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Cheng H, Ling Y, Li Q, Tang Y, Li X, Liang X, Huang X, Su L, Lyu J. ICU admission Braden score independently predicts delirium in critically ill patients with ischemic stroke. Intensive Crit Care Nurs 2024; 82:103626. [PMID: 38219301 DOI: 10.1016/j.iccn.2024.103626] [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: 09/23/2023] [Revised: 12/08/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management. OBJECTIVE To examine the association between the Braden score and delirium. METHODS A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated. RESULTS The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001). CONCLUSIONS The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke. IMPLICATION FOR CLINICAL PRACTICE The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs.
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Affiliation(s)
- Hongtao Cheng
- School of Nursing, Jinan University, Guangzhou, China; Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yitong Ling
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Qiugui Li
- School of Nursing, Jinan University, Guangzhou, China
| | - Yonglan Tang
- School of Nursing, Jinan University, Guangzhou, China
| | - Xinya Li
- School of Nursing, Jinan University, Guangzhou, China
| | - Xin Liang
- School of Nursing, Jinan University, Guangzhou, China
| | - Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ling Su
- College of Pharmacy, Jinan University, Guangzhou, China.
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China; Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China.
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Rood PJT, Ramnarain D, Oldenbeuving AW, den Oudsten BL, Pouwels S, van Loon LM, Teerenstra S, Pickkers P, de Vries J, van den Boogaard M. The Impact of Non-Pharmacological Interventions on Delirium in Neurological Intensive Care Unit Patients: A Single-Center Interrupted Time Series Trial. J Clin Med 2023; 12:5820. [PMID: 37762760 PMCID: PMC10532134 DOI: 10.3390/jcm12185820] [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: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Delirium is a pathobiological brain process that is frequently observed in Intensive Care Unit (ICU) patients, and is associated with longer hospitalization as well as long-term cognitive impairment. In neurological ICU patients, delirium may be more treatment-resistant due to the initial brain injury. This study examined the effects of a multicomponent non-pharmacological nursing intervention program on delirium in neurological ICU patients. Methods: A single-center interrupted time series trial was conducted in adult neurological ICU patients at high risk for developing delirium who were non-delirious at admission. A multicomponent nursing intervention program focusing on modifiable risk factors for delirium, including the optimalization of vision, hearing, orientation and cognition, sleep and mobilization, was implemented as the standard of care, and its effects were studied. The primary outcome was the number of delirium-free and coma-free days alive at 28 days after ICU admission. The secondary outcomes included delirium incidence and duration, ICU and hospital length-of-stay and duration of mechanical ventilation. Results: Of 289 eligible patients admitted to the ICU, 130 patients were included, with a mean age of 68 ± 11 years, a mean APACHE-IV score of 79 ± 25 and a median predicted delirium risk (E-PRE-DELIRIC) score of 42 [IQR 38-50]). Of these, 73 were included in the intervention period and 57 in the control period. The median delirium- and coma-free days alive were 15 days [IQR 0-26] in the intervention group and 10 days [IQR 0-24] in the control group (level change -0.48 days, 95% confidence interval (95%CI) -7 to 6 days, p = 0.87; slope change -0.95 days, 95%CI -2.41 to 0.52 days, p = 0.18). Conclusions: In neurological ICU patients, our multicomponent non-pharmacological nursing intervention program did not change the number of delirium-free and coma-free days alive after 28 days.
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Affiliation(s)
- Paul J. T. Rood
- Department of Intensive Care Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, P.O. Box 6960, 6503 GL Nijmegen, The Netherlands
| | - Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth Tweesteden Hospital, Hilvarenbeekseweg, P.O. Box 90151, 5000 LE Tilburg, The Netherlands
- Department of Medical and Clinical Psychology, Center of Research on Psychological Disorders and Somatic Diseases (CoRPS), Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
| | - Annemarie W. Oldenbeuving
- Department of Intensive Care Medicine, Elisabeth Tweesteden Hospital, Hilvarenbeekseweg, P.O. Box 90151, 5000 LE Tilburg, The Netherlands
| | - Brenda L. den Oudsten
- Department of Medical and Clinical Psychology, Center of Research on Psychological Disorders and Somatic Diseases (CoRPS), Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth Tweesteden Hospital, Hilvarenbeekseweg, P.O. Box 90151, 5000 LE Tilburg, The Netherlands
- Department of General and Abdominal Surgery, Helios Klinikum, Lutherplatz 40, 47805 Krefeld, Germany
| | - Lex M. van Loon
- Department of Intensive Care Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- College of Health and Medicine, Australian National University, 131 Garran Rd, Acton, Canberra, ACT 2601, Australia
| | - Steven Teerenstra
- Department for Health Evidence, Section Biostatistics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Center of Research on Psychological Disorders and Somatic Diseases (CoRPS), Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
- Admiraal de Ruyter Hospital (Adrz), P.O. Box 15, 4462 RA Goes, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Thilges S, Egbert J, Jakuboski S, Qeadan F. Associations between delirium and SARS-CoV-2 pandemic visitor restrictions among hospitalized patients. Public Health 2023; 222:45-53. [PMID: 37517161 PMCID: PMC10293895 DOI: 10.1016/j.puhe.2023.06.031] [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: 03/03/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic. STUDY DESIGN Retrospective epidemiological assessment. METHODS The medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed. RESULTS The overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before. CONCLUSIONS Medically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.
