Derivation and Validation of a Severity Scoring Method for the 3-Minute Diagnostic Interview for Confusion Assessment Method--Defined Delirium

Research progress of postoperative delirium in neurosurgery

Delirium is a transient and acute syndrome of encephalopathy, characterized by disturbances in consciousness, orientation, cognition, perception, and emotional regulation, often accompanied by hallucinations, illusions, psychomotor agitation, and restlessness. Postoperative delirium (POD), a common complication particularly in elderly patients, significantly impacts recovery by prolonging mechanical ventilation, neurosurgical intensive care unit stays, and overall hospitalization durations, while severely diminishing patients’ quality of life after discharge. Despite its prevalence, POD remains underrecognized in clinical practice, with significant gaps in its diagnosis and management. This review explores the definition, diagnostic criteria, underlying pathogenesis, and associated risk factors of POD in neurosurgical patients, aiming to offer valuable insights for improving clinical diagnosis and therapeutic strategies.

Protocol and design of the REPOSE study: a double-blinded, randomised, placebo-controlled trial to evaluate the efficacy of suvorexant to improve postoperative sleep and reduce delirium severity in older patients undergoing non-cardiac surgery

INTRODUCTION

Postoperative delirium occurs in up to 40% of older surgical patients and has been associated with prolonged hospital stays, long-term cognitive impairment and increased 1-year postoperative mortality. Postoperative sleep disturbances may increase the risk of delirium, but studies investigating pharmacotherapies to improve postoperative sleep to prevent delirium remain limited. Suvorexant is a selective antagonist of orexin 1 and 2 receptors and is approved for insomnia pharmacotherapy by the Food and Drug Administration. It has the potential to improve postoperative sleep and reduce postoperative delirium rates, but randomised controlled trials (RCTs) are needed to determine the efficacy of postoperative suvorexant administration. The REPOSE study (reducing delirium by enhancing postoperative sleep with suvorexant) is a single-centre, randomised, double-blinded RCT that aims to evaluate the efficacy of suvorexant in increasing total sleep time (TST) and decreasing delirium severity in older patients undergoing non-cardiac surgery.

METHODS AND ANALYSIS

REPOSE will enroll 130 patients (aged ≥65 years) undergoing non-cardiac surgery with a planned postoperative inpatient stay. Participants will be randomised to receive 20 mg oral suvorexant or placebo nightly on postoperative nights 0, 1 and 2. The primary endpoint is TST on the first postoperative night, as measured using an electroencephalography headband. The secondary endpoint is peak postoperative delirium severity as measured by the 3-minute diagnostic interview for the confusion assessment method severity scores. Primary endpoint data will be analysed with a two-sample t-test using an intent-to-treat approach to compare TST on the first night that a patient received a study drug dose. Secondary and exploratory endpoint data will be analysed using two-sample t-tests between groups.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Duke Institutional Review Board (protocol #00111869). Results of the REPOSE study will be published in a peer-reviewed journal and presented at academic conferences. Trial data will be deposited in ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05733286.

Development and validation of a nomogram for delirium in the old ischaemic stroke patients

AIM

To investigate the predictors of post-stroke delirium (PSD) in the old ischaemic stroke patients, and develop a nomogram to predict the risk of PSD.

METHODS

A cross-observational study was conducted. The old ischaemic stroke patients in a tertiary hospital in South China were recruited and randomly divided into the train group and test group. Multivariate logistic regression analysis was performed in the train group to screen out predictors of PSD, and develop a nomogram. The receiver operating characteristic (ROC) curve, calibration curve, Hosmer-Lemeshow goodness-of-fit test (H-L test) and decision curve analysis (DCA) were used to evaluate the nomogram. The internal validation was performed in test group.

RESULTS

The incidence of PSD was 21.1% (105/497). Coronary heart disease (CHD), indwelling catheter, physical restraint, and neutrophil-to-lymphocyte ratio (NLR) were significantly associated with PSD. The area under the ROC curve of the nomogram was 0.885 in the train group, and 0.865 in the test group. The calibration curves of the two groups were close to the standardised line. The P-values of H-L test were over 0.05. The DCA presented some net benefits in the two groups.

CONCLUSION

CHD, indwelling catheter, restraint, and NLR were strongly associated with PSD in the old. A nomogram with good prediction effect and advisable clinical applicability was developed.

