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Resnick B, Boltz M, Galik E, Kuzmik A, McPherson R, Drazich B, Kim N, Zhu S, Wells CL. Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01745-9. [PMID: 37580439 PMCID: PMC10864680 DOI: 10.1007/s40615-023-01745-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA.
| | - Marie Boltz
- Penn State University, University Park, State College, PA, USA
| | - Elizabeth Galik
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Ashley Kuzmik
- Penn State University, University Park, State College, PA, USA
| | | | - Brittany Drazich
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Nayeon Kim
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Chris L Wells
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
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Resnick B, Boltz M, Galik E, Kuzmik A, Drazich BF, McPherson R, Wells CL, Renn C, Dorsey SG, Ellis J. Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia. Crit Care Nurs Q 2023; 46:299-309. [PMID: 37226921 PMCID: PMC10508903 DOI: 10.1097/cnq.0000000000000466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.
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Affiliation(s)
- Barbara Resnick
- School of Nursing (Drs Resnick, Galik, Drazich, Wells, Renn, and Dorsey, and Ms Ellis) and School of Medicine (Dr McPherson), University of Maryland, Baltimore; and Penn State University, University Park, Pennsylvania (Drs Boltz and Kuzmik)
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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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Byrnes T, Woodward J. Implementing a Delirium Risk Stratification Tool and Rounds to Identify and Prevent Delirium in Hospitalized Older Adults. J Nurs Care Qual 2023; 38:158-163. [PMID: 36322042 DOI: 10.1097/ncq.0000000000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Up to 40% of delirium cases are preventable, and early identification is key to improve patient outcomes. PURPOSE To implement and evaluate a multidisciplinary delirium intervention program. INTERVENTION The delirium intervention program targeted patients at high risk for delirium and included patient and nurse education, risk stratification, multidisciplinary rounds, a nonpharmacological intervention bundle, and a treatment order set. RESULTS After implementation, there was a reduction in length of stay of 6.3 days ( P = .01), a 24% decrease in disposition to a skilled nursing facility ( P = .05), and increased detection of delirium by nurses. CONCLUSION Positive patient outcomes were achieved by employing a multifactorial approach for delirium identification, prevention, and management. The components of this quality improvement project provide guidance to hospitals seeking to develop a delirium intervention program.
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Affiliation(s)
- Tru Byrnes
- Carolinas Medical Center, Charlotte, North Carolina (Dr Byrnes); and Geriatric Medicine CHS Senior Care, Charlotte, North Carolina (Dr Woodward)
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2019] [Indexed: 01/27/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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Guay CS, Kafashan M, Huels ER, Jiang Y, Beyoglu B, Spencer JW, Geczi K, Apakama G, Ju YES, Wildes TS, Avidan MS, Palanca BJA. Postoperative Delirium Severity and Recovery Correlate With Electroencephalogram Spectral Features. Anesth Analg 2023; 136:140-151. [PMID: 36130079 PMCID: PMC9653519 DOI: 10.1213/ane.0000000000006075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period. METHODS Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons. RESULTS Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002). CONCLUSIONS Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.
