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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Glynn K, McKenna F, Lally K, Grover S, Chakrabarti S, Mattoo SK, Avasthi A, Sharma A, Adamis D, Awan F, Dunne CP, McFarland J, Jabbar F, O’Connell H, Leonard M, Meagher DJ. Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study. J Geriatr Psychiatry Neurol 2024; 37:125-133. [PMID: 37566435 PMCID: PMC10802083 DOI: 10.1177/08919887231195232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K. Mattoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajita Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dimitrios Adamis
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
- Sligo Mental Health Services, Sligo, Ireland
| | - Fahad Awan
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Colum P. Dunne
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - John McFarland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Faiza Jabbar
- Psychiatry for Later Life Service, University College Hospital, Galway, Ireland
| | - Henry O’Connell
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - David J. Meagher
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
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Hollenbeck BK, Dunn RL, Sukul D, Modi PK, Nallamothu BK, Sen A, Bynum JP. Aortic valve replacement among patients with Alzheimer's disease and related dementias. J Am Geriatr Soc 2021; 69:3468-3475. [PMID: 34498253 DOI: 10.1111/jgs.17432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/16/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has made palliation from aortic stenosis more broadly available to populations previously thought to be too high risk for surgery, such as those with Alzheimer's disease and related dementias (ADRD); however, its safety and effectiveness in this context are uncertain. METHODS We performed a retrospective cohort study of national Medicare beneficiaries, aged 66 and older with Parts A and B, between 2010 and 2016. Patients undergoing AVR were identified, and follow-up was available through 2017. Multivariable regression was used to measure the independent association between having a diagnosis of ADRD at the time of AVR, stratified by TAVR and surgery, and outcomes (mortality and Medicare institutional days at 1 year after AVR). RESULTS The average rate of increase in AVR per year was 17.5 cases per 100,000 ADRD and 8.4 per 100,000 non-ADRD beneficiaries, largely driven by more rapid adoption of TAVR. Adjusted mortality following AVR declined significantly between those treated in 2010 and 2016, from 13.5% (95% CI 10.2%-17.7%) to 6.3% (95% CI 5.2%-7.6%) and from 13.7% (95% CI 12.7%-14.7%) to 6.3% (95% CI 5.8%-6.9%) in those with and without ADRD, respectively. The sharpest decline was noted for patients undergoing TAVR between 2011 and 2016, with adjusted mortality declining from 19.9% (95% CI 11.2%-32.8%) to 5.2% (95% CI 4.1%-6.5%) and from 12.2% (95% CI 9.3%-15.8%) to 5.0% (95% CI 4.4%-5.6%) in patients with and without ADRD, respectively. Similar declines were evident for Medicare institutional days in the year after AVR in both patient groups. CONCLUSIONS Rates of AVR in those with ADRD increased during the past decade largely driven by the diffusion of TAVR. The use of TAVR in this vulnerable population did not come at the expense of increasing Medicare institutional days or mortality at 1-year.
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Affiliation(s)
- Brent K Hollenbeck
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney L Dunn
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Parth K Modi
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Brahmajee K Nallamothu
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Ananda Sen
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie P Bynum
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
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Smulter N, Claesson Lingehall H, Gustafson Y, Olofsson B, Engström KG. The use of a screening scale improves the recognition of delirium in older patients after cardiac surgery-A retrospective observational study. J Clin Nurs 2019; 28:2309-2318. [PMID: 30791158 DOI: 10.1111/jocn.14838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 12/16/2018] [Accepted: 02/09/2019] [Indexed: 12/29/2022]
Abstract
AIMS AND OBJECTIVES To analyse postoperative delirium (POD) in clinical practice after cardiac surgery, how it is detected and documented and if the use of a screening scale improves the detection rate. BACKGROUND Cardiac surgery is considered a routine procedure with few complications. However, POD remains a concern, although often being overlooked in clinical practice. DESIGN Retrospective observational analysis. METHODS Patients 70 years and older with POD (n = 78) undergoing cardiac surgery were included in the study. Discharge summaries of both nurses and physicians were reviewed together with the clinical database for information about POD, to be compared with symptom screening using the Nursing Delirium Screening Scale (Nu-DESC). A quantitative content analysis was used for the review of discharge summaries, with a coding scheme adopted from the Nu-DESC method. The STROBE checklist was followed. RESULTS In discharge summaries, 41 of the 78 POD patients were correctly recognised, and 22 of these were identified in the clinical database. Screening by the Nu-DESC identified delirium at a measurably higher rate, 56/78 patients. The review of discharge summaries showed that patients expressing "inappropriate behaviour" was the most easily identified sign for POD for both nurses and physicians. CONCLUSIONS Healthcare professionals underdiagnose delirium after cardiac surgery, with a low detection rate described in both discharge summaries and in the clinical database. Recognition of delirium improved when Nu-DESC was used for systematic screening. RELEVANCE TO CLINICAL PRACTICE This study emphasises the need for better screening for the detection of delirium in daily clinical practice.