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Affiliation(s)
- S Thilges
- Loyola University Medical Center, Department of Psychiatry and Behavioral Neurosciences, 2160 South First Avenue, Maywood, IL, United States.
| | - J Egbert
- Loyola University Chicago, Parkinson School of Health Sciences and Public Health, 2160 South First Avenue, Maywood, IL, United States.
| | - S Jakuboski
- Loyola University Chicago, Stritch School of Medicine, 2160 South First Avenue, Maywood, IL, United States.
| | - F Qeadan
- Loyola University Chicago, Parkinson School of Health Sciences and Public Health, 2160 South First Avenue, Maywood, IL, United States.
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Droś J, Kowalska K, Pasińska P, Klimkowicz-Mrowiec A. Transient cognitive impairment in the acute phase of stroke - prevalence, risk factors and influence on long-term prognosis in population of patients with stroke (research study - part of the PROPOLIS study). BMC Neurol 2023; 23:75. [PMID: 36803740 PMCID: PMC9936649 DOI: 10.1186/s12883-023-03120-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Cognitive impairment is a common complication of the acute phase of stroke, which can be transient and resolve while still in the hospital. This study evaluated the prevalence and risk factors for transient cognitive impairment and their impact on long-term prognosis in a population of acute-phase stroke patients. METHODS Consecutive patients admitted to a stroke unit with acute stroke or transient ischemic attack were screened twice for cognitive impairment using the parallel version of Montreal Cognitive Assessment: the first time between the first and third day and the second time between the fourth and seventh day of hospitalization. If the second test score increased by two or more points, transient cognitive impairment was diagnosed. Patients were scheduled for follow-up visits three and 12 months after stroke. Outcome assessment included place of discharge, current functional status, dementia, or death. RESULTS Four hundred forty-seven patients were included in the study, 234 (52.35%) were diagnosed with transient cognitive impairment. Delirium was the only independent risk factor for transient cognitive impairment (OR 2.417, 95%CI 1.096-5.333, p = 0.029). In the analysis of effects on three- and twelve-month prognosis, patients with transient cognitive impairment had a lower risk of hospital or institution stay 3 months after stroke compared with patients with permanent cognitive impairment (OR 0.396, 95%CI 0.217-0.723, p = 0.003). There was no significant effect on mortality, disability or risk of dementia. CONCLUSIONS Transient cognitive impairment, which often occurs in the acute phase of stroke, does not increase the risk of long-term complications.
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Affiliation(s)
- Jakub Droś
- grid.5522.00000 0001 2162 9631Doctoral School in Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | | | - Paulina Pasińska
- grid.5522.00000 0001 2162 9631Department of Medical Didactics, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Klimkowicz-Mrowiec
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.
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Greenway MRF, Robinson MT. Palliative care approaches to acute stroke in the hospital setting. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:13-27. [PMID: 36599505 DOI: 10.1016/b978-0-12-824535-4.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.
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Affiliation(s)
| | - Maisha T Robinson
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States; Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States.
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Hsu PC, Shahed-Al-Mahmud M. SARS-CoV-2 mediated neurological disorders in COVID-19: Measuring the pathophysiology and immune response. Life Sci 2022; 308:120981. [PMID: 36150465 PMCID: PMC9490490 DOI: 10.1016/j.lfs.2022.120981] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022]
Abstract
The emergence of beta-coronavirus SARS-CoV-2 gets entry into its host cells by recognizing angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRESS2) receptors, which are responsible for coronavirus diseases-2019 (COVID-19). Global communities have been affected by COVID-19, especially caused the neurological complications and other critical medical issues. COVID-19 associated complications appear in aged people with underlying neurological states, especially in Parkinson's disease (PD) and Alzheimer's disease (AD). ACE2 receptors abundantly expressed in dopamine neurons may worsen the motor symptoms in PD and upregulates in SARS-CoV-2 infected aged patients' brain with AD. Immune-mediated cytokines released in SARS-CoV-2 infection lead to an indirect immune response that damages the central nervous system. Extreme cytokines release (cytokine storm) occurs due to aberrant immune pathways, and activation in microglial propagates CNS damage in COVID-19 patients. Here, we have explored the pathophysiology, immune responses, and long-term neurological impact on PD and AD patients with COVID-19. It is also a crucial step to understanding COVID-19 pathogenesis to reduce fatal outcomes of neurodegenerative diseases.
