[Delirium in stroke: systematic review and meta-analysis]

BACKGROUND

Due to the complexity of the symptoms, delirium detection poses a challenge in stroke patients. A large body of literature has established that neurospecific challenges can have a considerable impact on diagnosis and are underrepresented in screening.

OBJECTIVES

An analysis of current scientific literature on delirium screening tests and their applicability in stroke patients, acknowledging neurospecific challenges and evaluating diagnostic test accuracy.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, and Cochrane Library databases. Studies published between 2018 and 2021 were evaluated and the study quality was assessed according to the Institute for Clinical Systems Improvement. Furthermore, the specificity and sensitivity of delirium screening tests were pooled RESULTS: The systematic literature review found a total of 2636 articles, following a review of the inclusion and exclusion criteria. Thus, 18 moderate-quality studies with a total of 3320 patients and 9 distinct delirium screenings were identified. Within those 18 studies, the prevalence of delirium was 34.2%. However, the delirium prevalence was significantly lower in 6 studies that included patients with neurologic impairments (26.5 vs. 32.1%, p = 0.0004). Pooled sensitivity and specificity for the 4AT (Rapid assessment test for delirium ) were 82 and 77%, while these values were 72 and 93% for the CAM-ICU (Confusion Assessment Method for Intensive Care Units) and 79 and 72% for the ICDSC (Intensive Care Delirium Screening Checklist).

CONCLUSIONS

Neurological impairments may influence the test quality of delirium screening in stroke patients. The CAM-ICU can be recommended for nonaphasic patients. The ICDSC can be used in all stroke patients on stoke units with an adjusted cut-off value of > 5 points.

Delirium screening in a stroke unit by nurses using 4AT: Results from a quality improvement project

AIM

To assess the feasibility of delirium screening with the screening tool 4AT conducted by stroke unit nurses.

DESIGN

Observational.

METHODS

Patients with confirmed acute stroke admitted to the stroke unit at Baerum Hospital, Norway, from March to October 2020, were consecutively recruited. Nurses performed delirium screening using the rapid screening tool 4AT within 24 h of admission, at discharge and when delirium was suspected, and filled out a questionnaire assessing their experiences with the delirium screening. A geriatrician validated the delirium diagnosis.

RESULTS

In all, 62 patients were included, mean age 73.3 years. 4AT was performed according to protocol in 49 (79.0%) and 39 (62.9%) patients at admission and discharge respectively. Lack of time (40%) was reported as the most common reason for not performing delirium screening. The nurses reported that the felt competent to carry out the 4AT screening, and did not experience it as significant extra workload. Five patients (8%) were diagnosed with delirium. Delirium screening performed by stroke unit nurses seemed feasible and the nurses experienced that 4AT was a useful tool for this purpose.

Associations between early in-hospital medications and the development of delirium in patients with stroke

OBJECTIVES

Patients hospitalized with stroke develop delirium at higher rates than general hospitalized patients. While several medications are associated with existing delirium, it is unknown whether early medication exposures are associated with subsequent delirium in patients with stroke. Additionally, it is unknown whether delirium identification is associated with changes in the prescription of these medications.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients admitted to a comprehensive stroke center, who were assessed for delirium by trained nursing staff during clinical care. We analyzed exposures to multiple medication classes in the first 48 h of admission, and compared them between patients who developed delirium >48 hours after admission and those who never developed delirium. Statistical analysis was performed using univariate testing. Multivariable logistic regression was used further to evaluate the significance of univariately significant medications, while controlling for clinical confounders.

RESULTS

1671 unique patients were included in the cohort, of whom 464 (27.8%) developed delirium >48 hours after admission. Delirium was associated with prior exposure to antipsychotics, sedatives, opiates, and antimicrobials. Antipsychotics, sedatives, and antimicrobials remained significantly associated with delirium even after accounting for several clinical covariates. Usage of these medications decreased in the 48 hours following delirium identification, except for atypical antipsychotics, whose use increased. Other medication classes such as steroids, benzodiazepines, and sleep aids were not initially associated with subsequent delirium, but prescription patterns still changed after delirium identification.

CONCLUSIONS

Early exposure to multiple medication classes is associated with the subsequent development of delirium in patients with stroke. Additionally, prescription patterns changed following delirium identification, suggesting that some of the associated medication classes may represent modifiable targets for future delirium prevention strategies, although future study is needed.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cortical reactivity to transcranial magnetic stimulation predicts risk of post-stroke delirium

OBJECTIVE

Post-stroke delirium (PSD) is a frequent and with regard to outcome unfavorable complication in acute stroke. The neurobiological mechanisms predisposing to PSD remain poorly understood, and biomarkers predicting its risk have not been established. We tested the hypothesis that hypoexcitable or disconnected brain networks predispose to PSD by measuring brain reactivity to transcranial magnetic stimulation with electroencephalography (TMS-EEG).

METHODS

We conducted a cross-sectional study in 33 acute stroke patients within 48 hours of stroke onset. Brain reactivity to single-pulse TMS of dorsolateral prefrontal cortex, primary motor cortex and superior parietal lobule of the right hemisphere was quantified by response intensity, effective connectivity, perturbational complexity index (PCI^ST), and natural frequency of the TMS-EEG response. PSD development was clinically tracked every 8 hours before and for 7 days following TMS-EEG.