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Affiliation(s)
- Christian S Guay
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - MohammadMehdi Kafashan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emma R Huels
- Neuroscience Graduate Program
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Bora Beyoglu
- Baylor Scott and White Research Institute, Plano, Texas
| | | | - Kristin Geczi
- From the Department of Anesthesiology
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Yo-El S Ju
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Neurology
- Hope Center for Neurological Disorders
| | | | - Michael S Avidan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Psychiatry
| | - Ben Julian A Palanca
- Department of Psychiatry
- Division of Biology and Biomedical Sciences
- Department of Biomedical Engineering; Washington University School of Medicine in St Louis, St Louis, Missouri
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Li N, Liu X, Gao Y, Yin L, Zhao W, Ma R, Ni X. Association of electroencephalogram epileptiform discharges during cardiac surgery with postoperative delirium: An observational study. Front Surg 2022; 9:900122. [PMID: 36147691 PMCID: PMC9485598 DOI: 10.3389/fsurg.2022.900122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDelirium is a frequent and serious complication following cardiac surgery involving cardiopulmonary bypass (CPB). Electroencephalography reflects the electrical activity of the cerebral cortex. The impact of electroencephalographic epileptiform discharges during cardiac surgery on postoperative delirium remains unclear. This study was designed to investigate the relationship between intraoperative epileptiform discharges and postoperative delirium in patients undergoing cardiac surgery.MethodsA total of 76 patients who underwent cardiac surgery under CPB were included. The baseline cognitive status was measured before surgery. Electroencephalograms were monitored continuously from entry into the operating room to the end of surgery. The presence of delirium was assessed through the Confusion Assessment Method or the Confusion Assessment Method for the Intensive Care Unit on the first 3 days after surgery. Univariate and multivariate logistic regression analyses were performed to evaluate the association between epileptiform discharges and delirium.ResultsDelirium occurred in 31% of patients and epileptiform discharges were present in 26% of patients in the study. Patients with delirium had a higher incidence of epileptiform discharges (52.63% vs. 13.95%, P < 0.001) and longer durations of anesthesia and CPB (P = 0.023 and P = 0.015, respectively). In addition, patients with delirium had a longer length of hospital stay and a higher incidence of postoperative complications. Multivariate logistic regression analysis showed that age and epileptiform discharges were significantly associated with the incidence of postoperative delirium [odds ratio, 4.75 (1.26–17.92), P = 0.022; 5.00 (1.34–18.74), P = 0.017, respectively].ConclusionsPostoperative delirium is significantly related to the occurrence of epileptiform discharges during cardiac surgery.
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Affiliation(s)
- Na Li
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xing Liu
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yuhua Gao
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lingzi Yin
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wanli Zhao
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Rongxing Ma
- Department of Neuroelectrophysiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xinli Ni
- Department of Anaesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Correspondence: XinLi Ni
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Resnick B, Boltz M, Galik E, Kuzmik A, Ellis J, Wells C, Zhu S. Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description. Res Nurs Health 2022; 45:300-313. [PMID: 35274750 PMCID: PMC9064936 DOI: 10.1002/nur.22223] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 11/09/2022]
Abstract
This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Marie Boltz
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Ashley Kuzmik
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Jeanette Ellis
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Chris Wells
- Department of Rehabilitation Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, Baltimore, Maryland, USA
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Kong H, Xu LM, Wang DX. Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther 2022; 28:1147-1167. [PMID: 35652170 PMCID: PMC9253756 DOI: 10.1111/cns.13873] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/13/2022] Open
Abstract
Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.
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Affiliation(s)
- Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Long-Ming Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.,Outcomes Research Consortium, Cleveland, Ohio, USA
