Recognition of Delirium in Postoperative Elderly Patients: A Multicenter Study

Preoperative Delirium Risk Screening in Patients Undergoing a Cardiac Surgery: Results from the Prospective Observational FINDERI Study

OBJECTIVE

Postoperative delirium (POD) is a common complication of cardiac surgery that is associated with higher morbidity, longer hospital stay, cognitive decline, and mortality. Preoperative assessments may help to identify patients´ POD risk. However, a standardized screening assessment for POD risk has not been established.

DESIGN

Prospective observational FINd DElirium RIsk factors (FINDERI) study.

PARTICIPANTS

Patients aged ≥50 years undergoing cardiac surgery.

MEASUREMENTS

The primary aim was to analyze the predictive value of the Delirium Risk Screening Questionnaire (DRSQ) prior to cardiac surgery. Secondary aims are to investigate cognitive, frailty, and geriatric assessments, and to use data-driven machine learning (ML) in predicting POD. Predictive properties were assessed using receiver operating characteristics analysis and multivariate approaches (regularized LASSO regression and decision trees).

RESULTS

We analyzed a data set of 504 patients (68.3 ± 8.2 years, 21.4% women) who underwent cardiac surgery. The incidence of POD was 21%. The preoperatively administered DRSQ showed an area under the curve (AUC) of 0.68 (95% CI 0.62, 0.73), and the predictive OR was 1.25 (95% CI 1.15, 1.35, p <0.001). Using a ML approach, a three-rule decision tree prediction model including DRSQ (score>7), Trail Making Test B (time>118), and Montreal Cognitive Assessment (score ≤ 22) was identified. The AUC of the three-rule decision tree on the training set was 0.69 (95% CI 0.63, 0.75) and 0.62 (95% CI 0.51, 0.73) on the validation set.

CONCLUSION

Both the DRSQ and the three-rule decision tree might be helpful in predicting POD risk before cardiac surgery.

Electroencephalogram Biomarkers from Anesthesia Induction to Identify Vulnerable Patients at Risk for Postoperative Delirium

BACKGROUND

Postoperative delirium is a common complication in elderly patients undergoing anesthesia. Even though it is increasingly recognized as an important health issue, the early detection of patients at risk for postoperative delirium remains a challenge. This study aims to identify predictors of postoperative delirium by analyzing frontal electroencephalogram at propofol-induced loss of consciousness.

METHODS

This prospective, observational single-center study included patients older than 70 yr undergoing general anesthesia for a planned surgery. Frontal electroencephalogram was recorded on the day before surgery (baseline) and during anesthesia induction (1, 2, and 15 min after loss of consciousness). Postoperative patients were screened for postoperative delirium twice daily for 5 days. Spectral analysis was performed using the multitaper method. The electroencephalogram spectrum was decomposed in periodic and aperiodic (correlates to asynchronous spectrum wide activity) components. The aperiodic component is characterized by its offset (y intercept) and exponent (the slope of the curve). Computed electroencephalogram parameters were compared between patients who developed postoperative delirium and those who did not. Significant electroencephalogram parameters were included in a binary logistic regression analysis to predict vulnerability for postoperative delirium.

RESULTS

Of 151 patients, 50 (33%) developed postoperative delirium. At 1 min after loss of consciousness, postoperative delirium patients demonstrated decreased alpha (postoperative delirium: 0.3 μV2 [0.21 to 0.71], no postoperative delirium: 0.55 μV2 [0.36 to 0.74]; P = 0.019] and beta band power [postoperative delirium: 0.27 μV2 [0.12 to 0.38], no postoperative delirium: 0.38 μV2 [0.25 to 0.48]; P = 0.003) and lower spectral edge frequency (postoperative delirium: 10.45 Hz [5.65 to 15.04], no postoperative delirium: 14.56 Hz [9.51 to 16.65]; P = 0.01). At 15 min after loss of consciousness, postoperative delirium patients displayed a decreased aperiodic offset (postoperative delirium: 0.42 μV2 (0.11 to 0.69), no postoperative delirium: 0.62 μV2 [0.37 to 0.79]; P = 0.004). The logistic regression model predicting postoperative delirium vulnerability demonstrated an area under the curve of 0.73 (0.69 to 0.75).

CONCLUSIONS

The findings suggest that electroencephalogram markers obtained during loss of consciousness at anesthesia induction may serve as electroencephalogram-based biomarkers to identify at an early time patients at risk of developing postoperative delirium.

EDITOR’S PERSPECTIVE

Inactivity May Identify Older Intensive Care Unit Survivors at Risk for Post-Intensive Care Syndrome

BACKGROUND

Older adults (≥age 65) admitted to an intensive care unit (ICU) are profoundly inactive during hospitalization. Older ICU survivors often experience life-changing symptoms, including cognitive dysfunction, physical impairment, and/or psychological distress, which are components of post-intensive care syndrome (PICS).

OBJECTIVES

To explore trends between inactivity and symptoms of PICS in older ICU survivors.

METHODS

This study was a secondary analysis of pooled data obtained from 2 primary, prospective, cross-sectional studies of older ICU survivors. After ICU discharge, 49 English- and Spanish-speaking participants who were functionally independent before admission and who had received mechanical ventilation while in the ICU were enrolled. Actigraphy was used to measure post-ICU hourly activity counts (12:00 AM to 11:59 PM). Selected instruments from the National Institutes of Health Toolbox and Patient-Reported Outcomes Measurement Information System were used to assess symptoms of PICS: cognitive dysfunction, physical impairment, and psychological distress.

