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Ajmera Y, Paul K, Khan MA, Kumari B, Kumar N, Chatterjee P, Dey AB, Chakrawarty A. The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'. Asian J Psychiatr 2024; 94:103990. [PMID: 38447233 DOI: 10.1016/j.ajp.2024.103990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes. AIM To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults. METHODS A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge. RESULTS The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up. CONCLUSION Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.
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Affiliation(s)
- Yamini Ajmera
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Karandeep Paul
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Bharti Kumari
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nand Kumar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Prasun Chatterjee
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Aparajit Ballav Dey
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avinash Chakrawarty
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Geetha J, Babu H, George C. Determinants of delirium in elderly in-patients in a general ward setting in a teaching hospital: A case control study. Ind Psychiatry J 2024; 33:41-47. [PMID: 38853788 PMCID: PMC11155642 DOI: 10.4103/ipj.ipj_16_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/15/2023] [Indexed: 06/11/2024] Open
Abstract
Background There is a dearth of research on risk factors of delirium among elderly inpatients in nonintensive low resource settings. Aim To determine the risk factors of delirium in elderly inpatients in a nonintensive care unit setting. Materials and Methods Sixty two elderly patients with delirium (cases) and 62 patients without delirium (controls) were administered a semi-structured proforma with socio-demographic variables and putative predisposing and precipitating risk factors and the Vellore screening instrument for dementia. Results On univariate analysis, factors such as past cognitive impairment, history of nocturnal confusion and delirium, diminished daily living activities, severe medical illness, history of psychiatric illness, presence of dementia, infection, fever above 1000F, abnormal electrolytes abnormal RFT, leukocytes in urine, hypoxia, anticholinergics and benzodiazepines, emergency admission, use of physical restraints, bladder catheterization, more than routine investigations, intensive care unit admission, surgery, and duration of hospital stay more than 10 days were found to be significantly associated with delirium. On multivariate analysis with binary logistic regression, bladder catheterization (odds ratio [OR] = 13.85; confidence interval [CI] = 1.44-133.14), abnormal electrolytes (OR = 5.12; CI = 1.11-23.69), and hypoxia (OR = 75.52; CI = 4.64-1.134E3) were detected to be independently associated with delirium. Conclusion Acute modifiable rather than long-term factors were risk factors for delirium among the elderly. An awareness of modifiable risk factors has the potential of developing targeted interventions for the early mitigation of delirium.
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Affiliation(s)
- Jitha Geetha
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
| | - Haritha Babu
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
| | - Christina George
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
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3
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The Risk Factors for Delirium in Patients with Stroke in Palliative Care. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.969181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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4
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Ibrahim MHED, Elmasry M, Nagy F, Abdelghani A. Prevalence and risk factors of delirium and subsyndromal delirium in older adults. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Delirium is a common geriatric problem associated with poor outcomes. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium yet, not satisfying the definition of full-blown delirium, defined by categorical elements, and is usually referred to as the presence of one or more symptoms in the confusion assessment method (CAM). This study aimed to investigate the prevalence and risk factors of delirium and SSD in older adults admitted to the hospital. Five hundred eighty-eight elderly (above 65 years) Egyptian patients were recruited from January 2019 to February 2020. After explaining the purpose of the study and assuring the confidentiality of all participants, an informed consent was obtained from the participant or a responsible care giver for those who were not able to give consent. All patients were subjected ‘on admission’ to thorough history taking, clinical examination, and comprehensive geriatric assessment including confusion assessment tools, mini-mental state examination, and functional assessment using Barthel index score.
Results
The current study showed that 19.6% of patients had delirium and 14.1% of patients had SSD with combined prevalence of 33.7%. Most common causes included metabolic, infection, organic brain syndrome, and dehydration. The current study reported significant proportionate relation between cognitive assessment and functional ability, so patients with a score of 23 MMSE had good functional ability, while cognitive assessment using mini-mental score shows inversed relation to delirium and SSD using CAM score.
