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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Tandon D, Curlewis K, Vusirikala A, Subramanian P, Patel A. The impact of electronic pathways and digital systems on neck of femur fracture outcomes globally: a systematic review. Ann R Coll Surg Engl 2023; 105:685-691. [PMID: 36927067 PMCID: PMC10618033 DOI: 10.1308/rcsann.2022.0152] [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: 03/18/2023] Open
Abstract
INTRODUCTION Electronic pathways (e-pathways) and digital systems are novel interventions with several uses in healthcare, ranging from clinical decision support systems to checklists for care delivery. Their application in the management of neck of femur (NOF) fractures is evolving and they may play a key role in facilitating improvements in care delivery. The primary aim of this review was to outline the impact of e-pathways/digital systems on NOF fracture outcomes. METHODS A systematic literature search was performed using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A total of 698 citations were evaluated, of which 38 passed the inclusion/exclusion criteria. Six studies were then finalised following full-text review. Heterogenous data meant a narrative synthesis was undertaken. Risk of bias for each paper was assessed using the Downs and Black scale. RESULTS A statistically significant improvement was demonstrated for time to theatre (3/6 studies), length of hospital stay (2/6 studies) and secondary fracture prevention (2/6 studies). Although postoperative delirium and mortality improved with the introduction of e-pathways/digital systems, statistical significance was not achieved. No outcome measures were adversely affected. CONCLUSIONS This systematic review of the literature demonstrates that e-pathways and digital systems are promising novel interventions, displaying a significant positive impact on several NOF fracture outcomes. Owing to the novel nature of e-pathways and digital systems in orthopaedics, a limited number of studies were identified for review, each with variable study design. More high quality homogenous prospective cohort studies with a standardised primary outcome measure are required for more definitive conclusions of efficacy to be drawn.
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Affiliation(s)
| | - K Curlewis
- Royal Free London NHS Foundation Trust, UK
| | - A Vusirikala
- Royal National Orthopaedic Hospital NHS Trust, UK
| | | | - A Patel
- University College London, UK
- Royal Free London NHS Foundation Trust, UK
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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Ackermann LL, Schwenk ES, Li CJ, Vaile JR, Weitz H. The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture. Hosp Pract (1995) 2023; 51:233-239. [PMID: 37927222 DOI: 10.1080/21548331.2023.2274307] [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: 03/15/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. METHODS An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. RESULTS Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). CONCLUSIONS A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.
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Affiliation(s)
- Lily L Ackermann
- Department of Medicine, Division of Hospital Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chris J Li
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John R Vaile
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Weitz
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Mundu M, Besra RC, Mardi N, Singh SK, Pallavi P, Bakhla AK. The Association of Preoperative Trail Making Tests With Postoperative Delirium. Cureus 2023; 15:e44171. [PMID: 37753023 PMCID: PMC10519443 DOI: 10.7759/cureus.44171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 09/28/2023] Open
Abstract
Aims The aim of the present study was to investigate the preoperative Trail Making Test (TMT) and its association with postoperative delirium. Materials and methods This cross-sectional, observational study consisted of 51 patients admitted to the surgical ward for any planned operative procedure. Consenting patients provided their sociodemographic information, and the Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) test, and Trail Making Test (TMT) were applied. Results A total of 51 patients (66.7% male and 33.3% female) were categorized as the "normal" group (n=34), completing TMT in time, and the "slow" group (n=17). The mean age was 45.05 ± 13.69 for the normal group and 44.29 ± 10.95 for the slow group. The HADS score mean was 15.02 ± 9.52 and 11.64 ± 5.73, respectively, for these two groups (t = -1.577; degrees of freedom {df} = 47.11; p = 0.121). However, the "normal" group scored significantly higher MoCA scores in comparison to the slow group (26.35 ± 1.06 and 24.29 ± 1.10, respectively) (t = -6.410; df = 49; p = 0.000). Conclusions The study shows that the TMT can indicate effectively the cognitive decline in preoperative patients, which predicts postoperative delirium.
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Affiliation(s)
| | - Ram Chandra Besra
- General Surgery, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Niranjan Mardi
- General Surgery, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Saurav K Singh
- Surgery, Sheikh Bhikhari Medical College, Hazaribagh, IND
| | - Puja Pallavi
- Psychiatry, Narayan Medical College and Hospital, Rohtas, IND
| | - Ajay K Bakhla
- Psychiatry, Rajendra Institute of Medical Sciences, Ranchi, IND
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Igwe EO, Nealon J, O'Shaughnessy P, Bowden A, Chang HCR, Ho MH, Montayre J, Montgomery A, Rolls K, Chou KR, Chen KH, Traynor V, Smerdely P. Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis. Worldviews Evid Based Nurs 2023. [PMID: 37128953 DOI: 10.1111/wvn.12649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.
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Affiliation(s)
- Ezinne Oyidia Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Jessica Nealon
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- School of Mathematics and Applied Statistics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Alera Bowden
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Hui-Chen Rita Chang
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Mu-Hsing Ho
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jed Montayre
- School of Nursing, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Kaye Rolls
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Peter Smerdely
- School of Population Health, UNSW Medicine, Sydney, New South Wales, Australia
- St George Hospital, Kogarah, New South Wales, Australia
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Li S, Jiang H, Liu W, Yin Y, Yin C, Chen H, Du Y, Zhao Q, Zhang Y, Li C. Transcutaneous electrical acupoint stimulation for the prevention of perioperative neurocognitive disorders in geriatric patients: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e32329. [PMID: 36550918 PMCID: PMC9771360 DOI: 10.1097/md.0000000000032329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To evaluate whether transcutaneous electrical acupoint stimulation (TEAS) decreases rates of perioperative neurocognitive disorders (PND) when used as an adjuvant method during perioperative period in geriatric patients since the new definition was released in 2018. METHODS Six databases [Chinese National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, WanFang Database, PubMed, EMBASE, and Cochrane Library] were systematically searched. Data analysis was performed using RevMan 5.4.1 software (Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2020). Risk ratios (RR) with 95% confidence interval were calculated using a random effects model. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS 13 randomized clinical trials (999 patients) in total were included. TEAS had positive effects on preventing the incidence of PND (RR: 0.43; 0.31, 0.61; P < .001; low certainty) [postoperative delirium within 7 days (RR: 0.39; 0.26, 0.59; P < .001), delayed neurocognitive recovery within 3 months (RR: 0.51; 0.33, 0.78; P = .002)]. TEAS could also improve the scores of the confusion assessment method (CAM) (Mean difference: -1.30; -2.14, -0.46; P = .003; low certainty). Limited evidence suggested that TEAS could reduce the serum levels of biochemical indicator (S100β) (SMD = -1.08, -1.67, -0.49, P < .001; I2 = 83%; very low certainty) as well as anesthetic requirements (remifentanil) (SMD: -1.58; -2.54, -0.63; P = .001; I2 = 87%; very low certainty). Subgroup analysis indicated that different protocols of TEAS had significant pooled benefits (TEAS used only in surgery and in combination with postoperative intervention) (RR: 0.45; 0.31, 0.63; P < .001). Acupoint combination (LI4 and PC6) in the TEAS group had more significantly advantages (RR: 0.34; 0.17, 0.67; P = .002). TEAS group had a lower incidence of PND in different surgery type (orthopedic surgery and abdominal surgery) (RR: 0.43; 0.30, 0.60; P < .001), as well as with different anesthetic modality (intravenous anesthesia and intravenous and inhalational combined anesthesia) (RR: 0.38; 0.23, 0.61; P < .001). CONCLUSION In terms of clinical effectiveness, TEAS appeared to be beneficial for prophylaxis of PND during a relatively recent period, noting the limitations of the current evidence.