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Affiliation(s)
- Pi-Ching Hsu
- Workplace Heath Promotion Center, Changhua Christian Hospital, Changhua, Taiwan
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Klimiec-Moskal E, Slowik A, Dziedzic T. Delirium and subsyndromal delirium are associated with the long-term risk of death after ischaemic stroke. Aging Clin Exp Res 2022; 34:1459-1462. [PMID: 35015294 PMCID: PMC9151505 DOI: 10.1007/s40520-021-02071-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post-stroke delirium has a negative impact on functional outcome. We explored if there is any association between delirium, subsyndromal delirium and long-term mortality after ischaemic stroke and transient ischaemic attack. METHODS We included 564 patients with ischaemic stroke or transient ischaemic attack. We assessed symptoms of delirium during the first 7 days after admission. We used Cox proportional hazards models to analyse all-cause mortality during the first 5 years after stroke. RESULTS We diagnosed delirium in 23.4% and subsyndromal delirium in 10.3% of patients. During the follow-up, 72.7% of patients with delirium, 51.7% of patients with subsyndromal delirium and 22.7% of patients without delirious symptoms died (P < 0.001). Patients with subsyndromal delirium and delirium had higher risk of death in the multivariate analysis (HR 1.72, 95% CI 1.11-2.68, P = 0.016 and HR 3.30, 95% CI 2.29-4.76, P < 0.001, respectively). CONCLUSIONS Post-stroke delirium is associated with long-term mortality. Patients with subsyndromal delirium are at the intermediate risk of death.
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Affiliation(s)
- Elzbieta Klimiec-Moskal
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland.
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Vybornykh DE, Zakharov VV, Gemdzhian EG, Drokov MY, Fedorova SY, Khrushchev SO. [Predictors of severe lesions of the central nervous system in the treatment of blood system diseases]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:33-38. [PMID: 34932283 DOI: 10.17116/jnevro202112111133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the types, frequency and key symptoms of severe lesions of the central nervous system (SLCNS) that occurred in patients with hematological malignancies (HM). MATERIALS AND METHODS The authors conducted a retrospective exploratory study by analyzing the data of 3.620 patients with HM during the period from 01.01.18 to 31.12.19. Thirty-four patients (14 men and 20 women, median age 39 years), who developed SLCNS during treatment, were selected. For comparison with the main group of patients and exclusion of predictors associated with the development of SLCNS, a comparison group was added (by Kernel matching method). A comparison group consisted of 137 patients (59 men and 78 women, median age - 36 years) and was similar to the main group by clinical and laboratory characteristics. A neurological complication was marked as SLCNS if it was an indication for transfer to the intensive care unit (ICU). Statistical analysis included multivariate analysis - multiple binary logistic regression with stepwise inclusion of variables (that were found in the preliminary contingency table analysis) in the model, with control false results (by the false discovery rate method) and estimating the odds ratio, OR (95% CI). RESULTS SLCNS in patients with HM developed in 0.94% of cases. The main SLCNS in patients with HM were: epileptic seizure (50.0%, n=17), ischemic stroke (20.6%, n=7), hemorrhagic stroke (17.6%, n=6) and meningoencephalitis (11.8%, n=4). The following independent significant (Wald test p≤0.05) predictors associated with the development of SLCNS in patients with HM during inpatient treatment were identified: antibiotic therapy (when more than 5 drugs are prescribed), OR=2.9 (1.2-7, four); polychemotherapy (if more than 4 drugs are prescribed), OR=2.9 (1.1-7.8); thrombocytopenia (with a platelet count less than 50·109 g/l), OR=2.3 (1.0-5.2) and delirium, OR=3.7 (1.3-10.8), and also the presence of neurological disorders in the patient's history, OR=2.6 (1.1-6.3). CONCLUSION The main types of SLCNS in patients with HM were: epileptic seizure, ischemic and hemorrhagic strokes, and meningoencephalitis. Four predictors associated with the development of SLCNS in the course of HM treatment were identified: massive antibacterial (with more than 5 drugs) and chemotherapeutic (with more than 4 drugs) effects, thrombocytopenia and manifestation of delirium, as well as one risk factor: a history of neurological disorder. These factors need to be considered and monitored during treatment, because each of them increases the risk of developing SLCNS.