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Affiliation(s)
- Nina Smulter
- Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Nursing, Umeå University, Umeå, Sweden
| | - Helena Claesson Lingehall
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Yngve Gustafson
- Geriatric Medicine Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | | | - Karl Gunnar Engström
- Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Music intervention to prevent delirium among older patients admitted to a trauma intensive care unit and a trauma orthopaedic unit. Intensive Crit Care Nurs 2018; 47:7-14. [PMID: 29735284 DOI: 10.1016/j.iccn.2018.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Evaluate music listening for delirium prevention among patients admitted to a Trauma Intensive Care and Trauma Orthopaedic Unit. The Roy Adaptation Model provided the theoretical framework focusing on modifying contextual stimuli. METHODS Randomised controlled trial, 40 patients aged 55 and older. INTERVENTION Participants randomly assigned to receive music listening or usual care for 60 minutes, twice a day, over three days. Pre-recorded self-selected music using an iPod and headsets, with slow tempo, low pitch and simple repetitive rhythms to alter physiologic responses. OUTCOMES Heart rate, respiratory rate, systolic and diastolic blood pressure, confusion assessment method. RESULTS Repeated measures ANOVA, F(4, 134) = 4.75, p = .001, suggested statistically significant differences in heart rate pre/post music listening, and F(1, 37) = 10.44, p = .003 in systolic blood pressure pre/post music listening. Post-hoc analysis reported changes at three time periods of statistical significance; (p = .010), (p = .005) and (p = .039) and a change in systolic blood pressure pre/post music listening; (p = .001) of statistical significance. All participants screened negative for delirium. CONCLUSION Music addresses pathophysiologic mechanisms that contribute to delirium; neurotransmitter imbalance, inflammation and acute physiologic stressors. Music to prevent delirium is one of few that provide support in a critical care setting.
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Fong TG, Albuquerque A, Inouye SK. The Search for Effective Delirium Treatment for Persons with Dementia in the Postacute-Care Setting. J Am Geriatr Soc 2016; 64:2421-2423. [DOI: 10.1111/jgs.14585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tamara G. Fong
- Department of Neurology; Beth Israel Deaconess Medical Center; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
| | - Asha Albuquerque
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
| | - Sharon K. Inouye
- Harvard Medical School; Boston Massachusetts
- Aging Brain Center; Institute for Aging Research; Hebrew SeniorLife; Boston Massachusetts
- Department of Medicine; Beth Israel Deaconess Medical Center; Boston Massachusetts
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7
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Leonard M, O'Connell H, Williams O, Awan F, Exton C, O'Connor M, Adamis D, Dunne C, Cullen W, Meagher DJ. Attention, vigilance and visuospatial function in hospitalized elderly medical patients: Relationship to neurocognitive diagnosis. J Psychosom Res 2016; 90:84-90. [PMID: 27772564 DOI: 10.1016/j.jpsychores.2016.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/02/2016] [Accepted: 09/27/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Efficient detection of neurocognitive disorders is a key diagnostic challenge. We explored how simple bedside tests of attention, vigilance and visuospatial function might assist in identifying delirium in hospitalized patients. METHODS Performance on a battery of bedside cognitive tests was compared in elderly medical inpatients with DSM-IV delirium, dementia, comorbid delirium-dementia, and no neurocognitive disorder. RESULTS 193 patients [mean age 79.9±7.3; 97 male] were assessed with delirium (n=45), dementia (n=33), comorbid delirium-dementia (n=65) and no neurocognitive disorder (NNCD) (n=50). The ability to meaningfully engage with the tests varied from 84% (Spatial Span Forwards) to 57% (Vigilance B test), and was especially problematic among the comorbid delirium-dementia group. The NNCD was distinguished from the delirium groups for most tests, and from the dementia group for the Vigilance B test and the Clock Drawing Test. The dementia group differed from delirium groups in respect of the Months Backward Test, Vigilance A and B tests, Global assessment of visuospatial ability and the Interlocking Pentagons Test. Overall, patients with delirium were best identified by three tests - the Months Backward Test, Vigilance A test and the Global Assessment of visuospatial function with failure to correctly complete any two of these predicting delirium status in 80% of cases. CONCLUSION Simple bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. There is a need to develop more accurate methods specifically designed to assess patients with neurocognitive disorder who are unable to engage with conventional tests.
