Subtypes of delirium after ischaemic stroke-predisposing factors and outcomes: a prospective observational study (PROPOLIS)

The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review

INTRODUCTION

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

METHODS

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

RESULTS

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively.

CONCLUSION

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

The Role of Vascular Risk Factors in Post-Stroke Delirium: A Systematic Review and Meta-Analysis

Vascular risk factors may predispose to post-stroke delirium (PSD). A systematic review and meta-analysis were performed by searching PubMed, Web of Science, and Scopus. The primary outcome was the prevalence of vascular risk factors in PSD vs. non-PSD patients. Odds ratios (ORs) with 95% confidence intervals (CIs) and mean differences (MDs) with 95% CIs were calculated for categorical and continuous variables, respectively. Fixed effects or random effects models were used in case of low- or high-statistical heterogeneity, respectively. We found an increased prevalence of atrial fibrillation (OR = 1.74, p = 0.0004), prior stroke (OR = 1.48, p < 0.00001), coronary artery disease (OR = 1.48, p < 0.00001), heart failure (OR = 2.01, p < 0.0001), and peripheral vascular disease (OR = 2.03, p < 0.00001) in patients with vs. without PSD. PSD patients were older (MD = 5.27 y, p < 0.00001) compared with their non-PSD counterparts. Advanced age, atrial fibrillation, prior stroke, coronary artery disease, heart failure, and peripheral vascular disease appeared to be significantly associated with PSD.

Serum C-reactive protein adds predictive information for post-stroke delirium: The PROPOLIS study

OBJECTIVE

Delirium is common and serious complication after stroke. Accurate prediction of delirium is important for prevention and monitoring of high-risk patients. Our study aimed to determine if addition of C-reactive protein (CRP) to a model based on easy-to-access clinical predictors improves accuracy of delirium prediction in acute stroke patients.

METHODS

We analyzed data of patients participating in the Prospective Observational Polish Study on post-stroke delirium. We included patients admitted within 24 h after stroke or transient ischemic attack (TIA) in whom serum CRP was measured on admission. We examined core features of delirium during first 7 days of hospitalization. We assessed if addition of CRP to two clinical models improved metrics of discrimination and reclassification. Model A included age and stroke severity and Model B included stroke severity, atrial fibrillation, diabetes mellitus, pre-stroke dependency, and hemorrhagic stroke.

RESULTS

We included 459 patients. We diagnosed delirium in 29.2% of them. Patients who developed delirium had higher CRP level than those without delirium (median: 13.2 vs. 4.4 mg/L, p < 0.001). CRP >7.09 mg/L was associated with an increased risk of delirium (adjusted OR: 2.98, 95%CI: 1.71-5.19, p < 0.001). After adding CRP to clinical models, an area under receiver operator curve increased from 0.77 to 0.80 (p = 0.038) for Model A and from 0.81 to 0.84 (p = 0.016) for Model B. There was also improvement in reclassification.

CONCLUSIONS

Addition of CRP to clinical predictors moderately improved prediction of post-stroke delirium. CRP could be considered as a potential biomarker to stratify risk of delirium after stroke.