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Affiliation(s)
- D E Vybornykh
- National Research Center for Hematology, Moscow, Russia
| | - V V Zakharov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - E G Gemdzhian
- National Research Center for Hematology, Moscow, Russia
| | - M Yu Drokov
- National Research Center for Hematology, Moscow, Russia
| | - S Yu Fedorova
- National Research Center for Hematology, Moscow, Russia
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Guldolf K, Vandervorst F, Gens R, Ourtani A, Scheinok T, De Raedt S. Neutrophil-to-lymphocyte ratio predicts delirium after stroke. Age Ageing 2021; 50:1626-1632. [PMID: 34218276 DOI: 10.1093/ageing/afab133] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delirium is an underdiagnosed and possibly preventable complication in acute stroke and is linked to poor outcome. Neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, is also associated with poor outcome after acute ischemic stroke. AIM To determine whether NLR is a predictor of post-stroke delirium (PSD). METHODS We reviewed the UZ Brussel stroke database and included 514 patients with acute ischemic stroke within 24 hours from stroke onset between February 2009 and December 2014. The presence of delirium was evaluated by two raters based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, using a retrospective chart review method. When no consensus was reached, a third evaluator was consulted. Patients were divided into two groups: those who developed delirium within the first week after stroke onset (n = 201; 39%) and those who did not (n = 313; 61%). Receiver operating characteristics (ROC) and multiple logistic regression analysis (MLRA) were used to identify predictors of PSD. RESULTS MLRA showed that NLR (odds ratio (OR) 1.14; 95% confidence interval (CI) 1.04-1.26), age (OR 1.05; 95% CI 1.03-1.07), National Institutes of Health Stroke Scale (NIHSS; OR 1.14; 95% CI 1.10-1.18), premorbid modified Rankin Scale (mRS) (OR 1.35; 95% CI 1.05-1.74) and premorbid cognitive dysfunction (OR 3.16; 95% CI 1.26-7.92) predicted PSD. ROC curve of a prediction model including NLR, age, NIHSS and premorbid cognitive dysfunction showed an area under the curve of 0.84 (95% CI = 0.81-0.88). CONCLUSIONS Besides age, stroke severity, premorbid mRS and cognitive impairment, NLR is a predictor of PSD, even independent of the development of pneumonia or urinary tract infection.
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Affiliation(s)
- Kaat Guldolf
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Fenne Vandervorst
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Robin Gens
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Anissa Ourtani
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Neurology, UVC Brugmann or CHU Brugmann, Brussels, Belgium
| | - Thomas Scheinok
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Sylvie De Raedt
- Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Kumar D, Jahan S, Khan A, Siddiqui AJ, Redhu NS, Wahajuddin, Khan J, Banwas S, Alshehri B, Alaidarous M. Neurological Manifestation of SARS-CoV-2 Induced Inflammation and Possible Therapeutic Strategies Against COVID-19. Mol Neurobiol 2021; 58:3417-3434. [PMID: 33715108 PMCID: PMC7955900 DOI: 10.1007/s12035-021-02318-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/01/2021] [Indexed: 01/08/2023]
Abstract
There are regular reports of extrapulmonary infections and manifestations related to the ongoing COVID-19 pandemic. Coronaviruses are potentially neurotropic, which renders neuronal tissue vulnerable to infection, especially in elderly individuals or in those with neuro-comorbid conditions. Complaints of ageusia, anosmia, myalgia, and headache; reports of diseases such as stroke, encephalopathy, seizure, and encephalitis; and loss of consciousness in patients with COVID-19 confirm the neuropathophysiological aspect of this disease. The brain is linked to pulmonary organs, physiologically through blood circulation, and functionally through the nervous system. The interdependence of these vital organs may further aggravate the pathophysiological aspects of COVID-19. The induction of a cytokine storm in systemic circulation can trigger a neuroinflammatory cascade, which can subsequently compromise the blood-brain barrier and activate microglia- and astrocyte-borne Toll-like receptors, thereby leading to neuronal tissue damage. Hence, a holistic approach should be adopted by healthcare professionals while treating COVID-19 patients with a history of neurodegenerative disorders, neuropsychological complications, or any other neuro-compromised conditions. Imperatively, vaccines are being developed at top priority to contain the spread of the severe acute respiratory syndrome coronavirus 2, and different vaccines are at different stages of development globally. This review discusses the concerns regarding the neuronal complications of COVID-19 and the possible mechanisms of amelioration.
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Affiliation(s)
- Dipak Kumar
- Zoology Department, KKM College, Jamui, Munger University, Munger, India
| | - Sadaf Jahan
- Department of Medical Laboratories, College of Applied Medical Sciences, Majmaah University, Majmaah, 11952, Saudi Arabia, Kingdom of Saudi Arabia.
