Impact of Delirium and Its Motor Subtypes on Stroke Outcomes

ICU admission Braden score independently predicts delirium in critically ill patients with ischemic stroke

BACKGROUND

Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management.

OBJECTIVE

To examine the association between the Braden score and delirium.

METHODS

A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated.

RESULTS

The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001).

CONCLUSIONS

The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke.

IMPLICATION FOR CLINICAL PRACTICE

The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs.

Impact of delirium on acute stroke outcomes: A systematic review and meta-analysis

Delirium is a common complication in acute stroke patients. A 2011 meta-analysis showed an increased risk of in-hospital mortality and mortality within 12 months post-stroke, longer hospitalization durations, and increased likelihood of being discharged to a nursing home for patients experiencing post-stroke delirium. There is a need for an updated meta-analysis with several new studies having been since published. The PubMed and Scopus databases were screened for relevant studies. Inclusion criteria were as follows: retrospective or prospective studies reporting on the effects of delirium accompanying acute stroke on mortality, functional outcomes, length of hospital stay and need for re-admission. Strength of association was presented as pooled adjusted relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Statistical analysis was done using STATA version 16.0. The meta-analysis included 22 eligible articles. Eighteen of the 22 studies were prospective follow ups. Included studies were of good quality. Post-stroke delirium was associated with increased risk of in-hospital mortality, as well as mortality within 12 months post-stroke. Patients with delirium experienced increased hospital stay durations, were at greater risk for hospital readmission, and showed elevated risk for poor functional outcome. Compared to those who did not have delirium, stroke patients with delirium were 42% less likely to be discharged to home. Acute stroke patients with delirium are at an increased risk for poor short- and long-term outcomes. More research is needed to identify the best set of interventions to manage such patients and improve outcomes.

The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey

BACKGROUND

Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association.

OBJECTIVES

The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units.

METHODS

A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied.

RESULTS

One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001).

DISCUSSION

Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

Associations of Delirium to Posthospital Outcomes After Acute Stroke: A Scoping Review

ABSTRACT

Background: Delirium is a common and distressing manifestation of acute brain dysfunction that is associated with poor outcomes in various critically ill patient populations. Although patients with acute stroke experience delirium, understanding of delirium in this population is limited. The purpose of this scoping review is to describe existing evidence about delirium and associations with posthospital outcomes after acute stroke. Methods: Arksey and O'Malley's 5-stage framework was used to perform a scoping review. PubMed, CINAHL, and EMBASE electronic databases were searched. Outcome domains of interest included mortality, cognitive function, physical function, mental health, and quality of life. Full-text, peer-reviewed articles with adult stroke sample populations (acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) were included. Results: Nineteen articles, involving 5611 unique patients, were included. Most sample populations included patients with either acute ischemic stroke or intracerebral hemorrhage. Heterogeneous research aims, methods, and outcome measures limit the ability to compare specific findings across studies. However, included studies suggest higher mortality at 12 months, worse cognition, and greater functional impairment in patients who have experienced acute stroke and delirium. Limited information regarding associations of delirium with posthospital mental health outcomes and quality of life precluded the ability to analyze these relationships and warrants further investigation. Conclusion: This review suggests concerning findings about associations of delirium to posthospital outcomes after acute stroke. Better characterization of delirium after acute stroke and analysis of its impact on long-term outcomes are needed.

