Relationship between symptoms and motoric subtype of delirium

Efficacy of repetitive transcranial magnetic stimulation in preventing postoperative delirium in elderly patients undergoing major abdominal surgery: A randomized controlled trial

BACKGROUND

Postoperative delirium (POD) is a serious complication in elderly patients after major surgery, associated with high morbidity and mortality. Treatment and prevention methods are limited. Repetitive transcranial magnetic stimulation (rTMS) shows potential in enhancing cognitive function and improving consciousness.

OBJECTIVE

To evaluate whether early postoperative rTMS has a protective effect against POD and to explore its potential mechanisms.

METHODS

Patients aged 60 years or older, scheduled for major abdominal surgery, were randomly assigned to receive rTMS at 100 % RMT, 10 Hz, with 2000 pulses targeting the DLPFC after extubation in PACU, either as active rTMS(n = 61) or sham rTMS (n = 61). The primary outcome was the incidence of POD during the first 3 postoperative days.

RESULTS

In the modified intention-to-treat analysis of 122 patients (mean [SD] age, 70.2 [4.1] years; 53.3 % women), POD incidence was lower in the rTMS group (11.5 %) compared to the sham rTMS group (29.5 %) (relative risk, .39; 95 % CI, .18 to .86; P = .01). rTMS patients had higher BDNF (8.47 [2.68] vs. 5.76 [1.42] ng/mL; P < .001) and lower NfL (.05 [.04] vs. .06 [.04] ng/mL; P = .02) levels. Mediation analysis suggests that rTMS may reduce POD by increasing brain-derived neurotrophic factor (z = -3.72, P < .001) rather than decreasing neurofilament light (z = 1.92, P = .06).

CONCLUSIONS

Immediate postoperative rTMS can reduce the incidence of POD in elderly patients undergoing major abdominal surgery, probably by upregulating brain-derived neurotrophic factor levels.

Global Trends in Research Related to Emergence Agitation From 1978 to 2023: A Bibliometric Analysis

PURPOSE

Emergence agitation (EA) is a postoperative behavioral disorder characterized by a lack of connection between consciousness and behavior. Despite its clinical importance and prevalence in the postoperative setting, the research focus and knowledge structure remain to be systematically mapped. Therefore, we conducted a bibliometric analysis from 1978 to 2023 to address this gap. This study aims to excavate research hotspots, map knowledge structure, uncover emerging trends, and provide invaluable insights for guiding future research endeavors.

DESIGN

A bibliometric analysis of emergency agitation.

METHODS

We conducted a literature search in the Web of Science Core Collection for articles on EA published between 1978 and 2023. We collected data on countries, institutions, journals, authors, citations, and keywords. Subsequently, we comprehensively analyzed the gathered knowledge units using three tools, including VOSviewer, HistCite Pro, and ArcGIS Pro.

FINDINGS

From 1978 to 2023, we retrieved 948 pieces of literature on EA, with the number of publications increasing yearly. China ranked first in the number of publications (n = 253, 26.69%). The United States was the most cited and influential country, closely collaborating with other countries (5,661 citations, H-index 57, citations per publication 37.99, total link strength [TLS] 24). Yonsei University was the most productive and influential institution (n = 18, 1.9%, 427 citations, H-index 12, citations per publication 23.72). Shanghai Jiao Tong University had close collaborative relationships with other universities (TLS 7). The journal with the most publications and influence was Pediatric Anaesthesia (n = 46, 4.92%, H-index 32). Anaesthesia and Analgesia was the most cited journal (2,849 citations). M.T. Aouad was the most influential and productive author devoted to studying EA (n = 6, 0.63%, 173 citations, TLS 3,002). The most influential reference was "Greater incidence of delirium during recovery from sevoflurane anaesthesia in preschool boys" (author J. Aono, No. 19, IF = 8.8, Q1, local citation score 147). Hot research directions in EA include EA and emergence delirium, propofol and EA, risk factors of EA, EA in pediatric anaesthesia, dexmedetomidine, and EA induced by sevoflurane. Esketamine, nalbuphine, sugammadex, and dezocine are drugs that have received increased attention in recent years.

CONCLUSIONS

The study mapped the knowledge structure of EA and identified six prominent research directions, four drugs of significant research interest, and emerging thematic trends. These findings offer insights into the current state of research on EA, providing a comprehensive view of the field's landscape.

Prevalence and risk factors of emergence agitation among pediatric patients undergo ophthalmic and ENT Surgery: a cross-sectional study

BACKGROUND

Some studies reported that pediatric patients undergoing otorhinolaryngology (ENT) and ophthalmic surgeries have higher incidences of emergence agitation (EA). Children with EA tend to carry the risk of self-harm, have longer periods of recovery and delayed hospital discharge. Consequently, EA needs to be monitored and risk factors ought to be emphasized to implement preventative measures. The objective of this study was to describe EA and to identify risk factors after pediatric ophthalmic or ENT surgery.