| | - Andleeb Khan
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, Jazan, 45142, Saudi Arabia
| | - Arif Jamal Siddiqui
- Department of Biology, College of Science, University of Hail, Hail, PO Box 2440, Saudi Arabia
| | - Neeru Singh Redhu
- Department of Molecular Biology, Biotechnology and Bioinformatics, Chaudhary Charan Singh Haryana Agricultural University, Hisar, Haryana 125004, India
| | - Wahajuddin
- Division of Pharmaceutics & Pharmacokinetics, CSIR-Central Drug Research Institute, Lucknow, UP, India
| | - Johra Khan
- Department of Medical Laboratories, College of Applied Medical Sciences, Majmaah University, Majmaah, 11952, Saudi Arabia, Kingdom of Saudi Arabia
| | - Saeed Banwas
- Department of Medical Laboratories, College of Applied Medical Sciences, Majmaah University, Majmaah, 11952, Saudi Arabia, Kingdom of Saudi Arabia
- Health and Basic Sciences Research Center, Majmaah University, Majmaah, 11952, Saudi Arabia
- Departments of Biomedical Sciences, Oregon State University, Corvallis, OR, 97331, USA
| | - Bader Alshehri
- Department of Medical Laboratories, College of Applied Medical Sciences, Majmaah University, Majmaah, 11952, Saudi Arabia, Kingdom of Saudi Arabia
- Health and Basic Sciences Research Center, Majmaah University, Majmaah, 11952, Saudi Arabia
| | - Mohammed Alaidarous
- Department of Medical Laboratories, College of Applied Medical Sciences, Majmaah University, Majmaah, 11952, Saudi Arabia, Kingdom of Saudi Arabia
- Health and Basic Sciences Research Center, Majmaah University, Majmaah, 11952, Saudi Arabia
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11
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Elevated plasma levels of galectin-3 binding protein are associated with post-stroke delirium - A pilot study. J Neuroimmunol 2021; 356:577579. [PMID: 33901789 DOI: 10.1016/j.jneuroim.2021.577579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/22/2022]
Abstract
To explore the role of systemic inflammation in post-stroke delirium, we investigated the level of two inflammatory mediators: high mobility group box 1 (HMGB1) and galectin-3 binding protein (Gal-3BP). Of 571 stroke patients, we compared plasma levels of HMGB1 and Gal-3BP in 79 delirious patients with 81 non-delirious patients matched for age and stroke severity. Delirious patients had higher Gal-3BP level (median: 1440 vs 1053 ng/mL, P < 0.01). An elevated level of Gal-3BP was associated with an increased risk of delirium. HMGB1 levels did not differ between groups. Our results suggest that pro-inflammatory monocytes and macrophages might be involved in delirium pathophysiology.
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12
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Lopatkiewicz AM, Pera J, Slowik A, Dziedzic T. Association of early and later depressive symptoms with functional outcome after ischemic stroke. J Neural Transm (Vienna) 2021; 128:679-686. [PMID: 33728483 PMCID: PMC8105243 DOI: 10.1007/s00702-021-02328-w] [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: 01/05/2021] [Accepted: 03/10/2021] [Indexed: 12/01/2022]
Abstract
Background Post-stroke depressive symptoms (DS) can be chronic or transient, occurring shortly or long after stroke and lasting only few months. It remains unclear if the prognosis differs between patients with DS in the acute phase of stroke and those who develop DS several months later. We aimed to determine whether outcomes vary among patients with different trajectories of post-stroke depressive symptoms. Methods Of 698 enrolled patients with ischemic stroke, we included 335 participants (median age: 68, 48% female) who were assessed for DS both 8 days and 3 months post-stroke. We divided patients into 4 groups: without greater DS (Group 1), only earlier DS (Group 2), only later DS (Group 3), and persistent DS (Group 4). Logistic regression was used to determine the association between DS and 3- and 12-month functional outcome. Results Group 2 was predominantly female and had the highest rate of previous stroke or transient ischemic attack. Group 3 was more likely to suffer from delirium and more severe stroke. Group 4 had the highest frequency of vascular risk factors, pre-morbid psychiatric symptoms, and cognitive decline. In multivariate analysis, Group 3, but not Groups 2 and 4, had an increased risk of poor 3- and 12-month functional outcome (adjusted OR 2.59, 95% CI 1.64–4.07, P < 0.01 and OR 3.97, 95% CI 2.32–6.76, P < 0.01, respectively) compared with Group 1. Conclusions Different trajectories of post-stroke DS are related to different outcomes. Patients who only have later DS also have the worst prognosis.
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Affiliation(s)
- Anna Maria Lopatkiewicz
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Krakόw, Poland
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Krakόw, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Krakόw, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Krakόw, Poland.
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13
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Rollo E, Callea A, Brunetti V, Vollono C, Marotta J, Imperatori C, Frisullo G, Broccolini A, Della Marca G. Delirium in acute stroke: A prospective, cross-sectional, cohort study. Eur J Neurol 2021; 28:1590-1600. [PMID: 33476475 DOI: 10.1111/ene.14749] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Delirium is a neuropsychiatric disorder of attention and awareness that develops over a short time and fluctuates in severity. Although delirium has been extensively studied in intensive care units, the incidence of delirium in stroke units and its predictors in stroke patients need further investigation. The endpoints of our study were incidence of delirium in acute stroke and the risk factors that predispose to this condition. METHODS Patients were consecutively enrolled in a stroke unit from April to October 2020. Inclusion criteria were: age ≥18 years, acute stroke and National Institute of Health Stroke Scale (NIHSS) score ≥1 at the time of clinical assessment of delirium. Exclusion criteria were: transient ischemic attack; absence of neuroimaging evidence of brain lesion; cerebral venous thrombosis; subarachnoid hemorrhage; and clinical conditions requiring intensive care unit treatment. All patients were evaluated by means of Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) scores at baseline, evaluations which were repeated within 72 h or when patients developed symptoms suggesting delirium. RESULTS The overall incidence of delirium was 36/120 (30%). Delirium was associated with aphasia (odds ratio [OR] 9.77; confidence interval [CI] 1.2-79.6), chronic obstructive pulmonary disease (COPD; OR 16.67; CI 1.1-263.0), deep Fazekas score (OR 5.05; CI 1.7-14.8), and physical restraint (OR 45.02; CI 1.4-1411.5). Diabetes was associated with a lower incidence of delirium (OR 0.04; CI 0.026-0.7). CONCLUSIONS Nearly one-third of patients (30%) had delirium in the acute phase of stroke. This finding supports the notion that delirium is a common complication of stroke. Delirium was associated with speech disorder, leukoencephalopathy, COPD and early use of physical restraint.