Modulating delirium through stimulation (MoDeSt): study protocol for a randomized, double-blind, sham-controlled trial assessing the effect of postoperative transcranial electrical stimulation on delirium incidence

BACKGROUND

Postoperative delirium (POD) is the most common neurological adverse event among elderly patients undergoing surgery. POD is associated with an increased risk for postoperative complications, long-term cognitive decline, an increase in morbidity and mortality as well as extended hospital stays. Delirium prevention and treatment options are currently limited. This study will evaluate the effect of transcranial electrical stimulation (tES) on the incidence of POD.

METHODS

We will perform a randomized, double-blind, sham-controlled trial using single-session postoperative application of tES in the recovery room in 225 patients (> 65 years) undergoing elective major surgery. Patients will be randomly allocated (ratio 1:1:1) to one of three study groups: (1) alpha-tACS over posterior parietal cortex [2 mA, 20 min], (2) anodal tDCS over left dorsolateral prefrontal cortex [2 mA, 20 min], (3) sham [2 mA, 30 s]. Delirium will be screened twice daily with the 3-min diagnostic interview Confusion Assessment Method (3D-CAM) in the 5 days following surgery. The primary outcome is the incidence of POD defined as at least one positive screening during the five first postoperative days compared between tACS and sham groups. Secondary outcomes include delirium severity, duration, phenotype, postoperative pain, postoperative nausea and vomiting, electroencephalographic (EEG) markers, and fluid biomarkers.

DISCUSSION

If effective, tES is a novel, easily applicable, non-invasive method to prevent the occurrence of POD. The comprehensive neurophysiological and biofluid assessments for markers of (neuro-)inflammation and neurodegeneration will shed light on the pathomechanisms behind POD and further elucidate the (after-)effects of tES. The potential implications for the postoperative recovery comprise enhanced patient safety, neurocognitive outcome, perioperative manageability but also reduced healthcare costs.

TRIAL REGISTRATION

German Clinical Trial Registry DRKS00033703. Registered on February 23, 2024.

Role of Blood-Brain Barrier Dysfunction in Delirium following Non-cardiac Surgery in Older Adults

OBJECTIVE

Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients.

METHODS

Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR).

RESULTS

Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = -0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [-0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03-1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09-1.22, p < 0.001).

INTERPRETATION

Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024-1035.

A Role for Blood-brain Barrier Dysfunction in Delirium following Non-Cardiac Surgery in Older adults

Objective

Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients.

Methods

Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR).

Results

Of 207 patients (median age 68, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24-hours after surgery (median postoperative change 0.28, [IQR] [-0.48-1.24]; Wilcoxon p=0.001). Preoperative to 24-hour postoperative change in CPAR was greater among patients who developed delirium vs those who did not (median [IQR] 1.31 [0.004, 2.34] vs 0.19 [-0.55, 1.08]; p=0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24-hour postoperative change in CPAR was independently associated with delirium incidence (per CPAR increase of 1, OR = 1.30, [95% CI 1.03-1.63]; p=0.026) and increased hospital length of stay (IRR = 1.15 [95% CI 1.09-1.22]; p<0.001).

Interpretation

Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay.

An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes

An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.

One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders

INTRODUCTION

One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously.

METHODS

Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission.

RESULTS

Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods.

DISCUSSION

Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures.

HIGHLIGHTS

Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.

Deconstructing delirium in the post anaesthesia care unit

The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ −2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ −2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.

Predictors of Caregiver Burden in Delirium: Patient and Caregiver Factors

The current study examined the association of patient factors, patient/caregiver relationships, and living arrangements with caregiver burden due to delirium. The sample included a subset (N = 207) of hospitalized medical and surgical patients (aged >70 years) enrolled in the Better Assessment of Illness Study and their care-givers. The majority of caregivers were female (57%) and married (43%), and 47% reported living with the patient. Delirium occurred in 22% of the sample, and delirium severity, pre-existing cognitive impairment, and impairment of any activities of daily living (ADL) were associated with higher caregiver burden. However, only the ADL impairment of needing assistance with transfers was independently significantly associated with higher burden (p < 0.01). Child, child-in-law, and other relatives living with or apart from the patient reported significantly higher caregiver burden compared to spouse/partners (p < 0.01), indicating caregiver relationship and living arrangement are associated with burden. Future studies should examine additional factors contributing to delirium burden. [Journal of Gerontological Nursing, 47(9), 32-39.].

A nurse-administered 3-Minute diagnostic interview for CAM-defined Delirium (3D-CAM Chinese version) in hospitalized elderly patients: A validation study

BACKGROUND

Delirium is a common complication in hospitalized elderly patients, yet often remains unrecognized in the clinical care unit. The newly developed 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM) has high sensitivity and specificity when administered by trained researchers. However, diagnostic characteristics of the 3D-CAM as performed in routine practice are unclear.