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Affiliation(s)
- Maeve Leonard
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - Henry O'Connell
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Laois-Offaly Mental Health Services, St Fintan's Hospital, Portlaoise, Ireland
| | - Olugbenga Williams
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - Fahad Awan
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - Chris Exton
- Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland
| | - Margaret O'Connor
- Graduate Entry Medical School, University of Limerick, Ireland; Department of Geriatric Medicine, University Hospital Limerick, Ireland
| | - Dimitrios Adamis
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Sligo Mental Health Services, Ballytivan, Sligo, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland
| | - Walter Cullen
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland.
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Tarazona-Santabalbina FJ, Belenguer-Varea Á, Rovira E, Cuesta-Peredó D. Orthogeriatric care: improving patient outcomes. Clin Interv Aging 2016; 11:843-56. [PMID: 27445466 PMCID: PMC4928624 DOI: 10.2147/cia.s72436] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.
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Affiliation(s)
- Francisco José Tarazona-Santabalbina
- Geriatric Medicine Unit, Internal Medicine Department, Hospital Universitario de la Ribera; Medical School, Universidad Católica de Valencia San vicente Mártir, Valencia, Spain
| | - Ángel Belenguer-Varea
- Geriatric Medicine Unit, Internal Medicine Department, Hospital Universitario de la Ribera; Medical School, Universidad Católica de Valencia San vicente Mártir, Valencia, Spain
| | - Eduardo Rovira
- Geriatric Medicine Unit, Internal Medicine Department, Hospital Universitario de la Ribera; Medical School, Universidad Católica de Valencia San vicente Mártir, Valencia, Spain
| | - David Cuesta-Peredó
- Geriatric Medicine Unit, Internal Medicine Department, Hospital Universitario de la Ribera; Medical School, Universidad Católica de Valencia San vicente Mártir, Valencia, Spain
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Leonard M, McInerney S, McFarland J, Condon C, Awan F, O'Connor M, Reynolds P, Meaney AM, Adamis D, Dunne C, Cullen W, Trzepacz PT, Meagher DJ. Comparison of cognitive and neuropsychiatric profiles in hospitalised elderly medical patients with delirium, dementia and comorbid delirium-dementia. BMJ Open 2016; 6:e009212. [PMID: 26956160 PMCID: PMC4785299 DOI: 10.1136/bmjopen-2015-009212] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Differentiation of delirium and dementia is a key diagnostic challenge but there has been limited study of features that distinguish these conditions. We examined neuropsychiatric and neuropsychological symptoms in elderly medical inpatients to identify features that distinguish major neurocognitive disorders. SETTING University teaching hospital in Ireland. PARTICIPANTS AND MEASURES 176 consecutive elderly medical inpatients (mean age 80.6 ± 7.0 years (range 60-96); 85 males (48%)) referred to a psychiatry for later life consultation-liaison service with Diagnostic and Statistical Manual of Mental Disorders (DSM) IV delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Participants were assessed cross-sectionally with comparison of scores (including individual items) for the Revised Delirium Rating Scale (DRS-R98), Cognitive Test for Delirium (CTD) and Neuropsychiatric Inventory (NPI-Q). RESULTS The frequency of neurocognitive diagnoses was delirium (n=50), dementia (n=32), comorbid delirium-dementia (n=62) and cognitively intact patients (n=32). Both delirium and comorbid delirium-dementia groups scored higher than the dementia group for DRS-R98 and CTD total scores, but all three neurocognitively impaired groups scored similarly in respect of total NPI-Q scores. For individual DRS-R98 items, delirium groups were distinguished from dementia groups by a range of non-cognitive symptoms, but only for impaired attention of the cognitive items. For the CTD, attention (p=0.002) and vigilance (p=0.01) distinguished between delirium and dementia. No individual CTD item distinguished between comorbid delirium-dementia and delirium. For the NPI-Q, there were no differences between the three neurocognitively impaired groups for any individual item severity. CONCLUSIONS The neurocognitive profile of delirium is similar with or without comorbid dementia and differs from dementia without delirium. Simple tests of attention and vigilance can help to distinguish between delirium and other presentations. The NPI-Q does not readily distinguish between neuropsychiatric disturbances in delirium versus dementia. Cases of suspected behavioural and psychological symptoms of dementia should be carefully assessed for possible delirium.