METHODS

Between September 2021 and December 2021, a cross-sectional study was conducted in 100 children aged of 0-12 years who underwent ophthalmic or ENT surgery. The Watcha scale was used to observe and record EA, which was defined at levels of 3 or 4 at any time in the post-anesthesia care unit (PACU). The pain intensity was graded with the Face, Legs, Activity, Cry, Consolability (FLACC) Scale after surgery. Patient and surgery-related characteristics, the behavioral criteria of EA, the pharmacologic and non-pharmacologic interventions and recovery outcomes were objectively recorded. A binary logistic regression model was constructed to identify the associated factors of EA.

RESULTS

From the 100 analyzed children, 58 were males and 42 were females, and 44 patients received ophthalmic surgery and 56 ENT surgery. The median age was 6 (IQR 4-7) years. The overall incidence of EA among pediatrics was 30% (34.5% for ENT and 24.4% for ophthalmic surgery). High preoperative modified Yale Preoperative Anxiety scale (m-YPAS) grade (OR = 1.19, 95%CI 1.06-1.33, P = 0.003) and high postoperative FLACC score (OR = 3.36, 95%CI 1.88-6.02, P < 0.001) were risk factors for EA.

CONCLUSIONS

This study identified that preoperative anxiety and postoperative pain are associated with EA in children after ophthalmic or ENT surgery. Preoperative anxiety assessment and management, and administration of adjunct analgesic treatments should be considered in the routine care.

Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review

This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.

Postoperative Delirium after Reconstructive Surgery in the Head and Neck Region

Postoperative delirium (POD) is an acute and serious complication following extended surgery. The aim of this study was to identify possible risk factors and scores associated with POD in patients undergoing reconstructive head and neck surgery. A collective of 225 patients was retrospectively evaluated after receiving reconstructive surgery in the head and neck region, between 2013 to 2018. The incidence of POD was examined with regards to distinct patient-specific clinical as well as perioperative parameters. Uni- and multivariate statistics were performed for data analysis. POD occurred in 49 patients (21.8%) and was strongly associated with an increased age-adjusted Charlson Comorbidity Index (ACCI) and a prolonged stay in the ICU (p = 0.009 and p = 0.000, respectively). Analogous, binary logistic regression analysis revealed time in the ICU (p < 0.001), an increased ACCI (p = 0.022) and a Nutritional Risk Screening (NRS) score ≠ 0 (p = 0.005) as significant predictors for a diagnosis of POD. In contrast, the extent of reconstructive surgery in terms of parameters such as type of transplant or duration of surgery did not correlate with the occurrence of POD. The extension of reconstructive interventions in the head and neck region is not decisive for the development of postoperative delirium, whereas patient-specific parameters such as age and comorbidities, as well as nutritional parameters, represent predictors of POD occurrence.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies

BACKGROUND

To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA).

METHODS

The databases of PubMed, Google scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV).

RESULTS

Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I² = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I² = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I² = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications.

CONCLUSION

This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.

Effectiveness of Intravenous Ibuprofen on Emergence Agitation in Children Undergoing Tonsillectomy with Propofol and Remifentanil Anesthesia: A Randomized Controlled Trial

Background

Emergence agitation (EA) has a negative effect on the recovery from general anesthesia in children. This study aimed to evaluate the effectiveness of intravenous ibuprofen in reducing the incidence of EA in children.

Methods

This randomized, double-blind, placebo-controlled, single-center study analyzed data from patients aged 3–9 years undergoing tonsillectomy under general anesthesia with propofol and remifentanil. These patients were randomly assigned to receive either the ibuprofen or the placebo intraoperatively. The primary endpoint was a between-group difference in the incidence of EA at 15 min following extubation. EA was defined as Pediatric Anesthesia Emergence Delirium score ≥10. The secondary endpoint included the associated factors of EA.

Results

Eighty-nine patients were included in the study. Ibuprofen decreased the incidence of EA at 15 min following extubation (8.9% in the treatment group vs 34.1% in the control group; odds ratio [OR], 0.261; 95% confidence interval [CI], 0.094–0.724; P=0.004). Compared with the control group, there was a significant reduction in the number of rescue fentanyl doses (P=0.045), and fewer patients experienced moderate to severe pain at 15 min following extubation in the treatment group (P=0.048). Upon logistic regression analysis, high modified Pediatric Anesthesia Behavior and pain scores following surgery were considered the risk factors related to EA (OR, 8.07; 95% CI, 1.12–58.07, P=0.038 and OR, 2.78; 95% CI, 1.60–4.82, P<0.001, respectively). Ibuprofen administration was the protective factor related to EA (OR, 0.05; 95% CI, 0.01–0.67, P=0.023).

Conclusion

Intraoperative ibuprofen infusion can significantly reduce the incidence of EA following general anesthesia with propofol and remifentanil in children.

Trial Registration

The study was registered with the Chinese Clinical Trial Registry on 7 April 2021 (number: ChiCTR2100045128; https://www.chictr.org.cn/edit.aspx?pid=124595&htm=4).

The family in preventing delirium in the intensive care unit: Scoping review

INTRODUCTION

Delirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.