Conclusion
Delirium is independently associated with adverse short-term and long-term outcomes, including an increase in mortality, length of hospital stay, discharge to an institution, and functional decline on discharge. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium, not yet satisfying the definition of full-blown delirium but it can identify patients with early cognitive and functional disabilities, and because of high prevalence of delirium and SSD. Efforts to prevent or early detection may identify patients who warrant clinical attention.
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Remelli F, Castellucci F, Vitali A, Mattioli I, Zurlo A, Spadaro S, Volpato S. Predictive value of geriatric-quickSOFA in hospitalized older people with sepsis. BMC Geriatr 2021; 21:241. [PMID: 33849471 PMCID: PMC8045242 DOI: 10.1186/s12877-021-02182-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND QuickSOFA, a prognostic score proposed for patients with infection, has shown a poor predictive value in the geriatric population, probably because of the inappropriateness of the Glasgow Coma Scale (GCS) in assessing acute alteration of mental status in older patients. Indeed, the GCS might result chronically low in older patient with pre-existing cognitive disorders. The aim of this study was to develop an alternative quickSOFA (geriatric-quickSOFA), using the presence of delirium, assessed according to DSM-5 criteria, instead of GCS assessment, to predict mortality in hospitalized older patients with sepsis. METHODS Retrospective observational study in Acute Geriatrics Unit of St. Anna Hospital of Ferrara (Italy). The study enrolled 165 patients hospitalized between 2017 and 2018 with diagnosis of sepsis or septic shock. Demographic, clinical data and 30-day survival were collected for each patient. Based on arterial blood pressure, respiratory rate, and the presence of delirium, geriatric-quickSOFA was calculated at admission. Primary outcome was 30-day mortality. RESULTS One hundred sixty-five patients were enrolled with a median age of 88 years; 60.6% were men. High quickSOFA score was not significantly correlated neither with in-hospital nor 30-day mortality. High geriatric-qSOFA score was significantly related to both in-hospital (13.3%vs 51.5%, p = 0.0003) and 30-day mortality (30.0%vs 84.3%, p < 0.00001). CONCLUSION Geriatric-quickSOFA is significantly associate with short-term mortality risk in older patients with sepsis. Geriatric quickSOFA seems to represent a more suitable and useful predictive tool than the traditional quickSOFA in the geriatric population.
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Affiliation(s)
- Francesca Remelli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | | | - Aurora Vitali
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Irene Mattioli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Amedeo Zurlo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Anestesiology and Resuscitation Unit, Department of Morfology, Surgery and Sperimental Medicine, University of Ferrara, Ferrara, Italy
| | - Stefano Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy. .,Orthogeriatrics Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
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Abstract
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles (
n
= 81), and these were followed by, case reports (
n
= 58), review articles (
n
= 10), letter to the editor (not as case reports but as a communication;
n
= 13), editorials (
n
= 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devakshi Dua
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Reynish E, Hapca S, Walesby R, Pusram A, Bu F, Burton JK, Cvoro V, Galloway J, Ebbesen Laidlaw H, Latimer M, McDermott S, Rutherford AC, Wilcock G, Donnan P, Guthrie B. Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.
Objective
This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.
Design
For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.
Data sources
Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.
Results
In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.
Limitations
A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.
Conclusions
Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.
Future work
Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.