OBJECTIVE

To determine the diagnostic characteristics of a Chinese version of the 3D-CAM administered to hospitalized elderly patients by bedside nurses.

DESIGN

A prospective cohort study.

SETTING

A tertiary geriatric hospital in China.

PARTICIPANTS

323 patients and 49 bedside nurses.

METHODS

This prospective cohort study was conducted at a tertiary geriatric hospital in China. A Chinese version of 3D-CAM was administered by trained bedside nurses and compared against the reference standard performed by experienced neurologists using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. All assessors were blinded to each other's assessment results. Sensitivity and specificity of the 3D-CAM among bedside nurses were analysed by comparing with the reference standard to test the ability of 3D-CAM in detecting delirium.

RESULTS

A total of 323 patients were included in the study, of whom 64 were classified as delirium positive by the neurologists. The 3D-CAM had a sensitivity of 92% (95% confidence interval, 82-97%), specificity of 89% (95% confidence interval, 84-92%), respectively.

CONCLUSION

The Chinese version of 3D-CAM demonstrated good performance as a bedside nurse-administered screening tool for delirium detection among hospitalized Chinese geriatric patients. Registration number: ChiCTR-IOR-17,010,368.

Assessing method agreement for paired repeated binary measurements administered by multiple raters

Method comparison studies are essential for development in medical and clinical fields. These studies often compare a cheaper, faster, or less invasive measuring method with a widely used one to see if they have sufficient agreement for interchangeable use. Moreover, unlike simply reading measurements from devices, eg, reading body temperature from a thermometer, the response measurement in many clinical and medical assessments is impacted not only by the measuring device but also by the rater. For example, widespread inconsistencies are commonly observed among raters in psychological or cognitive assessment studies due to different characteristics such as rater training and experience, especially in large-scale assessment studies when many raters are employed. This paper proposes a model-based approach to assess agreement of two measuring methods for paired repeated binary measurements under the scenario where the agreement between two measuring methods and the agreement among raters are required to be studied simultaneously. Based upon the generalized linear mixed models (GLMMs), the decision on the adequacy of interchangeable use is made by testing the equality of fixed effects of methods. Approaches for assessing method agreement, such as the Bland-Altman diagram and Cohen's kappa, are also developed for repeated binary measurements based upon the latent variables in GLMMs. We assess our novel model-based approach by simulation studies and a real clinical application, in which patients are evaluated repeatedly for delirium with two validated screening methods. Both the simulation studies and the real data analyses demonstrate that our proposed approach can effectively assess method agreement.

The MARBLE Study Protocol: Modulating ApoE Signaling to Reduce Brain Inflammation, DeLirium, and PostopErative Cognitive Dysfunction

BACKGROUND

Perioperative neurocognitive disorders (PND) are common complications in older adults associated with increased 1-year mortality and long-term cognitive decline. One risk factor for worsened long-term postoperative cognitive trajectory is the Alzheimer's disease (AD) genetic risk factor APOE4. APOE4 is thought to elevate AD risk partly by increasing neuroinflammation, which is also a theorized mechanism for PND. Yet, it is unclear whether modulating apoE4 protein signaling in older surgical patients would reduce PND risk or severity.

OBJECTIVE

MARBLE is a randomized, blinded, placebo-controlled phase II sequential dose escalation trial designed to evaluate perioperative administration of an apoE mimetic peptide drug, CN-105, in older adults (age≥60 years). The primary aim is evaluating the safety of CN-105 administration, as measured by adverse event rates in CN-105 versus placebo-treated patients. Secondary aims include assessing perioperative CN-105 administration feasibility and its efficacy for reducing postoperative neuroinflammation and PND severity.

METHODS

201 patients undergoing non-cardiac, non-neurological surgery will be randomized to control or CN-105 treatment groups and receive placebo or drug before and every six hours after surgery, for up to three days after surgery. Chart reviews, pre- and postoperative cognitive testing, delirium screening, and blood and CSF analyses will be performed to examine effects of CN-105 on perioperative adverse event rates, cognition, and neuroinflammation. Trial results will be disseminated by presentations at conferences and peer-reviewed publications.

CONCLUSION

MARBLE is a transdisciplinary study designed to measure CN-105 safety and efficacy for preventing PND in older adults and to provide insight into the pathogenesis of these geriatric syndromes.

Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes

OBJECTIVE

To determine which findings on routine clinical EEGs correlate with delirium severity across various presentations and to determine whether EEG findings independently predict important clinical outcomes.