OBJECTIVE

To identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF.

INCLUSION CRITERIA

Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.

METHODS

A scope review was conducted using the keywords "Critical Care, Delirium, Family, Primary Prevention" in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.

RESULTS

The results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.

CONCLUSION

Extended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.

Delirium in Intensive Care

Purpose of Review

Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge.

Recent Findings

This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged.

Summary

With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.

The frequency and quality of delirium documentation in discharge summaries

BACKGROUND

The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services.

METHODS

This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary.

RESULTS

We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01).

CONCLUSIONS

The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.

The family in preventing delirium in the intensive care unit: Scoping review

INTRODUCTION

Delirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.

OBJECTIVE

To identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF.

INCLUSION CRITERIA

Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.

METHODS

A scope review was conducted using the keywords "Critical Care, Delirium, Family, Primary Prevention" in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.

RESULTS

The results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.

CONCLUSION

Extended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.

Incidence and Risk Factors of Delirium in the Intensive Care Unit: A Prospective Cohort

Purpose

The purpose of this study was to determine the incidence, risk factors, and impact of delirium on outcomes in ICU patients. In addition, the scoring systems were measured consecutively to characterize how these scores changed with time in patients with and without delirium. Material and Methods. A prospective cohort study enrolling 400 consecutive patients admitted to the ICU between 2018 and 2019 due to trauma or surgery. Patients were followed up for the development of delirium over ICU days using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC). Cox model logistic regression analysis was used to explore delirium risk factors.

Results

Delirium occurred in 108 (27%) patients during their ICU stay, and the median onset of delirium was 4 (IQR 3–4) days after admission. According to multivariate cox regression, the expected hazard for delirium was 1.523 times higher in patients who used mechanical ventilator as compared to those who did not (HR: 1.523, 95% CI: 1.197-2.388, P < 0.001).

Conclusion

Our findings suggest that an important opportunity for improving the care of critically ill patients may be the determination of modifiable risk factors for delirium in the ICU. In addition, the scoring systems (APACHE IV, SOFA, and RASS) are useful for the prediction of delirium in critically ill patients.

Evaluation of Pediatric Delirium Awareness and Management in Pediatric Intensive Care Units in Turkey

Delirium has been associated with prolonged pediatric intensive care unit (PICU) stay and mechanical ventilation times as well as high hospital costs and mortality rates. This work aimed to examine pediatric delirium awareness and delirium management in Turkey. A total of 19 physicians responsible for their respective PICUs completed the survey. Most of the units (57.9%) did not use any assessment tool. Varying measures were applied in different units to reduce the prevalence of delirium. The number of units that continuously measured noise was very low (15.8%). Eye mask and earpiece usage rates were also very low. In pharmacological treatment, haloperidol, dexmedetomidine, benzodiazepines, and atypical antipsychotics were the most preferred options. Some units have reached a sufficient level of pediatric delirium awareness and management. However, insufficiencies in delirium awareness and management remain in general.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care

Background

Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death.

Methods

This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017.

Results

In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% ‐ 6.3%) vs. 1.4% (0.7% ‐ 2.3%) on admission (p < 0.001) and 7.6% (6.4% ‐ 8.9%) vs. 5.4% (4.0% ‐ 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms.

Conclusions

There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

Episodes of psychomotor agitation among medical patients: findings from a longitudinal multicentre study

BACKGROUND

The management of delirium among older in-hospital patients is a challenge, leading to worse outcomes, including death. Specifically, psychomotor agitation, one of the main characteristics of hyperactive delirium, requires a significant amount of medical and nursing surveillance. However, despite its relevance, to date incidence and/or prevalence of psychomotor agitation, its predictors and outcomes have not been studied among Italian older patients admitted in medical units.

AIMS

To describe the incidence and the prevalence of psychomotor agitation among patients aged > 65 years admitted to medical units and identify predictors at the individual, nursing care and hospital levels.

METHODS

A longitudinal multicentre study was conducted involving 12 medical units in 12 northern Italian hospitals. Descriptive, bivariate and multivariate logistic regression analyses were performed.

RESULTS

Among the 1464 patients included in the study, two hundred (13.6%) have manifested episode(s), with an average of 3.46/patient (95% confidence of interval [CI] 2.73-4.18). In 108 (54.0%) patients, episode(s) were present also in the week prior to hospitalisation: therefore, in-hospital-acquired psychomotor agitation was reported in 92 patients (46%). The multivariate logistic regression analysis explained the 25.4% of the variance and identified the following variables as psychomotor agitation predictors: the risk of falls (relative risk [RR] 1.314, 95% CI 1.218-1.417), the amount of missed nursing care (RR 1.078, 95% CI 1.037-1.12) and the patient's age (RR 1.018, 95% CI 1.002-1.034). Factors preventing the occurrence of episode(s) were: the amount of care received from graduated nurses (RR 0.978; 95% CI 0.965-0.992) and the lower functional dependence at admission (RR 0.987, 95% CI 0.977-0.997).