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Affiliation(s)
- Eleonora Rollo
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Callea
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio Brunetti
- Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Catello Vollono
- Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Jessica Marotta
- Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Claudio Imperatori
- Cognitive and Clinical Psychology Laboratory, Department of Human Sciences, European University of Rome, Rome, Italy
| | - Giovanni Frisullo
- 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.,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.,Dipartimento Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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14
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Czyzycki M, Glen A, Slowik A, Chrzan R, Dziedzic T. Clinical utility of brain computed tomography in prediction of post-stroke delirium. J Neural Transm (Vienna) 2021; 128:207-213. [PMID: 33417010 DOI: 10.1007/s00702-020-02294-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Delirium is a common and serious complication of stroke. Early prediction of delirium is important for preventive strategies and close monitoring of high-risk patients. Pre-existing degenerative and vascular changes in the brain could predispose to delirium. We aimed to determine if computed tomography (CT)-based indices could provide additional information about a risk of stroke-associated delirium beyond easiest-to-access clinical predictors. Using semi-quantitative scales (global cortical atrophy, age-related white matter changes, and Scheltens scale), we assessed global and regional brain atrophy and white matter changes in 88 stroke patients with delirium and 142 patients without delirium matched for age and stroke severity. Patients with delirium had greater global and local brain atrophy (the right temporal region, the left parieto-occipital region, the right frontal and occipital horn, and the right and left temporal horn) than patients without delirium. Scores of white matter changes did not differ between groups with exception of greater white matter damage in the right parieto-occipital area in patients with delirium. The discriminatory properties of studied radiological indices were modest (areas under receiver operator curves: 0.58-0.64). CT-based indices of brain atrophy and white matter changes do not provide additional information about a risk of post-stroke delirium beyond the most important clinical predictors.
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Affiliation(s)
- Mateusz Czyzycki
- Department of Neurology, Jagiellonian University Medical College, 31-503 Kraków, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Agnieszka Glen
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, 31-503 Kraków, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Robert Chrzan
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, 31-503 Kraków, ul. Botaniczna 3, 31-503, Kraków, Poland.
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15
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Stroke-related delirium. J Neurol Sci 2020; 420:117250. [PMID: 33264682 DOI: 10.1016/j.jns.2020.117250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 11/20/2022]
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16
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Haight TN, Marsh EB. Identifying Delirium Early after Stroke: A New Prediction Tool for the Intensive Care Unit. J Stroke Cerebrovasc Dis 2020; 29:105219. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/24/2022] Open
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17
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van der Linden MC, van den Wijngaard IR, van der Linden S, van der Linden N. Night-time confusion in an elderly woman post-stroke. BMJ Case Rep 2020; 13:13/5/e230693. [PMID: 32444438 DOI: 10.1136/bcr-2019-230693] [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] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Naomi van der Linden
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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18
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Yang HW, Lee M, Shin JW, Jeong HS, Kim J, Kim JL. Outcome Differences by Delirium Motor Subtype in Patients with Ischemic Stroke. Psychiatry Investig 2019; 16:852-859. [PMID: 31648422 PMCID: PMC6877462 DOI: 10.30773/pi.2019.0120] [Citation(s) in RCA: 5] [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: 05/14/2019] [Accepted: 07/30/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE This study evaluated the outcomes of ischemic stroke patients according to delirium motor subtype. METHODS This study included patients who were admitted to the stroke unit between August 2017 and March 2019 and met the DSM-5 diagnostic criteria for delirium. Patients were assessed twice weekly throughout their delirium episodes using the Korean version of the Delirium Motor Subtype Scale (K-DMSS) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). The clinical characteristics and short-term outcomes of the patients were also assessed. RESULTS A total of 943 stroke patients were included; the rate of incident delirium was 10.18%. Of the 95 delirium patients, 34 were classified as the hyperactive subtype, 30 as the mixed subtype, 25 as the hypoactive and six as no subtype. Among the subtype groups, the hypoactive subtype had the highest initial scores on the National Institutes of Health Stroke Scale (NIHSS; 6.72±4.75, p=0.02) and the modified Rankin Scale (mRS; 3.96±1.24, p<0.01). Additionally, the mixed and hypoactive subtypes had longer durations (p<0.01) and more severe symptoms of delirium (p=0.03) than the other motor subtypes, and the hypoactive subtype group had a significantly longer hospital stay (36.88±27.71 days, p<0.01) than the other subtype groups. After adjusting for baseline covariates in a multiple linear regression analysis, these differences remained significant. CONCLUSION The present results suggest that the motor subtype of delirium is associated with different characteristics and outcomes in ischemic stroke patients.