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Oberhaus J, Wang W, Mickle AM, Becker J, Tedeschi C, Maybrier HR, Upadhyayula RT, Muench MR, Lin N, Schmitt EM, Inouye SK, Avidan MS. Evaluation of the 3-Minute Diagnostic Confusion Assessment Method for Identification of Postoperative Delirium in Older Patients. JAMA Netw Open 2021; 4:e2137267. [PMID: 34902038 PMCID: PMC8669542 DOI: 10.1001/jamanetworkopen.2021.37267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Delirium is a common postoperative complication in older patients that often goes undetected and might lead to worse outcomes. The 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) might be a practical tool for routine clinical diagnosis of delirium. OBJECTIVE To assess the 3D-CAM for detecting postoperative delirium compared with the long-form CAM used for research purposes. DESIGN, SETTING, AND PARTICIPANTS This cohort study of older patients enrolled in ongoing clinical trials between 2015 and 2018 was conducted at a single tertiary US hospital. Included participants were aged 60 years or older undergoing major elective surgical procedures that required at least a 2-day hospital stay. Data were analyzed between February and April 2019. EXPOSURES Surgical procedures of at least 2 hours in length requiring general anesthesia with planned extubation. MAIN OUTCOMES AND MEASURES Patients were concurrently assessed for delirium using the 3D-CAM assessment and the long-form CAM, scored based on a standardized cognitive assessment. Agreement between these 2 methods was tested using Cohen κ with repeated measures, a generalized linear mixed-effects model, and Bland-Altman analysis. RESULTS Sixteen raters conducted 471 concurrent CAM and 3D-CAM interviews including 299 patients (mean [SD] age, 69 [6.5] years), the majority of whom were men (152 [50.8%]), were White (263 [88.0%]), and had noncardiac operations (211 [70.6%]). Both instruments had good intraclass correlation (0.84 for the CAM and 0.98 for the 3D-CAM). Cohen κ demonstrated good overall agreement between the CAM and 3D-CAM (κ = 0.71; 95% CI, 0.58 to 0.83). According to the mixed-effects model, there was statistically significant disagreement between the 3D-CAM and CAM (estimated difference in fixed effect, -0.68; 95% CI, -1.32 to -0.05; P = .04). Bland-Altman analysis showed the probability of a delirium diagnosis with the 3D-CAM was more than twice the probability of a delirium diagnosis with the CAM (probability ratio, 2.78; 95% CI, 2.44 to 3.23). CONCLUSIONS AND RELEVANCE The 3D-CAM instrument demonstrated agreement with the long-form CAM and might provide a pragmatic and sensitive clinical tool for detecting postoperative delirium, with the caveat that the 3D-CAM might overdiagnose delirium.
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Affiliation(s)
- Jordan Oberhaus
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Wei Wang
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Jennifer Becker
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Catherine Tedeschi
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Ravi T. Upadhyayula
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Maxwell R. Muench
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Eva M. Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
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12
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Postoperative delirium following total joint arthroplasties in a multi-ethnic population - A prospective observational study. Knee 2021; 32:103-111. [PMID: 34455160 DOI: 10.1016/j.knee.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postoperative delirium (POD) is a cause of poorer patient outcomes following total joint arthroplasties (TJA). However, it often goes undiagnosed. Although various risk factors have been documented, study heterogeneity leads to poor understanding within a South East Asian population. This study aims to evaluate POD within this demographic and elucidate its risk factors. METHODS This was a single-centre prospective observational study comprising 462 patients. Inclusion criteria was patients 65-90 years old undergoing elective TJA. Exclusion criteria was patients unable to personally provide consent for TJA. Preoperative, intraoperative, and postoperative data was recorded to analyse treatment pathway factors. Patients were assessed for POD twice daily for 3 days after TJA using the Confusion Assessment Method (CAM). RESULTS Mean age of the study cohort was 72 ± 5 years; 70.1% were female; and mean MMSE score preoperatively was 27.3 ± 3.3. 419 patients underwent total knee arthroplasty (TKA) and 43 patients underwent total hip arthroplasty (THA). 164 patients received general anaesthesia, and 298 patients received regional anaesthesia. Overall, 0% (0/462) of patients tested positive for POD at any postoperative timepoint. While various CAM components were met, no patients were positive for the complete requisite criteria for POD diagnosis. CONCLUSION We report zero incidence of POD in 462 patients who underwent elective TJA in our institution. We believe that our streamlined care process including pre-operative assessment, patient-specific anaesthesia regime as well as a strictly administered inpatient clinical care pathway with opioid-reducing strategy and early mobilization are protective factors against POD.