RESULTS

Graphs illustrated trends between inactivity and greater symptom severity of PICS: participants who were less active tended to score worse than one standard deviation of the mean on each outcome. Greater daytime activity was concurrently observed with higher performances on cognitive and physical assessments and better scores on psychological measures.

CONCLUSIONS

Post-ICU inactivity may identify older ICU survivors who may be at risk for PICS and may guide future research interventions to mitigate symptom burden.

DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study

OBJECTIVES

To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs).

DESIGN

Prospective cross-sectional study.

SETTING

Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals.

PARTICIPANTS

494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious.

MEASUREMENTS

DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets.

METHODS

Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus.

RESULTS

DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity.

CONCLUSIONS

DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.

Prophylactic effect of exogenous melatonin and melatonin receptor agonists on postoperative delirium in elderly patients: a systemic review and meta-analysis of randomized controlled trials

BACKGROUND

The prophylactic effect of exogenous melatonin and melatonin receptor agonists (MMRAs) on postoperative delirium (POD) in elderly patients remains controversial.

OBJECTIVE

This study aimed to assess the prophylactic effect of MMRAs on POD by conducting a systemic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We systematically searched four electronic databases including PubMed, Web of Science, Cochrane Library, and Embase for the eligible studies up to February 28, 2023. The Cochrane risk of bias tool was used for assessing the risk of bias in the included RCTs. The occurrence of POD was the primary outcome. The quality of evidence was evaluated by Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

A total of 11 RCTs comprising patients (MMRA group: 777 patients and placebo group: 781 patients) were included. The results of the meta-analysis showed that the MMRA group had a lower occurrence of POD than the placebo group (risk ratio = 0.70, 95% confidence interval: 0.51-0.97, P < 0.05, I2 = 59%). The subgroup analysis showed that melatonin significantly reduced the occurrence of POD (moderate-quality evidence), whereas ramelteon and tryptophan had no significant impact (moderate-quality evidence).

CONCLUSION

Existing evidence suggested that perioperative use of melatonin can prevent POD in elderly patients.

Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives

BACKGROUND

Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units.

METHODS

This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets.

RESULTS

Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization.

CONCLUSION

At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

The Delirium Interview as a new reference standard in studies on delirium assessment tools

BACKGROUND

The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports.

METHODS

We tested the diagnostic accuracy of our standardized Delirium Interview by comparing delirium assessments of the reported results with live assessments. Our reference, the live assessment, was performed by two delirium experts and one well-trained researcher who registered the results. Their delirium assessment was compared to the majority vote of three other independent delirium experts who judged the rapportage of the Delirium Interview. Our total pool consisted of 13 delirium experts with an average of 13 ± 8 years of experience.

RESULTS

We included 98 patients (62% male, mean age 69 ± 12 years), of whom 56 (57%) intensive care units (ICUs) patients, 22 (39%) patients with a Richmond Agitation Sedation Scale (RASS) < 0 and 26 (27%) non-verbal assessments. The overall prevalence of delirium was 28%. The Delirium Interview had a sensitivity of 89% (95% confidence interval [CI]: 71%-98%) and specificity of 82% (95% CI: 71%-90%), compared to the diagnosis of an independent panel of two delirium experts and one researcher who examined the patients themselves. Negative and positive predictive values were 95% (95% CI: 86%-0.99%), respectively, 66% (95% CI: 49%-80%). Stratification into ICU and non-ICU patients yielded similar results.

CONCLUSION

The Delirium Interview is a feasible reference method for large study cohorts evaluating delirium assessment tools since experts could assess delirium with high accuracy without seeing the patient at the bedside.

Anesthetic Practice Trends and Perceptions Toward Postoperative Delirium: A Mixed-Methods Analysis

BACKGROUND

Delirium is the most common postoperative complication in older adults, though anesthesiologist awareness of delirium prevention guidelines-and associated practice trends-remains unknown.

METHODS

This was a convergent mixed-methods study, which simultaneously analyzed quantitative and qualitative data to determine delirium guideline awareness among anesthesiologists and practice patterns based on guideline recommendations. Quantitative data were abstracted from the Multicenter Perioperative Outcomes Group database for noncardiac surgery patients (2009-2020) aged 65 years and older. Linear trends were reported for select guideline-based delirium prevention recommendations via regression modeling. Anesthesiologists (n = 40) from a major academic center without a structured delirium reduction program on hospital wards were then surveyed regarding knowledge and practices with respect to postoperative delirium. For qualitative data, 3 focus groups were held to further discuss guideline awareness and identify challenges with delirium prevention.

RESULTS

Quantitative results demonstrated a significant decline in the proportion of cases with midazolam between 2009 and 2020, with the largest decrease observed with urologic surgeries (-3.9%/y; 95% confidence interval [CI], -4.2 to -3.6; P < .001). Use of regional anesthesia increased over this period, particularly with gynecologic surgeries (+2.3%/y; 95% CI, 1.2-3.4; P = .001). Anesthesiologist survey results revealed variable guideline awareness, as 21 of 39 (54%) respondents reported being aware of guidelines for anesthetic management of older adults. Importantly, unawareness of delirium management guidelines was the most frequently cited challenge (17 of 37, 46%) when caring for older adults. Finally, focus group participants were largely unaware of postoperative delirium guidelines. However, participants conveyed key barriers to delirium identification and prevention, including the unclear pathophysiology, nonmodifiable risk factors, and system-based hospital challenges. Participants also expressed a desire for decision-support systems, integrated within the perioperative workflow, that provide evidence-based recommendations for reducing delirium risk.