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Affiliation(s)
- Shuying Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Hailun Jiang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Wei Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Yu Yin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Chunsheng Yin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Hao Chen
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Yuzheng Du
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- * Correspondence: Yuzheng Du, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China (e-mail: )
| | - Qi Zhao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Yi Zhang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Chen Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
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Ding Y, Yu J, Cui F, Li J. Comparison of Intravenous and Inhalational Anesthetic on Postoperative Cognitive Outcomes in Elderly Patients Undergoing Cancer Surgery: Systematic Review and Meta-analysis. J Perianesth Nurs 2022; 37:683-690. [PMID: 35618615 DOI: 10.1016/j.jopan.2021.11.017] [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: 09/15/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Previous studies have documented consistent findings on the long-term cognitive effects such as postoperative cognitive dysfunction (POCD), delirium and delayed recovery among elderly undergoing cancer surgery. This review was conducted to compare the effect of intravenous and inhalational anesthetic on the postoperative cognitive outcomes among elderly patients undergoing cancer surgery. DESIGN Systematic review and meta-analysis METHODS: We searched Medline, EMBASE, PubMed Central, ScienceDirect, Google Scholar, and Cochrane library from inception until May 2021. We carried out a meta-analysis with a random-effects model and reported pooled risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) depending on the type of outcome. FINDINGS In total, we analyzed 10 studies including 2,333 participants. Half of the studies had high risk of bias. For the cognitive score, the pooled SMD was -0.87 [95% CI: -3.97 to 2.24] indicating no statistically significant difference between inhalational and intravenous anesthetic. For POCD, the pooled RR was 1.24 (95% CI: 0.83-1.84); for postoperative delirium, the pooled RR was 2.26 (95% CI: 0.79-6.44); for delayed neurocognitive recovery, the pooled RR was 1.49 (95% CI: 1.09-2.03). CONCLUSION Inhalational anesthetics did not show a significant difference in postoperative cognitive outcomes, except delayed neurocognitive recovery, compared to intravenous anesthetic following cancer surgery.
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Affiliation(s)
- Yongbo Ding
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Jianhong Yu
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Fenghe Cui
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China.
| | - Jie Li
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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Wiegand TLT, Rémi J, Dimitriadis K. Electroencephalography in delirium assessment: a scoping review. BMC Neurol 2022; 22:86. [PMID: 35277128 PMCID: PMC8915483 DOI: 10.1186/s12883-022-02557-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Background Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments. Methods We therefore conducted a scoping review on EEG findings in delirium. One thousand two hundred thirty-six articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis. Results EEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive. Conclusion Future studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02557-w.
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Wang T, Guo J, Hou Z, Zhang Y. Risk Factors of Postoperative Delirium in Elderly Patients With Intertrochanteric Fracture: An Age-Stratified Retrospective Analysis of 2307 Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221081779. [PMID: 35237460 PMCID: PMC8883295 DOI: 10.1177/21514593221081779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a serious and common complication of intertrochanteric fracture (IF). However, the risk factors for POD remain debated. The purpose of this study was to explore risk factors for POD after IF surgery in elderly patients by age-stratified analysis. METHODS A total of 2307 patients who underwent IF surgery in our hospital between Jan. 2017 and Nov. 2020 were included. 128 patients suffering from POD were regarded as the delirium group (DG) and the other patients as the normal group (NG). Univariate and multivariate analyses were conducted. RESULTS In our study, the occurrence of POD after IF surgery in elderly patients was 5.55% (128 of 2307). The results of univariate and multivariate analysis showed that advanced age and patients with a history of dementia were identified as the risk factors for POD. Age-stratified analysis showed different comorbidities influencing POD at different stages of age. Additionally, POD markedly increased along with age. Moreover, compared with younger than 70 years in male patients and younger than 80 years in female patients, patients over the age of 70 for males and over the age of 80 for females had a higher rate of POD. CONCLUSIONS Advanced age and patients with a history of dementia were independent risks of delirium after IF surgery in both univariate and multivariate analyses. 70 years old in male patients and 80 years old in female patients may be the cut-off values for a significantly increased rate of POD. Preoperative measures should be taken to lower the incidence of POD. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Tao Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Orthopaedic Research Institute of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment ,The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China.,Orthopaedic Research Institute of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopaedic Equipment ,The Third Hospital of Hebei Medical University, Shijiazhuang, China
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11
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Association of preoperative frailty with postoperative delirium in elderly orthopedic trauma patients. Aging Clin Exp Res 2022; 34:625-631. [PMID: 34417994 DOI: 10.1007/s40520-021-01961-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/09/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients. AIM Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients. METHODS We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders. RESULTS Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02-1.72, p = 0.03). CONCLUSIONS Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.
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12
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The Risk of Preoperative Central Nervous System-Acting Medications on Delirium Following Hip or Knee Surgery: A Matched Case-Control Study. Drug Saf 2021; 45:75-82. [PMID: 34748199 DOI: 10.1007/s40264-021-01136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear. OBJECTIVES We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery. METHODS A matched case-control study was conducted using data from the Australian Government Department of Veterans' Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls. RESULTS A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24-2.64), sertraline (OR = 1.50, 95% CI 1.20-1.87), mirtazapine (OR = 1.38, 95% CI 1.11-1.74), venlafaxine (OR = 1.42, 95% CI 1.02-1.98), citalopram (OR = 1.54, 95% CI 1.19-1.99), escitalopram (OR = 1.42, 95% CI 1.06-1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15-11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05-1.37) and antidepressants (OR = 1.64, 95% CI 1.47-1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances. CONCLUSIONS People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium.
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13
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Han QYC, Rodrigues NG, Klainin-Yobas P, Haugan G, Wu X. Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2021; 23:23-32.e27. [PMID: 34648761 DOI: 10.1016/j.jamda.2021.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults. METHODS Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I2 statistics were used to assess heterogeneity, which was investigated using subgroup analyses. RESULTS A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia. CONCLUSIONS AND IMPLICATIONS These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.
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Affiliation(s)
- Qin Yun Claudia Han
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Natalie Grace Rodrigues
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gørill Haugan
- Department of Public Health and Nursing, Centre for Health Promoting Research, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - XiVivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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14
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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15
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Abstract
Despite substantial advances in anesthesia safety within the past decades, perioperative mortality remains a prevalent problem and can be considered among the top causes of death worldwide. Acute organ failure is a major risk factor of morbidity and mortality in surgical patients and develops primarily as a consequence of a dysregulated inflammatory response and insufficient tissue perfusion. Neurological dysfunction, myocardial ischemia, acute kidney injury, respiratory failure, intestinal dysfunction, and hepatic impairment are among the most serious complications impacting patient outcome and recovery. Pre-, intra-, and postoperative arrangements, such as enhanced recovery after surgery programs, can contribute to lowering the occurrence of organ dysfunction, and mortality rates have improved with the advent of specialized intensive care units and advances in procedures relating to extracorporeal organ support. However, no specific pharmacological therapies have proven effective in the prevention or reversal of perioperative organ injury. Therefore, understanding the underlying mechanisms of organ dysfunction is essential to identify novel treatment strategies to improve perioperative care and outcomes for surgical patients. This review focuses on recent knowledge of pathophysiological and molecular pathways leading to perioperative organ injury. Additionally, we highlight potential therapeutic targets relevant to the network of events that occur in clinical settings with organ failure.
