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Labaste F, Delort F, Ferré F, Bounes F, Reina N, Valet P, Dray C, Minville V. Postoperative delirium is a risk factor of institutionalization after hip fracture: an observational cohort study. Front Med (Lausanne) 2023; 10:1165734. [PMID: 37649978 PMCID: PMC10464946 DOI: 10.3389/fmed.2023.1165734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction Hip fracture is a common clinical problem in geriatric patients often associated with poor postoperative outcomes. Postoperative delirium (POD) and postoperative neurocognitive disorders (NCDs) are particularly frequent. The consequences of these disorders on postoperative recovery and autonomy are not fully described. The aim of this study was to determine the role of POD and NCDs on the need for institutionalization at 3 months after hip fracture surgery. Method A population-based prospective cohort study was conducted on hip fracture patients between March 2016 and March 2018. The baseline interview, which included a Mini-Mental State Examination (MMSE), was conducted in the hospital after admission for hip fracture. NCDs were appreciated by MMSE scoring evolution (difference between preoperative MMSE and MMSE at day 5 >2 points). POD was evaluated using the Confusion Assessment Method. The primary endpoint was the rate of new institutionalization at 3 months. We used a multivariate analysis to assess the risk of new institutionalization. Results A total of 63 patients were included. Thirteen patients (20.6%) were newly institutionalized at 3 months. Two factors were significantly associated with the risk of postoperative institutionalization at 3 months: POD (OR = 5.23; 95% CI 1.1-27.04; p = 0.04) and IADL evolution (OR = 1.8; 95% CI 1.23-2.74; p = 0.003). Conclusion Only POD but not NCDs was associated with the risk of dependency and institutionalization after hip fracture surgery. The prevention of POD appears to be essential for improving patient outcomes and optimizing the potential for returning home.
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Affiliation(s)
- François Labaste
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - François Delort
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Fabrice Ferré
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Fanny Bounes
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Nicolas Reina
- Orthopedic Surgery Department, CHU Toulouse, Toulouse, France
| | - Philippe Valet
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - Cédric Dray
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - Vincent Minville
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
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Barnes J, Sewart E, Armstrong RA, Pufulete M, Hinchliffe R, Gibbison B, Mouton R. Does melatonin administration reduce the incidence of postoperative delirium in adults? Systematic review and meta-analysis. BMJ Open 2023; 13:e069950. [PMID: 36990485 PMCID: PMC10069576 DOI: 10.1136/bmjopen-2022-069950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023] Open
Abstract
Postoperative delirium (POD) is common. It is associated with increased morbidity and mortality. Many cases may be preventable and melatonin offers promise as a preventative agent. OBJECTIVE This systematic review provides an up-to-date synthesis of the evidence on the effect of melatonin in preventing POD. DESIGN A systematic search of randomised controlled trials of melatonin in POD was run across multiple databases (EMBASE, MEDLINE, CINAHL, PsycINFO) and a clinical trials registry (ClinicalTrials.org) (1 January 1990 to 5 April 2022). Studies examining the effects of melatonin on POD incidence in adults are included. Risk of bias was assessed using the Cochrane risk of bias 2 tool. OUTCOME MEASURES The primary outcome is POD incidence. Secondary outcomes are POD duration and length of hospital stay. Data synthesis was undertaken using a random-effects meta-analysis and presented using forest plots. A summary of methodology and outcome measures in included studies is also presented. RESULTS Eleven studies, with 1244 patients from a range of surgical specialties were included. Seven studies used melatonin, in variable doses, and four used ramelteon. Eight different diagnostic tools were used to diagnose POD. Time points for assessment also varied. Six studies were assessed as low risk of bias and five as some concern. The combined OR of developing POD in the melatonin groups versus control was 0.41 (95% CI 0.21 to 0.80, p=0.01). CONCLUSION This review found that melatonin may reduce the incidence of POD in adults undergoing surgery. However, included studies displayed inconsistency in their methodology and outcome reporting. Further work to determine the optimum regime for melatonin administration, along with consensus of how best to evaluate results, would be beneficial. PROSPERO REGISTRATION NUMBER CRD42021285019.
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Affiliation(s)
- Jonathan Barnes
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Emma Sewart
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | | | | | - Robert Hinchliffe
- Department of Surgery, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
| | - Ben Gibbison
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
- University of Bristol, Bristol, UK
| | - Ronelle Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
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Dulin JD, Zhang J, Marsden J, Mauldin PD, Moran WP, Kalivas BC. Association of delirium screening on hospitalized adults and postacute care utilization: A retrospective cohort study. Am J Med Sci 2022; 364:554-564. [PMID: 35793733 DOI: 10.1016/j.amjms.2022.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 04/11/2022] [Accepted: 06/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with delirium have increased hospital length of stay (LOS), morbidity and mortality. Impact of delirium on postacute care (PAC) utilization is not fully characterized. Impact of screening for delirium on general medicine patients is unknown. The objective of this study was to assess impact of screening for delirium on inpatient PAC utilization. METHODS This was a single center, retrospective cohort study at an academic tertiary care center in Charleston, SC. Patients were selected from adults hospitalized from home and discharged alive between June 2014 and June 2018. The brief confusion assessment method (bCAM) screening was conducted and documented by nursing on admission and every shift thereafter. Outcome measure was the proportion of patients discharged to facility. RESULTS Of 93,388 non-ICU adult admission between June 2014 and June 2018, 4.4% of those not screened for delirium were discharged to facility versus 15.0% in those screened and 41.4% in those screening positive. Multivariable regression analysis showed that patients screened for delirium were 2.3 times more likely to discharge to facility (95% CI (2.145, 2.429)) while those with a positive bCAM were 3.3 times more likely than those with a negative bCAM to discharge to facility (95% CI (2.949, 3.712)). CONCLUSIONS After adjusting for demographics, medication orders and comorbidities there was an association between screening for delirium, positive delirium screen and discharge to facility. An appreciation of where and why patients are discharged is imperative to optimize both patient care and cost utilization.
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Affiliation(s)
- Jennifer D Dulin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin C Kalivas
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Sewart E, Barnes J, Armstrong RA, Pufulete M, Hinchliffe R, Gibbison B, Mouton R. Melatonin for the prevention of postoperative delirium in older adults: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e063405. [PMID: 36153032 PMCID: PMC9511532 DOI: 10.1136/bmjopen-2022-063405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a major cause of morbidity, particularly in elderly patients. Melatonin has been suggested as a low-risk pharmacological intervention to help prevent POD. A previous systematic review found limited high-quality evidence to support the use of melatonin in the prevention of POD. Several further randomised studies have since been published. This systematic review aims to synthesise the evidence from randomised controlled trials (RCTs) examining the effect of melatonin on the prevention of POD in older adults. METHODS AND ANALYSIS A systematic search of RCTs of melatonin (any dose and formulation) in POD will be run across Embase, Medline, CINAHL and PsychInfo. RCTs published from January 1990 until the end of February 2022 and reporting outcomes for melatonin use to prevent POD in patients will be included. Screening of search results and data extraction from included articles will be performed by two independent reviewers. The primary outcome will be incidence of POD in older adults undergoing surgery. Secondary outcomes are delirium duration and length of hospital stay. The review will also describe the dosage, timing and administration regimes of melatonin therapy and as well as the scales and definitions used to describe POD. A registry review of ongoing trials will be also be performed. For the meta-analysis, data will be pooled using a random effects model to generate a forest plot and obtain an odds ratio (OR) for the incidence of POD. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ETHICS AND DISSEMINATION No ethical approval is required. This review will be disseminated via peer-reviewed manuscript and conferences. The results will be used as the basis of work to optimise this intervention for future trials in surgical populations. PROSPERO REGISTRATION NUMBER This review is registered with PROSPERO (CRD42021285019).