CONCLUSIONS

A considerable number of elderly patients admitted in medical units develop psychomotor agitation; its predictors need to be identified early to inform decisions regarding the personal care needed to prevent its occurrence, especially by acting on modifiable factors, such as the risk of falls, missed nursing care and functional dependence.

Emergence agitation: current knowledge and unresolved questions

Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.

Delirium in hospitalised children

Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).

Role of Wearable Accelerometer Devices in Delirium Studies: A Systematic Review

We sought to determine the feasibility of using wearable accelerometer devices for determining delirium effects on patients' physical activity patterns and detecting delirium and delirium subtype.

DATA SOURCES

PubMed, Embase, and Web of Science.

STUDY SELECTION

Screening was performed using predefined search terms to identify original research studies using accelerometer devices for studying physical activity in relation to delirium.

DATA EXTRACTION

Key data were extracted from the selected articles.

DATA SYNTHESIS

Among the 14 studies identified, there were a total of 315 patients who wore accelerometer devices to record movements related to delirium. Eight studies (57.1%) used accelerometer devices to compare the activity of delirious and nondelirious patients. Delirious patients had lower activity levels, lower restlessness index, higher number of daytime immobility minutes, lower mean activity levels during the day, and higher mean activity levels at night. Delirious patients also had lower actual sleep time, lower sleep efficiency, fewer nighttime minutes resting, fewer minutes resting over 24 hours, and smaller change in activity from day to night. Six studies (42.9%) evaluated the feasibility of using accelerometer devices for detection of delirium and its subtype. Variables including number of postural changes during daytime, frequency of ultrashort, short, and continuous movements were significantly different among the nondelirium and the three delirium subtypes.

CONCLUSIONS

The results from the studies using accelerometer devices in studying delirium demonstrate that accelerometer devices can potentially detect the differences between delirious and nondelirious patients, detect delirium, and determine delirium subtype. We suggest the following directions as the next steps for future studies using accelerometer devices for predicting delirium: benchmark studies with longer data collection, larger and more diverse population size, incorporating related factors (e.g., medications), and evaluating delirium subtype and severity.

The incidence and prevalence of delirium across palliative care settings: A systematic review

BACKGROUND

Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed.

AIM

Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings.

DESIGN

This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment.

DATA SOURCES

Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included.

RESULTS

Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used.

CONCLUSION

Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.

Incidence and risk factors of PostopeRativE delirium in intensive care unit patients: A study protocol for the PREDICt study

AIM

The aims of this study are: (a) to determine the incidence of postoperative delirium (POD) among surgical intensive care unit (ICU) patients in China and identify risk factors, especially, which are modifiable and have value for developing a prediction model; (b) to develop and validate a prediction model of delirium to recognize high-risk patients in surgical ICUs; (c) to investigate the short- and long-term outcomes of delirious patients and identify the predictors of patient outcomes.

DESIGN

A single-centre prospective cohort study.

METHODS

Patients will be enrolled from three surgical ICUs in a tertiary teaching hospital. Delirium assessment and perioperative data will be collected throughout the hospitalization. Delirious patients will be followed up for 2 years. The study was approved by the ethics committee in May 2018 and was funded by the clinical research grant from Zhongshan hospital, Fudan University, Shanghai.

DISCUSSION

Developing POD can be a burden to patients both for the short- and long-term period. Due to the lack of effective treatments for POD, prevention remains the best strategy. This study will provide an effective tool for early screening of high-risk patients of POD and provide a better understanding of the aetiology and outcome of delirium.

IMPACT

In clinical practice, a prediction model will offer an effective tool for ICU nurses to assess high-risk patients, which can support them to implement preventive strategies at the early stages to targeted patients. The follow-up results will help us better understand the impact of delirium on patients' long-term outcome.

Postoperative delirium

Delirium can be defined as an ‘acute brain dysfunction.’ Compared to dementia, which is a disease that deteriorates the brain function chronically, delirium shows very similar symptoms but is mostly ameliorated when the causative factors are normalized. Due to the heterogeneity in etiologies and symptoms, people including health care workers often mistake delirium for dementia or other psychiatric disorders. Delirium has attracted global interest increasingly and a vast amount of research on its management has been conducted. Experts in the field have constantly suggested that systematic intervention should be implemented through a team-based multicomponent approach aimed to reduce the incidence and duration of delirium. Surgery involves many health care workers with different expertise who are not familiar with delirium. For a team-based approach on the management of delirium, it is vital that all medical personnel concerned have a common understanding of delirium and keep in constant communication. Postoperative delirium is a common complication and exerts an enormous burden on patients, their families, hospitals, and public resources. To alleviate this burden, this article aimed to review general features and the latest evidence-based knowledge of delirium with a focus on postoperative delirium.

Delirium in the Intensive Care Unit: Incidence, Risk Factors, and Impact on Outcome

Background:

The incidence and risk factors for delirium vary among studies.

Objective:

We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study.

Patients:

All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU.