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Affiliation(s)
- Hee Won Yang
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Miji Lee
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong Wook Shin
- Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jei Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Neurology, School of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jeong Lan Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Psychiatry, School of Medicine, Chungnam National University, Daejeon, Republic of Korea
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19
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Mansutti I, Saiani L, Palese A. Delirium in patients with ischaemic and haemorrhagic stroke: findings from a scoping review. Eur J Cardiovasc Nurs 2019; 18:435-448. [PMID: 31027426 DOI: 10.1177/1474515119846226] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Irene Mansutti
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Luisa Saiani
- 2 Department of Diagnostics and Public Health, University of Verona, Italy
| | - Alvisa Palese
- 3 Department of Medical Science, University of Udine, Italy
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20
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Klimiec-Moskal E, Lis A, Pera J, Slowik A, Dziedzic T. Subsyndromal delirium is associated with poor functional outcome after ischaemic stroke. Eur J Neurol 2019; 26:927-934. [PMID: 30674083 DOI: 10.1111/ene.13912] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Subsyndromal delirium (SSD) refers to patients with delirious symptoms who do not meet the criteria for delirium. The aim was to determine the prognostic significance of SSD in stroke patients. METHODS In all, 564 patients with ischaemic stroke (median age 71 years, 50.5% female) were included. The Confusion Assessment Method was used to assess symptoms of delirium and the Diagnostic and Statistical Manual of Mental Disorders, 5th edn, criteria were used to diagnose delirium. SSD was defined as one or more core features of delirium without fulfilling diagnostic criteria. Functional outcome was assessed using the modified Rankin Scale at 3 and 12 months after stroke. RESULTS Delirium was diagnosed in 23.4% of patients and SSD in 10.3% of patients. SSD was associated with increased risk of poor functional outcome. The adjusted odds ratios (ORs) for unfavourable outcome at 3 and 12 months were 2.88 [95% confidence interval (CI) 1.43-5.79, P < 0.01] and 2.93 (95% CI 1.39-6.22, P < 0.01), respectively. In multivariate analysis, delirium was an independent predictor of poor functional outcome at 3 months (OR 6.41, 95% CI 3.36-12.21, P < 0.01) and 12 months (OR 6.11, 95% CI 3.05-12.27, P < 0.01) after stroke. Delirium was also independently associated with increased risk of death within 3 months (hazard ratio 3.68, 95% CI 1.69-8.02, P < 0.01) and 12 months (hazard ratio 3.76, 95% CI 2.05-6.90, P < 0.01). SSD was not associated with increased risk of death. CONCLUSIONS In SSD patients the risk of poor functional outcome after stroke is increased and intermediate between patients with and patients without delirium.
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Affiliation(s)
- E Klimiec-Moskal
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - A Lis
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - J Pera
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - A Slowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - T Dziedzic
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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21
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Patel MB, Bednarik J, Lee P, Shehabi Y, Salluh JI, Slooter AJ, Klein KE, Skrobik Y, Morandi A, Spronk PE, Naidech AM, Pun BT, Bozza FA, Marra A, John S, Pandharipande PP, Ely EW. Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review. Crit Care Med 2018; 46:1832-1841. [PMID: 30142098 PMCID: PMC6185789 DOI: 10.1097/ccm.0000000000003349] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.