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Affiliation(s)
- Emma Sewart
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - Jonathan Barnes
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | | | | | - Robert Hinchliffe
- Department of Vascular Surgery, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ben Gibbison
- University of Bristol, Bristol, UK
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Ronelle Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, University of Bristol, Bristol, UK
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Levy I, Gavrieli S, Hefer T, Attias S, Schiff A, Oliven R, Wisberg-Levi S, Hanchinsky R, Schiff E. Acupuncture Treatment of Delirium in Older Adults Hospitalized in Internal Medicine Departments: An Open-Label Pragmatic Randomized-Controlled Trial. J Geriatr Psychiatry Neurol 2022; 35:333-343. [PMID: 33685268 DOI: 10.1177/0891988721996804] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acupuncture seems to improve cognitive function in experimental models and to reduce agitation in dementia. The addition of acupuncture to standard-of-care (SOC) may improve clinical outcomes related to delirium in hospitalized older adults. METHODS This pragmatic open-label randomized-controlled trial evaluated 81 older adults hospitalized in an internal medicine ward and diagnosed with delirium. Fifty were randomized to daily acupuncture combined with SOC and 31 to SOC only for up to 1 week. Delirium was diagnosed using Confusion Assessment Method (CAM) tool, and its severity was assessed by the long CAM-Severity (CAM-S) tool. The primary study outcome was delirium resolution evaluated as time-to-first delirium remission (over 7 days) and the number of days spent delirium-free. RESULTS Time-to-first delirium remission was shorter in the acupuncture arm as compared to the SOC only arm (p < 0.001). A multivariate Cox regression analysis showed a shorter time-to-first remission of delirium in the acupuncture arm as compared with SOC arm [Hazard Ratio 0.267 (95% CI 0.098-0.726, p = 0.010)]. In the 7 days of evaluation, a significantly higher number of delirium-free days was found in the acupuncture arm compared to the SOC arm (p < 0.001), and CAM-S sum from day 2 to day 7 of evaluation was significantly lower in the acupuncture group compared to the control group (p = 0.002). No adverse safety event was found in the acupuncture group. CONCLUSION Acupuncture seems to be safe and effective in the treatment of delirium in older patients hospitalized in internal medicine departments.
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Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Hematology Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Sagi Gavrieli
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Talia Hefer
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Samuel Attias
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Ariel Schiff
- Faculty of Medicine, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Ron Oliven
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Geriatric Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Shikma Wisberg-Levi
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Rina Hanchinsky
- Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Elad Schiff
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Hall A, Boulton E, Kunonga P, Spiers G, Beyer F, Bower P, Craig D, Todd C, Hanratty B. Identifying older adults with frailty approaching end-of-life: A systematic review. Palliat Med 2021; 35:1832-1843. [PMID: 34519246 PMCID: PMC8637378 DOI: 10.1177/02692163211045917] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND People with frailty may have specific needs for end-of-life care, but there is no consensus on how to identify these people in a timely way, or whether they will benefit from intervention. AIM To synthesise evidence on identification of older people with frailty approaching end-of-life, and whether associated intervention improves outcomes. DESIGN Systematic review (PROSPERO: CRD42020462624). DATA SOURCES Six databases were searched, with no date restrictions, for articles reporting prognostic or intervention studies. Key inclusion criteria were adults aged 65 and over, identified as frail via an established measure. End-of-life was defined as the final 12 months. Key exclusion criteria were proxy definitions of frailty, or studies involving people with cancer, even if also frail. RESULTS Three articles met the inclusion criteria. Strongest evidence came from one study in English primary care, which showed distinct trajectories in electronic Frailty Index scores in the last 12 months of life, associated with increased risk of death. We found no studies evaluating established clinical tools (e.g. Gold Standards Framework) with existing frail populations. We found no intervention studies; the literature on advance care planning with people with frailty has relied on proxy definitions of frailty. CONCLUSION Clear implications for policy and practice are hindered by the lack of studies using an established approach to assessing frailty. Future end-of-life research needs to use explicit approaches to the measurement and reporting of frailty, and address the evidence gap on interventions. A focus on models of care that incorporate a palliative approach is essential.
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Affiliation(s)
- Alex Hall
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Elisabeth Boulton
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Patience Kunonga
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Gemma Spiers
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Fiona Beyer
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Dawn Craig
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Chris Todd
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Barbara Hanratty
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Sabbe K, van der Mast R, Dilles T, Van Rompaey B. The prevalence of delirium in belgian nursing homes: a cross-sectional evaluation. BMC Geriatr 2021; 21:634. [PMID: 34742251 PMCID: PMC8571852 DOI: 10.1186/s12877-021-02517-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/28/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Delirium is a common geriatric syndrome, but only few studies have been done in nursing home residents. Therefore, the aim of this study was to investigate (point) prevalence of and risk factors for delirium in nursing homes in Belgium. METHODS A multisite, cross-sectional study was conducted in six nursing homes in Belgium. Residents of six nursing homes were screened for delirium. Exclusion criteria were coma,'end-of-life' status and residing in a dementia ward. Delirium was assessed using the Delirium Observation Screening Scale. RESULTS 338 of the 448 eligible residents were included in this study. Of the 338 residents who were evaluated, 14.2 % (95 %CI:3.94-4.81) screened positive for delirium with the Delirium Observation Screening Scale. The mean age was 84.7 years and 67.5 % were female. Taking antipsychotics (p = 0.009), having dementia (p = 0.005), pneumonia (p = 0.047) or Parkinson's disease (p = 0.03) were more present in residents with delirium. The residents were more frequently physically restrained (p = 0.001), participated less in activities (p = 0.04), had had more often a fall incident (p = 0.007), had lower levels of cognition (p < 0.001; MoCA ≥ 26, p = 0.04; MoCA ≥ 25, p = 0.008) and a higher "Activities of Daily Living" score (p = 0.001). In multivariable binary logistic regression analysis, a fall incident (2.76; 95 %CI: 1.24-6.14) and cognitive impairment (OR: 0.69; 95 %CI: 0.63-0.77) were significantly associated with delirium. CONCLUSIONS Delirium is an important clinical problem affecting almost 15 % of the nursing home residents at a given moment. Screening of nursing home residents for risk factors and presence of delirium is important to prevent delirium if possible and to treat underlying causes when present.
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Affiliation(s)
- Kelly Sabbe
- University of Antwerp, Centre for Research and Innovation in Care, Universiteitsplein 1, 2610, Antwerp, Belgium.
- Attaché statistician at Statistics Belgium, 1000, Brussels, Belgium.
| | - Roos van der Mast
- University of Antwerp, Centre for Research and Innovation in Care, Universiteitsplein 1, 2610, Antwerp, Belgium
- University of Leiden, Leids Universitair Medisch Centrum, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - Tinne Dilles
- University of Antwerp, Centre for Research and Innovation in Care, Universiteitsplein 1, 2610, Antwerp, Belgium
- University of Antwerp, Nurse and Pharmaceutical Care, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Bart Van Rompaey
- University of Antwerp, Centre for Research and Innovation in Care, Universiteitsplein 1, 2610, Antwerp, Belgium
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Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study. J Am Med Dir Assoc 2021; 23:66-72.e2. [PMID: 34174195 DOI: 10.1016/j.jamda.2021.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium. DESIGN Population-based cross-sectional study using routinely collected administrative health data. SETTING AND PARTICIPANTS All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217). METHODS Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. RESULTS Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability). CONCLUSIONS AND IMPLICATIONS There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.
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9
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage 2021; 61:1118-1126.e5. [PMID: 33157179 DOI: 10.1016/j.jpainsymman.2020.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly distressing neurocognitive disorder for patients at the end of life. OBJECTIVES To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life. METHODS Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium. RESULTS Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05). CONCLUSION In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada.
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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10
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Chyou TY, Nishtala PS. Identifying frequent drug combinations associated with delirium in older adults: Application of association rules method to a case-time-control design. Pharmacoepidemiol Drug Saf 2021; 30:1402-1410. [PMID: 33991132 DOI: 10.1002/pds.5292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/28/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Older adults are at an increased risk of delirium because of age, polypharmacy, multiple comorbidities, frailty, and acute illness. Although medication-induced delirium in older adults is well understood, limited population-level evidence is available, particularly on combinations of medications associated with delirium in older adults. OBJECTIVES We aimed to apply association rule analysis to identify drug combinations contributing to delirium risk in adults aged 65 and older using a case-time-control design. METHOD We sourced a nationwide representative sample of New Zealander's aged ≥65 years from the pharmaceutical collections and hospital discharge information. Prescription records (2005-2015) were obtained from New Zealand pharmaceutical collections (Pharms). Medication exposures were coded as binary variables (exposed vs. not exposed) at the individual drug level. All medications, including antimicrobials, antihistamines, diuretics, opioids, and nonsteroidal anti-inflammatory medications, were considered drugs of interest. The first-time coded diagnosis of delirium was extracted from the National Minimal Dataset (NMDS). A unique patient identifier linked the prescription dataset to the event dataset to set up a case-time-control cohort, indexed at the first delirium event. Association rules were then applied to identify frequent drug combinations in the case and the control periods (l-day with a 35-day washout period) that are statistically associated with delirium, and the association was tested by computing a time-trend adjusted matched odds-ratio (MOR) and its 95% confidence interval (CI). RESULTS We identified 28 503 individuals (mean age 84.1 years) from 2005 to 2015 with delirium. Our combined association rule and case-time-control analysis identified several drug classes, including antipsychotics, benzodiazepines, opioids, and diuretics associated with delirium. Our analysis also identified frequently used drug combinations that are associated with delirium. Examples include combined exposures to quetiapine and furosemide (MOR = 6.17; 95%CI = [2.05-18.54]), haloperidol (MOR = 4.81; 95%CI = [3.16-6.69]), combined exposures to furosemide, omeprazole, and lorazepam (MOR = 3.94; 95%CI = [3.03-5.10]), and fentanyl exposure (MOR = 3.46; 95%CI [2.05-9.21]). CONCLUSION The association rule method applied to a case-time-control design is a novel approach to identifying drug combinations contributing to delirium with adjustment for any temporal trends in exposures. The study provides new insight into the combination of medicines linked to delirium.
