1
|
Gerakios F, Yarnall AJ, Bate G, Wright L, Davis D, Stephan BCM, Robinson L, Brayne C, Stebbins G, Taylor JP, Burn DJ, Allan LM, Richardson SJ, Lawson RA. Delirium is more common and associated with worse outcomes in Parkinson's disease compared to older adult controls: results of two prospective longitudinal cohort studies. Age Ageing 2024; 53:afae046. [PMID: 38497236 PMCID: PMC10945294 DOI: 10.1093/ageing/afae046] [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: 08/04/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Inpatient prevalence of Parkinson's disease (PD) delirium varies widely across the literature. Delirium in general older populations is associated with adverse outcomes, such as increased mortality, dementia, and institutionalisation. However, to date there are no comprehensive prospective studies in PD delirium. This study aimed to determine delirium prevalence in hospitalised PD participants and the association with adverse outcomes, compared to a control group of older adults without PD. METHODS Participants were hospitalised inpatients from the 'Defining Delirium and its Impact in Parkinson's Disease' and the 'Delirium and Cognitive Impact in Dementia' studies comprising 121 PD participants and 199 older adult controls. Delirium was diagnosed prospectively using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Outcomes were determined by medical note reviews and/or home visits 12 months post hospital discharge. RESULTS Delirium was identified in 66.9% of PD participants compared to 38.7% of controls (p < 0.001). In PD participants only, delirium was associated with a significantly higher risk of mortality (HR = 3.3 (95% confidence interval [CI] = 1.3-8.6), p = 0.014) and institutionalisation (OR = 10.7 (95% CI = 2.1-54.6), p = 0.004) 12 months post-discharge, compared to older adult controls. However, delirium was associated with an increased risk of developing dementia 12 months post-discharge in both PD participants (OR = 6.1 (95% CI = 1.3-29.5), p = 0.024) and in controls (OR = 13.4 (95% CI = 2.5-72.6), p = 0.003). CONCLUSION Delirium is common in hospitalised PD patients, affecting two thirds of patients, and is associated with increased mortality, institutionalisation, and dementia. Further research is essential to understand how to accurately identify, prevent and manage delirium in people with PD who are in hospital.
Collapse
Affiliation(s)
- Florence Gerakios
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Gemma Bate
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Wright
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Blossom C M Stephan
- Institute of Mental Health, School of Medicine, Nottingham University, Nottingham, UK
- Dementia Centre of Excellence, EnAble Institute, Curtin University, Perth, Australia
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Carol Brayne
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Glenn Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - David J Burn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Louise M Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
| | - Sarah J Richardson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Rachael A Lawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| |
Collapse
|
2
|
Gao L, Gaba A, Li P, Saxena R, Scheer FAJL, Akeju O, Rutter MK, Hu K. Heart rate response and recovery during exercise predict future delirium risk-A prospective cohort study in middle- to older-aged adults. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:312-323. [PMID: 34915199 DOI: 10.1016/j.jshs.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/10/2021] [Accepted: 11/17/2021] [Indexed: 05/17/2023]
Abstract
BACKGROUND Delirium is a neurocognitive disorder characterized by an abrupt decline in attention, awareness, and cognition after surgical/illness-induced stressors on the brain. There is now an increasing focus on how cardiovascular health interacts with neurocognitive disorders given their overlapping risk factors and links to subsequent dementia and mortality. One common indicator for cardiovascular health is the heart rate response/recovery (HRR) to exercise, but how this relates to future delirium is unknown. METHODS Electrocardiogram data were examined in 38,740 middle- to older-aged UK Biobank participants (mean age = 58.1 years, range: 40-72 years; 47.3% males) who completed a standardized submaximal exercise stress test (15-s baseline, 6-min exercise, and 1-min recovery) and required hospitalization during follow-up. An HRR index was derived as the product of the heart rate (HR) responses during exercise (peak/resting HRs) and recovery (peak/recovery HRs) and categorized into low/average/high groups as the bottom quartile/middle 2 quartiles/top quartile, respectively. Associations between 3 HRR groups and new-onset delirium were investigated using Cox proportional hazards models and a 2-year landmark analysis to minimize reverse causation. Sociodemographic factors, lifestyle factors/physical activity, cardiovascular risk, comorbidities, cognition, and maximal workload achieved were included as covariates. RESULTS During a median follow-up period of 11 years, 348 participants (9/1000) newly developed delirium. Compared with the high HRR group (16/1000), the risk for delirium was almost doubled in those with low HRR (hazard ratio = 1.90, 95% confidence interval (95%CI): 1.30-2.79, p = 0.001) and average HRR (hazard ratio = 1.54, 95%CI: 1.07-2.22, p = 0.020)). Low HRR was equivalent to being 6 years older, a current smoker, or ≥3 additional cardiovascular disease risks. Results were robust in sensitivity analysis, but the risk appeared larger in those with better cognition and when only postoperative delirium was considered (n = 147; hazard ratio = 2.66, 95%CI: 1.46-4.85, p = 0.001). CONCLUSION HRR during submaximal exercise is associated with future risk for delirium. Given that HRR is potentially modifiable, it may prove useful for neurological risk stratification alongside traditional cardiovascular risk factors.