CONCLUSIONS

Perioperative practice trends are indicative of an improving environment for postoperative delirium. However, delirium guideline awareness remains variable among anesthesiologists, and key barriers continue to exist for identifying and preventing postoperative delirium.

The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery.

METHODS

A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology.

RESULTS

Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events.

CONCLUSIONS

No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.

Delirium in hospitalised adults with acute burns - A systematic review

INTRODUCTION

Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research.

METHODS

A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality.

RESULTS

Investigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias.

CONCLUSION

Delirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.

Delirium detection methodologies: Implications for outcome measurement in clinical trials in postoperative delirium

OBJECTIVE

Delirium is a common postoperative complication of hip fracture. Various methods exist to detect delirium as a reference standard. The goal of this study was to characterize the properties of the measures obtained in a randomized controlled trial, to document their relationship to the Diagnostic and Statistical Manual of Mental Disorders:Text Revision based diagnosis of postoperative delirium by a consensus panel, and to describe the method in detail to allow replication by others.

METHODS

A secondary analysis of the randomized trial STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) was conducted. Delirium assessments were performed in 200 consecutive hip fracture repair patients ≥65 years old. Assessors underwent extensive training in delirium assessment and the final delirium diagnosis was adjudicated by a consensus panel of three physicians with expertise in delirium assessment.

RESULTS

A total of 680 consensus panel delirium diagnoses were completed. There were only 19 (2.8%, 19/678) evaluations where the delirium adjudication by the consensus panel differed from delirium findings by the Confusion Assessment Method (CAM). In 16 (84%, 16/19) of the cases, CAM was negative but the consensus panel diagnosed the patient as having delirium based on all of the available information including the CAM.

CONCLUSION

The consensus panel diagnosis was more sensitive compared to CAM alone, however the magnitude of the difference was not large. When assessors are well trained and delirium assessments are closely supervised throughout the study, CAM may be adequate for delirium diagnosis in a clinical trial. Future studies are needed to test this hypothesis.

The effects of interactive E-learning on delirium recognition ability and delirium-related strain of care among critical care nurses

Background

Nursing care for patients with delirium is very complex and stressful and is associated with considerable care strain for nurses. Delirium recognition is the first step to the prevention and management of delirium and reduction of strain of care. Education is one of the strategies for improving nurses' delirium recognition ability.

Objectives

This study aimed to evaluate the effects of interactive E-learning on delirium recognition ability and delirium-related strain of care among critical care nurses.

Methods

This quasi-experimental study was conducted in 2019 using a two-group pretest-posttest design. Participants were 98 critical care nurses recruited through a census from two hospitals in Iran. They were non-randomly allocated to an intervention and a control group. Study intervention was an interactive E-learning program with four parts on delirium, its prevention, its treatment, and its diagnostic and screening procedures. The program was uploaded on a website and its link was provided to participants in the intervention group. Before and two months after the intervention, data were collected using the Strain of Care for Delirium Index and five case vignettes. For data analysis, the Chi-square, Fisher's exact, independent-sample t, and paired-sample t tests were performed usingthe SPSS software (v. 16.0).

Findings

Groups did not significantly differ from each other regarding the pretest mean scores of delirium recognition ability and strain of care. After the intervention, the mean score of delirium recognition ability in the intervention group was significantly greater and the mean score of strain of care was significantly lower than the control group (P < 0.05).

Conclusion

Interactive E-learning is effective in significantly improving critical care nurses' delirium recognition ability and reducing their strain of care. As nurses' heavy workload and limited free time are among the main barriers to their participation in face-to-face educational programs, interactive E-learning can be used for in-service education.

Understanding Disorders of Consciousness: Opportunities for Critical Care Nurses

BACKGROUND

Disorders of consciousness are powerful predictors of outcomes including mortality among critically ill patients. Encephalopathy, delirium, and coma are disorders of consciousness frequently encountered by critical care nurses but often classified incorrectly.

OBJECTIVE

To provide a greater understanding of disorders of consciousness and to provide standardized assessments and nursing interventions for these disorders.

METHODS

A literature search was conducted by using the terms consciousness, mental status, awareness, arousal, wakefulness, assessment, disorders of consciousness, delirium, encephalopathy, coma, vegetative state, and minimal consciousness. Articles were published in the past 10 years in CINAHL and PubMed. Articles were excluded if they were not in English or directly related to caring for patients with a disorder of consciousness. The remaining 142 articles were evaluated for inclusion; 81 articles received full review.

RESULTS

A disorder of consciousness signifies that the threshold for compensation has been surpassed with potentially irreversible damage. Altered thalamocortical interactions and reduced cortical activity impair communication networks across the various parts of the brain, causing a disturbance in consciousness.

DISCUSSION

The cue-response theory is a model that describes the process and impact of nursing care on recovery from acute brain injury. Appropriate standardized assessments and interventions must be used to manage altered levels of consciousness in critically ill patients.

CONCLUSIONS

Paying close attention to neurological changes and monitoring them with standardized assessments are critical to implementing early measures to prevent complications.