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13
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Ragheb J, McKinney A, Zierau M, Brooks J, Hill-Caruthers M, Iskander M, Ahmed Y, Lobo R, Mentz G, Vlisides PE. Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: a cohort study. BMJ Open 2021; 11:e050045. [PMID: 34535480 PMCID: PMC8450964 DOI: 10.1136/bmjopen-2021-050045] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes. DESIGN Retrospective chart review and prospective survey study. SETTING Intensive care units, large academic tertiary-care centre (USA). PARTICIPANTS Patients (n=148) with COVID-19 admitted to an intensive care unit at Michigan Medicine between 1 March 2020 and 31 May 2020 were eligible for inclusion. PRIMARY AND SECONDARY OUTCOME MEASURES Delirium was the primary outcome, assessed via validated chart review method. Secondary outcomes included measures related to delirium, such as delirium duration, antipsychotic use, length of hospital and intensive care unit stay, inflammatory markers and final disposition. Neuroimaging data were also collected. Finally, a telephone survey was conducted between 1 and 2 months after discharge to determine neuropsychological function via the following tests: Family Confusion Assessment Method, Short Blessed Test, Patient-Reported Outcomes Measurement Information System Cognitive Abilities 4a and Patient-Health Questionnaire-9. RESULTS Delirium was identified in 108/148 (73%) patients, with median (IQR) duration lasting 10 (4-17) days. In the delirium cohort, 50% (54/108) of patients were African American and delirious patients were more likely to be female (76/108, 70%) (absolute standardised differences >0.30). Sedation regimens, inflammation, delirium prevention protocol deviations and hypoxic-ischaemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/108, 38%). Among patients who were delirious during hospitalisation, 4/17 (24%) later screened positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia and 3/25 (12%) screened positive for depression within 2 months after discharge. CONCLUSION Patients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.
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Affiliation(s)
| | - Amy McKinney
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | - Joseph Brooks
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | | | - Yusuf Ahmed
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Remy Lobo
- Radiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Graciela Mentz
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Phillip E Vlisides
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan, USA
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14
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Kappen PR, Kakar E, Dirven CMF, van der Jagt M, Klimek M, Osse RJ, Vincent APJE. Delirium in neurosurgery: a systematic review and meta-analysis. Neurosurg Rev 2021; 45:329-341. [PMID: 34396454 PMCID: PMC8827408 DOI: 10.1007/s10143-021-01619-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/08/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022]
Abstract
Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.
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Affiliation(s)
- P R Kappen
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.
| | - E Kakar
- Department of Neuroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - C M F Dirven
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - R J Osse
- Department of Psychiatry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A P J E Vincent
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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15
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Hu AM, Qiu Y, Zhang P, Zhao R, Li ST, Zhang YX, Zheng ZH, Hu BL, Yang YL, Zhang ZJ. Higher versus lower mean arterial pressure target management in older patients having non-cardiothoracic surgery: A prospective randomized controlled trial. J Clin Anesth 2021; 69:110150. [PMID: 33418429 DOI: 10.1016/j.jclinane.2020.110150] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/01/2020] [Accepted: 11/21/2020] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE This study aimed to evaluate the effects of low versus high mean arterial pressure (MAP) levels on the incidence of postoperative delirium during non-cardiothoracic surgery in older patients. DESIGN Multicenter, randomized, parallel-controlled, open-label, and assessor-blinded clinical trial. SETTING University hospital. PATIENTS Three hundred twenty-two patients aged ≥65 with an American Society of Anesthesiologists physical status of I-II who underwent non-cardiothoracic surgery with general anaesthesia. INTERVENTIONS Participants were randomly assigned into a low-level MAP (60-70 mmHg) or high-level MAP (90-100 mmHg) group during general anaesthesia. The study was conducted from November 2016 to February 2020. Participants were older patients having non-cardiothoracic surgery. The follow-up period ranged from 1 to 7 days after surgery. The primary outcome was the incidence of postoperative delirium. MAIN RESULTS In total, 322 patients were included and randomized; 298 completed in-hospital delirium assessments [median (interquartile range) age, 73 (68-77) years; 173 (58.1%) women]. Fifty-four (18.1%) patients total, including 36 (24.5%) and 18 (11.9%) in the low-level and high-level MAP groups [relative risk (RR) 0.48, 95% confidence interval (CI) 0.25 to 0.87, P = 0.02], respectively, experienced postoperative delirium. The adjusted RR was 0.34 (95% CI 0.16 to 0.70, P < 0.01) in the multiple regression analysis. High-level MAP was associated with a shorter delirium span and a higher intraoperative urine volume than low-level MAP. CONCLUSIONS In older patients during non-cardiothoracic surgery, high-level blood pressure management might help reduce the incidence of postoperative delirium.