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Affiliation(s)
- Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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11
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Remelli F, Castellucci F, Vitali A, Mattioli I, Zurlo A, Spadaro S, Volpato S. Predictive value of geriatric-quickSOFA in hospitalized older people with sepsis. BMC Geriatr 2021; 21:241. [PMID: 33849471 PMCID: PMC8045242 DOI: 10.1186/s12877-021-02182-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND QuickSOFA, a prognostic score proposed for patients with infection, has shown a poor predictive value in the geriatric population, probably because of the inappropriateness of the Glasgow Coma Scale (GCS) in assessing acute alteration of mental status in older patients. Indeed, the GCS might result chronically low in older patient with pre-existing cognitive disorders. The aim of this study was to develop an alternative quickSOFA (geriatric-quickSOFA), using the presence of delirium, assessed according to DSM-5 criteria, instead of GCS assessment, to predict mortality in hospitalized older patients with sepsis. METHODS Retrospective observational study in Acute Geriatrics Unit of St. Anna Hospital of Ferrara (Italy). The study enrolled 165 patients hospitalized between 2017 and 2018 with diagnosis of sepsis or septic shock. Demographic, clinical data and 30-day survival were collected for each patient. Based on arterial blood pressure, respiratory rate, and the presence of delirium, geriatric-quickSOFA was calculated at admission. Primary outcome was 30-day mortality. RESULTS One hundred sixty-five patients were enrolled with a median age of 88 years; 60.6% were men. High quickSOFA score was not significantly correlated neither with in-hospital nor 30-day mortality. High geriatric-qSOFA score was significantly related to both in-hospital (13.3%vs 51.5%, p = 0.0003) and 30-day mortality (30.0%vs 84.3%, p < 0.00001). CONCLUSION Geriatric-quickSOFA is significantly associate with short-term mortality risk in older patients with sepsis. Geriatric quickSOFA seems to represent a more suitable and useful predictive tool than the traditional quickSOFA in the geriatric population.
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Affiliation(s)
- Francesca Remelli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | | | - Aurora Vitali
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Irene Mattioli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Amedeo Zurlo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Geriatrics Unit, Azienda Ospedaliero- universitaria di Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Anestesiology and Resuscitation Unit, Department of Morfology, Surgery and Sperimental Medicine, University of Ferrara, Ferrara, Italy
| | - Stefano Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy. .,Orthogeriatrics Unit, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
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12
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AlSalem M, AlHarbi MA, Badeghiesh A, Tourian L. Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review. Medicine (Baltimore) 2020; 99:e23708. [PMID: 33371117 PMCID: PMC7748330 DOI: 10.1097/md.0000000000023708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 12/03/2022] Open
Abstract
Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.
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Affiliation(s)
- Moayyad AlSalem
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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13
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Pieri M, De Simone A, Rose S, De Domenico P, Lembo R, Denaro G, Landoni G, Monaco F. Trials Focusing on Prevention and Treatment of Delirium After Cardiac Surgery: A systematic Review of Randomized Evidence. J Cardiothorac Vasc Anesth 2020; 34:1641-1654. [DOI: 10.1053/j.jvca.2019.09.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/11/2022]
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14
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van Montfort SJT, van Dellen E, Wattel LL, Kant IMJ, Numan T, Stam CJ, Slooter AJC. Predisposition for delirium and EEG characteristics. Clin Neurophysiol 2020; 131:1051-1058. [PMID: 32199395 DOI: 10.1016/j.clinph.2020.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 12/19/2019] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - E van Dellen
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - L L Wattel
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Faculty of Science, University of Amsterdam, the Netherlands
| | - I M J Kant
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - T Numan
- Department of Anatomy and Neurosciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - C J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
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15
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Gual N, García-Salmones M, Brítez L, Crespo N, Udina C, Pérez LM, Inzitari M. The role of physical exercise and rehabilitation in delirium. Eur Geriatr Med 2020; 11:83-93. [PMID: 32297245 PMCID: PMC7224129 DOI: 10.1007/s41999-020-00290-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/15/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research. METHODS In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other. RESULTS This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function. CONCLUSION The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.
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Affiliation(s)
- N Gual
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain. .,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M García-Salmones
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - L Brítez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - N Crespo
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - C Udina
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L M Pérez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - M Inzitari
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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16
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Wang YY, Yue JR, Xie DM, Carter P, Li QL, Gartaganis SL, Chen J, Inouye SK. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:17-25. [PMID: 31633738 PMCID: PMC6806427 DOI: 10.1001/jamainternmed.2019.4446] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline. OBJECTIVE To investigate the effectiveness of the Tailored, Family-Involved Hospital Elder Life Program (t-HELP) for preventing POD and functional decline in older patients after a noncardiac surgical procedure. DESIGN, SETTING, AND PARTICIPANTS A 2-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted from August 24, 2015, to February 28, 2016, on 6 surgical floors (gastric, colorectal, pancreatic, biliary, thoracic, and thyroid) of West China Hospital in Chengdu, China. Eligible participants (n = 281) admitted to each of the 6 surgical floors were randomized into a nursing unit providing t-HELP (intervention group) or a nursing unit providing usual care (control group). All randomized patients were included in the intention-to-treat analyses for the primary outcome of POD incidence. Statistical analysis was performed from April 3, 2016, to December 30, 2017. INTERVENTIONS In addition to receiving usual care, all participants in the intervention group received the t-HELP protocols, which addressed each patient's risk factor profile. Besides nursing professionals, family members and paid caregivers were involved in the delivery of many of the program interventions. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of POD, evaluated with the Confusion Assessment Method. Secondary outcomes included the pattern of functional and cognitive changes (activities of daily living [ADLs], instrumental activities of daily living [IADLs], Short Portable Mental Status Questionnaire [SPMSQ]) from hospital admission to 30 days after discharge, and the length of hospital stay (LOS). RESULTS Of the 475 patients screened for eligibility, 281 (171 [60.9%] male, mean [SD] age 74.7 [5.2] years) were enrolled and randomized to receive t-HELP (n = 152) or usual care (n = 129). Postoperative delirium occurred in 4 participants (2.6%) in the intervention group and in 25 (19.4%) in the control group, with a relative risk of 0.14 (95% CI, 0.05-0.38). The number needed to treat to prevent 1 case of POD was 5.9 (95% CI, 4.2-11.1). Participants in the intervention group compared with the control group showed less decline in physical function (median [interquartile range] for ADLs: -5 [-10 to 0] vs -20 [-30 to -10]; P < .001; for IADLs: -2 [-2 to 0] vs -4 [-4 to -2]; P < .001) and cognitive function (for the SPMSQ level: 1 [0.8%] vs 8 [7.0%]; P = .009) at discharge, as well as shorter mean (SD) LOS (12.15 [3.78] days vs 16.41 [4.69] days; P < .001). CONCLUSIONS AND RELEVANCE The findings suggest that t-HELP, with family involvement at its core, is effective in reducing POD for older patients, maintaining or improving their physical and cognitive functions, and shortening the LOS. The results of this t-HELP trial may improve generalizability and increase the implementation of this program. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR-POR-15006944.
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Affiliation(s)
- Yan-Yan Wang
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,School of Nursing, The University of Texas at Austin, Austin
| | - Ji-Rong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Dong-Mei Xie
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Patricia Carter
- School of Nursing, The University of Texas at Austin, Austin
| | - Quan-Lei Li
- School of Nursing, The Johns Hopkins University, Baltimore, Maryland
| | - Sarah L Gartaganis
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jie Chen
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Sharon K Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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17
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McNeil JB, Hughes CG, Girard T, Ware LB, Ely EW, Chandrasekhar R, Han JH. Plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients. PLoS One 2019; 14:e0226412. [PMID: 31856187 PMCID: PMC6922408 DOI: 10.1371/journal.pone.0226412] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Background Delirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration. Methods We enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status. Results A total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09–2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed. Conclusions Plasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.