A delirium prevalence audit and a pre and post evaluation of an interprofessional education intervention to increase staff knowledge about delirium in older adults

Background

Delirium is more prevalent in older people and estimated to occur in up to 50% of the hospital population. Delirium comprises a spectrum of behaviours, including cognitive and attention deficits, and fluctuating levels of consciousness, often associated with an underlying physiological disturbance. Delirium has been increasingly associated with adverse outcomes. Although often preventable or can at least be mitigated, delirium may not be a standard part of assessment and thus may not be recognized in the early stages when it is most likely to be treated successfully. The aim of this study was to evaluate the level of knowledge of delirium amongst clinicians caring for patients at high risk of developing delirium and to determine whether education can improve clinical assessment of delirium.

Methods

Two hundred and forty-six case notes were audited before and 149 were reviewed after the education intervention and implementation of a delirium screening tool. Clinicians at the hospital were invited to complete a questionnaire on knowledge of delirium. The questionnaire was based on a validated tool which contained 39 questions about delirium. The questionnaire also contained 28 questions on delirium knowledge. Additional questions were included to gather demographic information specific to the hospital. Descriptive statistics, chi square and independent t-tests were conducted to test for differences in knowledge between the pre and post periods. The Squire Checklist Reporting Guidelines for Quality Improvement Studies informed the preparation of the manuscript.

Results

The audit demonstrated that the use of a cognitive assessment tool overall increased from 8.5% in pre education to 43% in the post education period. One hundred and fifty-nine staff completed the questionnaire in total, 118 the pre and 41 post. The knowledge subscale score was high pre and post education and no statistically significant difference was observed. The greatest increase in knowledge was related to knowledge of the risk factors subscale. The increase in knowledge (6.8%) was statistically significant.

Conclusion

An interprofessional approach to delirium education was effective in not only increasing awareness of the factors associated with this syndrome but also increased the use of a delirium assessment tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00692-2.

Physiological Assessment of Delirium Severity: The Electroencephalographic Confusion Assessment Method Severity Score (E-CAM-S)

OBJECTIVES

Delirium is a common and frequently underdiagnosed complication in acutely hospitalized patients, and its severity is associated with worse clinical outcomes. We propose a physiologically based method to quantify delirium severity as a tool that can help close this diagnostic gap: the Electroencephalographic Confusion Assessment Method Severity Score (E-CAM-S).

DESIGN

Retrospective cohort study.

SETTING

Single-center tertiary academic medical center.

PATIENTS

Three-hundred seventy-three adult patients undergoing electroencephalography to evaluate altered mental status between August 2015 and December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We developed the E-CAM-S based on a learning-to-rank machine learning model of forehead electroencephalography signals. Clinical delirium severity was assessed using the Confusion Assessment Method Severity (CAM-S). We compared associations of E-CAM-S and CAM-S with hospital length of stay and inhospital mortality. E-CAM-S correlated with clinical CAM-S (R = 0.67; p < 0.0001). For the overall cohort, E-CAM-S and CAM-S were similar in their strength of association with hospital length of stay (correlation = 0.31 vs 0.41, respectively; p = 0.082) and inhospital mortality (area under the curve = 0.77 vs 0.81; p = 0.310). Even when restricted to noncomatose patients, E-CAM-S remained statistically similar to CAM-S in its association with length of stay (correlation = 0.37 vs 0.42, respectively; p = 0.188) and inhospital mortality (area under the curve = 0.83 vs 0.74; p = 0.112). In addition to previously appreciated spectral features, the machine learning framework identified variability in multiple measures over time as important features in electroencephalography-based prediction of delirium severity.

CONCLUSIONS

The E-CAM-S is an automated, physiologic measure of delirium severity that predicts clinical outcomes with a level of performance comparable to conventional interview-based clinical assessment.

Research status and prospect of peri-extubation delirium

Peri-extubation delirium is a clinical syndrome caused by multiple factors, and it is not a simple disease. It occurs within a period of time after extubation when the effect of general anesthesia is reduced. And the incidence is different in disparate populations, and it is more common in elderly patients. Current studies have shown that iatrogenic factors and patients' own factors are the main risk factors for the syndrome. Early identification of risk factors can help clinicians make early diagnosis. The earlier the diagnosis and treatment begin, the more significantly the prognosis of patients can be improved. At present, the treatment of perioperative delirium is based on non-drug therapy, supplemented by drug therapy. This review will introduce in detail the risk factors, population status and prevention measures of delirium during peri-extubation, and look forward to the new research direction in the future.

Development and validation of a risk score for predicting postoperative delirium after major abdominal surgery by incorporating preoperative risk factors and surgical Apgar score

STUDY OBJECTIVE

To develop and validate a simple delirium-predicting scoring system in patients undergoing major abdominal surgery by incorporating preoperative risk factors and intraoperative surgical Apgar score (SAS).

DESIGN

Observational retrospective cohort study.

SETTING

A tertiary general hospital in China.

PATIENTS

1055 patients who received major abdominal surgery from January 2015 to December 2019.

MEASUREMENTS

We collected data on preoperative and intraoperative variables, and postoperative delirium. A risk scoring system for postoperative delirium in patients after major open abdominal surgery was developed and validated based on traditional logistic regression model. The elastic net algorithm was further developed and evaluated.