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Affiliation(s)
- An-Min Hu
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China; The Second Clinical Medical College, Jinan University, Shenzhen, China; First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Yan Qiu
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
| | - Peng Zhang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Rui Zhao
- Department of Anesthesiology, Kunming Children's Hospital, Kunming, China
| | - Shu-Tao Li
- Department of Anesthesiology, Jinan University-affiliated Shenzhen Baoan Women's and Children's Hospital, Shenzhen, China
| | - Yao-Xian Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China; The Second Clinical Medical College, Jinan University, Shenzhen, China; First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Zi-Hao Zheng
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China; The Second Clinical Medical College, Jinan University, Shenzhen, China; First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Bai-Long Hu
- Department of Anesthesiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Ya-Li Yang
- Department of Anesthesiology, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Zhong-Jun Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China; The Second Clinical Medical College, Jinan University, Shenzhen, China; First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China.
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16
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Garcez FB, Avelino-Silva TJ, Castro REVD, Inouye SK. Delirium in older adults. GERIATRICS, GERONTOLOGY AND AGING 2021. [DOI: 10.53886/gga.e0210032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.
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17
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Abstract
Supplemental Digital Content is available in the text. Objective: Summarize performance and development of ICU delirium-prediction models published within the past 5 years. Data Sources: Systematic electronic searches were conducted in April 2019 using PubMed, Embase, Cochrane Central, Web of Science, and Cumulative Index to Nursing and Allied Health Literature to identify peer-reviewed studies. Study Selection: Eligible studies were published in English during the past 5 years that specifically addressed the development, validation, or recalibration of delirium-prediction models in adult ICU populations. Data Extraction: Screened citations were extracted independently by three investigators with a 42% overlap to verify consistency using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. Data Synthesis: Eighteen studies featuring 23 distinct prediction models were included. Model performance varied greatly, as assessed by area under the receiver operating characteristic curve (0.62–0.94), specificity (0.50–0.97), and sensitivity (0.45–0.96). Most models used data collected from a single time point or window to predict the occurrence of delirium at any point during hospital or ICU admission, and lacked mechanisms for providing pragmatic, actionable predictions to clinicians. Conclusions: Although most ICU delirium-prediction models have relatively good performance, they have limited applicability to clinical practice. Most models were static, making predictions based on data collected at a single time-point, failing to account for fluctuating conditions during ICU admission. Further research is needed to create clinically relevant dynamic delirium-prediction models that can adapt to changes in individual patient physiology over time and deliver actionable predictions to clinicians.
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18
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Smith SK, Nguyen T, Labonte AK, Kafashan M, Hyche O, Guay CS, Wilson E, Chan CW, Luong A, Hickman LB, Fritz BA, Emmert D, Graetz TJ, Melby SJ, Lucey BP, Ju YES, Wildes TS, Avidan MS, Palanca BJA. Protocol for the Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography (P-DROWS-E) study: a prospective observational study of delirium in elderly cardiac surgical patients. BMJ Open 2020; 10:e044295. [PMID: 33318123 PMCID: PMC7737109 DOI: 10.1136/bmjopen-2020-044295] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Delirium is a potentially preventable disorder characterised by acute disturbances in attention and cognition with fluctuating severity. Postoperative delirium is associated with prolonged intensive care unit and hospital stay, cognitive decline and mortality. The development of biomarkers for tracking delirium could potentially aid in the early detection, mitigation and assessment of response to interventions. Because sleep disruption has been posited as a contributor to the development of this syndrome, expression of abnormal electroencephalography (EEG) patterns during sleep and wakefulness may be informative. Here we hypothesise that abnormal EEG patterns of sleep and wakefulness may serve as predictive and diagnostic markers for postoperative delirium. Such abnormal EEG patterns would mechanistically link disrupted thalamocortical connectivity to this important clinical syndrome. METHODS AND ANALYSIS P-DROWS-E (Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography) is a 220-patient prospective observational study. Patient eligibility criteria include those who are English-speaking, age 60 years or older and undergoing elective cardiac surgery requiring cardiopulmonary bypass. EEG acquisition will occur 1-2 nights preoperatively, intraoperatively, and up to 7 days postoperatively. Concurrent with EEG recordings, two times per day postoperative Confusion Assessment Method (CAM) evaluations will quantify the presence and severity of delirium. EEG slow wave activity, sleep spindle density and peak frequency of the posterior dominant rhythm will be quantified. Linear mixed-effects models will be used to evaluate the relationships between delirium severity/duration and EEG measures as a function of time. ETHICS AND DISSEMINATION P-DROWS-E is approved by the ethics board at Washington University in St. Louis. Recruitment began in October 2018. Dissemination plans include presentations at scientific conferences, scientific publications and mass media. TRIAL REGISTRATION NUMBER NCT03291626.