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Affiliation(s)
- Catharina Conrad
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas.,Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Holger K Eltzschig
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
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16
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Tasbihgou SR, Absalom AR. Postoperative neurocognitive disorders. Korean J Anesthesiol 2020; 74:15-22. [PMID: 32623846 PMCID: PMC7862941 DOI: 10.4097/kja.20294] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022] Open
Abstract
A decline in cognitive function is a frequent complication of major surgery. Postoperative cognitive impairments have generally been divided into short- (postoperative delirium) and long-term disturbances (postoperative cognitive dysfunction [POCD]). Long-term impairments are often subtle and overlooked. They need to be objectively assessed using neuropsychological tests to be diagnosed. Although POCD has been the subject of considerable research over the past decades, it remains uncertain why some patients do not return to preoperative levels of cognitive function. Surgery and anesthesia have both been implicated to play a role in POCD development, and certain patient-related factors, such as advanced age and low preoperative baseline cognitive function, have consistently been found to predict postoperative cognitive decline. This article will present an overview of POCD and its etiology and provide advice on possible strategies on its prevention.
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Affiliation(s)
- Setayesh Reza Tasbihgou
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony Ray Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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Hasan TF, Kelley RE, Cornett EM, Urman RD, Kaye AD. Cognitive impairment assessment and interventions to optimize surgical patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:225-253. [PMID: 32711831 DOI: 10.1016/j.bpa.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/20/2020] [Indexed: 12/22/2022]
Abstract
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Roger E Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, Massachussetts, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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18
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Abstract
As the silver tsunami hits the world, older patients with hip fractures are expected to increase to 6.3 million by the year 2050, of which the majority will occur in Asia. The estimated global cost of hip fractures in the year 2050 is estimated to reach U.S. $130 billion. Hence, in addition to implementation of prevention strategies, it is important to develop an optimal model of care for older patients with hip fracture to minimize the huge medical and socioeconomic burden, especially in rapidly aging nations. This review summarizes the complications of hip fractures, importance of comprehensive geriatric assessment, and multidisciplinary rehabilitation, as well as predictors of rehabilitation outcome in older patients with hip fracture.
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19
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Austin CA, O'Gorman T, Stern E, Emmett D, Stürmer T, Carson S, Busby-Whitehead J. Association Between Postoperative Delirium and Long-term Cognitive Function After Major Nonemergent Surgery. JAMA Surg 2020; 154:328-334. [PMID: 30649138 DOI: 10.1001/jamasurg.2018.5093] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Postoperative delirium is associated with decreases in long-term cognitive function in elderly populations. Objective To determine whether postoperative delirium is associated with decreased long-term cognition in a younger, more heterogeneous population. Design, Setting, and Participants A prospective cohort study was conducted at a single academic medical center (≥800 beds) in the southeastern United States from September 5, 2017, through January 15, 2018. A total of 191 patients aged 18 years or older who were English-speaking and were anticipated to require at least 1 night of hospital admission after a scheduled major nonemergent surgery were included. Prisoners, individuals without baseline cognitive assessments, and those who could not provide informed consent were excluded. Ninety-day follow-up assessments were performed on 135 patients (70.7%). Exposures The primary exposure was postoperative delirium defined as any instance of delirium occurring 24 to 72 hours after an operation. Delirium was diagnosed by the research team using the Confusion Assessment Method (CAM). Main Outcomes and Measures The primary outcome was change in cognition at 90 days after surgery compared with baseline, preoperative cognition. Cognition was measured using a telephone version of the Montreal Cognitive Assessment (T-MoCA) with cognitive impairment defined as a score less than 18 on a scale of 0 to 22. Results Of the 191 patients included in the study, 110 (57.6%) were women; the mean (SD) age was 56.8 (16.7) years. For the primary outcome of interest, patients with and without delirium had a small increase in T-MoCA scores at 90 days compared with baseline on unadjusted analysis (with delirium, 0.69; 95% CI, -0.34 to 1.73 vs without delirium, 0.67; 95% CI, 0.17-1.16). The initial multivariate linear regression model included age, preoperative American Society of Anesthesiologists Physical Status Classification System score, preoperative cognitive impairment, and duration of anesthesia. Preoperative cognitive impairment proved to be the only notable confounder: when adjusted for preoperative cognitive impairment, patients with delirium had a 0.70-point greater decrease in 90-day T-MoCA scores than those without delirium compared with their respective baseline scores (with delirium, 0.16; 95% CI, -0.63 to 0.94 vs without delirium, 0.86; 95% CI, 0.40-1.33). Conclusions and Relevance Although a statistically significant association between 90-day cognition and postoperative delirium was not noted, patients with preoperative cognitive impairment appeared to have improvements in cognition 90 days after surgery; however, this finding was attenuated if they became delirious. Preoperative cognitive impairment alone should not preclude patients from undergoing indicated surgical procedures.
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Affiliation(s)
- C Adrian Austin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Thomas O'Gorman
- Medical student, University of North Carolina School of Medicine, Chapel Hill
| | - Elizabeth Stern
- Division of Hospitalist Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Douglas Emmett
- Division of Neuromuscular Diseases, Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill
| | - Shannon Carson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Jan Busby-Whitehead
- Center for Aging and Health, Division of Geriatric Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
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20
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Effect of Perioperative Low-Dose Dexmedetomidine on Postoperative Delirium After Living-Donor Liver Transplantation: A Randomized Controlled Trial. Transplant Proc 2020; 52:239-245. [DOI: 10.1016/j.transproceed.2019.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/26/2019] [Accepted: 11/10/2019] [Indexed: 12/13/2022]
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21
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Effectiveness of local anesthetic injection in geriatric patients following operative management of proximal and diaphyseal femur fracture. Injury 2019; 50:2055-2059. [PMID: 31564373 DOI: 10.1016/j.injury.2019.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/17/2019] [Accepted: 09/08/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Geriatric fracture patients are at risk for poorly controlled pain and side effects of opioid medications. The arthroplasty literature has demonstrated that infiltration of long-acting local anesthetic or anesthetic cocktails improves pain control and reduces post-operative opioid use resulting in better postoperative mobility without the deleterious effects of narcotics. Despite having a higher risk for adverse events, there is limited data among geriatric trauma patients. The aim this study was to evaluate whether local anesthetic infiltration (LAI) into the soft tissues surrounding the surgical field reduces narcotic use or pain scores in patients undergoing surgical management of proximal and diaphyseal femur fractures. MATERIALS AND METHODS A retrospective review was performed of patients age >65 undergoing operative intervention for proximal and diaphyseal femur fracture. The electronic record was utilized to determine if local anesthetic was injected into the surgical wound, the amount of narcotics administered over 48 h in four-hour intervals, and to obtain visual analog scale (VAS) pain scores associated with patients post-operative course in four-hour intervals. The amount of narcotics was converted to morphine milligram equivalents (MME). RESULTS Among 477 patients with femur fracture, 358 did not receive LAI and 119 patients received LAI. Baseline demographics, fracture types, and surgical procedure were equivalent between the groups. In the first 28 h following surgery, compared with those who did not receive LAI, those who did required significantly less opioid (57.8 MME versus 94.3 MME, p = 0.034) and despite decreased narcotics, had equal pain scores (mean difference 0.37, p = 0.22). There was no difference in rates of post-operative complications. CONCLUSION LAI is associated with a reduction in opioid consumption in geriatric fracture patients with equivalent pain scores. Optimizing pain control is a critical issue in caring for geriatric fracture patients since both under-treated pain and opioid medications are implicated in postoperative delirium, complications, and ability to mobilize early. More research is needed to identify effective ways to optimize pain management in this at-risk patient population.
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Agrawal S, Turk R, Burton BN, Ingrande J, Gabriel RA. The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly. J Clin Anesth 2019; 60:28-33. [PMID: 31437598 DOI: 10.1016/j.jclinane.2019.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/26/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly. DESIGN Retrospective cohort study. SETTING Postoperative recovery. PATIENTS 8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class. INTERVENTIONS We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate. MEASUREMENTS Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality. MAIN RESULTS After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without. CONCLUSIONS After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.