MAIN RESULTS

The incidence of postoperative delirium was 17.8% (188/1055) in these patients. They were randomly divided into the development (n = 713) and validation (n = 342) cohorts. Both the logistic regression model and the elastic net regression model identified that advanced age, arrythmia, hypoalbuminemia, coagulation dysfunction, mental illness or cognitive impairments and low surgical Apgar score are related with increased risk of postoperative delirium. The elastic net algorithm has an area under the receiver operating characteristic curve (AUROC) of 0.842 and 0.822 in the development and validation cohorts, respectively. A prognostic score was calculated using the following formula: Prognostic score = Age classification (0 to 3 points) + arrythmia + 2 * hypoalbuminemia + 2 * coagulation dysfunction + 4 * mental illness or cognitive impairments + (10-surgical Apgar score). The 22-point risk scoring system had good discrimination and calibration with an AUROC of 0.823 and 0.834, and a non-significant Hosmer-Lemeshow test P = 0.317 and P = 0.853 in the development and validation cohorts, respectively. The bootstrapping internal verification method (R = 1000) yielded a C-index of 0.822 (95% CI: 0.759-0.857).

CONCLUSION

The prognostic scoring system, which used both preoperative risk factors and surgical Apgar score, serves as a good first step toward a clinically useful predictive model for postoperative delirium in patients undergoing major open abdominal surgery.

Daytime activity and sleep are associated with motor function in older intensive care unit survivors

BACKGROUND

Hospitalized older intensive care unit (ICU) survivors are often inactive and experience sleep disturbances.

OBJECTIVE

We explored associations between post-ICU activity, sleep/rest, and motor function among hospitalized older ICU survivors.

METHODS

We enrolled 30 older ICU survivors, ages 65 and older, within 24-48 h of ICU discharge. Actigraphy measured post-ICU activity and sleep/rest. Selected measures from the National Institutes of Health Toolbox Motor Battery assessed grip strength and dexterity. Multivariate regression examined associations between post-ICU activity, sleep/rest, and motor function, adjusting for covariates.

RESULTS

Lower daytime activity (β = 0.258, p = .035) and greater daytime sleep/rest (β = -0.295, p = .022) were associated with worse grip strength. Lower daytime activity (β = -0.376, p = .037) and greater daytime sleep/rest (β = 0.409, p = .026) were associated with worse dexterity.

CONCLUSION

Post-ICU inactivity and prolonged rest periods are associated with worse motor function in hospitalized older ICU survivors.

Risk Factors of Postoperative Delirium in Older Adult Spine Surgery Patients: A Meta-Analysis

This literature review identifies factors that may place older adult patients at risk for developing delirium after spine surgery. We conducted a meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using a variety of electronic databases, we identified five studies for inclusion that represent 645 patients who were 65 years or older. The pooled incidence rate of postoperative delirium was 13.0%. Factors associated with developing postoperative delirium included preoperative opioid use, cervical spine surgery versus lumbar or thoracic spine surgery, spine fusion versus simple spine surgery, hypertension, cerebrovascular disease, pulmonary disease, duration of surgery, and infused IV fluid volume. Nurses who provide perioperative care for older adult patients undergoing spine surgery should be aware of the potential risk factors of delirium to ensure patient safety. Further research is required to clearly delineate the risk factors for postoperative delirium in older adults.

Implementing Delirium Screening in an Intermediate Care Unit

BACKGROUND

Delirium occurs in as many as 82% of hospitalized patients. Use of a valid and reliable tool allows for early detection and management to mitigate adverse effects, including a decrease in patient falls.

OBJECTIVE

To conduct a quality improvement project to implement the confusion assessment method (CAM) tool in an intermediate care unit and measure delirium screening compliance, feasibility of the tool, and the effect on reported patient falls.

METHODS

Web-based training using a 14-item pre-post assessment for knowledge comprehension. The CAM tool was added to the electronic health record (EHR), and documentation compliance was measured for eight weeks. Afterwards, a nurse perception survey was distributed, and 60-day pre- and post-intervention patient falls were compared.

RESULTS

Forty-seven nurses completed the training. Post-test averages were higher than the pre-test (p = .16); five answers showed significant improvement (p < .02). Screening and documentation compliance were 79.1%. Twenty-one nurses completed the perception survey, demonstrating agreement that delirium CAM screening is a feasible intervention. Patient falls were reduced by 57%.

CONCLUSION

Addition of the CAM tool into the EHR-enhanced screening compliance.

IMPLICATIONS FOR NURSING

Early delirium detection may reduce patient falls. The CAM is a feasible instrument and delirium screening is a worthwhile intervention.

Roadmap for Conducting Neuroscience Research in the COVID-19 Era and Beyond: Recommendations From the SNACC Research Committee

The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of neuroscience research. At the 2020 Society of Neuroscience in Anesthesiology and Critical Care (SNACC) Annual Meeting, the SNACC Research Committee met virtually to discuss research challenges encountered during the COVID-19 pandemic along with possible strategies for facilitating research activities. These challenges and recommendations are included in this Consensus Statement. The objectives are to: (1) provide an overview of the disruptions and challenges to neuroscience research caused by the COVID-19 pandemic, and; (2) put forth a set of consensus recommendations for strengthening research sustainability during and beyond the current pandemic. Specific recommendations are highlighted for adapting laboratory and human subject study activities to optimize safety. Complementary research activities are also outlined for both laboratory and clinical researchers if specific investigations are impossible because of regulatory or societal changes. The role of virtual platforms is discussed with respect to fostering new collaborations, scheduling research meetings, and holding conferences such that scientific collaboration and exchange of ideas can continue. Our hope is for these recommendations to serve as a valuable resource for investigators in the neurosciences and other research disciplines for current and future research disruptions.

Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors

BACKGROUND

Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit.

OBJECTIVE

To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors.

METHODS

The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates.

RESULTS

The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = -0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = -0.373, P = .008) were negatively associated with DCCST scores.

CONCLUSIONS

The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.

Delirium in Emergency Departments: Is it Recognized?

BACKGROUND

Delirium is a complex neurocognitive manifestation of an underlying medical or surgical abnormality such as substance abuse, infection, sepsis, or organ failure. A recognized risk factor for delirium is advanced age (age >65 years). The projected demographic changes over the next 2 decades suggest that the number of aging adults will grow dramatically, and emergency nurses will see an increasing number of older patients manifesting the wide range of neuropsychiatric symptoms associated with delirium.

METHOD

An examination of 5 commonly used delirium assessment tools was undertaken specific to clinical features, use, scoring, findings, advantages, and disadvantages.

FINDINGS

Numerous factors contribute to the lack of effective delirium recognition. However, emergency nurses, with educational support, can successfully use the delirium assessment tools to recognize delirium.

CONCLUSION

Emergency nurses face challenges in recognizing delirium. One key challenge for many of these nurses is the appropriate use of assessment tools suitable for the ED setting.

Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium

BACKGROUND

Delirium is a common postoperative complication in geriatric patients, especially in those with underlying risk factors. Multicomponent nonpharmacologic interventions are effective in preventing delirium, however, implementation of these measures is variable in perioperative care. The aim of our study was to assess the impact of our Perioperative Optimization of Senior Health Program (UTSW POSH) on postoperative delirium in patients undergoing elective spine surgery.

STUDY DESIGN

The UTSW POSH program is an interdisciplinary perioperative initiative involving geriatrics, surgery, and anesthesiology to improve care for high-risk geriatric patients undergoing elective spine surgery. Preoperatively, enrolled patients (n = 147) were referred for a geriatric assessment and optimization for surgery. Postoperatively, patients were co-managed by the primary surgical team and the geriatrics consult service. UTSW POSH patients were retrospectively compared to a matched historical control group (n = 177) treated with usual care. Main outcomes included postoperative delirium and provider recognition of delirium.

RESULTS

UTSW POSH patients were significantly older (75.5 vs 71.5 years; P < .001), had more comorbidities (8.02 vs 6.58; P < .001), and were more likely to undergo pelvic fixation (36.1% vs 17.5%; P < .001). The incidence of postoperative delirium was lower in the UTSW POSH group compared to historical controls, although not statistically significant (11.6% vs 19.2%; P = .065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N = 106) in the UTSW POSH group (11.7% vs 28.9%, P = .03). There was a threefold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs 23.5%; P = .001).

CONCLUSIONS

This study suggests that interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.

A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons

BACKGROUND/OBJECTIVES

The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium.

DESIGN

Hypothesis testing was carried out using a pretest-posttest design on program administrative data.

SETTING

Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium.

INTERVENTION

A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system.

MEASUREMENTS

Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units.

RESULTS

There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units.

CONCLUSION

Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.

Executive Function, Dexterity, and Discharge Disposition in Older Intensive Care Unit Survivors

BACKGROUND

Dexterity is a component of motor function. Executive function, a subdomain of cognition, may affect dexterity in older adults recovering from critical illness after discharge from an intensive care unit (ICU).

OBJECTIVES

To explore associations between executive function (attention and cognitive flexibility) and dexterity (fine motor coordination) in the early post-ICU period and examine dexterity by acuity of discharge disposition.

METHODS

The study involved 30 older adults who were functionally independent before hospitalization, underwent mechanical ventilation in the ICU, and had been discharged from the ICU 24 to 48 hours previously. Dexterity was evaluated with the National Institutes of Health Toolbox (NIHTB) Motor Battery 9-Hole Pegboard Dexterity Test (PDT); attention, with the NIHTB Cognition Battery Flanker Inhibitory Control and Attention Test (FICAT); and cognitive flexibility, with the NIHTB Cognition Battery Dimensional Change Card Sort Test (DCCST). Exploratory regression was used to examine associations between executive function and dexterity (fully corrected T scores). Independent-samples t tests were used to compare dexterity between participants discharged home and those discharged to a facility.

RESULTS

FICAT (β = 0.375, P = .03) and DCCST (β = 0.698, P = .001) scores were independently and positively associated with PDT scores. Further, PDT scores were worse among participants discharged to a facility than among those discharged home (mean [SD], 26.71 [6.14] vs 36.33 [10.30]; t24 = 3.003; P = .006).

CONCLUSIONS

Poor executive function is associated with worse dexterity; thus, dexterity may be a correlate of both post-ICU cognitive impairment and functional decline. Performance on dexterity tests could identify frail older ICU survivors at risk for worse discharge outcomes.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study

BACKGROUND

Preventing dementia onset is one of the global public health priorities: around 35% of dementia cases could be attributable to modifiable risk factors. These estimates relied on secondary data and did not consider the concurrent effect of non-modifiable factors and death. Here, we aimed to estimate the potential reduction of dementia incidence due to modifiable risk factors elimination, controlling for non-modifiable risk factors and for the competing risk of death.