Study registration
This study is registered as PROSPERO CRD42015024492.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emma Reynish
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Simona Hapca
- School of Medicine, University of Dundee, Dundee, UK
| | - Rebecca Walesby
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Angela Pusram
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Feifei Bu
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Jennifer K Burton
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Vera Cvoro
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - James Galloway
- Health Informatics Centre, University of Dundee, Dundee, UK
| | | | - Marion Latimer
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | | | - Gordon Wilcock
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
| | - Peter Donnan
- School of Medicine, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- School of Medicine, University of Dundee, Dundee, UK
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Jeong E, Park J, Chang SO. Development and Evaluation of Clinical Practice Guideline for Delirium in Long-Term Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8255. [PMID: 33182243 PMCID: PMC7664888 DOI: 10.3390/ijerph17218255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Delirium is highly prevalent and leads to several bad outcomes for older long-term care (LTC) residents. For a more successful translation of delirium knowledge, Clinical Practice Guidelines (CPGs) tailored to LTC should be developed and applied based on the understanding of the barriers to implementation. This study was conducted to develop a CPG for delirium in LTC and to determine the barriers perceived by healthcare professionals related to the implementation of the CPG. We followed a structured, evidence- and theory-based procedure during the development process. After a systematic search, quality appraisal, and selection for eligible up-to-date CPGs for delirium, the recommendations applicable to the LTC were drafted, evaluated, and confirmed by an external group of experts. To evaluate the barriers to guideline uptake from the users' perspectives, semi-structured interviews were conducted which resulted in four major themes: (1) a lack of resources, (2) a tendency to follow mindlines rather than guidelines, (3) passive attitudes, and (4) misunderstanding delirium care in LTC. To minimize adverse prognoses through prompt delirium care, the implementation of a CPG with an approach that comprehensively considers various barriers at the system, practice, healthcare professional, and patients/family levels is necessary.
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Affiliation(s)
- Eunhye Jeong
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Jinkyung Park
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Sung Ok Chang
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
- Transdisciplinary Major in Learning Health Systems, Graduate School, Korea University, Seoul 02841, Korea
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9
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Delirium After TAVR. JACC Cardiovasc Interv 2020; 13:2453-2466. [DOI: 10.1016/j.jcin.2020.07.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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He R, Wang F, Shen H, Zeng Y, LijuanZhang. Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture. BMC Psychiatry 2020; 20:496. [PMID: 33028273 PMCID: PMC7539448 DOI: 10.1186/s12888-020-02908-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/30/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Delirium is a common complication in elderly patients with total hip arthroplasty (THA) for hip fracture. The mechanism of postoperative delirium (POD) is associated with the neuroinflammatory process. The aim of this study was to the incidence and perioperative risk factors of POD and investigate whether NLR could serve as a potential marker for POD in elderly patients with THA for hip fracture. METHODS This was a multicenter prospective study, we included elderly patients with THA for hip fracture under general anesthesia. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD was analyzed by multivariable analysis. RESULTS Seven hundred eighty patients (mean age 73.33 ± 7.66) were eligible for inclusion in the study. 23.33% (182/780) of patients had POD. ROC curve analysis showed that the optimal cut point of NLR for POD was NLR ≥ 3.5. Compared with no POD, higher NLR, older age, diabetes, and higher neutrophil count were more likely in patients with POD(P < 0.05). Multivariate logistic regression analysis showed that NLR ≥ 3.50 [adjusted odds ratio(aOR), 3.93; confidence interval (CI), 2.47-6.25; P < 0.001)], older age (aOR, 1.04; 95%CI, 1.02-1.07; P = 0.001), diabetes (aOR, 1.58; 95% CI, 1.06-2.36; P = 0.025),higher neutrophil count (aOR, 1.25; 95%CI, 1.15-1.35; P < 0.001) were associated with increased risk of POD. CONCLUSIONS Older age, diabetes, higher neutrophil count, and NLR ≥ 3.5 were independent risk factors for POD, and NLR can be used as a potential marker for prediction of delirium in elderly patients with THA for hip fracture.