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Affiliation(s)
- Shubham Agrawal
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Robby Turk
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Brittany N Burton
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jerry Ingrande
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, San Diego, CA, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA.
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23
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Choi EJ, Choi YJ, Lee SW, Choi YM, Ri HS, Park JY, Park SJ, Son JM, Lee YS. Effect of anesthetic method on incidence of delirium after total hip replacement arthroplasty in South Korea: a population-based study using National Health Insurance claims data. Korean J Anesthesiol 2019; 73:36-43. [PMID: 31378056 PMCID: PMC7000278 DOI: 10.4097/kja.19091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/22/2019] [Indexed: 11/11/2022] Open
Abstract
Background There are various reports on the effects of the anesthetic method on neurologic complications. A population-based study was conducted to estimate the effect of anesthetic method on the incidence of postoperative delirium in patients that underwent total hip replacement arthroplasty in South Korea. Methods The Korean National Health Insurance claims database was used to retrospectively identify and analyze 24,379 cases of total hip replacement arthroplasty, defined as patients having a claim record with the operation code ‘N0711,’ from January 2008 to December 2017. Patients were divided into two groups, a general anesthesia group (n = 9,921) and a regional anesthesia group (n = 14,458). The incidence of delirium was assessed in cases when patients used medications for delirium, such as haloperidol, chlorpromazine, olanzapine, and risperidone. Results Of the 9,921 patients receiving general anesthesia and 14,458 receiving regional anesthesia, 142 (1.43%) and 209 (0.86%) experienced postoperative delirium after total hip replacement arthroplasty, respectively. There was no significant difference between the groups (P = 0.92). In logistic regression analysis, sex (P = 0.038) and patients with acquired immune deficiency syndrome (P = 0.008) were predictors of postoperative delirium. Conclusions Our results revealed that the anesthetic method was not associated with the incidence of postoperative delirium. In addition, the results suggest that male patients and patients with acquired immune deficiency syndrome undergoing total hip replacement arthroplasty carefully managed for postoperative delirium after surgery.
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Affiliation(s)
- Eun-Ji Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Sang Won Lee
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Yun-Mi Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun-Su Ri
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ju Yeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ji Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung-Min Son
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yoon Sook Lee
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
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Chou MY, Wang YC, Peng LN, Liang CK, Chu CS, Liao MC, Lin YT, Hsu CJ, Chen LK. Intraoperative blood transfusion predicts postoperative delirium among older patients undergoing elective orthopedic surgery: A prospective cohort study. Int J Geriatr Psychiatry 2019; 34:881-888. [PMID: 30761615 DOI: 10.1002/gps.5086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 02/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery. METHODS This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis. RESULTS Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates. CONCLUSIONS Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.
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Affiliation(s)
- Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Chia Nan University of Pharmacy and Science
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Li-Ning Peng
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Mei-Chen Liao
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Jen Hsu
- Department of Orthopedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Department of Geriatric Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan.,Chia Nan University of Pharmacy and Science
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"Just another piece of paperwork": perceptions of clinicians on delirium screening following hip fracture repair elicited in focus groups. Int Psychogeriatr 2019; 31:877-884. [PMID: 30318020 DOI: 10.1017/s1041610218001369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:Delirium is a complex clinical syndrome characterized by disturbed consciousness, cognitive function, or perception and associated with serious adverse outcomes such as death, dementia, and the need for long-term care. However, recognition and management of delirium is poorly prioritized even though it is the most frequent complication among patients undergoing surgery following hip fracture. The aim of this study was to understand clinicians' from orthopedic speciality perceptions in relation to recognition, diagnosis, and management of delirium. METHODS This was a qualitative study using in-depth focus groups discussions with clinical staff of one orthopedic unit within a level 1 trauma center, south of Adelaide, South Australia. RESULTS A total number of 17 individuals (14 nurses, 1 geriatric registrar, 1 nursing manager, and 1 speech therapist) participated in the focus groups. Four major themes were identified: (1) Delirium is important but can be hard to recognize and validate; (2) ambiguity on the use of delirium screening tool; (3) need of designated delirium care pathway; and (4) vital role of the family. Despite the initial lack of agreement on use of the objective tool to screen delirium, nurses did propose a number of ways that formal delirium screening could be included in routine nursing duties and existing nursing documentation. CONCLUSION Although orthopedic nurses aim to provide effective care to patients experiencing delirium symptoms following hip fracture, they are doing so in the absence of structured screening, assessment, and multidisciplinary team approach. This study emphasizes the various barriers which need to be considered before attempting to change practice in this important area.
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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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Abstract
Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 311 Oxford House, Nashville, TN 37232, USA.
| | - Joe Suyama
- Department of Emergency Medicine, Magee-Womens Hospital of UPMC, University of Pittsburgh School of Medicine, 3600 Forbes Tower, Pittsburgh, PA 15213, USA
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Kin K, Yasuhara T, Tomita Y, Umakoshi M, Morimoto J, Date I. SF-36 scores predict postoperative delirium after surgery for cervical spondylotic myelopathy. J Neurosurg Spine 2019; 30:777-782. [PMID: 30835706 DOI: 10.3171/2018.11.spine181031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord dysfunction. Surgery for CSM is generally effective, but postoperative delirium is a potential complication. Although there have been some studies that investigated postoperative delirium after spine surgery, no useful tool for identifying high-risk patients has been established, and it is unknown if 36-Item Short Form Health Survey (SF-36) scores can predict postoperative delirium. The objective of this study was to evaluate the correlation between preoperative SF-36 scores and postoperative delirium after surgery for CSM. METHODS Sixty-seven patients who underwent surgery for CSM at the authors' institution were enrolled in this study. Medical records of these patients were retrospectively reviewed. Patient background, preoperative laboratory data, preoperative SF-36 scores, the preoperative Japanese Orthopaedic Association (JOA) score for the evaluation of cervical myelopathy, and perioperative factors were selected as potential risk factors for postoperative delirium. These factors were evaluated using univariable and multivariable logistic regression analysis. RESULTS Ten patients were diagnosed with postoperative delirium. Univariable analysis revealed that the physical functioning score (p = 0.01), general health perception score (p < 0.01), and vitality score (p < 0.01) of the SF-36 were significantly lower in patients with postoperative delirium than in those without. The total number of medications was significantly higher in the delirium group compared with the no-delirium group (p = 0.02). In contrast, there were no significant differences between the delirium group and the no-delirium group in cervical JOA scores (p = 0.20). Multivariable analysis revealed that a low general health perception score was an independent risk factor for postoperative delirium (p = 0.02; odds ratio 0.810, 95% confidence interval 0.684-0.960). CONCLUSIONS Some of the SF-36 scores were significantly lower in patients with postoperative delirium than in those without. In particular, the general health perception score was independently correlated with postoperative delirium. SF-36 scores could help identify patients at high risk for postoperative delirium and aid in the development of prevention strategies.