Use of Family Photographs Reduces Restlessness in Neurocritical Care Patients

ABSTRACT

BACKGROUND: Patients admitted to the neuroscience intensive care unit often experience varying states of confusion and restlessness. The purpose of this study was to examine restlessness in acutely confused patients through use of familiar photographs. METHODS : This randomized prospective pilot study placed family photographs (photos) on the bedrail of confused patients during the night shift (8 pm to 4 am ) in a neuroscience intensive care unit. Wrist actigraphy was used to examine restlessness when patients were turned to face the photos versus when they were not facing the photos. RESULTS: The 20 patients enrolled provided 34 nights worth of data during which 32 640 actigraph readings were obtained. On the first night of study, the odds of wrist movement were higher when the patient was facing the photos compared with not (odds ratio, 1.51; 95% confidence interval, 1.42-1.61). During subsequent nights, the odds of wrist movement were lower when the patient was facing the photos compared with not (odds ratio, 0.82; 95% confidence interval, 0.75-0.90). CONCLUSION : Use of familiar photos does not change restlessness, agitation, or delirium on the first night of observation. However, the use of familiar photos may decrease restlessness on the subsequent nights. There are important subjective observations from researchers and family that suggest all subjects had a noticeable response when initially seeing the familiar photos.

Long-term functional outcome and quality of life 2.5 years after thrombolysis in acute ischemic stroke

BACKGROUND

Evaluation of outcome after stroke is largely based on assessment of gross function 3 months after stroke onset using scales such as mRS. Cognitive or social functions, level of symptom burden or emotional health are not usually assessed, nor are data available on long-term functional outcomes years after stroke.

METHODS

Analysis of 1141 patients with AIS treated with IVT from two major German university hospitals between 2017 and 2020. Patient characteristics and short-term outcome were analysed from patient records. Long-term outcome of 228 patients with prior written informed consent was assessed via telephone survey using mRS and PROMs (EQ-5D-5L, EQ-VAS) 2.5 years after stroke.

RESULTS

Predictors of excellent to good long-term outcome were younger age, event to door time ≤ 2 h, NIHSS ≤ 6 on admission and NIHSS ≤ 6 after IVT. Stroke recurrence was a negative predictor. Predictors of excellent quality of life at 2.5 years included age < 73 years, lower NIHSS after IVT, absence of hypertension. Quality of life was rated in all dimensions with a medium score of 1 and a medium EQ-VAS of 70, representing the good general health status of this stroke population.

CONCLUSION

Main predictors of an excellent to good long-term outcome and excellent QoL 2.5 years after stroke are younger age, lower NIHSS, and event to door time ≤ 2 h. Research on long-term outcome after disease and treatment is of utmost importance, as it has the ability to reveal the patient true functional outcome and quality of life and to provide information on the status of independence and self-esteem.

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

Arrival time at a referral hospital and functional disability of people with stroke: a cohort study

BACKGROUND

Stroke is a major cause of death and functional disability worldwide. Knowledge of the associated factors is essential for defining education, management, and healthcare strategies.

OBJECTIVE

To analyze the association between arrival time at a neurology referral hospital (ATRH) and functional disability in patients with ischemic stroke 90 days after the event.

DESIGN AND SETTING

Prospective cohort study conducted at a public institution of higher education in Brazil.

METHODS

This study included 241 people aged ≥ 18 years who presented ischemic stroke. The exclusion criteria were death, inability to communicate without companions who could answer the research questions, and > 10 days since ictus. Disability was assessed using the Rankin score (mR). Variables for which associations showed a P value ≤ 0.20 in bivariate analysis were tested as modifiers between ATRH and disability. Significant interaction terms were used for multivariate analysis. Multivariate logistic regression analysis was performed with all variables, arriving at the complete model and adjusted beta measures. The confounding variables were included in the robust logistic regression model, and Akaike's Information Criterion was adopted to choose the final model. The Poisson model assumes a statistical significance of 5% and risk correction.

RESULTS

Most participants (56.0%) arrived at the hospital within 4.5 hours of symptom onset, and 51.7% presented with mRs of 3 to 5 after 90 days of ictus. In the multivariate model, ATRH ≥ 4.5 hours and females were associated with more significant disability.

CONCLUSIONS

Arrival at the referral hospital 4.5 hours after the onset of symptoms or wake-up stroke was an independent predictor of a high degree of functional disability.

Ischemic stroke mortality and time for hospital arrival: analysis of the first 90 days

OBJECTIVE

To analyze the association between time of arrival at a reference hospital and mortality of people with ischemic stroke.

