cognitive impairment? A two-year follow-up study

OBJECTIVE

Delirium is an independent risk factor for cognitive impairment and development of dementia in medical patients. It has never been thoroughly studied whether this association is also present in the stroke population. Our aim was to evaluate the effects of delirium in the acute phase after stroke on cognitive functioning two years later.

METHODS

Two years after stroke, 50 patients (22 with and 28 without delirium in the acute phase) were assessed on two screening instruments for dementia and a neuropsychological test battery.

RESULTS

Delirium was an independent predictor for development of dementia as assessed by the Clinical Dementia Rating Scale (odds ratio (OR) 4.7; 95% confidence interval (CI) 1.08 to 20.42) and by the Rotterdam-CAMCOG (OR 7.2, 95% CI 1.88 to 27.89). Cognitive domains most affected in patients with previous delirium were memory, language, visual construction and executive functioning.

CONCLUSIONS

Delirium in the acute phase after stroke is an independent predictor for severe cognitive impairment two years after stroke. These findings emphasize the importance of both rapid detection and treatment of delirium after stroke. Furthermore, periodic monitoring and evaluation of cognitive functioning in these vulnerable patients in the years after stroke is strongly recommended.

Evaluation and management of the elderly patient at risk for postoperative delirium

Geriatric patients are at a high risk for the development of postoperative delirium. By recognizing predisposing and precipitating risk factors, preventive measures can be undertaken to reduce this risk. Accurate and timely diagnosis is essential, and we offer therapeutic strategies to help reduce the high morbidity and mortality of this important condition.

A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative

Background

Delirium is a common disorder in the early phase of stroke. Given the presumed cholinergic deficiency in delirium, we tested treatment with the acetylcholinesterase inhibitor rivastigmine.

Methods

This pilot study was performed within an epidemiological study. In 527 consecutive stroke patients presence of delirium was assessed during the first week with the confusion assessment method. Severity was scored with the delirium rating scale (DRS). Sixty-two patients developed a delirium in the acute phase of stroke. Only patients with a severe and persistent delirium (defined as a DRS of 12 or more for more than 24 hours) were enrolled in the present study. In total 26 fulfilled these criteria of whom 17 were treated with orally administered rivastigmine with a total dose between 3 and 12 mg a day. Eight patients could not be treated because of dysphagia and one because of early discharge.

Results

No major side effects were recorded. In 16 patients there was a considerable decrease in severity of delirium. The mean DRS declined from 14.8 on day one to 8.5 after therapy and 5.6 after tapering. The mean duration of delirium was 6.7 days (range; 2–17).

Conclusion

Rivastigmine is safe in stroke patients with delirium even after rapid titration. In the majority of patients the delirium improved after treatment. A randomized controlled trial is needed to establish the usefulness of rivastigmine in delirium after stroke.

Trial registration

Nederlands Trial Register NTR1395

Types of brain dysfunction in critical illness

Cerebral dysfunction and injury in the ICU presents as focal neurologic deficits, seizures, coma, and delirium. These syndromes may result from a primary brain insult, such as stroke or trauma, but commonly are a complication of a systemic insult, such as cardiac arrest, hypoxemia, sepsis, metabolic derangements, and pharmacologic exposures. Many survivors of critical illness have cognitive impairment, which is believed to underlie the poor long-term functional status and quality of life observed in many critical illness survivors. Although progress has been made in characterizing the epidemiology of cerebral dysfunction in the ICU, more research is needed to elucidate underlying mechanisms that might represent targets for therapeutic intervention.

Delirium post-stroke

Delirium is not only one of the most common complications that older patients develop after admission to hospital but it is also one of the most serious. Although stroke is a known predisposing factor for delirium, few studies have investigated this association and results from existing studies give conflicting results with prevalence estimates ranging from 13 to 48%. The aetiology of delirium post-stroke is poorly understood. There is no consensus on the best screening tool to use to detect delirium in the post-stroke setting. Specific stroke types may be more likely to precipitate delirium than others, for example, delirium is more frequent after intracerebral haemorrhage and total anterior circulation infarction (TACI). In addition, case reports have suggested that delirium may be associated with specific lesions, for example, in the thalamus and caudate nucleus. There is a lack of intervention data in both the prevention and treatment of delirium post-stroke. However, it is known that the development of delirium post-stroke has grave prognostic implications. It is associated with longer stay in hospital, increased mortality and increased risk of institutionalisation post discharge. In this article, we review the literature to date on delirium in the acute stroke setting.