Results:

A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6–20] vs. 2 days[0–7]) respectively and length of stay in ICU (21.5 days [10.5–32.5] vs. 8 days [5–13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39–12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31–8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47–8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05–7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08–13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality.

Conclusion:

Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.

Validation of the Korean Version of the Delirium Motor Subtype Scale

OBJECTIVE

The Delirium Motor Subtype Scale (DMSS) is a validated and reliable instrument developed from various methods previously used to assess delirium motor subtypes. It focuses on pure motor disturbances with a relative specificity for delirium. The aim of this study was to investigate the validity and reliability of a Korean version of the DMSS (K-DMSS).

METHODS

We recruited 145 patients who were older than 60 years and had been referred for psychiatric consultation for delirium. These patients were evaluated using the K-DMSS, Liptzin & Levkoff criteria, and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-R98) to compare delirium motor subtypes.

RESULTS

The internal consistency of the K-DMSS in assessing delirium motor subtypes was acceptable (Cronbach's alpha=0.79). Delirium motor subtypes identified with the K-DMSS and K-DRS-R98 showed almost perfect agreement (Cohen's Kappa=0.81), while those identified with the K-DMSS and Liptzin & Levkoff criteria showed substantial agreement (Cohen's Kappa=0.78).

CONCLUSION

Our results suggest that the K-DMSS is a valid and reliable tool for identifying delirium subtypes.

Nu-DESC DK: the Danish version of the nursing delirium screening scale (nu-DESC)

BACKGROUND

Delirium is one of the most common complications among elderly hospitalized patients, postoperative patients and patients on intensive care units with a prevalence between 11 and 80%. Delirium is associated with higher morbidity and mortality. Reliable instruments are required to detect delirium at an early time point. The Nursing-Delirium Screening Scale (Nu-DESC) is a screening tool with high sensitivity and good specificity. However, there is currently no official translation after ISPOR guidelines of any Danish delirium assessment tools available. Thereby hampering the implementation of 2017 ESA-Guidelines on postoperative Delirium in the clinical routine. The aim of this study is to provide an official translation and evaluation of the Nu-DESC into Danish following the ISPOR process.

METHODS

The Nu-DESC was translated after International Society for Pharmacoecomonics and Outcome Research (ISPOR) guidelines to Danish after permission of the original author, and is evaluated by medical staff and finally approved by the original author.

RESULTS

All steps of the ISPOR guideline were consecutively followed, without any major problems. The evaluation of the Nu-DESC DK regarding its intelligibility and feasibility showed no statistically significant differences between nurses and medical doctors ratings. The translation was authorized and approved by the original author.

CONCLUSION

This study provides the Nu-DESC DK, an official Danish delirium screening instrument, which can detect all psychomotor types of delirium.

Validation and Psychometric Properties of the German Version of the Delirium Motor Subtype Scale (DMSS)

Objective: Delirium has been characterized into its subtypes—hypoactive, hyperactive, mixed, or no motor subtype—along with the use of the Delirium Motor Symptom Scale (DMSS). The German version of this scale (DMSS-G), however, has not yet been validated. Method: We determined internal consistency, reliability, and validity of the DMSS-G in the surgical intensive care unit, using DSM-IV-TR criteria and the Delirium Rating Scale–Revised–98. Results: In total, 289 patients were included, and out of these, 122 were delirious. The DMSS-G showed excellent internal consistency (Cronbach’s α = 0.92) and interrater reliability (Fleiss κ = 0.83). Additionally, the overall concurrent validity was substantial (Cramer’s V = 0.69); within subtypes, hyperactive, hypoactive, or mixed, the concurrent validity remained at least substantial (Cohen’s κ = 0.73-0.82) and the sensitivity ranged from 60% to 97%. In contrast, in those with no motor subtype, we found the concurrent validity (Cohen’s κ = 0.31) and sensitivity to be low (22%). Overall, specificity for all individual subtypes was high (82% to 100%). The DMSS was very sensitive in both rating hyperactive and hypoactive motor symptoms of delirium. Conclusion: The DMSS-G is a highly reliable and valid instrument for detecting motor symptoms in delirium, which provides an accurate instrument to classify the motor subtypes of delirium.

Using simulated family presence to decrease agitation in older hospitalized delirious patients: A randomized controlled trial

BACKGROUND

Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed.

OBJECTIVES

To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients.

DESIGN

Single site randomized control trial, 3 groups×4 time points mixed factorial design conducted from July 2015 to March 2016.

SETTING

Acute care level one trauma center in an inner city of the state of Connecticut, USA.

PARTICIPANTS

Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n=126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia.

METHODS

Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30min following the intervention.

RESULTS

Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p<0.001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p<0.001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p<0.001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p=0.001) between family video(60%) and usual care (35.1%) immediately following the intervention CONCLUSION: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia.