METHODS

We prospectively studied a cohort of nonintubated inpatients undergoing EEG for evaluation of altered mental status. Patients were assessed for delirium within 1 hour of EEG with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and 3D-CAM severity score. EEGs were interpreted clinically by neurophysiologists, and reports were reviewed to identify features such as theta or delta slowing and triphasic waves. Generalized linear models were used to quantify associations among EEG findings, delirium, and clinical outcomes, including length of stay, Glasgow Outcome Scale scores, and mortality.

RESULTS

We evaluated 200 patients (median age 60 years, IQR 48.5-72 years); 121 (60.5%) met delirium criteria. The EEG finding most strongly associated with delirium presence was a composite of generalized theta or delta slowing (odds ratio 10.3, 95% confidence interval 5.3-20.1). The prevalence of slowing correlated not only with overall delirium severity (R 2 = 0.907) but also with the severity of each feature assessed by CAM-based delirium algorithms. Slowing was common in delirium even with normal arousal. EEG slowing was associated with longer hospitalizations, worse functional outcomes, and increased mortality, even after adjustment for delirium presence or severity.

CONCLUSIONS

Generalized slowing on routine clinical EEG strongly correlates with delirium and may be a valuable biomarker for delirium severity. In addition, generalized EEG slowing should trigger elevated concern for the prognosis of patients with altered mental status.

Home-based Cognitive Prehabilitation in Older Surgical Patients: A Feasibility Study

BACKGROUND

Cognitive training is beneficial in various clinical settings, although its perioperative feasibility and impact remain unknown. The objective of this pilot study was to determine the feasibility of home-based cognitive prehabilitation before major surgery in older adults.

MATERIALS AND METHODS

Sixty-one patients were enrolled, randomized, and allocated to either a home-based preoperative cognitive training regimen or no training before surgery. Outcomes included postoperative delirium incidence (primary outcome; assessed with the 3D-Confusion Assessment Method), perioperative cognitive function based on NIH Toolbox measures, hospital length of stay, and physical therapy session participation. Reasons for declining enrollment were reported, as were reasons for opting out of the training program.

RESULTS

Postoperative delirium incidence was 6 of 23 (26%) in the prehabilitation group compared with 5 of 29 (17%) in the control group (P=0.507). There were no significant differences between groups in NIH Toolbox cognitive function scoring, hospital length of stay, or physical therapy participation rates. Study feasibility data were also collected and reported. The most common reasons for declining enrollment were lack of computer access (n=19), time commitment (n=9), and feeling overwhelmed (n=9). In the training group, only 5 of 29 (17%) included patients were able to complete the prescribed 7 days of training, and 14 of 29 (48%) opted out of training once home. Most common reasons were feeling overwhelmed (n=4) and computer difficulties (n=3).

CONCLUSIONS

Short-term, home-based cognitive training before surgery is unlikely to be feasible for many older patients. Barriers to training include feeling overwhelmed, technical issues with training, and preoperative time commitment.

Penehyclidine hydrochloride on postoperatively cognitive function

There are many drugs that affect postoperative cognitive function in patients under general anesthesia. Pentanethaquine hydrochloride (PHC), as a new type of anti-cholinergic drug, has been widely used. In clinical practice, many patients, especially elderly patients, have suffered from obvious postoperative cognitive dysfunction, but the incidence of pulmonary infection, reduced probably due to the decease of secretion production. Therefore, the effect of PHC on postoperative cognitive functions and inflammatory factors in elderly lung cancer patients under general anesthesia were mainly discussed to determine the clinical advantages and disadvantages. Ninety elderly patients undergoing thoracoscopic surgery for lung cancer under general anesthesia were selected and divided into PHC group (group A, n = 30), atropine group (group B, n = 30) and normal saline control group (group C, n = 30). The incidence of postoperative blurred vision was higher in group A compared to group B and C (both p < 0.05). The incidence of other adverse reactions was higher in group A compared to group C (all p < 0.05), but there was no difference between group A and group B (all p > 0.05). There was no significant difference in preoperative and day 1 post-surgery mini-mental state examination (MMSE) scores among the three groups (both p > 0.05), but the day 1 post-surgery MMSE scores of three groups were lower (all p < 0.05). PHC increased the incidence of postoperative cognitive impairment and postoperative delirium in elderly lung cancer patients undergoing thoracoscopic surgery under general anesthesia, but reduced the incidence of postoperative pulmonary complications possibly by reducing the expression of pro-inflammatory cytokines.