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Affiliation(s)
- Rui He
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - Fei Wang
- Department of Joint Surgery, The Third People’s Hospital of Chengdu, Chengdu, 610000 People’s Republic of China
| | - Huarui Shen
- Department of Joint Surgery, Affiliated Traditional Chinese Medical Hospital of Southwest Medical University of Sichuan Province, Luzhou, 646000 People’s Republic of China
| | - Yong Zeng
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - LijuanZhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610051 People’s Republic of China
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11
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Agarwal K, Thakur D, Gupta A, Gupta R. Clinical profile of acute confusional state in elderly patients in a tertiary hospital in western Rajasthan. JOURNAL OF GERIATRIC MENTAL HEALTH 2020. [DOI: 10.4103/jgmh.jgmh_36_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Grover S, Mehra A, Chakrabarti S, Avasthi A. Association of Cognitive and Noncognitive Symptoms of Delirium: A Study from Consultation-liaison Psychiatry Set-up. J Neurosci Rural Pract 2019; 7:S7-S12. [PMID: 28163496 PMCID: PMC5244065 DOI: 10.4103/0976-3147.196440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aims: This study aims to evaluate the cognitive functions of patients with delirium using Hindi Mental Status Examination (HMSE), to study the correlation of cognitive functions assessed by HMSE with noncognitive symptoms as assessed using Delirium Rating Scale-Revised 1998 (DRS-R-98) and to study the association of cognitive functions assessed using HMSE and DRS-R98. Methods: A total of 76 consecutive patients fulfilling the diagnosis of delirium were evaluated on DRS-R-98, HMSE, and Short Informant Questionnaire on Cognitive Decline in the Elderly (retrospective IQCODE). Results: The mean DRS-R-98 score 33.9 (standard deviation [SD] - 7.2) and the mean DRS-R-98 severity score was 25.9 (SD - 7.2). The mean score on HMSE was 19.3 (7.98). There were significant correlations of all the domains of HMSE with DRS-R-98 total score, DRS-R-98 severity score, DRS-R-98 cognitive subscale score, DRS-R-98 noncognitive domain subscale score, and DRS severity score without attention score. When the association of each item of DRS-R-98 and HMSE was evaluated, except for the items of delusions, lability of affect and motor retardation, there were significant negative association between all the items of DRS-R-98 and HMSE, indicating that higher severity of cognitive symptoms as assessed on HMSE is associated with higher severity of all the cognitive symptoms and most of the noncognitive symptoms as assessed by DRS-R-98. Conclusion: The present study suggests that attention deficits in patients with delirium influence the severity of cognitive and noncognitive symptoms of delirium. Further, the present study suggests an increase in the severity of cognitive symptoms in other domains is also associated with an increase in the severity of noncognitive symptoms of delirium.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aseem Mehra
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajit Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia. Geriatrics (Basel) 2019; 4:geriatrics4030052. [PMID: 31514465 PMCID: PMC6787739 DOI: 10.3390/geriatrics4030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022] Open
Abstract
The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.
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Radinovic K, Markovic Denic L, Milan Z, Cirkovic A, Baralic M, Bumbasirevic V. Impact of intraoperative blood pressure, blood pressure fluctuation, and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study. Injury 2019; 50:1558-1564. [PMID: 31279476 DOI: 10.1016/j.injury.2019.06.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 05/18/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
AIM Postoperative delirium (PD) is a frequent complication of hip fracture surgery, but its pathophysiology remains poorly understood. We investigated the impact of a single episode of intraoperative hyper/hypotension, blood pressure (BP) fluctuation (ΔMAP), and pulse pressure (PP) on hyper/hypoactive PD in elderly patients undergoing surgery for hip fracture. We also assessed the effect of PD on clinical outcomes. METHODS This was a prospective 1-year follow-up study of patients over 60 years of age with a primary diagnosis of acute low-energy hip fracture. Perioperative delirium was assessed using the Confusion Assessment Method (CAM); the development of PD and the type, hyperactive or hypoactive PD, were recorded. Cognitive assessment was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ). The lowest and highest BP values were extracted from the patients' anaesthesia charts. Postoperative complications, reinterventions and 1-month mortality were recorded. RESULTS PD occurred in 148 (53%) patients during the first postoperative week, with 75% of the cases diagnosed as hypoactive PD. Patients developing PD of any type were older, had a lower body mass index, higher SPMSQ and Charlson scores, more severe systemic diseases, a lower lowest intraoperative BP, a higher ΔMAP, a lower PP, and a higher postoperative pain score. They also took more drugs and received more blood transfusion intraoperatively. Multivariate logistic regression analyses showed that a higher MAP min had a protective effect on the occurrence of any type of PD, as well as hypoactive and hyperactive. PD had negative effect on outcomes. CONCLUSION Our results provide evidence of an association between maximal hypotension, the lowest intraoperative mean blood pressure (MAP), ΔMAP, PP, and PD. A progressive decrease in MAP during surgery was associated with the increased odds of developing either type of PD.