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Affiliation(s)
- J. Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christopher G. Hughes
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Timothy Girard
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
| | - Rameela Chandrasekhar
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jin H. Han
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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Menzenbach J, Guttenthaler V, Kirfel A, Ricchiuto A, Neumann C, Adler L, Kieback M, Velten L, Fimmers R, Mayr A, Wittmann M. Estimating patients' risk for postoperative delirium from preoperative routine data - Trial design of the PRe-Operative prediction of postoperative DElirium by appropriate SCreening (PROPDESC) study - A monocentre prospective observational trial. Contemp Clin Trials Commun 2019; 17:100501. [PMID: 31890984 PMCID: PMC6926123 DOI: 10.1016/j.conctc.2019.100501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 11/09/2022] Open
Abstract
Background Postoperative Delirium (POD) is the most common complication of elderly patients after surgery associated with increased postoperative morbidity, persistent care dependency and even mortality. Prevention of POD requires detection of patients at high risk prior to surgery. PROPDESC intends to provide an instrument for preoperative routine screening of patients' risk for POD. Methods PROPDESC is a monocentric prospective observatory trial including 1000 patients older than 60 years from various disciplines of a university hospital planned for surgery of at least 60 min. To develop a score predicting the risk for POD, anesthesiological stratifications, laboratory values, medication and known risk factors as well as quality of life and cognitive performance are taken into account. POD assessment is performed daily on the first five days after the operation respectively the end of sedation in the intensive care units and normal wards. The score is evaluated from 600 data sets and subsequently validated internally. The most appropriate predictors are determined by a component-wise gradient boosting approach. Discussion Based on retrospective investigations, etiology of POD is considered multifactorial. By a prospective analysis of various factors, PROPDESC intends to provide an applicable tool to predict the risk for POD from preoperative routine data and assessment of cognitive function. Objective is to establish an automatically generating score in preoperative routine to screen patients for increased risk of POD as starting point for POD reduction and management. Model compilation requires a high significance and enhancement within compound as well as regular availability of the selected predictors. Trial registration DRKS, DRKS00015715. Registered 13 December 2018 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015715.
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Affiliation(s)
- Jan Menzenbach
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Vera Guttenthaler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andrea Kirfel
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Arcangelo Ricchiuto
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Claudia Neumann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Linda Adler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Marjetka Kieback
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Lisa Velten
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andreas Mayr
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Maria Wittmann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
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Rohatgi N, Weng Y, Bentley J, Lansberg MG, Shepard J, Mazur D, Ahuja N, Hopkins J. Initiative for Prevention and Early Identification of Delirium in Medical-Surgical Units: Lessons Learned in the Past Five Years. Am J Med 2019; 132:1421-1430.e8. [PMID: 31228413 DOI: 10.1016/j.amjmed.2019.05.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/14/2019] [Accepted: 05/18/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Delirium is an acute change in mental status affecting 10%-64% of hospitalized patients, and may be preventable in 30%-40% of cases. In October 2013, a task force for delirium prevention and early identification in medical-surgical units was formed at our hospital. We studied whether our standardized protocol prevented delirium among high-risk patients. METHODS We studied 105,455 patient encounters between November 2013 and January 2018. Since November 2013, there has been ongoing education to decrease deliriogenic medications use. Since 2014, nurses screen all patients for presence or absence of delirium using the Confusion Assessment Method (CAM). Since 2015, nurses additionally screen all patients for risk of delirium. In 2015, a physician order set for delirium was created. Nonpharmacological measures are implemented for high-risk or CAM positive patients. RESULTS 98.8% of patient encounters had CAM screening, and 99.6% had delirium risk screening. Since 2013, odds of opiate use decreased by 5.0% per year (P < .001), and odds of benzodiazepine use decreased by 8.0% per year (P < .001). There was no change in anticholinergic use. In the adjusted analysis, since 2015, odds of delirium decreased by 25.3% per year among high-risk patients (n = 21,465; P < .001). Among high-risk patients or those diagnosed with delirium (n = 22,121), estimated length of stay decreased by 0.13 days per year (P < .001), odds of inpatient mortality decreased by 16.0% per year (P = .011), and odds of discharge to a nursing home decreased by 17.1% per year (P < .001). CONCLUSION With high clinician engagement and simplified workflows, our delirium initiative has shown sustained results.
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Affiliation(s)
- Nidhi Rohatgi
- Department of Medicine, Stanford University School of Medicine, Stanford, Calif.
| | - Yingjie Weng
- Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Jason Bentley
- Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, Calif
| | - John Shepard
- Department of Quality, Patient Safety, and Clinical Effectiveness, Stanford, Calif
| | - Diana Mazur
- Department of Nursing, Stanford Health Care, Stanford, Calif
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Joseph Hopkins
- Department of Medicine, Stanford University School of Medicine, Stanford, Calif; Department of Quality, Patient Safety, and Clinical Effectiveness, Stanford, Calif
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Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis. BMC Geriatr 2019; 19:272. [PMID: 31619178 PMCID: PMC6796479 DOI: 10.1186/s12877-019-1297-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 09/26/2019] [Indexed: 12/02/2022] Open
Abstract
Background Older surgical patients are at high risk of developing postoperative delirium. Non-pharmacological strategies are recommended for delirium prevention, but no pharmacological agents have compelling evidence to decrease the incidence of delirium. The purpose of this study was to assess whether perioperative melatonin decreases the incidence of delirium in older adults undergoing surgical procedures. Methods A systematic search using PubMed/Medline, Embase, PsycINFO, CINAHL, and references of identified articles published in English between January 1990 and October 2017 was performed. Two independent reviewers screened titles and abstracts, and then extracted data following a full-text review of included articles with consensus generation and bias assessment. Studies reporting outcomes for melatonin or ramelteon use to prevent delirium in postoperative hospitalized patients (mean age ≥ 50 years) were eligible for inclusion. Data were pooled using a fixed-effects model to generate a forest plot and obtain a summary odds ratio for the outcome of interest (delirium incidence). Cochran’s Q and I2 values were used to investigate heterogeneity. Results Of 335 records screened, 6 studies were selected for the qualitative analysis and 6 were included in the meta-analysis (n = 1155). The mean age of patients in included studies ranged from 59 to 84 years. Patients in intervention groups typically received melatonin or ramelteon at daily doses of two to eight milligrams around cardiothoracic, orthopedic, or hepatic surgeries for one to nine days, starting on the evening before or the day of surgery. The incidence of delirium ranged from 0 to 30% in the intervention groups versus 4–33% in the comparator groups, and was significantly reduced in the melatonin group, with a summary effect of the meta-analysis yielding an odds ratio of 0.63 (95% CI 0.46 to 0.87; 0.006; I2 = 72.1%). A one study removed analysis reduced overall odds ratio to 0.310 (95% CI 0.19 to 0.50), while reducing heterogeneity (Cochran’s Q = 0.798, I2 = 0.000). Conclusion Perioperative melatonin reduced the incidence of delirium in older adults in the included studies. While optimal dosing remains an unanswered question, the potential benefit of melatonin and melatonin receptor agonists may make them a reasonable option to use for delirium prevention in older adults undergoing surgical procedures.
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Gual N, García-Salmones M, Pérez LM. Diagnosing delirium in patients with dementia, a great challenge. Med Clin (Barc) 2019; 153:284-289. [PMID: 31253478 DOI: 10.1016/j.medcli.2019.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/17/2022]
Abstract
Delirium, despite its high incidence, serious consequences and potential reversibility, remains an underdiagnosed syndrome. In patients with dementia, the healthcare professional may find significant difficulties in differentiating whether the patient presents cognitive alterations and behavioural disorders characteristic of dementia or, on the contrary, is faced with a delirium superimposed on dementia (DSD). In view of this difficulty, many tools have been proposed in recent years to improve the diagnosis of DSD in these highly complex patients. The aim of these tools is to be easy and quick to apply, and although focusing on assessing cognitive aspects such as attention or level of consciousness, some of them have also incorporated the assessment of other more novel aspects, such as the ability to respond to external stimuli (Arousal) or the degree of mobility.
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Affiliation(s)
- Neus Gual
- Parc Sanitari Pere Virgili, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España.