Delirium and Dementia

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.

The use of a screening scale improves the recognition of delirium in older patients after cardiac surgery-A retrospective observational study

AIMS AND OBJECTIVES

To analyse postoperative delirium (POD) in clinical practice after cardiac surgery, how it is detected and documented and if the use of a screening scale improves the detection rate.

BACKGROUND

Cardiac surgery is considered a routine procedure with few complications. However, POD remains a concern, although often being overlooked in clinical practice.

DESIGN

Retrospective observational analysis.

METHODS

Patients 70 years and older with POD (n = 78) undergoing cardiac surgery were included in the study. Discharge summaries of both nurses and physicians were reviewed together with the clinical database for information about POD, to be compared with symptom screening using the Nursing Delirium Screening Scale (Nu-DESC). A quantitative content analysis was used for the review of discharge summaries, with a coding scheme adopted from the Nu-DESC method. The STROBE checklist was followed.

RESULTS

In discharge summaries, 41 of the 78 POD patients were correctly recognised, and 22 of these were identified in the clinical database. Screening by the Nu-DESC identified delirium at a measurably higher rate, 56/78 patients. The review of discharge summaries showed that patients expressing "inappropriate behaviour" was the most easily identified sign for POD for both nurses and physicians.

CONCLUSIONS

Healthcare professionals underdiagnose delirium after cardiac surgery, with a low detection rate described in both discharge summaries and in the clinical database. Recognition of delirium improved when Nu-DESC was used for systematic screening.

RELEVANCE TO CLINICAL PRACTICE

This study emphasises the need for better screening for the detection of delirium in daily clinical practice.

Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review

Importance

Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition.

Objectives

To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments.

Evidence Review

This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus.

Findings

Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale.

Conclusions and Relevance

The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.

Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients

ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology.

OBJECTIVES

We sought to determine how delirium subtyped by etiology affected six-month function and cognition.

DESIGN

Prospective cohort study.

SETTING

Tertiary care, academic medical center.

PARTICIPANTS

A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED).

MEASUREMENTS

The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition.

RESULTS

In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = -2.9 points, 95%CI: -0.3 to -5.6) and organ dysfunction (β coefficient = -4.3 points, 95%CI: -7.2 to -1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20).

CONCLUSIONS

Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.

A Novel Stress-Diathesis Model to Predict Risk of Post-operative Delirium: Implications for Intra-operative Management

Introduction: Risk assessment for post-operative delirium (POD) is poorly developed. Improved metrics could greatly facilitate peri-operative care as costs associated with POD are staggering. In this preliminary study, we develop a novel stress-diathesis model based on comprehensive pre-operative psychiatric and neuropsychological testing, a blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) carbon dioxide (CO₂) stress test, and high fidelity measures of intra-operative parameters that may interact facilitating POD. Methods: The study was approved by the ethics board at the University of Manitoba and registered at clinicaltrials.gov as NCT02126215. Twelve patients were studied. Pre-operative psychiatric symptom measures and neuropsychological testing preceded MRI featuring a BOLD MRI CO₂ stress test whereby BOLD scans were conducted while exposing participants to a rigorously controlled CO₂ stimulus. During surgery the patient had hemodynamics and end-tidal gases downloaded at 0.5 hz. Post-operatively, the presence of POD and POD severity was comprehensively assessed using the Confusion Assessment Measure -Severity (CAM-S) scoring instrument on days 0 (surgery) through post-operative day 5, and patients were followed up at least 1 month post-operatively. Results: Six of 12 patients had no evidence of POD (non-POD). Three patients had POD and 3 had clinically significant confusional states (referred as subthreshold POD; ST-POD) (score ≥ 5/19 on the CAM-S). Average severity for delirium was 1.3 in the non-POD group, 3.2 in ST-POD, and 6.1 in POD (F-statistic = 15.4, p < 0.001). Depressive symptoms, and cognitive measures of semantic fluency and executive functioning/processing speed were significantly associated with POD. Second level analysis revealed an increased inverse BOLD responsiveness to CO₂ pre-operatively in ST-POD and marked increase in the POD groups when compared to the non-POD group. An association was also noted for the patient population to manifest leucoaraiosis as assessed with advanced neuroimaging techniques. Results provide preliminary support for the interacting of diatheses (vulnerabilities) and intra-operative stressors on the POD phenotype. Conclusions: The stress-diathesis model has the potential to aid in risk assessment for POD. Based on these initial findings, we make some recommendations for intra-operative management for patients at risk of POD.