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Predictive nomogram for postoperative delirium in elderly patients with a hip fracture. Injury 2019; 50:392-397. [PMID: 30396771 DOI: 10.1016/j.injury.2018.10.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/18/2018] [Accepted: 10/27/2018] [Indexed: 02/02/2023]
Abstract
To evaluate the risk factors for the development of postoperative delirium and design a predictive nomogram for the prevention of delirium in elderly patients with a hip fracture, we retrospectively studied 825 patients who sustained a femoral neck fracture from January 2005 to December 2015. Independent risk factors for developing delirium within 6 months of surgery were identified using multivariable logistic regression analyses. A predictive nomogram model was built based on the results, and the discrimination and calibration were determined by C-index and calibration plot. Of the 825 patients who met inclusion criteria, 118 (14.3%) developed postoperative delirium. According to the results, preoperative cognitive impairment (OR, 4.132, 95% CI, 1.831 to 9.324, P<0.001), multiple medical comorbidities (OR, 1.452, 95% CI, 0.958-2.202, P = 0.079), ASA classification (OR, 1.655, 95% CI, 1.073-2.553, P = 0.023), transfusion exceeding 2 units of red blood cell (OR, 1.599, 95% CI, 1.043-2.451, P = 0.035), and intensive care (OR, 1.817, 95% CI, 1.127-2.930, P = 0.014) were identified to be the independent predictors of the development of postoperative delirium. The risk of postoperative delirium increased with the increasing risk score of predictive nomogram, and the C-index was 0.67 (0.62 - 0.72). The calibration showed that the predicted probabilities of delirium in the predictive nomogram were close to the observed frequency of delirium, and the decision curve analysis confirmed the clinical utility of the nomogram when the threshold probabilities were between 8% and 35% due to the net benefit.
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Arshi A, Lai WC, Chen JB, Bukata SV, Stavrakis AI, Zeegen EN. Predictors and Sequelae of Postoperative Delirium in Geriatric Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2018; 9:2151459318814823. [PMID: 30619641 PMCID: PMC6299329 DOI: 10.1177/2151459318814823] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium. Results: In total, 8,439 geriatric hip fracture patients were identified of whom 2,569 patients (30.4%) had postoperative delirium. Age (OR 1.03 [1.02-1.04, p < 0.001), white race (OR 1.54 [1.19-2.00], p = 0.001), American Society of Anesthesiologists classification (OR 1.20 [1.07-1.36], p = 0.003), baseline dementia (OR 2.46 [2.11-2.86], p < 0.001), and preoperative delirium (OR 10.06 [8.12-12.45], p < 0.001) were independent risk factors for postoperative delirium in multivariate analysis. Patients with postoperative delirium had a significantly higher risk-adjusted 30-day mortality (12.0% vs. 4.8%, OR 2.22 [1.74-2.84], p < 0.001) and morbidity profile. Postoperative delirium was also independently associated with higher rates of discharge to (OR 1.65 [1.32-2.06], p < 0.001) and prolonged stay in (OR 1.79 [1.53-2.09], p < 0.001) an inpatient facility, hospital readmission (OR 1.94 [1.58-2.38], p < 0.001) and hospital length of stay (7.6 ± 5.0 vs. 6.1 ± 4.1 days, p < 0.001), as well as lower rates of immediate postoperative weight bearing (OR 0.73 [0.63-0.86], p < 0.001). Discussion: Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes. Conclusions: Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.
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Affiliation(s)
- Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Wilson C Lai
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - James B Chen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Susan V Bukata
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexandra I Stavrakis
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Erik N Zeegen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Functional Outcome of Elderly Hip Fracture Patients Is Not Affected By Prefracture Dementia. Am J Phys Med Rehabil 2018; 97:789-792. [PMID: 29794529 DOI: 10.1097/phm.0000000000000969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries. Urol Oncol 2018; 36:341.e15-341.e22. [DOI: 10.1016/j.urolonc.2018.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/09/2018] [Accepted: 04/17/2018] [Indexed: 11/24/2022]
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Effectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review. Int Psychogeriatr 2018; 30:481-492. [PMID: 29295719 DOI: 10.1017/s1041610217002782] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED ABSTRACTBackground:Delirium is the most frequent complication among the hospitalized elderly with hip fracture. Although, delirium is associated with longer hospital stay, higher mortality rates, worse functional outcomes, and higher institutionalization rates yet health service planners have hugely ignored its existence. This review aims to identify the effectiveness of multicomponent interventions to prevent delirium in hospitalized elderly patients with hip fracture. METHODS This review includes experimental, non-experimental, and observational studies. Electronic searches were conducted in MEDLINE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Embase, and Web of science. RESULTS After inclusion and exclusion criteria were applied, nine full text articles were included in the review. The studies reported the following effect on delirium: We pooled data regarding incidence of delirium from the three RCTs. The effect was in favor of the intervention group (odds ratio 0.64, 95% CI 0.46-0.87). All three RCTs reported that duration of delirium was shorter in the intervention group than in the usual care group (mean 2.9 vs. 3.1 days, median 3 vs. 4 days, median 5.0 vs. 10.2 days). Four other studies reported on the duration of delirium with Milisen and colleagues reported shorter duration of delirium within the intervention group. Four studies reported on severity of delirium with two research groups reporting significant results. CONCLUSION Early engagement of multidisciplinary staff who addresses the risk factors of delirium as soon as the patient presents to the acute care environment is the key element of a successful delirium prevention program. Once delirium had developed, the multicomponent interventions did not appear to make a difference to the duration or severity of delirium.
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Clancy U, Brown M, Alio Z, Wardle K, Pendleton N. Older people with hip fracture transferred to intermediate care: outcomes in an integrated health and social care model. Future Healthc J 2018; 5:58-63. [PMID: 31098534 PMCID: PMC6510036 DOI: 10.7861/futurehosp.5-1-58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Following surgery for hip fracture almost a quarter of patients do not return directly to their usual residence, using the resources within intermediate care and enablement. This was a retrospective cohort study involving 156 Salford residents admitted with hip fracture in 2015. Linked health data were collected on those discharged to intermediate care vs home in terms of readmissions, mortality, lengths of stay, delayed transfers of care, diagnoses of delirium and pre-existing forms of dementia. The median duration of the continuous care episode in the intermediate care cohort, inclusive of readmissions to hospital, was 52 days. There was a 26% (n=20) readmission rate from intermediate care. Readmission rates at 120 days were higher among those discharged to intermediate care vs home (OR 3.21, 95% CI 1.37-7.54, p=0.007) and among those with a form of dementia (OR 4.76, 95% CI 1.79-12.63, p=0.0017). Patients with delirium during their acute admission were more likely to be discharged to intermediate care (OR 5.43, 95% CI 2.36-12.47, p=0.0001) and were less likely to ultimately be discharged home (OR 6.40, 95% CI 2.25-18.21, p=0.0005), as were those with some form of dementia (OR 6.60, 95% CI 1.97-22.08, p=0.002). Measurement of the entire care episode demonstrates significant lengths of stay. Medium term readmission rates are higher in those discharged to intermediate care. Delirium and dementia are associated with higher readmission rates and lower rates of discharge to own home. It is imperative that a whole pathway approach to commissioning hip fracture services is established.