METHOD

Descriptive and inferential statistics were used. Modifying and confounding variables between time of arrival and mortality were observed in the multivariate analysis. The Akaike Information Criterion was used to choose the model. Statistical significance of 5% and risk correction using the Poisson Model were adopted.

RESULTS

Most participants arrived within 4.5 hours of symptom onset or wake up stroke to the referral hospital and 19.4% died. The score of the National Institute of Health Stroke Scale was a modifier. In the multivariate model stratified by scale score ≥14, arrival time >4.5h was associated with lower mortality; and age ≥60 years and having Atrial Fibrillation, to higher mortality. In the model stratified by score ≤13, previous Rankin ≥3, and presence of atrial fibrillation were predictors of mortality.

CONCLUSION

The relationship between time of arrival and mortality up to 90 days was modified by the National Institute of Health Stroke Scale. Prior Rankin ≥3, atrial fibrillation, time to arrival ≤4.5h, and age ≥60 years contributed to higher mortality.

Association of Atrial Fibrillation and Cardioembolic Stroke with Poststroke Delirium Susceptibility: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Several studies have shown atrial fibrillation (AF) and cardioembolic stroke (CES) to be associated with the risk of poststroke delirium (PSD). However, other studies have reported inconsistent results. We performed a comprehensive meta-analysis to clarify the associations between AF and CES and PSD susceptibility.

METHODS

We searched relevant studies meeting inclusion criteria in PubMed, Google Scholar, and Web of Science. Useful data were pooled, and odds ratios and 95% confidence intervals were calculated. We also assessed heterogeneity among studies, performed sensitivity analyses, and estimated publication bias.

RESULTS

This meta-analysis containing 18 observational studies proved that AF (odds ratio =2.30, 95% confidence interval = 2.00-2.65, P < 0.0001) was associated with an increased risk of PSD. CES was also found to have a higher risk of delirium compared with other types of stroke based on the Trial of Org 10172 in Acute Stroke Treatment classification (odds ratio = 2.02, 95% confidence interval = 1.47-2.79, P < 0.0001).

CONCLUSIONS

Our meta-analysis suggested that AF and CES contribute to increased risk of PSD.

The Role of Vascular Risk Factors in Post-Stroke Delirium: A Systematic Review and Meta-Analysis

Vascular risk factors may predispose to post-stroke delirium (PSD). A systematic review and meta-analysis were performed by searching PubMed, Web of Science, and Scopus. The primary outcome was the prevalence of vascular risk factors in PSD vs. non-PSD patients. Odds ratios (ORs) with 95% confidence intervals (CIs) and mean differences (MDs) with 95% CIs were calculated for categorical and continuous variables, respectively. Fixed effects or random effects models were used in case of low- or high-statistical heterogeneity, respectively. We found an increased prevalence of atrial fibrillation (OR = 1.74, p = 0.0004), prior stroke (OR = 1.48, p < 0.00001), coronary artery disease (OR = 1.48, p < 0.00001), heart failure (OR = 2.01, p < 0.0001), and peripheral vascular disease (OR = 2.03, p < 0.00001) in patients with vs. without PSD. PSD patients were older (MD = 5.27 y, p < 0.00001) compared with their non-PSD counterparts. Advanced age, atrial fibrillation, prior stroke, coronary artery disease, heart failure, and peripheral vascular disease appeared to be significantly associated with PSD.

Impact of delirium on the outcome of stroke: a prospective, observational, cohort study

Introduction

Delirium is an acute fluctuating disorder of attention and awareness, which often complicates the clinical course of several conditions, including acute stroke. The aim of the present study was to determine whether delirium occurrence impacts the outcome of patients with acute stroke.

Methods

The study design is single center, prospective, observational. We consecutively enrolled patients admitted to the stroke unit from April to October 2020. Inclusion criteria were age ≥ 18 years and diagnosis of acute stroke. Exclusion criteria were stroke mimics, coma, and terminal conditions. All patients were screened for delirium upon admission, within 72 h, and whenever symptoms suggesting delirium occurred by means of the Confusion Assessment Method for Intensive Care Unit and the Richmond Agitation Sedation Scale. Outcomes were evaluated with the 90-days modified Rankin Scale (mRS) by telephone interview.