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Kimchi EY, Neelagiri A, Whitt W, Sagi AR, Ryan SL, Gadbois G, Groothuysen D, Westover MB. Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes. Neurology 2019; 93:e1260-e1271. [PMID: 31467255 PMCID: PMC7011865 DOI: 10.1212/wnl.0000000000008164] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/30/2019] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Eyal Y Kimchi
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston.
| | - Anudeepthi Neelagiri
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Wade Whitt
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Avinash Rao Sagi
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Sophia L Ryan
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Greta Gadbois
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Daniël Groothuysen
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - M Brandon Westover
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
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Dementia as a predictor of morbidity and mortality in patients with delirium. Maturitas 2019; 125:63-69. [DOI: 10.1016/j.maturitas.2019.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 11/18/2022]
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Dani M, Owen LH, Jackson TA, Rockwood K, Sampson EL, Davis D. Delirium, Frailty, and Mortality: Interactions in a Prospective Study of Hospitalized Older People. J Gerontol A Biol Sci Med Sci 2019; 73:415-418. [PMID: 29099916 PMCID: PMC5861945 DOI: 10.1093/gerona/glx214] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/25/2017] [Indexed: 11/14/2022] Open
Abstract
Background It is unknown whether the association between delirium and mortality is consistent for individuals across the whole range of health states. A bimodal relationship has been proposed, where delirium is particularly adverse for those with underlying frailty, but may have a smaller effect (perhaps even protective) if it is an early indicator of acute illness in fitter people. We investigated the impact of delirium on mortality in a cohort simultaneously evaluated for frailty. Methods We undertook an exploratory analysis of a cohort of consecutive acute medical admissions aged ≥70. Delirium on admission was ascertained by psychiatrists. A frailty index (FI) was derived according to a standard approach. Deaths were notified from linked national mortality statistics. Cox regression was used to estimate associations between delirium, frailty, and their interactions on mortality. Results The sample consisted of 710 individuals. Both delirium and frailty were independently associated with increased mortality rates (delirium: HR 2.4, 95% CI 1.8–3.3, p < .01; frailty (per SD): HR 3.5, 95% CI 1.2–9.9, p = .02). Estimating the effect of delirium in tertiles of FI, mortality was greatest in the lowest tertile: tertile 1 HR 3.4 (95% CI 2.1–5.6); tertile 2 HR 2.7 (95% CI 1.5–4.6); tertile 3 HR 1.9 (95% CI 1.2–3.0). Conclusion Although delirium and frailty contribute to mortality, the overall impact of delirium on admission appears to be greater at lower levels of frailty. In contrast to the hypothesis that there is a bimodal distribution for mortality, delirium appears to be particularly adverse when precipitated in fitter individuals.
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Affiliation(s)
- Melanie Dani
- Department of Medicine for the Elderly, Hammersmith Hospital, London, UK
| | - Lucy H Owen
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Thomas A Jackson
- Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Kenneth Rockwood
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients. Int Psychogeriatr 2019; 31:267-276. [PMID: 30021661 DOI: 10.1017/s1041610218000777] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology. OBJECTIVES We sought to determine how delirium subtyped by etiology affected six-month function and cognition. DESIGN Prospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED). MEASUREMENTS The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition. RESULTS In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = -2.9 points, 95%CI: -0.3 to -5.6) and organ dysfunction (β coefficient = -4.3 points, 95%CI: -7.2 to -1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20). CONCLUSIONS Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.
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Han JH, Hayhurst CJ, Chandrasekhar R, Hughes CG, Vasilevskis EE, Wilson JE, Schnelle JF, Dittus RS, Ely EW. Delirium's Arousal Subtypes and Their Relationship with 6-Month Functional Status and Cognition. PSYCHOSOMATICS 2019; 60:27-36. [PMID: 29929733 PMCID: PMC6296894 DOI: 10.1016/j.psym.2018.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/01/2018] [Accepted: 05/01/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We sought to determine how delirium subtyped by arousal affected 6-month function and cognition in acutely ill older patients. METHODS This was secondary analysis of a prospective cohort study which enrolled hospitalized patients ≥65 years old. Delirium and arousal were ascertained daily in the emergency department and the first 7 days of hospitalization using the modified Brief Confusion Assessment Method and Richmond Agitation Sedation Scale, respectively. For each day, patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Preillness and 6-month functional status were determined using the Older American Resources and Services activities of daily living scale which ranges from 0 (completely dependent) to 28 (completely independent). Preillness and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly which ranges from 1 (markedly improved cognition) to 5 (severe cognitive impairment). Multiple linear regression was performed adjusted for preillness Older American Resources and Services activities of daily living and Informant Questionnaire on Cognitive Decline in the Elderly and other relevant confounders. RESULTS In 228 older patients, delirium with normal arousal was the only subtype independently associated with poorer 6-month function and cognition. For every day spent in this subtype, the 6-month Older American Resources and Services activities of daily living decreased by 0.84 points (95% confidence interval: -1.59 to -0.09) and the patient's 6-month Informant Questionnaire on Cognitive Decline in the Elderly significantly increased by 0.14 points (95% confidence interval: 0.06-0.23). CONCLUSIONS Delirium with normal arousal, as opposed to delirium with decreased or increased arousal, was the only arousal subtype significantly associated with worsening 6-month function and cognition. Subtyping delirium by arousal may have important prognostic value.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
| | - Christina J Hayhurst
- Department of Anesthesia, Division of Critical Care; Vanderbilt University Medical Center, Nashville, TN
| | | | - Christopher G Hughes
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Department of Anesthesia, Division of Critical Care; Vanderbilt University Medical Center, Nashville, TN
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Jo Ellen Wilson
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Robert S Dittus
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
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Marra A, Jackson JC, Ely EW, Graves AJ, Schnelle JF, Dittus RS, Wilson A, Han JH. Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium. J Hosp Med 2018; 13:551-557. [PMID: 29578552 PMCID: PMC6502509 DOI: 10.12788/jhm.2943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word "LUNCH" backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance "A" task, and (4) 5 picture recognition task. DESIGN Preplanned secondary analysis of a prospective observational study. SETTING Emergency department located within an academic, tertiary care hospital. PARTICIPANTS 234 acutely ill patients who were =65 years old. MEASUREMENTS The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%- 63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSIONS MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.
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Affiliation(s)
- Annachiara Marra
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy J Graves
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John F Schnelle
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin H Han
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Burry L, Mehta S, Perreault MM, Luxenberg JS, Siddiqi N, Hutton B, Fergusson DA, Bell C, Rose L. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2018; 6:CD005594. [PMID: 29920656 PMCID: PMC6513380 DOI: 10.1002/14651858.cd005594.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Guidelines suggest limited and cautious use of antipsychotics for treatment of delirium where nonpharmacological interventions have failed and symptoms remain distressing or dangerous, or both. It is unclear how well these recommendations are supported by current evidence. OBJECTIVES Our primary objective was to assess the efficacy of antipsychotics versus nonantipsychotics or placebo on the duration of delirium in hospitalised adults. Our secondary objectives were to compare the efficacy of: 1) antipsychotics versus nonantipsychotics or placebo on delirium severity and resolution, mortality, hospital length of stay, discharge disposition, health-related quality of life, and adverse effects; and 2) atypical vs. typical antipsychotics for reducing delirium duration, severity, and resolution, hospital mortality and length of stay, discharge disposition, health-related quality of life, and adverse effects. SEARCH METHODS We searched MEDLINE, Embase, Cochrane EBM Reviews, CINAHL, Thomson Reuters Web of Science and the Latin American and Caribbean Health Sciences Literature (LILACS) from their respective inception dates until July 2017. We also searched the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database, Web of Science ISI Proceedings, and other grey literature. SELECTION CRITERIA We included randomised and quasi-randomised trials comparing 1) antipsychotics to nonantipsychotics or placebo and 2) typical to atypical antipsychotics for the treatment of delirium in adult hospitalised (but not critically ill) patients. DATA COLLECTION AND ANALYSIS We examined titles and abstracts of identified studies to determine eligibility. We extracted data independently in duplicate. Disagreements were settled by further discussion and consensus. We used risk ratios (RR) with 95% confidence intervals (CI) as a measure of treatment effect for dichotomous outcomes, and between-group standardised mean differences (SMD) with 95% CI for continuous outcomes. MAIN RESULTS We included nine trials that recruited 727 participants. Four of the nine trials included a comparison of an antipsychotic to a nonantipsychotic drug or placebo and seven included a comparison of a typical to an atypical antipsychotic. The study populations included hospitalised medical, surgical, and palliative patients.No trial reported on duration of delirium. Antipsychotic treatment did not reduce delirium severity compared to nonantipsychotic drugs (standard mean difference (SMD) -1.08, 95% CI -2.55 to 0.39; four studies; 494 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (SMD -0.17, 95% CI -0.37 to 0.02; seven studies; 542 participants; low-quality evidence). There was no evidence antipsychotics resolved delirium symptoms compared to nonantipsychotic drug regimens (RR 0.95, 95% CI 0.30 to 2.98; three studies; 247 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (RR 1.10, 95% CI 0.79 to 1.52; five studies; 349 participants; low-quality evidence). The pooled results indicated that antipsychotics did not alter mortality compared to nonantipsychotic regimens (RR 1.29, 95% CI 0.73 to 2.27; three studies; 319 participants; low-quality evidence) nor was there a difference between typical and atypical antipsychotics (RR 1.71, 95% CI 0.82 to 3.35; four studies; 342 participants; low-quality evidence).No trial reported on hospital length of stay, hospital discharge disposition, or health-related quality of life. Adverse event reporting was limited and measured with inconsistent methods; in those reporting events, the number of events were low. No trial reported on physical restraint use, long-term cognitive outcomes, cerebrovascular events, or QTc prolongation (i.e. increased time in the heart's electrical cycle). Only one trial reported on arrhythmias and seizures, with no difference between typical or atypical antipsychotics. We found antipsychotics did not have a higher risk of extrapyramidal symptoms (EPS) compared to nonantipsychotic drugs (RR 1.70, 95% CI 0.04 to 65.57; three studies; 247 participants; very-low quality evidence); pooled results showed no increased risk of EPS with typical antipsychotics compared to atypical antipsychotics (RR 12.16, 95% CI 0.55 to 269.52; two studies; 198 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There were no reported data to determine whether antipsychotics altered the duration of delirium, length of hospital stay, discharge disposition, or health-related quality of life as studies did not report on these outcomes. From the poor quality data available, we found antipsychotics did not reduce delirium severity, resolve symptoms, or alter mortality. Adverse effects were poorly or rarely reported in the trials. Extrapyramidal symptoms were not more frequent with antipsychotics compared to nonantipsychotic drug regimens, and no different for typical compared to atypical antipsychotics.