Delirium in Pediatric Critical Care

Delirium occurs frequently in the critically ill child. It is a syndrome characterized by an acute onset and fluctuating course, with behaviors that reflect a disturbance in awareness and cognition. Delirium represents global cerebral dysfunction due to the direct physiologic effects of an underlying medical illness or its treatment. Pediatric delirium is strongly associated with poor outcomes, including increased mortality, prolonged intensive care unit length of stay, longer time on mechanical ventilation, and increased cost of care. With heightened awareness, the pediatric intensivist can detect, treat, and prevent delirium in at-risk children.

Motor Disturbances in Elderly Medical Inpatients and Their Relationship to Delirium

Motor disturbances in delirious patients are common, but their relationship to cognition and severity of illness has not been studied. We examined motor subtypes in an older age inpatient population, their relationship to clinical variables including delirium, and their association with 1-year mortality in a prospective study, using the Confusion Assessment Method, Acute Physiology and Chronic Health Evaluation II, Montreal Cognitive Assessment (MoCA), Barthel Index, and Delirium Rating Scale-Revised 98 (DRS-R98). Motor subtypes were evaluated using 2 items of DRS-R98. Mortality rates were investigated 1 year later. Two hundred participated (mean age 81.1 [6.5]; 50% female). Thirty-four (17%) were identified with delirium. Motor subtypes were none: 119 (59.5%), hypoactive: 37 (18.5%), hyperactive: 29 (14.5%), and mixed: 15 (7.5%). Hypoactive and mixed subtypes were significantly more frequent in delirious patients. Regression analysis showed that hypoactive subtype was significantly associated with lower MoCA. No relationship between motor subtypes and mortality was found. Motor disturbances are not unique to delirium, with hypoactivity particularly associated with impaired cognition.

Infrared pupillometry helps to detect and predict delirium in the post-anesthesia care unit

This study evaluates the capability of pupillary parameters to detect and predict delirium in the post-anesthesia care unit (PACU-D) following general anesthesia. PACU-D may complicate and prolong the patient's postoperative course, consequently increasing hospital costs. After institutional approval, 47 patients undergoing surgical interventions with general anesthesia were included in the study. We measured the pupillary reflexes at signing of informed consent, during surgery 20 min after intubation and when the primary inhaled anesthetic was turned off, and 15 and 45 min after PACU admittance and upon discharge from the PACU. We evaluated patients for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) score after 15 and 60 min in the PACU. We chose receiver operating curve (ROC) and area under the curve (AUC) to compare the performance of non-pupillary parameters to pupillary parameters, such as pupil diameter, percent constriction, and dilation velocity, to detect and predict PACU-D. Percent constriction (AUC = 0.93, optimal threshold = 18.5%) and dilation velocity (AUC = 0.93, optimal threshold = 0.35 mm/s) showed excellent ability to detect and predict delirium persisting throughout the PACU stay. These pupillary measures showed superior performance compared to other pupillary measures and features commonly associated with delirium, e.g., age (AUC = 0.73), total opioids (AUC = 0.56), or length of surgery (AUC = 0.40). Our results suggest that pupillometry and the parameters derived from the recording may identify delirious patients in the PACU. This information can help to efficiently structure their care in a timely manner, and potentially avoid adverse complications for the patient and financial consequences for the hospital.

Delirium in critically ill patients

Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.

Smoking Cessation and the Risk of Hyperactive Delirium in Hospitalized Patients: A Retrospective Study

OBJECTIVES

The acute cessation of smoking often induces symptoms that are similar to those associated with delirium. We aimed to evaluate effects of sudden nicotine abstinence on the development of delirium and its motoric subtypes in hospitalized patients.

METHODS

The present study included patients who were referred to psychiatrists by ward physicians due to confusion. The presence of delirium was defined using the Confusion Assessment Method and the Delirium Rating Scale Revised-98, which was also used to assess the severity of delirium. Outcome variables, including the length of hospital stay and 3-month mortality rate, were collected by a retrospective chart review.

RESULTS

Delirium was confirmed in 210 of the 293 referred patients. Of the motoric subtypes of delirium, the hyperactive subtype was more common (68.1%) and was related to higher 3-month mortality (odds ratio [OR], 2.189; 95% confidence interval [CI], 1.07 to 4.49; P = 0.033) compared with hypoactive delirium. Patients undergoing sudden cessation of smoking (n = 55) were more likely to exhibit hyperactive delirium than were nonsmokers (P = 0.001). A multivariate analysis revealed that smoking cessation was an independent risk factor for hyperactive delirium (OR, 10.33; 95% CI, 2.31 to 46.09; P = 0.002). In addition, the amount of smoking was positively correlated with the severity of hyperactivity (r = 0.421, P = 0.003). Smoking status did not significantly influence overall delirium incidence.

CONCLUSIONS

The present findings demonstrated that nicotine withdrawal was associated with hyperactive delirium, which suggests that they share common pathophysiologies that involve the dopamine, opioid, and cholinergic systems.