METHODS

Participants from the InveCe.Ab population-based prospective cohort (Abbiategrasso, Italy) without a baseline dementia diagnosis and attending at least one follow-up visit were included (N = 1100). Participants underwent multidimensional assessment at baseline and after 2, 4, and 8 years, from November 2009 to January 2019. Modifiable risk factors were low education, obesity, hypertension, diabetes, depression, smoking, physical inactivity, hearing loss, loneliness, heart disease, stroke, head injury, and delirium. Non-modifiable risk factors were age, sex, and APOE ε4 genotype. The primary endpoint was dementia diagnosis within the follow-up period (DSM-IV criteria). We performed competing risk regression models to obtain sub-hazard ratio (SHR) for each exposure, with death as competing risk. The exposures associated with dementia were included in a multivariable model to estimate their independent influence on dementia and the corresponding population attributable fraction (PAF).

RESULTS

Within the study period (mean follow-up, 82.3 months), 111 participants developed dementia (10.1%). In the multivariable model, APOE ε4 (SHR = 1.89, 95% CI 1.22-2.92, p = 0.005), diabetes (SHR = 1.56, 95% CI 1.00-2.39, p = 0.043), heart disease (SHR = 1.56, 95% CI 1.03-2.36, p = 0.037), stroke (SHR = 2.31, 95% CI 1.35-3.95, p = 0.002), and delirium (SHR = 8.70, 95% CI 3.26-23.24, p <  0.001) were independently associated with increased dementia risk. In the present cohort, around 40% of dementia cases could be attributable to preventable comorbid diseases.

CONCLUSIONS

APOE ε4, diabetes, heart disease, stroke, and delirium independently increased the risk of late-life dementia, controlling for the competing risk of death. Preventive intervention addressed to these clinical populations could be an effective approach to reduce dementia incidence. Further studies on different population-based cohort are needed to obtain more generalizable findings of the potential of dementia prevention in the real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01345110 .

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.

Effects of Dexmedetomidine on Postoperative Delirium and Expression of IL-1β, IL-6, and TNF-α in Elderly Patients After Hip Fracture Operation

Objective

Postoperative delirium (POD) is a common surgical complication in elderly patients. This study investigated the effects of dexmedetomidine on POD and pro-inflammatory markers in elderly patients with hip fracture.

Methods

This randomized, double-blind, controlled trial enrolled patients ≥65 years of age who underwent an operation for hip fracture at Beijing JiShuiTan Hospital from October 2016 to January 2017. The patients were divided into the DEX group (injected with dexmedetomidine 0.5 µg/kg/h) and the NS group (injected with normal saline). After surgery, the incidence of delirium at postoperative day 1 (T1), 2 (T2), and 3 (T3) was assessed using the Confusion Assessment Method delirium scale. Interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α blood levels were detected at T0 (before surgery), T1, and T3.

Results

Data from 240 patients were analyzed, with 120/group (intent-to-treat analysis). Dexmedetomidine decreased POD incidence (18.2 vs. 30.6%, P = 0.033). Compared to T0, all three pro-inflammatory markers were higher at T1 and then decreased at T3 (time interaction, all P < 0.001). IL-6 (P < 0.001) levels were lower in the DEX group at T1, and TNF-α (P = 0.003) levels were lower in the DEX group at T1 and T3, but IL-1β levels were similar between the two groups. The rate of adverse events was similar in the two groups.

Conclusion

Dexmedetomidine reduced the incidence of POD in elderly patients on the first day after hip fracture surgery, and reduced IL-6 and TNF-α levels over the first 3 days after surgery.

Postoperative management considerations of the elderly patient undergoing orthopaedic surgery

INTRODUCTION

The elderly population is rapidly increasing, corresponding to an increase in orthopaedic surgical procedures for this group of patients. Current guidelines mostly concentrate on the patient's age when considering surgical fitness in the elderly. However, patient frailty may be a more significant factor when assessing postoperative risk in surgical management. In this article, we will analyse some of the factors associated with the postoperative care of the geriatric population after orthopaedic surgery.

METHODS

This manuscript summarizes a presentation from the 2019 Osteosynthesis and Trauma Care (OTC) meeting in Toronto, ON, given by an invited presenter on the topic of Postoperative medical management of the geriatric patient undergoing orthopaedic surgery. The information in the presentation is based on current literature and available guidelines.

RESULTS

Highlighted were factors that can have a significant impact on the management and outcomes of elderly patients undergoing orthopaedic surgery. These included: cognitive impairment, postoperative analgesic control, pulmonary complications, falls, nutrition optimization, urinary tract infections, pressure ulcers, and functional decline.

CONCLUSION

There is a higher rate of postoperative complications in the surgical management of the elderly, and thus, special considerations following orthopaedic surgery in this patient group are necessary. Determining patient frailty based on clinical judgment using specific postoperative considerations could be a more reliable method in determining the surgical risk in the elderly patient. Additionally, more attention needs to be diverted towards early mobilization and patient education, as these factors can significantly help to avoid some of the postoperative complications that seem to affect the geriatric population.

Predisposition for delirium and EEG characteristics

OBJECTIVE

Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our understanding of development of delirium, we studied whether non-delirious individuals with a predisposition for delirium also show these EEG abnormalities.

METHODS

Elderly subjects (N = 206) underwent resting-state EEG measurements and were assessed on predisposing delirium risk factors, i.e. older age, alcohol misuse, cognitive impairment, depression, functional impairment, history of stroke and physical status. Delirium-related EEG characteristics of interest were relative delta power, alpha connectivity strength (phase lag index) and network integration (minimum spanning tree leaf fraction). Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and EEG characteristics that are associated with delirium, adjusting for confounding and multiple testing.