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Affiliation(s)
- Lisa Burry
- Mount Sinai Hospital, Leslie Dan Faculty of Pharmacy, University of TorontoDepartment of Pharmacy600 University Avenue, Room 18‐377TorontoONCanadaM5G 1X5
| | - Sangeeta Mehta
- Mount Sinai Hospital, University of TorontoInterdepartmental Division of Critical Care Medicine600 University Ave, Rm 1504TorontoONCanadaM5G 1X5
| | - Marc M Perreault
- Université de MontréalFaculty of PharmacyC.P. 6128, succ Centre‐VilleMontrealQCCanadaH3C 3J7
| | | | - Najma Siddiqi
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Brian Hutton
- Ottawa Hospital Research InstituteKnowledge Synthesis Group501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Chaim Bell
- Mount Sinai HospitalMedicine600 University Street Room 433TorontoONCanadaM5G 1X5
| | - Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
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Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, Armstrong JJ, Rockwood K. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatr 2018; 18:139. [PMID: 29898673 PMCID: PMC6000922 DOI: 10.1186/s12877-018-0823-2] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022] Open
Abstract
Background The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. Methods This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Results Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. Conclusions Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined. Electronic supplementary material The online version of this article (10.1186/s12877-018-0823-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga Theou
- Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada. .,Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Emma Squires
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Kayla Mallery
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Jacques S Lee
- Sunnybrook Health Service, 2075 Bayview Avenue, BG-04, Toronto, ON, M4N 3M5, Canada
| | - Sherri Fay
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Judah Goldstein
- Emergency Health Services, 239 Brownlow Avenue, Suite 300, Dartmouth, NS, B3B 2B2, Canada
| | - Joshua J Armstrong
- Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.,Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
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Maalouf G, Chamaa El A, Tohme A, Haddad F, Maalouly G. Délirium intra-hospitalier : prédisposition, précipitation et sévérité. Rev Med Interne 2018. [DOI: 10.1016/j.revmed.2018.03.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.
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Peri- and postoperative cognitive and consecutive functional problems of elderly patients. Curr Opin Crit Care 2018; 22:406-11. [PMID: 27272100 DOI: 10.1097/mcc.0000000000000327] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW From an elderly patient's perspective, acute and chronic cognitive disturbances are among the most harmful complications that can occur following surgery. For elderly patients, these complications often mean the end of an independent life. This article focuses on this serious aspect, which is increasingly prevalent in our aging society. Cognitive disturbances are associated with severe outcome impairments and increased mortality. This article aims to provide a current overview regarding the diagnosis, pathophysiology, prevention, and treatment of this severe social problem. RECENT FINDINGS The current knowledge of risk factors, diagnosis, prevention, and treatment of postoperative delirium and postoperative cognitive dysfunction should help to raise awareness and improve the outcome of delirious patients, particularly in the elderly population. SUMMARY Especially in elderly patients, postoperative delirium constitutes a common, severe complication. Early diagnosis and supportive treatment are essential to improve outcome. To date, no pharmacological treatment strategy was effective, so that further research about the underlying pathophysiology and the development of treatment strategies are urgently required.
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Zieschang T, Wolf M, Vellappallil T, Uhlmann L, Oster P, Kopf D. The Association of Hyponatremia, Risk of Confusional State, and Mortality. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:855-862. [PMID: 28098064 DOI: 10.3238/arztebl.2016.0855] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 03/17/2016] [Accepted: 08/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hyponatremia and delirium are frequent problems in older hospitalized patients. Although confusional states are considered to be a possible complication of hyponatremia, there has been no systematic study to date of the precise prevalence of delirium among patients with hyponatremia and its effect on long-term outcomes. METHODS In a 13-month period in 2009/2010, all patients with a serum sodium level less than or equal to 130 mmol/L (the hyponatremia group) in a cohort of hospitalized older patients were studied and compared to a normonatremic control group of patients who were matched for age, sex, and diagnosis group. The prevalence of delirium was determined by two-stage examination. Inhospital mortality, mortality six months after initial examination, and functional status were prospectively analyzed. RESULTS 179 patients were identified whose serum sodium level was less than or equal to 130 mmol/L (7.9% of all treated patients), of whom 141 were included in the hyponatremia group. The mean age of the participants was 83 (range, 63-102), and 84% were women. Patients with hyponatremia suffered more often from delirium (22.7% versus 8.5%; p = 0.002) and had a higher inhospital mortality (10.6% versus 2.1%; p = 0.005). The mortality six months after initial examination was 31.9% versus 22.7% (p = 0.080). 59.7% of patients in the hyponatremia group and 49% in the control group (p = 0.146) needed a higher level of chronic care after discharge than they had needed before the hospitalization. CONCLUSION Hyponatremia in hospitalized older patients is associated with a higher likelihood of delirium and an elevated in-hospital mortality.
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Affiliation(s)
- Tania Zieschang
- Geriatric Centre at the University of Heidelberg, Agaplesion Bethanien Hospital Heidelberg; SLK-Kliniken Heilbronn GmbH; Department of Anesthesiology and Intensive Care, Evangelische Diakonissenanstalt Karlsruhe-Rüppurr; Institute for Medical Biometry and Informatics (IMBI), University of Heidelberg; Geriatric Hospital, Katholisches Marienkrankenhaus Hamburg, gGmbH
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Martínez-Ramírez A, Martinikorena I, Lecumberri P, Gómez M, Millor N, Casas-Herrero A, Zambom-Ferraresi F, Izquierdo M. Dual Task Gait Performance in Frail Individuals with and without Mild Cognitive Impairment. Dement Geriatr Cogn Disord 2018; 42:7-16. [PMID: 27459101 DOI: 10.1159/000447451] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Several studies have stated that frailty is associated with cognitive impairment. Based on various studies, cognition impairment has been considered as a component of frailty. Other authors have shown that physical frailty is associated with low cognitive performance. Dual task gait tests are used as a strong predictor of falls in either dementia or frailty. Consequently, it is important to investigate dual task walking tests in elderly populations including control robust oldest old, frail oldest old with mild cognitive impairment (MCI) and frail oldest old without MCI. METHODS Dual task walking tests were carried out to examine the association between frailty and cognitive impairment in a population with advanced age. Forty-one elderly men and women participated in this study. The subjects from control, frail with MCI and frail without MCI groups, completed the 5-meter walk test at their own gait velocity. Arithmetic and verbal dual task walking performance was also assessed. Kinematic data were acquired from a unique tri-axial inertial sensor. RESULTS The spatiotemporal and frequency parameters related to gait disorders did not show any significant differences between frail with and without MCI groups. CONCLUSIONS The evaluation of these parameters extracted from the acceleration signals led us to conclude that these results expand the knowledge regarding the common conditions in frailty and MCI and may highlight the idea that the impairment in walking performance does not depend of frailty and cognitive status.
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Meagher D, Leonard M. The active management of delirium: improving detection and
treatment. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.107.003723] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The management of delirium requires careful consideration of the potential
value both of pharmacological interventions and of a range of non-drug
strategies. Although placebo-controlled studies of delirium treatment are
lacking, less robust evidence can still inform practice. This review makes
the case for more active management of delirium on the basis of recent
studies of prevention, early identification and treatment both during an
episode and managing the aftermath in survivors. A drug-treatment algorithm
for delirium advising how drug treatments can be tailored to the specific
needs of individual patients is described.