Prevalence and Symptoms of Delirium Superimposed on Dementia

Delirium is a frequent syndrome among patients who are elderly. People who are older with cognitive impairment who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. This study goal was to describe the effect of severity of prior cognitive impairment on delirium prevalence and symptom presentation among patients who were older and were newly admitted to an acute care hospital. A total of 104 were included in this descriptive study and screened for delirium. The results showed that the prevalence of delirium increased according to the severity of the patients’ prior cognitive impairment. Except for disorganized thinking, all symptoms of delirium were similar among patients with mild, moderate, and severe prior cognitive impairment. The study concluded that training nurses to recognize subtle changes in mental status among those patients who were older with prior cognitive impairment may prevent the underdetection of delirium.

Delirium in Acute Stroke: A Review

Background

Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation.

Summary of review

Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke.

Conclusion

This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.

Existential Absence: The Lived Experience of Family Members During Their Older Loved One's Delirium

When older people develop delirium, their demeanor changes; they often behave in ways that are out of character and seem to inhabit another world. Despite this, little is known about the experiences of family members who are with their older loved one at this time. This article reports a phenomenological study that involved in-depth interviews with 14 women whose older loved one had delirium. Analysis and interpretation of the data depict the women's experiences as "Changing family portraits: Sudden existential absence during delirium," capturing the way family members lose the taken-for-granted presence of their familiar older loved one and confront a stranger during delirium.

Comparison of mental-status scales for predicting mortality on the general wards

BACKGROUND

Altered mental status is a significant predictor of mortality in inpatients. Several scales exist to characterize mental status, including the AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) scale, which is used in many early-warning scores in the general-ward setting. The use of the Glasgow Coma Scale (GCS) and Richmond Agitation Sedation Scale (RASS) is not well established in this population.

OBJECTIVE

To compare the accuracies of AVPU, GCS, and RASS for predicting inpatient mortality.

DESIGN

Retrospective cohort study.

SETTING

Single, urban, academic medical center.

PARTICIPANTS

Adult inpatients on the general wards.

MEASUREMENTS

Nurses recorded GCS and RASS on consecutive adult hospitalizations. AVPU was extracted from the eye subscale of the GCS. We compared the accuracies of each scale for predicting in-hospital mortality within 24 hours of a mental-status observation using area under the receiver operating characteristic curves (AUC).

RESULTS

There were 295,974 paired observations of GCS and RASS obtained from 26,873 admissions; 417 (1.6%) resulted in in-hospital death. GCS and RASS more accurately predicted mortality than AVPU (AUC 0.80 and 0.82, respectively, vs 0.73; P < 0.001 for both comparisons). Simultaneous use of GCS and RASS produced an AUC of 0.85 (95% confidence interval: 0.82-0.87, P < 0.001 when compared to all 3 scales).

CONCLUSIONS

In ward patients, both GCS and RASS were significantly more accurate predictors of mortality than AVPU. In addition, combining GCS and RASS was more accurate than any scale alone. Routine tracking of GCS and/or RASS on general wards may improve the accuracy of detecting clinical deterioration.

Using the Chinese version of Memorial Delirium Assessment Scale to describe postoperative delirium after hip surgery

OBJECTIVE

Memorial Delirium Assessment Scale (MDAS) assesses severity of delirium. However, whether the MDAS can be used in a Chinese population is unknown. Moreover, the optimal postoperative MDAS cutoff point for describing postoperative delirium in Chinese remains largely to be determined. We therefore performed a pilot study to validate MDAS in the Chinese language and to determine the optimal postoperative MDAS cutoff point for delirium.

METHODS

Eighty-two patients (80 ± 6 years, 21.9% male), who had hip surgery under general anesthesia, were enrolled. The Confusion Assessment Method (CAM) and Mini-Mental State Examination (MMSE) were administered to the patients before surgery. The CAM and MDAS were performed on the patients on the first, second and fourth postoperative days. The reliability and validity of the MDAS were determined. A receiver operating characteristic (ROC) curve was used to determine the optimal Chinese version MDAS cutoff point for the identification of delirium.

RESULTS

The Chinese version of the MDAS had satisfactory internal consistency (α = 0.910). ROC analysis obtained an average optimal MDAS cutoff point of 7.5 in describing the CAM-defined postoperative delirium, with an area under the ROC of 0.990 (95% CI 0.977-1.000, P < 0.001).

CONCLUSIONS

The Chinese version of the MDAS had good reliability and validity. The patients whose postoperative Chinese version MDAS cutoff point score was 7.5 would likely have postoperative delirium. These results have established a system for a larger scale study in the future.

Haloperidol, risperidone, olanzapine and aripiprazole in the management of delirium: A comparison of efficacy, safety, and side effects

OBJECTIVE

The aim of this study was to compare the efficacy and side-effect profile of the typical antipsychotic haloperidol with that of the atypical antipsychotics risperidone, olanzapine, and aripiprazole in the management of delirium.

METHOD

The Memorial Delirium Assessment Scale (MDAS), the Karnofsky Performance Status (KPS) scale, and a side-effect rating were recorded at baseline (T1), after 2-3 days (T2), and after 4-7 days (T3). Some 21 cases were case-matched by age, preexisting dementia, and baseline MDAS scores, and subsequently analyzed.