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Affiliation(s)
| | - Mark Brown
- Salford Royal Foundation Trust, Salford, UK
| | - Ziad Alio
- Salford Royal Foundation Trust, Salford, UK
| | | | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester Salford Royal Hospital, Manchester, UK
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Kobayashi K, Imagama S, Ando K, Ishiguro N, Yamashita M, Eguchi Y, Matsumoto M, Ishii K, Hikata T, Seki S, Terai H, Suzuki A, Tamai K, Aramomi M, Ishikawa T, Kimura A, Inoue H, Inoue G, Miyagi M, Saito W, Yamada K, Hongo M, Matsuoka Y, Suzuki H, Nakano A, Watanabe K, Chikuda H, Ohya J, Aoki Y, Shimizu M, Futatsugi T, Mukaiyama K, Hasegawa M, Kiyasu K, Iizuka H, Iizuka Y, Kobayashi R, Nishida K, Kakutani K, Nakajima H, Murakami H, Demura S, Kato S, Yoshioka K, Namikawa T, Watanabe K, Nakanishi K, Nakagawa Y, Yoshimoto M, Fujiwara H, Nishida N, Imajo Y, Yamazaki M, Sakane M, Abe T, Fujii K, Kaito T, Furuya T, Orita S, Ohtori S. Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study. Global Spine J 2017; 7:560-566. [PMID: 28894686 PMCID: PMC5582715 DOI: 10.1177/2192568217700115] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE Spine surgeries in elderly patients have increased in recent years due to aging of society and recent advances in surgical techniques, and postoperative complications have become more of a concern. Postoperative delirium is a common complication in elderly patients that impairs recovery and increases morbidity and mortality. The objective of the study was to analyze postoperative delirium associated with spine surgery in patients aged 80 years or older with cervical, thoracic, and lumbar lesions. METHODS A retrospective multicenter study was performed in 262 patients 80 years of age or older who underwent spine surgeries at 35 facilities. Postoperative complications, incidence of postoperative delirium, and hazard ratios of patient-specific and surgical risk factors were examined. RESULTS Postoperative complications occurred in 59 of the 262 spine surgeries (23%). Postoperative delirium was the most frequent complication, occurring in 15 of 262 patients (5.7%), and was significantly associated with hypertension, cerebrovascular disease, cervical lesion surgery, and greater estimated blood loss (P < .05). In multivariate logistic regression using perioperative factors, cervical lesion surgery (odds ratio = 4.27, P < .05) and estimated blood loss ≥300 mL (odds ratio = 4.52, P < .05) were significantly associated with postoperative delirium. CONCLUSIONS Cervical lesion surgery and greater blood loss were perioperative risk factors for delirium in extremely elderly patients after spine surgery. Hypertension and cerebrovascular disease were significant risk factors for postoperative delirium, and careful management is required for patients with such risk factors.
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Affiliation(s)
| | - Shiro Imagama
- Nagoya University, Nagoya, Aichi, Japan,Shiro Imagama, Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi 466-8550, Japan.
| | - Kei Ando
- Nagoya University, Nagoya, Aichi, Japan
| | | | | | - Yawara Eguchi
- Shimoshizu National Hospital, Yotsukaido-shi, Chiba, Japan
| | | | - Ken Ishii
- Keio University, Shinjuku-ku, Tokyo, Japan
| | | | - Shoji Seki
- University of Toyama, Toyama-shi, Toyama, Japan
| | | | | | - Koji Tamai
- Osaka City University, Abeno-ku, Osaka, Japan
| | | | | | - Atsushi Kimura
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Hirokazu Inoue
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Gen Inoue
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | | | - Wataru Saito
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | - Kei Yamada
- Kurume University, Kurume-shi, Fukuoka, Japan
| | | | | | | | | | | | | | - Junichi Ohya
- The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | | | | | | | | | | | - Haku Iizuka
- Gunma University, Maebashi-shi, Gunma, Japan
| | | | | | | | | | | | | | | | | | | | | | - Kei Watanabe
- Niigata University, Niigata-shi, Niigata, Japan,Sado General Hospital, Sado-shi, Niigata, Japan
| | | | | | | | | | | | | | | | | | - Tetsuya Abe
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kengo Fujii
- University of Tsukuba, Tsukuba, Ibaraki, Japan
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Perioperative hemodynamics and risk for delirium and new onset dementia in hip fracture patients; A prospective follow-up study. PLoS One 2017; 12:e0180641. [PMID: 28700610 PMCID: PMC5503267 DOI: 10.1371/journal.pone.0180641] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/19/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia. METHODS Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively. RESULTS Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively. CONCLUSION Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture.
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Wang Y, Tang J, Zhou F, Yang L, Wu J. Comprehensive geriatric care reduces acute perioperative delirium in elderly patients with hip fractures: A meta-analysis. Medicine (Baltimore) 2017; 96:e7361. [PMID: 28658156 PMCID: PMC5500078 DOI: 10.1097/md.0000000000007361] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of the current meta-analysis was to assess the treatment effect of comprehensive geriatric care in reducing acute perioperative delirium in older patients with hip fractures, compared with the effect of a routine orthopedic treatment protocol. METHODS We conducted a search of multiple databases to identify randomized controlled trials (RCTs) and quasi-RCTs comparing comprehensive geriatric care and routine orthopedic treatment regarding the following outcomes: incidence of delirium, assessment of cognitive status, and duration of delirium. Odds ratios (ORs) and mean differences (MDs) were pooled using either a fixed-effects or a random-effects model, depending on the heterogeneity of the trials included in the analysis. RESULTS Six RCTs and 1 quasi-RCT provided data from 1840 patients. These data revealed that comprehensive geriatric care may reduce the incidence of perioperative delirium (OR = 0.71; 95% confidence interval [CI], 0.57-0.89; P = .003) and that it was associated with higher cognitive status during hospitalization or at 1 month postoperatively (MD = 1.03; 95% CI, 0.93-1.13; P ≤ .00001). There was no significant difference in duration of perioperative delirium between the 2 treatment groups (MD = -2.48; 95% CI, -7.36 to 2.40; P = .32). CONCLUSION Based on the quality of evidence provided, comprehensive geriatric care may reduce the incidence of perioperative delirium. To obtain evidence regarding the merits of comprehensive geriatric care in reducing severity of delirium and shortening the duration of delirium, there is a need for multicenter RCTs with high methodological quality.
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Dasgupta M, Brymer C, Elsayed S. Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study. Arch Gerontol Geriatr 2017. [PMID: 28624753 DOI: 10.1016/j.archger.2017.05.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite clinical practice guidelines, asymptomatic bacteriuria (ASB) in older people is frequently treated. A common reason for treating ASB is a change in mental status. OBJECTIVE To determine how often asymptomatic UTI is treated in older medically ill delirious individuals and its association with functional recovery. METHODS Consecutive older medical in-patients were screened for delirium, and followed in hospital. Treatment for asymptomatic UTI was defined as documented treatment for a possible urinary tract infection with antibiotics, without concurrent infectious or urinary symptoms. The primary outcome was functional recovery at discharge or 3 months post-discharge. Poor functional recovery was defined by any one of death, new permanent long-term institutionalization or decreased ability to perform activities of daily living. RESULTS The study sample comprised 343 delirious in-patients, of which 237 (69%) had poor functional recovery. Ninety two (27%) delirious in-patients were treated for asymptomatic UTI. Treatment for asymptomatic UTI was associated with poor functional recovery compared to other delirious in-patients (RR 1.30, 95% CI: 1.14-1.48 overall). Similar results were seen when the analysis was restricted to only bacteriuric delirious individuals. Seven (7.5%) individuals treated for asymptomatic UTI developed Clostridium difficile infection compared to eight (3.2%) in the remainder of the delirious cohort (OR 2.45, 95% CI: 0.86-6.96). CONCLUSIONS These results suggest that treatment of asymptomatic UTI in older medical in-patients with delirium is common, and of questionable benefit. Further research is needed to establish guidelines to minimize over-treatment of UTI in older delirious in-patients.