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Jeong E, Chang SO. Exploring nurses' recognition of delirium in the elderly by using Q-methodology. Jpn J Nurs Sci 2017; 15:298-308. [PMID: 29266727 DOI: 10.1111/jjns.12199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/31/2017] [Accepted: 10/01/2017] [Indexed: 01/28/2023]
Abstract
AIM Despite its high prevalence and seriousness, delirium has been underrecognized by nurses. One reason is that the original characteristics of delirium are relatively unspecific and phenomenologically diverse, which makes a nurse's subjective decision more important in delirium detection. This study aims to identify the experiences, practices, and viewpoints of nurses in recognizing delirium in the elderly. METHODS In this study, Q-methodology, which is a method for analyzing subjectivity, was used. Following the steps of Q-methodology, 32 nurses with experiences in caring for the delirious elderly sorted 34 Q-statements into the shape of a normal distribution. A centroid factor analysis and varimax rotation using the PQMethod program were conducted. RESULTS This study revealed four factors regarding nurses toward delirium recognition in the elderly. They were: Factor I, prediction from the integrated signs; Factor II, visible symptom-centered detection; Factor III, the detection of abnormal changes based on concentrated observation; and Factor IV, identification by relying on the diagnostic data. CONCLUSION The result of the study can help to understand elderly delirium detection more practically from a nurse's point of view. It is expected to be used as a basis for a practical and accessible delirium education for nurses that reflects nurses' subjective viewpoints.
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Affiliation(s)
- Eunhye Jeong
- Nursing Department, College of Nursing, Korea University, Seoul, South Korea
| | - Sung Ok Chang
- Nursing Department, College of Nursing, Korea University, Seoul, South Korea
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A Systematic Review and Meta-analysis Examining the Impact of Incident Postoperative Delirium on Mortality. Anesthesiology 2017; 127:78-88. [DOI: 10.1097/aln.0000000000001660] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Background
Delirium is an acute and reversible geriatric syndrome that represents a decompensation of cerebral function. Delirium is associated with adverse postoperative outcomes, but controversy exists regarding whether delirium is an independent predictor of mortality. Thus, we assessed the association between incident postoperative delirium and mortality in adult noncardiac surgery patients.
Methods
A systematic search was conducted using Cochrane, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening and data extraction were conducted by two independent reviewers. Pooled-effect estimates calculated with a random-effects model were expressed as odds ratios with 95% CIs. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Non-Randomized Studies.
Results
A total of 34 of 4,968 screened citations met inclusion criteria. Risk of bias ranged from moderate to critical. Pooled analysis of unadjusted event rates (5,545 patients) suggested that delirium was associated with a four-fold increase in the odds of death (odds ratio = 4.12 [95% CI, 3.29 to 5.17]; I2 = 24.9%). A formal pooled analysis of adjusted outcomes was not possible due to heterogeneity of effect measures reported. However, in studies that controlled for prespecified confounders, none found a statistically significant association between incident postoperative delirium and mortality (two studies in hip fractures; n = 729) after an average follow-up of 21 months. Overall, as study risk of bias decreased, the association between delirium and mortality decreased.
Conclusions
Few high-quality studies are available to estimate the impact of incident postoperative delirium on mortality. Studies that controlled for prespecified confounders did not demonstrate significant independent associations of delirium with mortality.
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Han JH, Brummel NE, Chandrasekhar R, Wilson JE, Liu X, Vasilevskis EE, Girard TD, Carlo ME, Dittus RS, Schnelle JF, Ely EW. Exploring Delirium's Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients. Am J Geriatr Psychiatry 2017; 25:233-242. [PMID: 27623552 PMCID: PMC5321606 DOI: 10.1016/j.jagp.2016.05.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 04/29/2016] [Accepted: 05/25/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality. DESIGN This was a preplanned secondary analysis of two prospective cohort studies. SETTING Academic tertiary care emergency department (ED). PARTICIPANTS 1,084 ED patients who were 65 years old or older. MEASUREMENTS At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation Sedation Score to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality. RESULTS Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.3-7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95% CI: 0.9-2.1) and 1.3 (95% CI: 0.3-5.4), respectively. CONCLUSIONS Delirious ED patients with normal arousal at initial presentation had a threefold increased hazard of death within 6 months compared with patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Department of Emergency Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN.
| | - Nathan E Brummel
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jo Ellen Wilson
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Section of Hospital Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Timothy D Girard
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Maria E Carlo
- Division of Geriatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert S Dittus
- Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Division of Geriatrics, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
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Nonpharmacological Interventions Targeted at Delirium Risk Factors, Delivered by Trained Volunteers (Medical and Psychology Students), Reduced Need for Antipsychotic Medications and the Length of Hospital Stay in Aged Patients Admitted to an Acute Internal Medicine Ward: Pilot Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1297164. [PMID: 28164113 PMCID: PMC5259647 DOI: 10.1155/2017/1297164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/01/2016] [Accepted: 12/12/2016] [Indexed: 11/23/2022]
Abstract
Purpose. Effectiveness of nonpharmacological multicomponent prevention delivered by trained volunteers (medical and psychology students), targeted at delirium risk factors in geriatric inpatients, was assessed at an internal medicine ward in Poland. Patients and Methods. Participants were recruited to intervention and control groups at the internal medicine ward (inclusion criteria: age ≥ 75, acute medical condition, basic orientation, and logical contact on admission; exclusion criteria: life expectancy < 24 hours, surgical hospitalization, isolation due to infectious disease, and discharge to other medical wards). Every day trained volunteers delivered a multicomponent standardized intervention targeted at risk factors of in-hospital complications to the intervention group. The control group, selected using a retrospective individual matching strategy (1 : 1 ratio, regarding age, gender, and time of hospitalization), received standard care. Outcome Measures. Hospitalization time, deaths, falls, delirium episodes, and antipsychotic prescriptions were assessed retrospectively from medical documentation. Results. 130 patients (38.4% males) participated in the study, with 65 in the intervention group. Antipsychotic medications were initiated less frequently in the intervention group compared to the control group. There was a trend towards a shorter hospitalization time and a not statistically significant decrease in deaths in the intervention group. Conclusion. Nonpharmacological multicomponent intervention targeted at delirium risk factors effectively reduced length of hospitalization and need for initiating antipsychotic treatment in elderly patients at the internal medicine ward.
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Abstract
BACKGROUND Delirium may be more prevalent in elderly outpatients than has long been assumed. However, it may be easily missed due to overlap with dementia. Our aim was to study delirium symptoms and underlying somatic disorders in psycho-geriatric outpatients. METHODS We performed a case-control study among outpatients that were referred to a psychiatric institution between January 1st and July 1st 2010 for cognitive evaluation. We compared 44 cases with DSM-IV delirium (24 with and 20 without dementia) to 44 controls with dementia only. All participants were aged 70 years or older. We extracted from the medical files (1) referral characteristics including demographics, medical history, medication use, and referral reasons, (2) delirium symptoms, scored with the Delirium Rating Scale-Revised-98, and (3) underlying disorders categorized as: drugs/intoxication, infection, metabolic/endocrine disturbances, cardiovascular disorders, central nervous system disorders, and other health problems. RESULTS At referral, delirium patients had significantly higher numbers of chronic diseases and medications, and more often a history of delirium and a recent hospital admission than controls. Most study participants, including those with delirium, were referred for evaluation of (suspected) dementia. The symptoms that occurred more frequently in cases were: sleep disturbances, perceptual abnormalities, delusions, affect lability, agitation, attention deficits, acute onset, and fluctuations. Drug related (68%), infectious (61%), and metabolic-endocrine (50%) disturbances were often involved. CONCLUSIONS Detection of delirium and distinction from dementia in older outpatients was feasible but required detailed caregiver information about the presence, onset, and course of symptoms. Most underlying disorders could be managed at home.
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Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy. .,Geriatric Unit, San Gerardo University Hospital, Monza, Italy. .,Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy.,Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy.,Tor Vergata, Rome University, Rome, Italy.,Italian Psychogeriatric Association (AIP), Brescia, Italy
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Agar MR, Quinn SJ, Crawford GB, Ritchie CS, Phillips JL, Collier A, Currow DC. Predictors of Mortality for Delirium in Palliative Care. J Palliat Med 2016; 19:1205-1209. [PMID: 27309842 DOI: 10.1089/jpm.2015.0416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Delirium has a high mortality rate. Understanding predictors of prognosis in patients with delirium will aid treatment decisions and communication. This study aimed to explore variables associated with death during an established episode of delirium in palliative care when haloperidol treatment had been commenced. METHODS A consecutive cohort of palliative care patients, from 14 centers across four countries, is reported. The outcome of interest was death within 14 days from commencement of haloperidol treatment for delirium. Clinicodemographic variables explored were delirium severity, age, gender, primary life limiting illness, body mass index (BMI), total daily haloperidol dose at baseline (mg), functional status, and comorbidities. RESULTS One hundred and sixteen palliative care patients where vital status was known were included in the analysis; 45% (n = 52) died within 10 days, and 56% (n = 65) died within 14 days. In multivariate analyses no clinical or demographic variables predicted death, apart from lower BMI in noncancer patients. CONCLUSION This study has shown a very high mortality rate within two weeks of commencing haloperidol for delirium in palliative care, with no clear clinical predictors for those with a higher chance of dying. Having a higher BMI offered some benefit in survival, but only in noncancer patients. When delirium occurs in advanced illness, discussion should be initiated about the gravity of the clinical situation.