RESULTS

Fourteen patients developed PSD while 19 patients did not. The PSD group showed lower excitability, effective connectivity, PCI^ST and natural frequency compared to the non-PSD group. The maximum PCI^ST over all three TMS sites demonstrated largest classification accuracy with a ROC-AUC of 0.943. This effect was independent of lesion size, affected hemisphere and stroke severity. Maximum PCI^ST and maximum natural frequency correlated inversely with delirium duration.

CONCLUSIONS

Brain reactivity to TMS-EEG can unravel brain network states of reduced excitability, effective connectivity, perturbational complexity and natural frequency that identify acute stroke patients at high risk for development of delirium.

SIGNIFICANCE

Findings provide novel insight into the pathophysiology of pre-delirium brain states and may promote effective delirium prevention strategies in those patients at high risk.

Palliative care approaches to acute stroke in the hospital setting

Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.

Delirium Screening of Patients on a Neuroscience Step-Down Unit

This project aimed to identify patients who had experienced a stroke and were at risk for delirium earlier, and implement evidence-based protocols to reduce overall length of stay and mortality. Nurses were motivated to perform screening and implement strategies that benefit patients who had experienced acute stroke. Results suggest early identification and treatment of delirium, use of prevention strategies, and treatment of the underlying etiology can improve patient outcomes and reduce cost of care.

Impact of Delirium and Its Motor Subtypes on Stroke Outcomes

BACKGROUND AND PURPOSE

Delirium is an acute and fluctuating impairment of attention, cognition, and behavior. Although common in stroke, studies that associate the clinical subtypes of delirium with functional outcome and death are lacking. We aimed to evaluate the influence of delirium occurrence and its different motor subtypes over stroke patients' prognosis.

METHODS

Prospective cohort of stroke patients with symptom onset within 72 hours before research admission. Delirium was diagnosed by Confusion Assessment Method for the Intensive Care Unit, and its motor subtypes were defined according to the Richmond Agitation-Sedation Scale. The main outcome was functional dependence or death (modified Rankin Scale>2) at 90 days comparing: delirium versus no delirium patients; and between motor subtypes. Secondary outcomes included modified Rankin Scale score >2 at 30 days and 90-day-mortality.

RESULTS

Two hundred twenty-seven patients were enrolled. Delirium occurred in 71 patients (31.3%), with the hypoactive subtype as the most frequent, in 41 subjects (57.8%). Delirium was associated with increased risk of death and functional dependence at 30 and 90 days and higher 90-day mortality. Multivariate analysis showed delirium (odds ratio, 3.28 [95% CI, 1.17-9.22]) as independent predictor of modified Rankin Scale >2 at 90 days.

CONCLUSIONS

Delirium is frequent in stroke patients in the acute phase. Its occurrence-specifically in mixed and hypoactive subtypes-seems to predict worse outcomes in this population. To our knowledge, this is the first study to prospectively investigate differences between delirium motor subtypes over functional outcome three months poststroke. Larger studies are needed to elucidate the relationship between motor subtypes of delirium and functional outcomes in the context of acute stroke.

Occurrence Rate of Delirium in Acute Stroke Settings

Background and Purpose—

Delirium is associated with increased mortality, length of stay, and poor functional outcome following critical illness. The epidemiology of delirium in stroke is poorly described. We sought to collate evidence around occurrence (incidence or prevalence) of delirium in acute stroke.

Methods—

We searched multiple cross-disciplinary electronic databases using a prespecified search strategy, complemented by hand searching. Eligible studies described delirium in acute (first 6 weeks) stroke. We compared delirium occurrence using random-effects models to describe summary estimates. We assessed risk of bias using the Newcastle-Ottawa tool, incorporating this in sensitivity analyses. We performed subgroup analyses for delirium diagnostic method (confusion assessment method scoring, clinical diagnosis, other), duration and timing of delirium assessment (>1 or <1 week), and performed meta-regression based on the year of publication.

Results—

Of 8822 titles, we included 32 papers (6718 participants) in the quantitative analysis. Summary estimate for occurrence of delirium was 25% (95% CI, 20%–30%; moderate quality evidence). Limiting to studies at low risk of bias (22 studies, 4422 participants), the occurrence rate was 23% (95% CI, 17%–28%). Subgroup summary estimates suggest that delirium occurrence may vary with assessment method: confusion assessment method, 21% (95% CI, 16%–27%); clinical diagnosis, 27% (95% CI, 19%–38%); other, 32% (95% CI, 22%–43%) but not with duration and timing of assessment. Meta-regression suggested decline in occurrence of delirium comparing historical to more recent studies (slope, 0.03 [SE, 0.004]; P <0.0001).

Conclusions—

Delirium is common, affecting 1 in 4 acute stroke patients. Reported rates of delirium may be dependent on assessment method. Our estimate of delirium occurrence could be used for audit, to plan intervention studies, and inform clinical practice.

Clinical Trial Registration—

URL: http://www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD42015029251.