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Affiliation(s)
- Mayur B. Patel
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Section of Surgical Sciences, Departments of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN; Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Josef Bednarik
- Department of Neurology, University Hospital Brno, Czech Republic
- Applied Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Patricia Lee
- Center for Knowledge Management, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yahya Shehabi
- University New South Wales, Clinical School of Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jorge I. Salluh
- D’Or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Arjen J. Slooter
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Kate E. Klein
- Novant Health Presbyterian Medical Center, Charlotte, NC, USA
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Canada
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care of the Fondazione Camplani, Ancelle Hospital, Cremona, Italy. Geriatric Research Group, Brescia, Italy
| | - Peter E. Spronk
- Department of Intensive Care, Gelre Ziekenhuizen (Lukas), the Netherlands
| | - Andrew M. Naidech
- Departments of Neurology (Stroke and Neurocritical Care), Neurological Surgery, Anesthesiology, Medical Social Sciences, and Preventive Medicine (Health and Biomedical Informatics), Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Brenda T. Pun
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fernando A. Bozza
- Intensive Care Lab, Instituto Nacioinal de Infectologia Evandro, Chagas (INI), Fundacao Oswaldo Cruz, (FIOCRUZ), Rio De Janeiro, Brazil
| | - Annachiara Marra
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurosciences and Department of Public Health, University of Naples, Italy
| | - Sayona John
- Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Pratik P. Pandharipande
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Anesthesiology Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E. Wesley Ely
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Reduced ex vivo release of pro-inflammatory cytokines and elevated plasma interleukin-6 are inflammatory signatures of post-stroke delirium. J Neuroinflammation 2018; 15:111. [PMID: 29669581 PMCID: PMC5907192 DOI: 10.1186/s12974-018-1156-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 11/10/2022] Open
Abstract
Background Experimental studies suggest that systemic inflammation contributes to the pathophysiology of delirium. The aim of our study was to determine blood-derived inflammatory signatures of post-stroke delirium. Methods We included 144 ischemic stroke patients. We assessed delirium on a daily basis during the first 7 days of hospitalization. Venous blood was collected at day 3 after the onset of stroke and stimulated ex vivo with lipopolysaccharide (LPS). We measured LPS-induced cytokine concentration (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, and IL-12p70) as well as plasma levels of IL-6 and TNFα. Results Delirium was diagnosed in 21.5% of patients. After correction for monocyte count, patients with delirium had reduced LPS-induced TNFα, IP-10, IL-1β, IL-6, and IL-12 release. The plasma IL-6 level was higher in delirious patients compared to patients without delirium. After adjusting for stroke severity and infections, higher ex vivo TNFα (OR 0.29, 95%CI 0.11–0.72, P = 0.01), IP-10 (OR 0.25, 95%CI 0.08–0.73, P = 0.01), IL-1β (OR 0.42, 95%CI 0.20–0.89, P = 0.02), and IL-12 (OR 0.07, 95%CI 0.01–0.70, P = 0.02) release was associated with the reduced risk of delirium. In multivariate analysis, the higher plasma IL-6 was associated with the increased risk of delirium (OR 1.61, 95%CI 1.00–2.58, P = 0.04). Conclusions Reduced ex vivo release of pro-inflammatory cytokines after LPS stimulation and the elevated plasma IL-6 are signatures of post-stroke delirium.
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The association between plasma endotoxin, endotoxin pathway proteins and outcome after ischemic stroke. Atherosclerosis 2018; 269:138-143. [DOI: 10.1016/j.atherosclerosis.2017.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/14/2017] [Accepted: 12/22/2017] [Indexed: 11/21/2022]
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Klimiec E, Kowalska K, Pasinska P, Klimkowicz-Mrowiec A, Szyper A, Pera J, Slowik A, Dziedzic T. Pre-stroke apathy symptoms are associated with an increased risk of delirium in stroke patients. Sci Rep 2017; 7:7658. [PMID: 28794518 PMCID: PMC5550489 DOI: 10.1038/s41598-017-08087-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/06/2017] [Indexed: 12/24/2022] Open
Abstract
Neuropsychiatric symptoms can be interrelated to delirium. We aimed to investigate an association between pre-stroke neuropsychiatric symptoms and the risk of delirium in stroke patients. We included 606 patients (median age: 73, 53% female) with stroke or transient ischemic attack admitted within 48 hours from symptoms onset. We assessed delirium on a daily basis during the first 7 days of hospitalization. To make diagnosis of delirium we used DSM-5 criteria. We used Neuropsychiatric Inventory to assess neuropsychiatric symptoms occurring within 4 weeks prior to stroke. We diagnosed delirium in 28.2% of patients. On univariate analysis, higher score of pre-stroke depression (OR: 1.58, 95% CI: 1.04-2.40, P = 0.03), apathy (OR: 2.23, 95% CI: 1.44-3.45, P < 0.01), delusions (OR: 2.00, 95% CI: 1.09-3.68, P = 0.03), hallucinations (OR: 2.39, 95% CI: 1.19-4.81, P = 0.01) and disinhibition (OR: 2.10, 95% CI: 1.04-4.25, P = 0.04) was associated with the increased risk of delirium. On multivariate analysis adjusted for age, atrial fibrillation, diabetes mellitus, stroke severity, right hemisphere lesion, pre-stroke cognitive decline, pre-stroke disability and infections, higher apathy score (OR: 2.03, 95% CI: 1.17-3.50, P = 0.01), but no other neuropsychiatric symptoms, remained independent predictor of delirium. We conclude that pre-stroke apathy symptoms are associated with increased risk of delirium in stroke patients.
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Affiliation(s)
- Elzbieta Klimiec
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | - Katarzyna Kowalska
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | - Paulina Pasinska
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | | | - Aleksandra Szyper
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | - Joanna Pera
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | - Agnieszka Slowik
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland
| | - Tomasz Dziedzic
- Jagiellonin University Medical College, Department of Neurology, ul. Botaniczna 3, 31-503, Krakow, Poland.
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