Delirium due to Brain Microembolism: Diagnostic Value of Diffusion-Weighted MRI

Delirum is a common complication in hospitalized patients and it is characterized by acute disturbances of consciousness, attention, cognition, and perception. Despite the frequency with which it is observed, ischemic stroke is generally considered as an unusual cause of delirium. A subtype of brain embolism is characterized by multiple small emboli in different vascular territories, a condition known as "brain microembolism." Given the high contrast of acute ischemic lesions in diffusion weighted imaging (DWI) this technique is particularly helpful to detect these small infarctions. We present here a patient with pulmonary metastases who was treated with bronchial artery embolization and who subsequently developed delirium due to brain microembolism. The embolic material crossed through pulmonary arteriovenous fistulas, producing multiple areas of cerebral ischemia. The ischemic lesions could be visualized only on DWI, and they affected the periventricular region, caudate nucleus, thalamus, and cerebellum.

Mortality associated with incident mental health disorders after stroke

OBJECTIVE

Sparse information is currently available about the incidence of the major psychiatric syndromes following a stroke and their long-term contribution to morbidity and mortality. This study was designed to determine: (1) the incidence of first ever mental health disorder in amongst stroke patients; (2) the 10-year mortality associated with incident post-stroke mental health disorders.

DESIGN

Retrospective cohort study.

SETTING

Entire Western Australian community.

PARTICIPANTS

First-ever stroke in 1990. Subjects with a prior recorded history of any mental health disorder were excluded from the study. Main outcomes of interest: Incident mental health diagnoses and 10-year mortality.

RESULTS

1,129 hospital stroke contacts were recorded in 1990, with 21 people dying on the same day of contact. Between 1990-2002 36.6% of the survivors received a mental health diagnosis (6.1 per 1,000 person-years): alcohol-related disorders (16.2%), dementia (12.1%), delirium (7.6%), psychotic disorders (6.7%), and depression (5.5%). Mental health disorder onset was usually within 6 months of the stroke. Patients with an incident psychotic disorder were twice as likely to die during the subsequent 10 years as post-stroke controls with no mental health disorder (risk ratio = 2.03, 95%CI = 1.39-2.95). Being a widow (HR = 1.61, 95%CI = 1.13-2.30) or having been born in 'other countries' as opposed to Australia (HR = 1.56, 95%CI = 1.15-2.11) was also associated with increased death hazard.

CONCLUSIONS

Approximately 1 in 3 patients develop a mental health disorder after stroke, although incidence estimates are relatively low. Post-stroke psychosis is associated with greater 10-year mortality, but the mechanisms underlying such an association are yet to be determined.

Heterogeneous hyperactivity and distribution of ischemic lesions after focal cerebral ischemia in Mongolian gerbils

Various types of poststroke hyperactivity exist in humans, but studies of each mechanism using animal models are scarce. We aimed to analyze the heterogeneity of postischemic hyperlocomotion and to identify the ischemic lesions responsible for postischemic hyperlocomotion in rodent models of focal ischemia. Mongolian gerbils underwent right common carotid artery occlusion (CCAO) for 10 or 20 min. At 24 h, 2 days, and 7 days postischemia, we performed quantitative and qualitative locomotor analysis and correlated these results with the extent of ischemic lesions. Intermittent explosive hyperlocomotion was induced transiently in a 10-min CCAO group at 24 h after ischemia and continual unexplosive hyperlocomotion persisted for 7 days in the 20-min CCAO animals. Selective neuronal death, confined to the hippocampal cornu ammonis 1 (CA1), was observed in the 10-min CCAO group and widespread cortical and basal ganglia infarction was observed in the 20-min CCAO group. Amyloid precursor protein was transiently observed in the hippocampus at 24 h postischemia in the 10-min CCAO animals, while it was widely distributed over the ischemic regions throughout the 7 days postischemia in the 20-min CCAO animals. Incidence maps and correlation analysis revealed hippocampal neuronal death of the CA1 sector and widespread hemispheric infarction, including the cortex, as the region responsible for the 10-min and 20-min CCAO-induced hyperactivity, respectively. Two distinct types of locomotor hyperactivity were observed that varied with regard to the distribution of the ischemic lesion, that is, hippocampal neuronal death and widespread infarction involving the cortex. These two types of locomotor hyperactivity appear to be models of the different types of poststroke hyperactivity seen in stroke patients.