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Affiliation(s)
- Monidipa Dasgupta
- Division of Geriatric Medicine, Department of Medicine, Shulich School of Medicine, Western University, University Hospital (London Health Sciences Centre), 339 Windermere Road, London, Ontario, N6A 5A5, Canada; Lawson Health Research Institute, Canada.
| | - Chris Brymer
- Division of Geriatric Medicine, Department of Medicine, Shulich School of Medicine, Western University, University Hospital (London Health Sciences Centre), 339 Windermere Road, London, Ontario, N6A 5A5, Canada
| | - Sameer Elsayed
- Division of Infectious Diseases, Department of Medicine, Shulich School of Medicine, Western University, Victoria Hospital (London Health Sciences Centre), 800 Commissioner's Road, London, Ontario, N6A 5W9, Canada; Department of Pathology and Laboratory Medicine, Division of Microbiology, Western University, Canada
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chin YC, Koh GCH, Tay YK, Tan CH, Merchant RA. Underdiagnosis of delirium on admission and prediction of patients who will develop delirium during their inpatient stay: a pilot study. Singapore Med J 2017; 57:18-21. [PMID: 26831312 DOI: 10.11622/smedj.2016007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The study aimed to determine the prevalence and documentation of delirium among the elderly and if the Clock Drawing Test (CDT) can be used to predict which patients had delirium on admission and those who may develop delirium during their stay in acute medical wards. METHODS A single researcher performed the Mini-Mental State Examination (MMSE) and CDT on admission and discharge of 57 elderly adults at the National University Hospital, Singapore. Delirium was defined as a ≥ 3-point improvement or ≥ 2-point decline in MMSE scores from admission to discharge, where a fall denotes development of delirium and a rise denotes resolution. The case notes of the same patients were reviewed for documentation of delirium. All inpatients from two acute medical wards were examined. One CDT score and a pair of MMSE scores were collected from each patient. RESULTS A total of 57 patients (28 male, 29 female) were involved in the study. Their mean age was 76.0 ± 8.7 years. The prevalence of delirium based on MMSE scores was 40.4%; 16 patients had delirium on admission while seven developed delirium during their inpatient stay. However, delirium was documented in the case notes of only 7 (30%) of the 23 patients. CDT score was better than baseline MMSE score at predicting a decline in MMSE score. CONCLUSION The prevalence of delirium in the acute medical setting is high but underdiagnosed. The CDT may be a good screening tool to identify patients at risk of delirium during their inpatient stay. Baseline cognition screening should be performed in every elderly patient admitted to hospital.
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Affiliation(s)
- Yuin Cheng Chin
- Department of Medicine, Yong Loo Lin School of Medicine, Singapore
| | | | - Yee Kian Tay
- Department of Nursing, National University Hospital, Singapore
| | - Chay Hoon Tan
- Department of Psychiatric Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Post-Operative Delirium in Elderly People Diagnostic and Management Issues of Post-Operative Delirium in Elderly People. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 987:301-312. [DOI: 10.1007/978-3-319-57379-3_27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Brown CH, LaFlam A, Max L, Wyrobek J, Neufeld KJ, Kebaish KM, Cohen DB, Walston JD, Hogue CW, Riley LH. Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes. J Am Geriatr Soc 2016; 64:2101-2108. [PMID: 27696373 DOI: 10.1111/jgs.14434] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery. DESIGN Prospective observational study. SETTING Academic medical center. PARTICIPANTS Individuals aged 70 and older undergoing spine surgery (N = 89). MEASUREMENTS Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state. RESULTS Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home. CONCLUSION Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Andrew LaFlam
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Julie Wyrobek
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David B Cohen
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy D Walston
- Department of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lee H Riley
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Puustinen J, Luostarinen L, Luostarinen M, Pulliainen V, Huhtala H, Soini M, Suhonen J. The Use of MoCA and Other Cognitive Tests in Evaluation of Cognitive Impairment in Elderly Patients Undergoing Arthroplasty. Geriatr Orthop Surg Rehabil 2016; 7:183-187. [PMID: 27847677 PMCID: PMC5098689 DOI: 10.1177/2151458516669203] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine the prevalence and effect of cognitive impairment on treatment outcomes in elderly patients undergoing arthroplasty and to describe the feasibility of cognitive tests. MATERIALS AND METHODS The participants were 52 patients with a mean age of 78 years 11 months (SD: 3.3), waiting for primary arthroplasty. We translated Montreal Cognitive Assessment (MoCA) into Finnish and compared it with Mini-Mental State Examination (MMSE), Mini-Cog, and clock-drawing tests prior to and 3 months after the surgery. The ability to perform activities of daily living, depression, quality of life, and years of education were evaluated. RESULTS The mean MoCA score on the first visit was 20.7 (SD: 4.1). The pre- and postoperative cognitive tests implied there were no changes in cognitive functioning. Unambiguous delirium was detected in 6 patients. Delirium was not systematically assessed and consequently hypoactive delirium cases were possibly missed. Both MMSE and Mini-Cog found 3/6 of those and clock drawing and MoCA 6/6. Low preoperative MoCA, MMSE, and Mini-Cog scores predicted follow-up treatment in health-care center hospitals (P = .02, .011, and .044, respectively). During the 5-year follow-up period, 11/52 patients died. Higher education was the only variable associated with survival. The survivors had attained the median of 8 (range: 4-19) years of education compared with 6 (range: 4-8) years among the deceased. CONCLUSION The prevalence of cognitive impairment among older patients presenting for arthroplasty is high and mostly undiagnosed. It is feasible to use the MoCA to identify cognitive impairment preoperatively in this group. The clock-drawing test was abnormal in all patients with postoperative delirium, which could be used as a screening test. Higher education predicted survival on a 5-year follow-up period.
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Affiliation(s)
| | | | | | | | - Heini Huhtala
- Tampereen yliopisto Laaketieteen yksikko, Tampere, Finland
| | - Marjo Soini
- Paijat-Hameen sosiaali ja terveysyhtyma, Lahti, Finland
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Hamman RJ. Rehabilitation following hip fracture in patients with Alzheimer's disease and related disorders. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153331759701200504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examines patients who were rehabilitated in a long-term care facility specializing in the care of Alzheimer's disease and related disorders over a two-year period All of the patients were moderately to severely impaired cognitively on a standardized mental exam and were unable to live outside of a secured, long-term care facility. The patients ranged in age from 80 to 90 years old and were predominantly female. There were 19 patients, all but one of whom had had surgery; five patients had prostheses and 13 had ORIFs. All of the patients receivedphysical therapy q.d. and then q. o.d. for periods ranging from one week (patient deceased) to six months. The mean time of rehabilitation was 10 weeks. At the time of discharge from physical therapy, all of the patients who survived (two deceased), were able to ambulate with or without assistive devices at least 100 feet. some required assistance for safety due to decreased judgement and cognition, four were able to ambulate totally independently ad lib, and five needed supervision only. On follow-up of these patients, several improved on their own after discharge from physical therapy or with follow-up by restorative nursing. For Alzheimer patients, ambulation is a significant quality-of-life issue. These patients were all happier ambulating than in a wheelchair, especially since restraints would have been necessary to keep them there. The findings suggest that patients with Alzheimer's and other dementias may require slightly longer periods of rehabilitation but that the results are well worth the effort.
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Affiliation(s)
- Rosalyn J. Hamman
- Garden Terrace Alzheimer's Center of Excellence, Salt Lake City, Utah
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Cortese GP, Burger C. Neuroinflammatory challenges compromise neuronal function in the aging brain: Postoperative cognitive delirium and Alzheimer's disease. Behav Brain Res 2016; 322:269-279. [PMID: 27544872 DOI: 10.1016/j.bbr.2016.08.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/08/2016] [Accepted: 08/11/2016] [Indexed: 12/19/2022]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease that targets memory and cognition, and is the most common form of dementia among the elderly. Although AD itself has been extensively studied, very little is known about early-stage preclinical events and/or mechanisms that may underlie AD pathogenesis. Since the majority of AD cases are sporadic in nature, advancing age remains the greatest known risk factor for AD. However, additional environmental and epigenetic factors are thought to accompany increasing age to play a significant role in the pathogenesis of AD. Postoperative cognitive delirium (POD) is a behavioral syndrome that primarily occurs in elderly patients following a surgical procedure or injury and is characterized by disruptions in cognition. Individuals that experience POD are at an increased risk for developing dementia and AD compared to normal aging individuals. One way in which cognitive function is affected in cases of POD is through activation of the inflammatory cascade following surgery or injury. There is compelling evidence that immune challenges (surgery and/or injury) associated with POD trigger the release of pro-inflammatory cytokines into both the periphery and central nervous system. Thus, it is possible that cognitive impairments following an inflammatory episode may lead to more severe forms of dementia and AD pathogenesis. Here we will discuss the inflammation associated with POD, and highlight the advantages of using POD as a model to study inflammation-evoked cognitive impairment. We will explore the possibility that advancing age and immune challenges may provide mechanistic evidence correlating early life POD with AD. We will review and propose neural mechanisms by which cognitive impairments occur in cases of POD, and discuss how POD may augment the onset of AD.