RESULTS

Functional impairment was related to a decrease in connectivity strength (adjusted R² = 0.071, β = 0.201, p < 0.05). None of the other risk factors had significant influence on EEG delta power, connectivity strength or network integration.

CONCLUSIONS

Functional impairment seems to be associated with decreased alpha connectivity strength. Other predisposing risk factors for delirium had no effect on the studied EEG characteristics.

SIGNIFICANCE

Predisposition for delirium is not consistently related to EEG characteristics that can be found during delirium.

A smartphone-based test for the assessment of attention deficits in delirium: A case-control diagnostic test accuracy study in older hospitalised patients

BACKGROUND

Delirium is a common and serious acute neuropsychiatric syndrome which is often missed in routine clinical care. Inattention is the core cognitive feature. Diagnostic test accuracy (including cut-points) of a smartphone Delirium App (DelApp) for assessing attention deficits was assessed in older hospital inpatients.

METHODS

This was a case-control study of hospitalised patients aged ≥65 years with delirium (with or without pre-existing cognitive impairment), who were compared to patients with dementia without delirium, and patients without cognitive impairment. Reference standard delirium assessment, which included a neuropsychological test battery, was based on Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A separate blinded assessor administered the DelApp arousal assessment (score 0-4) and attention task (0-6) yielding an overall score of 0 to 10 (lower scores indicate poorer performance). Analyses included receiver operating characteristic curves and sensitivity and specificity. Optimal cut-points for delirium detection were determined using Youden's index.

RESULTS

A total of 187 patients were recruited, mean age 83.8 (range 67-98) years, 152 (81%) women; n = 61 with delirium; n = 61 with dementia without delirium; and n = 65 without cognitive impairment. Patients with delirium performed poorly on the DelApp (median score = 4/10; inter-quartile range 3.0, 5.5) compared to patients with dementia (9.0; 5.5, 10.0) and those without cognitive impairment (10.0; 10.0, 10.0). Area under the curve for detecting delirium was 0.89 (95% Confidence Interval 0.84, 0.94). At an optimal cut-point of ≤8, sensitivity was 91.7% (84.7%, 98.7%) and specificity 74.2% (66.5%, 81.9%) for discriminating delirium from the other groups. Specificity was 68.3% (56.6%, 80.1%) for discriminating delirium from dementia (cut-point ≤6).

CONCLUSION

Patients with delirium (with or without pre-existing cognitive impairment) perform poorly on the DelApp compared to patients with dementia and those without cognitive impairment. A cut-point of ≤8/10 is suggested as having optimal sensitivity and specificity. The DelApp is a promising tool for assessment of attention deficits associated with delirium in older hospitalised adults, many of whom have prior cognitive impairment, and should be further validated in representative patient cohorts.

Perioperative Epidural Use and Risk of Delirium in Surgical Patients: A Secondary Analysis of the PODCAST Trial

BACKGROUND

Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3.

METHODS

This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding.

RESULTS

In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32-1.35]; P = .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17-0.78]; P = .009). Adjusted pain scores (visual analog scale, 0-100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, -16 [95% CI, -26 to -7], P < .001; afternoon, -15 [95% CI, -25 to -5], P < .01) and postoperative day 3 (morning, -13 [95% CI, -20 to -5], P < .01). Adjusted mean oral and IV morphine equivalents were also significantly lower on postoperative day 1 in the epidural group (74% lower [95% CI, 55%-85%]; P < .0001). Finally, postoperative epidural use was not significantly associated with new sleep disturbances or changes in depression symptoms.

CONCLUSIONS

Postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption. An appropriately designed follow-up study is warranted to further analyze the relationship among epidural use, postoperative delirium, and related outcomes.

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.

Recent Advances in Preventing and Managing Postoperative Delirium

Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.

Use of the confusion assessment method in multicentre delirium trials: training and standardisation

Background

Delirium occurs commonly in older adults and is associated with adverse outcomes. Multicentre clinical trials evaluating interventions to prevent delirium are needed. The Confusion Assessment Method (CAM) is a validated instrument for delirium detection. We hypothesised it would be possible for a large feasibility study to train a large number of research assistants, with varying experience levels, to conduct CAM assessments reliably in multiple hospital sites.

Methods

A standardised training programme was followed, incorporating structured training at a central location and at study sites. CAM practice sessions on both delirious and non-delirious patients by research assistants were conducted and, thereafter, there was ongoing inter-rater reliability assessment on the CAM between research assistant pairs at study sites. The setting was eight acute care hospitals in England and Wales. Participants were research assistants working on a multicentre feasibility study of delirium prevention. The measurement used was the Confusion Assessment Method.

Results

Thirty-seven research assistants were trained in CAM assessment and 33 returned training logs. The logs showed there was 100% overall agreement between research assistant pairs on 295 CAM assessments, of which 263 (89.2%) were negative for delirium and 32 (10.8%) were positive. In the course of the feasibility study, research assistants successfully completed 5065 (89.7%) of the 5645 expected CAM assessments, with minimal missing data.

Conclusion

Using the training methods described in this study, it is possible to achieve high quality delirium assessments for large numbers of patients with little missing data across geographically dispersed sites in multicentre studies. The standardisation of multisite delirium assessments is an important contribution to research methodology, and provides a much-needed advance for the field.

Trial registration

ISRCT ISRCTN01187372. Registered 13 March 2014.

Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study

Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology.

Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics.

Participants: Fifty patients were included in the study.

Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology.

Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.