Delirium within Three Days of Stroke in a Cohort of Elderly Patients

OBJECTIVES

To evaluate the incidence of stroke, risk factors for stroke, and outcomes in elderly stroke patients with delirium.

DESIGN

Cohort study with 12-month follow-up.

SETTING

Bankstown-Lidcombe Hospital, a 450-bed teaching hospital of the University of New South Wales, Sydney, Australia.

PARTICIPANTS

One hundred fifty-six stroke patients aged 65 and older recruited over 1 year.

MEASUREMENTS

Incidence of delirium (defined in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria) within 3 days poststroke, length of hospital stay, discharge destination, short- and long-term mortality, Functional Independence Measure (FIM) scores, and Mini-Mental State Examination (MMSE) scores.

RESULTS

Thirty-nine (25%) elderly stroke patients had delirium within 3 days after stroke. Logistic regression analysis found that older age (P=.04), hemorrhagic stroke (P=.02), metabolic disorders (P=.003), dementia prestroke (P=.02), Glasgow Coma Scale (GCS) score less than 15 on admission (P<.001), and inability to lift both arms on admission (P=.03) were independent predisposing factors for delirium. Patients who had a cardioembolic stroke (odds ratio (OR)=5.58) or total anterior circulation infarction (OR=3.42) were also more likely to develop delirium. Patients with delirium were associated with higher 6- and 12-month mortality (P<.05), lower 12-month FIM and MMSE scores, and a higher 12-month institutionalization rate.

CONCLUSION

Delirium occurred frequently in acute stroke patients aged 65 and older. Factors independently associated with delirium included old age, intracerebral hemorrhage, metabolic factors, prestroke dementia, initial GCS less than 15, and inability to lift both arms on admission. Patients with delirium had higher long-term mortality and a worse functional outcome.

Delirium in older patients admitted to general internal medicine

Delirium on the day of admission to general internal medicine wards was studied in 400 consecutive patients aged 70 years and above regarding occurrence, associated factors, clinical profile, length of hospital stay, and mortality. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination, and delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day of admission occurred in 31.3% of the patients and was independently associated with old age, fever on the day of admission (> or = 38 degrees C), treatment with neuroleptics, impaired vision, male sex, and previous stroke. Delirious patients had longer hospital stay (15.4 vs 9.5 days, P < .001), a higher mortality rate during hospitalization (11/125 vs 5/275, P < .001), and a higher 1-year mortality rate (45/125 vs 55/275, P = .001). Delirium is a common complication with often easily identified causes, and it has a serious impact on outcome for older medical patients.

Delirium in the Hospitalized Elder and Recommendations for Practice

Delirium is a mental disorder of acute onset and fluctuating course, characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior. It occurs in up to 50% of elderly hospital inpatients, many with preexisting dementia, and is associated with significant increases in functional disability, length of hospital stay, rates of death, and health care costs. Despite its clinical importance, delirium often remains undetected or misdiagnosed as dementia or other psychiatric illness. Awareness of the etiologies and risk factors of delirium should enable nurses to focus on patients at risk and to recognize delirium symptoms early. Knowledge of pharmacological and nonpharmacological treatments for delirium will provide the nurse with an arsenal of potential interventions in the care of the delirious hospitalized elder.

Low and high circulating cortisol levels predict mortality and cognitive dysfunction early after stroke

OBJECTIVE

Elevated cortisol levels are associated with confusion and poor outcome after stroke. Dehydroepiandrosterone sulphate (DS), the most abundant adrenal androgen may act as an anti-glucocorticoid. An altered regulation of these steroids may affect numerous brain functions, including neuronal survival. The purpose of this study was to investigate serum cortisol and DS levels and the cortisol/DS ratio early after stroke and relate our findings to the presence of disorientation and mortality.