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Affiliation(s)
- Giuseppe P Cortese
- Department of Neurology, University of Wisconsin-Madison, Medical Sciences Center, 1300 University Ave, Room 73 Bardeen Madison, WI 53706, USA.
| | - Corinna Burger
- Department of Neurology, University of Wisconsin-Madison, Medical Sciences Center, 1300 University Ave, Room 73 Bardeen Madison, WI 53706, USA
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Liu Y, Ma L, Gao M, Guo W, Ma Y. Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment. Aging Clin Exp Res 2016; 28:729-36. [PMID: 26559412 DOI: 10.1007/s40520-015-0492-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/30/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Postoperative delirium (POD) is a common and serious surgical complication among the elderly, especially in those with amnestic mild cognitive impairment (aMCI). Dexmedetomidine (DEX) is neuroprotective for delirium. In this study, we determined the effect of intravenously administered DEX during general anesthesia on POD in elderly aMCI patients undergoing elective hip joint or knee joint or shoulder joint replacement surgery. METHODS This was a prospective, randomized parallel-group study of aMCI (n = 80) and normal elderly patients (n = 120). Prior to surgery, all subjects underwent neuropsychological assessment and were assigned to one of four groups: the aMCI DEX group (MD group, n = 40), the aMCI normal saline group (MN group, n = 40), the control DEX group (CD group, n = 60), and the control normal saline group (CN group, n = 60). The confusion assessment method was used to screen POD on postoperative days 1, 3, and 7. RESULTS We found patients age was positively correlated with POD incidence in the MN group (p < 0.05) but not in the CN group (p < 0.05). DEX treatment significantly decreased POD incidence in both control and aMCI groups relative to their respective placebo groups (all p < 0.05). The fraction of patients whose normal cognitive function was not restored by day 7 after surgery was significantly higher in the MN group than the MD and CN groups (all p < 0.05). CONCLUSIONS These findings suggested that DEX treatment during surgery significantly reduced POD incidence in both normal and aMCI elderly patients, suggesting that it may be an effective option for the prevention of POD.
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Sundsted KK, Mohabbat AB, Regan DW, Salonen BR, Daniels PR, Mauck KF. Update in perioperative medicine: practice-changing evidence published in 2015. Hosp Pract (1995) 2016; 44:157-63. [PMID: 27400757 DOI: 10.1080/21548331.2016.1210473] [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: 10/21/2022]
Abstract
Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.
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Affiliation(s)
- Karna K Sundsted
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Arya B Mohabbat
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Dennis W Regan
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Bradley R Salonen
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Paul R Daniels
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Karen F Mauck
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
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Yoshii I, Satake Y, Kitaoka K, Komatsu M, Hashimoto K. Relationship between dementia degree and gait ability after surgery of proximal femoral fracture: Review from Clinical Pathway with Regional Alliance data of rural region in Japan. J Orthop Sci 2016; 21:481-486. [PMID: 27075586 DOI: 10.1016/j.jos.2016.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/12/2016] [Accepted: 03/11/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Proximal femoral fracture (PFF) is one of the most serious injury-related problems in developed countries. Functional prognosis after operation for PFF is unsatisfactory, as a considerable number of patients cannot perform similar gait function before fracture. Postoperative gait function is a key in performing activities of daily living (ADL). It is well known that PFF patients with dementia result in worse prognosis compared to without dementia. It is believed that dementia affects gait function after operation. However, it is still unclear whether lost function recovers after dementia level improves. METHODS Relationship between ADL and dementia of PFF patients after surgery was investigated using data of Clinical Pathway with Regional Alliance system. Functional Independence Measurement (FIM), revised version of Hasegawa's Dementia Scale (HDS-R), motivation for rehabilitation (MR), and gait status (GS) measured in acute and recovery institute (A-I and R-I) of 266 patients were analyzed with linear regression analysis. Degrees of patients' dementia were classified into three groups with HDS-R for ten points increment partition, and their average FIM and GS in R-I for groups were compared statistically with ANOVA. FIM gain and GS gain from A-I to R-I were compared statistically with chi-square test. RESULTS FIM and HDS-R demonstrated significant regression with each of all other parameters (p < 0.01) for both A-I and R-I. The group with lowest HDS-R score demonstrated significant lower FIM gain and lower GS gain than groups with higher scores (p < 0.01). However, patients who demonstrated improvement in HDS-R at R-I demonstrated significant better GS gain (p < 0.05) even in the group with lowest HDS-R at A-I. CONCLUSIONS These results show that there is a very close correlation between patients' gait function and dementia and that it is necessary to control a patient's status not only for physical condition but also for mental status after PFF operation.
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Affiliation(s)
- Ichiro Yoshii
- In Yoshii Hospital from Medical Corporation Genyu, 6-7-5 Nakamura-Ohashidori, Shimanto-City, 787-0033 Kochi Prefecture, Japan.
| | - Yoshinori Satake
- Department of Orthopaedic Surgery, Kochi Prefectural Aki General Hospital, 3-33Hoheicho, Aki, 784-0027 Kochi Prefecture, Japan
| | - Kenichi Kitaoka
- Department of Orthopaedic Surgery, Kochi Prefectural Hata Kenmin Hospital, 3-1 Yoshina, Yamada-cho, 788-0785 Kochi Prefecture, Japan
| | - Makoto Komatsu
- Department of Orthopaedic Surgery, Kochi Prefectural Hata Kenmin Hospital, 3-1 Yoshina, Yamada-cho, 788-0785 Kochi Prefecture, Japan
| | - Kyuichi Hashimoto
- Department of Orthopaedic Surgery, Otsuki Hospital, 603 Hokotsuti, Otsuki, 788-0311 Kochi Prefecture, Japan
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Abstract
The term “dementia” describes various neurodegenerative disorders that effect cognition, including Alzheimer disease, vascular dementia, and others. This article reviews the diagnosis and management of common types of dementia and comorbidities. Dementias are differentiated clinically by history, symptom presentation, and exclusion of other causes through laboratory and imaging studies. Cholinesterase inhibitors are useful but may not be effective for all types of dementia and provide only modest benefits. Certain medical comorbidities may increase the risk of dementia, although genetics are also important in its etiology. Psychiatric comorbidities in dementia include delirium, which is treated primarily by addressing underlying medical disorders, but antipsychotics can be useful for symptom management and patient comfort. Nonpharmacologic interventions are first-line treatments for other psychiatric comorbidities, although drug therapy may be useful in some cases. The management of patients with dementia presents many challenges and will continue to do so unless agents with pronounced disease-modifying capabilities are developed.
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Affiliation(s)
- Keith A. Swanson
- The University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Oklahoma City, Oklahoma
| | - Ryan M. Carnahan
- The University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Tulsa, Oklahoma,
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