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Affiliation(s)
- Maeve Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Shane McInerney
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John McFarland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Acute Psychiatry, Midwestern Regional Hospital, Ennis, Clare, Ireland
| | - Candice Condon
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Fahad Awan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Margaret O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Geriatric Medicine, University Hospital Limerick, Limerick, Ireland
| | - Paul Reynolds
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Anna Maria Meaney
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Dimitrios Adamis
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland Research and Academic Institute of Athens, Athens, Greece Sligo Mental Health Services, Ballytivan, Sligo, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Walter Cullen
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Paula T Trzepacz
- Indiana University, School of Medicine, Indianapolis, Indiana, USA University of Mississippi Medical School, Jackson, Mississippi, USA Tufts University School of Medicine, Boston, Massachusetts, USA
| | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
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Identifying phenomenological differences and recovery of cognitive and non-cognitive symptomatology among delirium superimposed upon dementia patients (DsD) versus those without dementia (DaD) in an acute geriatric care setting. Int Psychogeriatr 2015; 27:1695-705. [PMID: 26055222 DOI: 10.1017/s1041610215000770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Phenomenological differences between delirium superimposed on dementia (DsD) versus delirium in the absence of dementia (DaD) remain poorly understood. We aimed to identify phenomenological differences in delirium symptoms (cognitive and non-cognitive) and compare delirium recovery trajectories between DsD and DaD. METHODS We conducted a prospective observational study on individuals admitted to the Geriatric Monitoring Unit (GMU), a five-bed unit specializing in managing older adults with delirium, between December 2010 and August 2012 (n = 234; mean age 84.1 ± 7.4). We collected data on demographics, comorbidities, severity of illness, cognitive and functional scores, and number of precipitants. Cognitive status was assessed using locally validated Chinese Mini-Mental State Examination (CMMSE) and delirium severity assessed using Delirium Rating Scale-Revised-98 (DRS-R98). Delirium disease trajectory was plotted over five days. RESULTS DsD patients had a longer duration of delirium with slower recovery in terms of cognition and delirium severity scores compared with DaD patients (0.33 (0.0-1.00) vs. 1.0 (0.36-2.00) increase in CMMSE per day, p < 0.001, and 1.49 ± 1.62 vs. 2.63 ± 2.28 decrease in DRS-R98 severity per day, p < 0.001). When cognitive and non-cognitive sub-scores of DRS-R98 were examined separately, we observed steeper recovery in both sub-scores in DaD patients. These findings remained significant after adjusting for significant baseline differences. CONCLUSIONS Our findings of slower cognitive symptom recovery in DsD patients suggest cognitive reserve play a role in delirium syndrome development and recovery. This merits further studies to potentially aid in appropriate discharge planning and to identify potential pharmacological and non-pharmacological cognitive interventions for hospitalized older persons with delirium.
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Recent Insights on Prevalence and Corelations of Hypoactive Delirium. Behav Neurol 2015; 2015:416792. [PMID: 26347584 PMCID: PMC4546955 DOI: 10.1155/2015/416792] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/27/2015] [Accepted: 07/05/2015] [Indexed: 01/21/2023] Open
Abstract
Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.
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Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients. Aging Clin Exp Res 2015; 27:53-60. [PMID: 24880696 DOI: 10.1007/s40520-014-0242-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Age is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the "oldest old" (i.e., in those aged >85 years). AIMS To compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of "oldest old" patients (group 1 = 85-89, group 2 > 90 years), after hip fracture surgery. METHODS Observational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012. RESULTS Two hundred seventy-five patients (group 1: N = 171; group 2: N = 104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient's caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95 % CI 1.08-4.65) and postoperative delirium (POD) (OR 3.80, 95 % CI 1.72-8.39) were predictors of 6-month mortality. CONCLUSIONS Patients aged >90 years who underwent hip fracture surgery are more likely to die at 6 months than those aged 85-89 years. Pre-fracture disability and POD are predictors of this excess of mortality.
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Dementia and sensitivity to anesthetics. Can J Anaesth 2014; 61:599-604. [DOI: 10.1007/s12630-014-0166-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 11/29/2022] Open
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