DESIGN

Patients with acute ischaemic stroke (n = 88, 56 men and 32 women) admitted to a stroke unit were investigated with repeated clinical assessments and scores for degree of confusion, extent of paresis and level of functioning. Serum cortisol (C) and DS were measured on day 1 and/or day 4. Data for 28-day and 1-year mortality are presented. A control group of 65 age-matched healthy individuals was used. Multivariate analyses of mortality rates in the different tertiles or sixtiles of serum cortisol were performed with logistic regression, adjusting for age, sex, diabetes and level of consciousness.

RESULTS

There was no difference in serum cortisol levels on day 1 for stroke patients when compared with control group values. Initial cortisol levels were significantly higher in the patients with acute disorientation versus orientated patients (P < 0.05). Cortisol levels on day 1 were an independent predictor of 28-day mortality, and patients with low cortisol levels (<270 nmol L(-1)) and increased levels (>550 nmol L(-1)) both had an increased 1-year mortality. DS levels on day 1 were significantly elevated in stroke patients.

CONCLUSION

Hypercortisolism is associated with cognitive dysfunction early after ischaemic stroke. High and low circulating cortisol levels are associated with increased mortality after stroke. DS levels were not associated with clinical outcome.

Treatment or prevention of complications of acute ischemic stroke

Both neurologic and medical complications influence outcome after stroke. Space-occupying supratentorial infarcts can cause transtentorial or uncal herniation, which leads to death. Treatments aimed at reducing intracranial pressure in patients with such infarcts are of unproven value. Mass-producing cerebellar infarction may lead to brainstem compression and obstructive hydrocephalus. These lesions often are treated surgically. Although anticonvulsants are not indicated for prophylaxis, the occurrence of epileptic seizures mandates treatment to prevent recurrences. Depression is common in the acute stage of stroke, but is probably not more prevalent after stroke than after myocardial infarction. Although dysphagia is common, it usually is a transient problem. Patients with a decrease of consciousness or brainstem dysfunction usually need tube feeding for a certain period of time. Medical complications, such as fever, infections, hyperglycemia, cardiac disorders, pressure sores, and deep venous thrombosis, are associated with a poor prognosis and should be treated as early as possible. Measures to prevent these complications are part of general care. Hypertension is very common during the week after stroke and should be treated only in case of extremely high values or malignant hypertension. A multidisciplinary approach in the stroke unit is necessary to prevent and manage complications in the acute phase of stroke.

A UK survey of psychiatric services for older people in general hospitals

BACKGROUND

Psychiatric illness is common in older people in general hospitals, but little is known of the service models operating in the UK, or of the views of old age psychiatrists regarding service provision in this area. We set out to determine the range of UK old age psychiatry service models for older people in general hospital wards, and the opinions of clinicians on future service priorities and development.

METHOD

A postal questionnaire survey of old age psychiatrists providing psychiatric services to older people in general hospital wards.

RESULTS

73% of services were provided through a generic, sector-based, consultation psychiatry model. The remaining 27% employed a range of general hospital-based liaison psychiatry services for older people, involved in proactively seeking referrals and educating general hospital staff. Those providing a generic sector-based model were significantly slower at responding to referrals. 89% of respondents were unhappy with their service to older people in general hospital wards, with only 11% preferring the generic sector-based model. Organisational barriers to change identified included the management of mental health care and physical care by different organisations. Training, both of psychiatric staff in this specialist area, and of general hospital staff in the detection and basic management of common psychiatric conditions in the general hospital setting, was felt to be necessary.

CONCLUSIONS

The management of co-morbid psychiatric and physical illness in older people is an important issue for health services. Old age psychiatrists are unhappy with the prevalent, reactive, consultation-based model, preferring a range of liaison psychiatry models based in the general hospital. The most important barriers to service development in this area were the separate managerial arrangements for psychiatric and physical care services, and a lack of evidence for effective old age psychiatry services in this setting.