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Affiliation(s)
- Meera R Agar
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia.,2 South West Sydney Clinical School, University of New South Wales , Sydney Australia .,3 Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney , Ultimo, Australia .,4 Ingham Institute of Applied Medical Research , Sydney, Australia
| | - Stephen J Quinn
- 5 Flinders Clinical Effectiveness, Flinders University , Adelaide, Australia
| | - Gregory B Crawford
- 6 Discipline of Medicine, University of Adelaide , Adelaide, Australia .,7 Northern Adelaide Local Health Network , Adelaide, Australia
| | - Christine S Ritchie
- 8 Department of Medicine, Division of Geriatrics, University of California San Francisco , San Francisco, California.,9 The Jewish Home of San Francisco, San Francisco, California
| | - Jane L Phillips
- 3 Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney , Ultimo, Australia
| | - Aileen Collier
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia
| | - David C Currow
- 1 Discipline of Palliative and Supportive Services, Flinders University , Adelaide, South Australia.,5 Flinders Clinical Effectiveness, Flinders University , Adelaide, Australia
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Cognitive Impairment in Hospitalized Seniors. Geriatrics (Basel) 2016; 1:geriatrics1010004. [PMID: 31022800 PMCID: PMC6371190 DOI: 10.3390/geriatrics1010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 11/16/2022] Open
Abstract
Cognitive disorders are highly prevalent in hospitalized seniors, and can be due to delirium, dementia, as well as other disorders. Hospitalization can have adverse cognitive effects, and cognitive dysfunction adversely affects hospital outcomes. In this article, the literature is reviewed on how hospitalization affects cognitive function and how cognitive impairment affects hospital outcomes. Possible interventions in cognitively impaired hospitalized seniors are reviewed.
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Hölttä E, Laakkonen ML, Laurila J, Strandberg T, Tilvis R, Pitkälä K. Psychotic symptoms of dementia, their relationship with delirium and prognostic value. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2014.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Ward G, Perera G, Stewart R. Predictors of mortality for people aged over 65 years receiving mental health care for delirium in a South London Mental Health Trust, UK: a retrospective survival analysis. Int J Geriatr Psychiatry 2015; 30:639-46. [PMID: 25315066 DOI: 10.1002/gps.4195] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 07/24/2014] [Accepted: 07/31/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Delirium is a common phenomenon in older people. Using a large mental health care data resource, we investigated mortality rates and predictors of mortality following delirium in older people. METHODS The South London and Maudsley NHS Foundation Trust (SLAM) Clinical Record Interactive Search (CRIS) was used to retrieve anonymised data on patients known to mental health services who were over 65 years of age and received a diagnosis of delirium during a 3-year period. Age-standardised and gender-standardised mortality rates (SMRs) were calculated, and predictors of survival were investigated considering demographic factors, health status rated on the Health of the National Outcome Scale (HoNOS), cognitive function and previous or contemporaneous diagnosed dementia. RESULTS In 974 patients with delirium, 1- and 3-year mortality rates were 37.2 and 54.9% respectively, representing an SMR of 4.7 overall (95% CI: 4.3-5.1). SMR was 5.2 (95% CI: 4.6-5.7) for patients with delirium without prior dementia; SMR was 4.1 (95% CI: 3.6-4.7) for patients with dementia preceding delirium and 2.2 (2.0-2.5) excluding deaths within 6 months of the delirium diagnosis. Significant predictors of mortality in fully adjusted models were older age, male gender, white (compared with non-white) ethnicity, and HoNOS subscales measuring physical ill-health and functional impairment. No mortality associations were found with cognitive function, dementia, or psychological symptoms. CONCLUSIONS In people with delirium diagnosed by mental health services, mortality risk was high and predicted by demographic and physical health status rather than by cognitive function or psychological profile.
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Affiliation(s)
- Geoff Ward
- Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK
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Saarinen E, Vuorisalo S, Kauhanen P, Albäck A, Venermo M. The Benefit of Revascularization in Nonagenarians with Lower Limb Ischemia is Limited by High Mortality. Eur J Vasc Endovasc Surg 2015; 49:420-5. [DOI: 10.1016/j.ejvs.2014.12.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
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McCusker J, Cole MG, Voyer P, Monette J, Champoux N, Ciampi A, Vu M, Belzile E. Six-month outcomes of co-occurring delirium, depression, and dementia in long-term care. J Am Geriatr Soc 2014; 62:2296-302. [PMID: 25482152 DOI: 10.1111/jgs.13159] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the 6-month outcomes of co-occurring delirium (full syndrome and subsyndromal symptoms), depression, and dementia in a long-term care (LTC) population. DESIGN Observational, prospective cohort study with 6-month follow-up conducted from 2005 to 2009. SETTING Seven LTC facilities in the province of Quebec, Canada. PARTICIPANTS Newly admitted and long-term residents recruited consecutively from lists of residents aged 65 and older admitted for LTC, with stratification into groups with and without severe cognitive impairment. The study sample comprised 274 residents with complete data at baseline on delirium, dementia, and depression. MEASUREMENTS Outcomes were 6-month mortality, functional decline (10-point decline from baseline on 100-point Barthel scale), and cognitive decline (3-point decline on 30-point Mini-Mental State Examination). Predictors included delirium (full syndrome or subsyndromal symptoms, using the Confusion Assessment Method), depression (Cornell Scale for Depression in Dementia), and dementia (chart diagnosis). RESULTS The baseline prevalences of delirium, subsyndromal symptoms of delirium (SSD), depression, and dementia were 11%, 44%, 19%, and 66%, respectively. By 6 months, 10% of 274 had died, 19% of 233 had experienced functional decline, and 17% of 246 had experienced cognitive decline. An analysis using multivariable generalized linear models found the following significant interaction effects (P < .15): between depression and dementia for mortality, between delirium and depression for functional decline, and between SSD and dementia for cognitive decline. CONCLUSION Co-occurrence of delirium, SSD, depression, and dementia in LTC residents appears to affect some 6-month outcomes. Because of limited statistical power, it was not possible to draw conclusions about the effects of the co-occurrence of some syndromes on poorer outcomes.
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Affiliation(s)
- Jane McCusker
- St. Mary's Research Centre, St Mary's Hospital Center, Montreal; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
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Han JH, Vasilevskis EE, Shintani A, Graves AJ, Schnelle JF, Dittus RS, Powers JS, Wilson A, Storrow AB, Ely EW. Impaired arousal at initial presentation predicts 6-month mortality: an analysis of 1084 acutely ill older patients. J Hosp Med 2014; 9:772-8. [PMID: 25352356 PMCID: PMC4326096 DOI: 10.1002/jhm.2276] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/24/2014] [Accepted: 10/03/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Impaired arousal signifies underlying brain dysfunction, but its clinical significance outside the intensive care unit remains unclear. We sought to determine if impaired arousal at initial presentation was associated with higher 6-month mortality and if this relationship existed in the absence of delirium. DESIGN Prospective cohort study. SETTING An emergency department located within an academic, tertiary care hospital. PARTICIPANTS A total of 1084 noncomatose patients who were aged 65 years or older. MEASUREMENTS The Richmond Agitation-Sedation Scale (RASS) is a 10-second arousal scale; a score of 0 indicates normal arousal. Cox proportional hazard regression was performed adjusting for patient characteristics, admission status, and psychoactive medication administration. To determine if impaired arousal in the absence of delirium was associated with 6-month mortality, Cox proportional hazard regression was performed in a subset of 406 patients who received a psychiatric assessment; the inverse weighted propensity score method was used to minimize residual confounding. Hazard ratios (HR) with their 95% confidence intervals (95% CI) were reported. RESULTS Patients with impaired arousal were 73% more likely to die within 6 months (HR: 1.73, 95% CI: 1.21-2.49). Even in the absence of delirium, patients with an abnormal RASS were more likely to die within 6 months (HR: 2.20, 95% CI: 1.10-4.41). CONCLUSION Impaired arousal at initial presentation is an independent predictor of death within 6 months in a diverse group of acutely ill older patients, even in the absence of delirium. Routine RASS assessment of arousal during clinical care may be warranted as it correlates with prognosis.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Amy J. Graves
- Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - John F. Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Robert S. Dittus
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - James S. Powers
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - E. Wesley Ely
- Center for Health Services Research; Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Hölttä E, Laurila J, Laakkonen M, Strandberg T, Tilvis R, Pitkala K. Precipitating factors of delirium: Stress response to multiple triggers among patients with and without dementia. Exp Gerontol 2014; 59:42-6. [DOI: 10.1016/j.exger.2014.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/22/2014] [Accepted: 04/28/2014] [Indexed: 01/10/2023]
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