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Affiliation(s)
| | - Ljiljana Markovic Denic
- Institute of Epidemiology, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Andja Cirkovic
- Institute of Medical Statistics and Medical Informatics, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Baralic
- Clinic for Nephrology, Clinical Center of Serbia, Belgrade, Serbia
| | - Vesna Bumbasirevic
- Clinic of Anesthesiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Maldonado JR. Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry 2018; 33:1428-1457. [PMID: 29278283 DOI: 10.1002/gps.4823] [Citation(s) in RCA: 268] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/19/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and the medically ill and is best characterized by 5 core domains: cognitive deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation, and alteration in psychomotor functioning. DESIGN An extensive literature review and consolidation of published data into a novel interpretation of known pathophysiological causes of delirium. RESULTS Available data suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On the basis of an extensive literature search, a newly proposed theory, the systems integration failure hypothesis, was developed to bring together the most salient previously described theories, by describing the various contributions from each into a complex web of pathways-highlighting areas of intersection and commonalities and explaining how the variable contribution of these may lead to the development of various cognitive and behavioral dysfunctions characteristic of delirium. The specific cognitive and behavioral manifestations of the specific delirium picture result from a combination of neurotransmitter function and availability, variability in integration and processing of sensory information, motor responses to both external and internal cues, and the degree of breakdown in neuronal network connectivity, hence the term acute brain failure. CONCLUSIONS The systems integration failure hypothesis attempts to explain how the various proposed delirium pathophysiologic theories interact with each other, causing various clinically observed delirium phenotypes. A better understanding of the underlying pathophysiology of delirium may eventually assist in designing better prevention and management approaches.
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Gotur DB. Delirium in the Critically Ill. JOURNAL OF MEDICAL SCIENCES AND HEALTH 2018. [DOI: 10.46347/jmsh.2018.v04i01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Nguyen PVQ, Malachane A, Minh TTV. Antipsychotic prescription patterns in the management of delirium symptoms in hospitalized elderly patients. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817697733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: The objective of this study was to study the pharmacological management of delirium in elderly hospitalized patients in acute geriatric medical wards. Method: We conducted a one-year retrospective cross-sectional study in patients 65 years of age or older who were admitted to an acute geriatric unit care at a teaching hospital with a delirium diagnosis. Results: A total of 133 subjects were included in the study. Delirium was prevalent in 78% of patients. The average length of delirium was 13 days. Antipsychotics were prescribed to 74% of patients with delirium. Patients with hyperactive, mixed and hypoactive delirium received antipsychotics regularly in a proportion of 68%, 54%, and 34% respectively. The length of antipsychotic prescription was of 11 days. Risperidone was the most commonly prescribed agent given on a regular basis while haloperidol was chosen for the as required prescriptions. Fifty-five percent of demented patients received a daily prescription of antipsychotics compared to 46% in the non-demented population. A shorter length of delirium episodes in subjects with acetylcholinesterase inhibitors was also observed. A higher mortality rate was observed in the group of subjects receiving benzodiazepine during the delirium episode. Conclusion: This study shows that antipsychotic treatment is widely, but not systematically prescribed in demented and non-demented patients in all types of delirium including hypoactive. Efforts should be made to increase appropriate antipsychotic prescription in this vulnerable population.