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Affiliation(s)
- S Kendall Smith
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Alyssa K Labonte
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Orlandrea Hyche
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Christian S Guay
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Elizabeth Wilson
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Courtney W Chan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Anhthi Luong
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Daniel Emmert
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Spencer J Melby
- Department of Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Yo-El S Ju
- Department of Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ben J A Palanca
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St Louis, Saint Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, Washington University in St Louis, Saint Louis, Missouri, USA
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19
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de Freitas SA, Wong E, Lee JY, Reppas-Rindlisbacher C, Gabor C, Curkovic A, Patterson CJ. The Effect of Multiple Assessments on Delirium Detection: a Pilot Study. Can Geriatr J 2020; 23:277-282. [PMID: 33282047 PMCID: PMC7704074 DOI: 10.5770/cgj.23.433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Delirium is characterized by fluctuating attention or arousal, with high prevalence in the orthopaedic ward. Our aim was to: 1) establish the prevalence of delirium on an orthopaedic ward, and 2) compare delirium prevalence using a single geriatrician assessment vs. multiple 3D-CAM (3-Minute Diagnostic Interview for Confusion Assessment Method) assessments during the day. We hypothesized that multiple assessments would increase the detection rate due to the fluctuating nature of delirium. Methods Comparative study conducted at an academic hospital in Hamilton, Ontario. Participants included patients 65 years and older admitted to the orthopaedic ward (n=55). After a geriatrician made the first assessment of delirium by 3D-CAM on each patient, teams with specialized geriatrics training re-assessed participants up to four times. Delirium rates based on first assessment were compared to cumulative end-of-day rates to determine if detection increased with multiple assessments. Results The prevalence of delirium was 30.9% (17 participants) using multiple assessments. Of these cases, 13 (76.4%) were detected in the initial geriatrician assessment. In patients with hip fractures, 70.6% (12 of 17) were identified as delirious by multiple assessments. Conclusion As symptoms fluctuate, multiple daily CAM assessments may increase the identification of delirium in orthopaedic inpatients.
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Affiliation(s)
- S A de Freitas
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton.,Joseph Brant Hospital Corporation, Burlington.,Hamilton Health Sciences Corporation, Hamilton
| | - Ekc Wong
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto.,Geriatric Education and Research in Aging Sciences (GERAS) Centre, Hamilton Health Sciences/McMaster University, Hamilton, ON
| | - J Y Lee
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton.,Geriatric Education and Research in Aging Sciences (GERAS) Centre, Hamilton Health Sciences/McMaster University, Hamilton, ON
| | | | - C Gabor
- Hamilton Health Sciences Corporation, Hamilton
| | - A Curkovic
- Hamilton Health Sciences Corporation, Hamilton
| | - C J Patterson
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton.,Hamilton Health Sciences Corporation, Hamilton.,Geriatric Education and Research in Aging Sciences (GERAS) Centre, Hamilton Health Sciences/McMaster University, Hamilton, ON
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20
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García PS. Meta-analysis and Megadata in Electroencephalogram-Based Techniques for Delirium Prevention. Anesth Analg 2020; 131:709-711. [PMID: 32940441 DOI: 10.1213/ane.0000000000004867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Paul S García
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York
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Abstract
Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.