RESULTS

The baseline characteristics of the medication groups were not different: The mean age of the patients ranged from 64.0 to 69.6 years, dementia was present in between 23.8 and 28.6%, and baseline MDAS scores were 19.9 (haloperidol), 18.6 (risperidone), 19.4 (olanzapine), and 18.0 (aripiprazole). The doses of medication at T3 were 5.5 mg haloperidol, 1.3 mg risperidone, 7.1 mg olanzapine, and 18.3 mg aripiprazole. Over one week, the decline in MDAS scores between medications was equal, and no differences between individual MDAS scores existed at T2 or T3. After one week, the MDAS scores were 6.8 (haloperidol), 7.1 (risperidone), 11.7 (olanzapine), and 8.3 (aripiprazole). At T2, delirium resolution occurred in 42.9-52.4% of cases and at T3 in 61.9-85.7%; no differences in assessments between medications existed. Recorded side effects were extrapyramidal symptoms (EPSs) in haloperidol- and risperidone-managed patients (19 and 4.8%, respectively) and sedation with olanzapine (28.6%).

SIGNIFICANCE OF RESULTS

Haloperidol, risperidone, aripiprazole, and olanzapine were equally effective in the management of delirium; however, they differed in terms of their side-effect profile. Extrapyramidal symptoms were most frequently recorded with haloperidol, and sedation occurred most frequently with olanzapine.

The pharmacologic management of delirium in children and adolescents

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

Comparison of symptoms of delirium across various motoric subtypes

AIM

The aim of this study was to determine the correlation between delirium motor subtypes and other symptoms of delirium.

METHODS

Three hundred and twenty-one (n = 321) consecutive patients referred to consultation-liaison psychiatry services were evaluated on Delirium Rating scale-Revised-98 version and amended Delirium Motor Symptom Scale.

RESULTS

Half of the patients had hyperactive subtype (n = 161; 50.15%) delirium. One-quarter of the study sample met the criteria for mixed subtype (n = 79; 24.61%), about one-fifth of the study sample met the criteria for hypoactive delirium subtype (n = 64; 19.93%), and only very few patients (n = 17; 5.29%) did not meet the required criteria for any of these three subtypes and were categorized as 'no subtype'. When the hyperactive and hypoactive subtypes were compared, significant differences were seen in the prevalence of perceptual disturbances, delusions, lability of affect, thought process abnormality, motor agitation and motor retardation. All the symptoms were more common in the hyperactive subtype except for thought process abnormality and motor retardation. Compared to hyperactive subtype, the mixed subtype had significantly higher prevalence of thought process abnormality and motor retardation. Significant differences emerged with regard to perceptual disturbances, delusions, lability of affect and motor agitation when comparing the patients with mixed subtype with those with hypoactive subtype. All these symptoms were found to be more common in the mixed subtype. No significant differences emerged for the cognitive symptoms as assessed on Delirium Rating scale-Revised-98 across the different motoric subtypes.

CONCLUSION

Different motoric subtypes of delirium differ on non-cognitive symptoms.

[Dexmedetomidine]

Dexmedetomidine is a highly selective α2-receptor agonist with sedative, analgetic and anxiolytic effects. It is chemically related to clonidine and has been an authorized drug in Europe since September 2011. Dexmedetomidine enables a level of sedation in which mechanically ventilated patients may be woken by verbal stimulation (Richmond agitation sedation scale RASS 0--3). In this respect dexmedetomidine achieves the same desired effect as propofol and midazolam; however, in direct comparison to a sedation regime with benzodiazepines, dexmedetomidine reduces the prevalence, duration and severity of delirium in intensive care. Patients sedated by dexmedetomidine can statistically be extubated earlier and an influence on duration of stay in the intensive care unit (ICU) has not been shown. Daily therapy costs are approximately 5 times higher than those of propofol but an objective standpoint in relation to clinical cost efficiency is unattainable.

Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile?

OBJECTIVE

To explore the frequency of different motor subtypes of delirium in children and adolescents and to study the relationship of motor subtypes with other symptoms, etiology and outcome of delirium.

METHODS

Forty-nine consecutive patients, aged 8-19 years, diagnosed as having delirium as per DSM-IV-TR were assessed on Delirium Rating Scale-Revised 98 (DRS-R-98), amended Delirium Motor Symptom Scale (DMSS), delirium etiology checklist and risk factors for delirium. Different motoric subtypes of delirium were compared with each other for symptoms of delirium as assessed by DRS-R-98, risk factors, etiology and outcome.

RESULTS

More than half (53%) of patients were classified as having hyperactive delirium, this was followed by the mixed (26.5%) and the hypoactive (16%) subtype. When the different subtypes were compared with each other, the 3 motor subtypes did not differ from each other in terms of frequency and severity of other symptoms except for minor differences. Hallucinations are more common in patients with hyperactive and mixed subtype. There is no significant difference in the outcome of delirium across different subtypes.

CONCLUSION

Unlike in adults, motoric subtypes of delirium in child and adolescents do not differ from each other with respect to other symptoms, risk factors and outcome.