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Affiliation(s)
- Patrick Viet-Quoc Nguyen
- Centre de recherche du CHUM, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Alice Malachane
- Institut des Sciences Pharmaceutiques et Biologiques, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Thien Tuong Vu Minh
- Centre de recherche du CHUM, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
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Kukreja D, Günther U, Popp J. Delirium in the elderly: Current problems with increasing geriatric age. Indian J Med Res 2016; 142:655-62. [PMID: 26831414 PMCID: PMC4774062 DOI: 10.4103/0971-5916.174546] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Delirium is an acute disorder of attention and cognition seen relatively commonly in people aged 65 yr or older. The prevalence is estimated to be between 11 and 42 per cent for elderly patients on medical wards. The prevalence is also high in nursing homes and long term care (LTC) facilities. The consequences of delirium could be significant such as an increase in mortality in the hospital, long-term cognitive decline, loss of autonomy and increased risk to be institutionalized. Despite being a common condition, it remains under-recognised, poorly understood and not adequately managed. Advanced age and dementia are the most important risk factors. Pain, dehydration, infections, stroke and metabolic disturbances, and surgery are the most common triggering factors. Delirium is preventable in a large proportion of cases and therefore, it is also important from a public health perspective for interventions to reduce further complications and the substantial costs associated with these. Since the aetiology is, in most cases, multfactorial, it is important to consider a multi-component approach to management, both pharmacological and non-pharmacological. Detection and treatment of triggering causes must have high priority in case of delirium. The aim of this review is to highlight the importance of delirium in the elderly population, given the increasing numbers of ageing people as well as increasing geriatric age.
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Affiliation(s)
| | | | - Julius Popp
- Department of Psychiatry, Service of Old Age Psychiatry, University Hospital of Lausanne, Switzerland. Site de Cery. 1008 ; Department of Clinical Neurosciences, Leenaards Memory Center, University Hospital of Lausanne, Lausanne, Switzerland. Ch. de Mont-Paisible 16, CH-1011 Lausanne, Switzerland
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Sehgal V, Bajwa SJS, Consalvo JA, Bajaj A. Clinical conundrums in management of sepsis in the elderly. J Transl Int Med 2015; 3:106-112. [PMID: 27847897 PMCID: PMC4936459 DOI: 10.1515/jtim-2015-0010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.
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Affiliation(s)
- Vishal Sehgal
- Department of Internal Medicine, The Common Wealth Medical College, Scranton, PA 18510, USA
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care Medicine, Gian Sagar Medical College, Banur, Patiala, Punjab, India
| | - John A Consalvo
- Chairman Emergency Medicine, Regional hospital of Scranton, PA, USA
| | - Anurag Bajaj
- Department of Internal Medicine, WCGME, SCRANTON, PA, USA
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Recent Insights on Prevalence and Corelations of Hypoactive Delirium. Behav Neurol 2015; 2015:416792. [PMID: 26347584 PMCID: PMC4546955 DOI: 10.1155/2015/416792] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/27/2015] [Accepted: 07/05/2015] [Indexed: 01/21/2023] Open
Abstract
Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.
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Varghese NC, Macaden L, Premkumar B, Mathews P, Kumar S. Delirium in older people in hospital: an education programme. ACTA ACUST UNITED AC 2014; 23:704-9. [DOI: 10.12968/bjon.2014.23.13.704] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nibi C Varghese
- Tutor, St. Theresa of Child Jesus School of Nursing, Chennai, South India
| | - Leah Macaden
- Lecturer in Older Person's Care, School of Nursing, Midwifery & Health, University of Stirling, Scotland
| | | | | | - Saravanan Kumar
- Research Fellow, Department of Biostatistics; Christian Medical College, Vellore, South India
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Dal-Pizzol F, Tomasi CD, Ritter C. Septic encephalopathy: does inflammation drive the brain crazy? REVISTA BRASILEIRA DE PSIQUIATRIA 2014; 36:251-8. [DOI: 10.1590/1516-4446-2013-1233] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/11/2013] [Indexed: 11/21/2022]
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Sabzwari S, Kumar D, Bhanji S, Sheerani M, Azhar G. Proportion, Predictors and Outcomes of Delirium at a Tertiary care Hospital in Karachi, Pakistan. AGEING INTERNATIONAL 2014. [DOI: 10.1007/s12126-012-9152-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry 2013; 21:1190-222. [PMID: 24206937 DOI: 10.1016/j.jagp.2013.09.005] [Citation(s) in RCA: 402] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/10/2013] [Accepted: 09/13/2013] [Indexed: 12/20/2022]
Abstract
Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.