Results

The final study cohort consisted of 103 patients (62 men; median age 75 years, interquartile range 63–81). Thirty-one patients (30%) developed delirium. In the multivariate ordinal logistic regression, patients with delirium had higher mRS scores at 3 months (DLR + : mRS = 4 (3–6); DLR–: mRS = 1 (1–3); adjusted odds ratio = 4.83; CI = 1.88–12.35; p = 0.006). Delirium was a risk factor for death (mRS = 6) in the univariate logistic regression (OR 4.5, CI = 1.44–14.07; p = 0.010), but not in the adjusted analysis (OR 3.45; CI = 0.66–17.95; p = 0.142). Survival time during 90-days follow-up was shorter in the delirium group (Log Rank χ² 3.89; p = 0.048).

Conclusion

Delirium negatively impacts the prognosis of patients with acute stroke. Patients with post-stroke delirium have a worse functional outcome and a shorter survival.

Delirium and subsyndromal delirium are associated with the long-term risk of death after ischaemic stroke

BACKGROUND

Post-stroke delirium has a negative impact on functional outcome. We explored if there is any association between delirium, subsyndromal delirium and long-term mortality after ischaemic stroke and transient ischaemic attack.

METHODS

We included 564 patients with ischaemic stroke or transient ischaemic attack. We assessed symptoms of delirium during the first 7 days after admission. We used Cox proportional hazards models to analyse all-cause mortality during the first 5 years after stroke.

RESULTS

We diagnosed delirium in 23.4% and subsyndromal delirium in 10.3% of patients. During the follow-up, 72.7% of patients with delirium, 51.7% of patients with subsyndromal delirium and 22.7% of patients without delirious symptoms died (P < 0.001). Patients with subsyndromal delirium and delirium had higher risk of death in the multivariate analysis (HR 1.72, 95% CI 1.11-2.68, P = 0.016 and HR 3.30, 95% CI 2.29-4.76, P < 0.001, respectively).

CONCLUSIONS

Post-stroke delirium is associated with long-term mortality. Patients with subsyndromal delirium are at the intermediate risk of death.

Subtypes of delirium after ischaemic stroke-predisposing factors and outcomes: a prospective observational study (PROPOLIS)

BACKGROUND AND PURPOSE

Delirium is a serious complication after stroke. It remains unclear whether different motor subtypes of delirium are associated with diverse risk factors and outcomes. The aim was to investigate if delirium subtypes differ in predisposing factors, clinical characteristics and outcomes.

METHODS

In all, 698 patients with ischaemic stroke or transient ischaemic attack (median age 73 years; 53.7% female) were prospectively included. Core features of delirium during the first 7 days after admission were examined. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for delirium were used. Pre-stroke characteristics were compared between different delirium subtypes and logistic regression and Cox proportional hazard models were used to explore the association between delirium, functional outcome and death.

RESULTS

Hyperactive, hypoactive and mixed delirium were diagnosed in 28, 75 and 66 patients, respectively. Patients with hyperactive delirium had less severe neurological deficit on admission and more often had transient ischaemic attack compared with patients with hypoactive and mixed delirium. Compared with patients with hypoactive delirium, those with hyperactive delirium more often suffered from irritability/lability prior to stroke. Hyperactive and hypoactive delirium did not differ in age, sex, comorbidities, pre-stroke dependency, cognitive decline and severity of delirium. Hyperactive, hypoactive and mixed delirium were associated with an increased risk of poor 3- and 12-month functional outcome compared with patients without delirium. Moreover, patients with hypoactive and mixed delirium had an elevated risk of death.

CONCLUSIONS

Hyperactive delirium is associated with less severe stroke and higher scores of pre-existing irritability/lability. All three motor subtypes of delirium are associated with poor outcome, although hyperactive delirium seems to have a less unfavourable prognosis.

Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression

Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.