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Affiliation(s)
- Anne M Meehan
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lena Kassab
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Haixia Qin
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
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22
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Vlisides PE, Ragheb JW, Leis A, Schoettinger A, Hickey K, McKinney A, Brooks J, Zierau M, Norcott A, Yang S, Avidan MS, Min L. Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial. F1000Res 2019; 8:1683. [PMID: 32934794 PMCID: PMC7471625 DOI: 10.12688/f1000research.20597.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jacqueline W. Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Aleda Leis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | | | - Kim Hickey
- University of Michigan School of Nursing, Ann Arbor, MI, 48109, USA
| | - Amy McKinney
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Joseph Brooks
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Mackenzie Zierau
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Alexandra Norcott
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
| | - Shirley Yang
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lillian Min
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Geriatric Research Education and Clinical Care, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
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Vlisides PE, Ragheb JW, Leis A, Schoettinger A, Hickey K, McKinney A, Brooks J, Zierau M, Norcott A, Yang S, Avidan MS, Min L. Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial. F1000Res 2019; 8:1683. [PMID: 32934794 PMCID: PMC7471625 DOI: 10.12688/f1000research.20597.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 03/30/2024] Open
Abstract
Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jacqueline W. Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Aleda Leis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | | | - Kim Hickey
- University of Michigan School of Nursing, Ann Arbor, MI, 48109, USA
| | - Amy McKinney
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Joseph Brooks
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Mackenzie Zierau
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Alexandra Norcott
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
| | - Shirley Yang
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, 48170, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lillian Min
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Geriatric Research Education and Clinical Care, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
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Electroencephalography-guided anaesthetic administration does not impact postoperative delirium among older adults undergoing major surgery: an independent discussion of the ENGAGES trial. Br J Anaesth 2019; 123:112-117. [PMID: 31079835 DOI: 10.1016/j.bja.2019.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
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Green JR, Smith J, Teale E, Collinson M, Avidan MS, Schmitt EM, Inouye SK, Young J. Use of the confusion assessment method in multicentre delirium trials: training and standardisation. BMC Geriatr 2019; 19:107. [PMID: 30991945 PMCID: PMC6466721 DOI: 10.1186/s12877-019-1129-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 04/04/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- John R Green
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD96RJ, UK.
| | - Jane Smith
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD96RJ, UK
| | - Elizabeth Teale
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD96RJ, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael S Avidan
- Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Eva M Schmitt
- Institute for Aging Research Hebrew SeniorLife and Harvard Medical School, 1200 Centre Street, Boston, MA, 02131, USA
| | - Sharon K Inouye
- Institute for Aging Research Hebrew SeniorLife and Harvard Medical School, 1200 Centre Street, Boston, MA, 02131, USA
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD96RJ, UK
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Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, Kronzer A, McKinnon SL, Park D, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Goswami S, Jordan K, Lin N, Fritz BA, Stevens TW, Jacobsohn E, Schmitt EM, Inouye SK, Stark S, Lenze EJ, Avidan MS. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA 2019; 321:473-483. [PMID: 30721296 PMCID: PMC6439616 DOI: 10.1001/jama.2018.22005] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. OBJECTIVE To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. INTERVENTIONS Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). MAIN OUTCOMES AND MEASURES The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. RESULTS Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. CONCLUSIONS AND RELEVANCE Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02241655.
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Affiliation(s)
- Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Sherry L. McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Brian A. Torres
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Graetz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel A. Emmert
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Ben J. Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine Jordan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology, University of Manitoba, Winnipeg, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Susan Stark
- Department of Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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