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Affiliation(s)
- José R Maldonado
- Departments of Psychiatry, Internal Medicine & Surgery and the Psychosomatic Medicine Service, Stanford University School of Medicine, and Board of Directors, American Delirium Society, Stanford, CA.
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Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India. Gen Hosp Psychiatry 2012; 34:639-46. [PMID: 22819154 DOI: 10.1016/j.genhosppsych.2012.06.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate the incidence, prevalence, risk factors and outcome of delirium in the respiratory intensive care unit of a tertiary care hospital. METHODS Consecutive patients admitted to an eight-bed respiratory intensive care unit were screened for presence of delirium by a psychiatrist. Patients found to have delirium were evaluated using univariate techniques for their clinical profiles, risk factors for delirium, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, duration of stay (in days) and outcome at discharge from intensive care unit besides evaluation on Delirium Rating Scale-Revised 98 version (DRS-R-98). RESULTS Incidence and prevalence rate of delirium were 24.4% and 53.6% respectively. Univariate analyses revealed that the prevalence of delirium was higher (64%) in mechanically ventilated patients. The predisposing risk factors identified for delirium in univariate analysis were higher age; higher Glasgow Coma Scale score; increased APACHE II score; hyperuricemia; hypoalbuminemia; presence of acidosis; abnormal alkaline transferase levels; use of mechanical ventilation; higher number of total medication received and use of sedative, steroids and insulin. Univariate analysis showed that patients who were diagnosed with delirium had significantly longer duration of intensive care unit (ICU) stay and higher mortality rates. Age, multiple organ failure, hypoactive delirium and higher DRS-R-98 scores were significant risk factors for mortality in patients with delirium. CONCLUSIONS Delirium is highly prevalent in the ICU setting and delirium is associated with longer ICU stay and higher mortality.
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Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, Anderson EL. Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. West J Emerg Med 2012; 13:3-10. [PMID: 22461915 PMCID: PMC3298208 DOI: 10.5811/westjem.2011.9.6863] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/15/2011] [Accepted: 09/29/2011] [Indexed: 11/11/2022] Open
Abstract
Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.
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Affiliation(s)
- Kimberly Nordstrom
- Denver Health Medical Center, University of Colorado Denver, Department of Psychiatry, Denver, Colorado
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Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol 2012; 3:101. [PMID: 22723791 PMCID: PMC3377955 DOI: 10.3389/fneur.2012.00101] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/01/2012] [Indexed: 01/12/2023] Open
Abstract
The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.
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Affiliation(s)
- Sónia Martins
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
| | - Lia Fernandes
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
- Clinical Neuroscience and Mental Health Department, Faculty of Medicine, University of PortoPorto, Portugal
- Psychiatry Service, S. João HospitalPorto, Portugal
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Kierner KA, Jagsch C, Watzke HH. Reversible delirium in an advanced cancer patient. Wien Med Wochenschr 2012; 162:8-10. [PMID: 22328048 DOI: 10.1007/s10354-011-0048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
Abstract
Delirium is still one of the most common and distressing symptoms in palliative care patients. Causes and pathophysiology of this neuropsychiatric dysfunction are multifactorial. Recent studies indicate that the interaction of special triggers facilitates development of delirium. Some of them are reversible. This case report presents a reversible delirium in an advanced cancer patient and offers a list of possible delirogen medications. This list might be useful to prevent delirium, particularly in older people.
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Affiliation(s)
- Katharina A Kierner
- Unit of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.
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