Collapse
Affiliation(s)
- Lei Gao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA.
| | - Arlen Gaba
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Peng Li
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK; Diabetes, Endocrinology and Metabolism Centre, Manchester University National Health Service Foundation Trust, Manchester M13 9WL, UK
| | - Kun Hu
- Medical Biodynamics Program, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
| |
Collapse
|
3
|
Russell G, Rana N, Watts R, Roshny S, Siddiqi N, Rose L. Reporting of outcomes and measures in studies of interventions to prevent and/or treat delirium in older adults resident in long-term care: a systematic review. Age Ageing 2022; 51:afac267. [PMID: 36434799 PMCID: PMC9701105 DOI: 10.1093/ageing/afac267] [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: 04/14/2022] [Revised: 08/18/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES to inform development of a core outcome set, we evaluated outcomes, definitions, measures and measurement time points in clinical trials of interventions to prevent and/or treat delirium in older adults resident in long-term care (LTC). DATA SOURCES we searched electronic databases, systematic review repositories and trial registries (1980 to 10 December 2021). STUDY SELECTION AND DATA EXTRACTION we included randomised, quasi-randomised and non-randomised intervention studies. We extracted data on study characteristics, outcomes and measurement features. We assessed outcome reporting quality using the MOMENT study scoring system. We categorised outcomes using the Core Outcome Measures in Effectiveness Trials taxonomy. DATA SYNTHESIS we identified 18 studies recruiting 5,639 participants. All evaluated non-pharmacological interventions; most (16 studies, 89%) addressed delirium prevention. We identified 12 delirium-specific outcomes (mean [SD] 2.4 [1.5] per study), of which delirium incidence (14 studies, 78%) and severity (6 studies, 33%) were most common. We found heterogeneity in description of outcomes and measurement time points. The Confusion Assessment Method (three versions) was the most common measure used to ascertain delirium incidence (7 of 14 studies, 50%). We identified 25 non-delirium specific outcomes (mean [SD] 4.0 [2.3] per study), with hospital admission the most commonly reported (9 studies, 50%). CONCLUSIONS we identified few studies of interventions for the prevention or treatment of delirium in older adults resident in LTC. These studies were heterogeneous in the outcomes reported and measures used. These data inform the consensus-building stage of a core outcome set.
Collapse
Affiliation(s)
- Gregor Russell
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | | | - Rahul Watts
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Sefat Roshny
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Najma Siddiqi
- Health Sciences, University of York and Hull York Medical School, York, UK
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| |
Collapse
|
4
|
Levy I, Gavrieli S, Hefer T, Attias S, Schiff A, Oliven R, Wisberg-Levi S, Hanchinsky R, Schiff E. Acupuncture Treatment of Delirium in Older Adults Hospitalized in Internal Medicine Departments: An Open-Label Pragmatic Randomized-Controlled Trial. J Geriatr Psychiatry Neurol 2022; 35:333-343. [PMID: 33685268 DOI: 10.1177/0891988721996804] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acupuncture seems to improve cognitive function in experimental models and to reduce agitation in dementia. The addition of acupuncture to standard-of-care (SOC) may improve clinical outcomes related to delirium in hospitalized older adults. METHODS This pragmatic open-label randomized-controlled trial evaluated 81 older adults hospitalized in an internal medicine ward and diagnosed with delirium. Fifty were randomized to daily acupuncture combined with SOC and 31 to SOC only for up to 1 week. Delirium was diagnosed using Confusion Assessment Method (CAM) tool, and its severity was assessed by the long CAM-Severity (CAM-S) tool. The primary study outcome was delirium resolution evaluated as time-to-first delirium remission (over 7 days) and the number of days spent delirium-free. RESULTS Time-to-first delirium remission was shorter in the acupuncture arm as compared to the SOC only arm (p < 0.001). A multivariate Cox regression analysis showed a shorter time-to-first remission of delirium in the acupuncture arm as compared with SOC arm [Hazard Ratio 0.267 (95% CI 0.098-0.726, p = 0.010)]. In the 7 days of evaluation, a significantly higher number of delirium-free days was found in the acupuncture arm compared to the SOC arm (p < 0.001), and CAM-S sum from day 2 to day 7 of evaluation was significantly lower in the acupuncture group compared to the control group (p = 0.002). No adverse safety event was found in the acupuncture group. CONCLUSION Acupuncture seems to be safe and effective in the treatment of delirium in older patients hospitalized in internal medicine departments.
Collapse
Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Hematology Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Sagi Gavrieli
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Talia Hefer
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Samuel Attias
- Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Ariel Schiff
- Faculty of Medicine, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Ron Oliven
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Geriatric Unit, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Shikma Wisberg-Levi
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Rina Hanchinsky
- Internal Medicine C Department, 37772Bnai Zion Medical Center, Haifa, Israel
| | - Elad Schiff
- Internal Medicine B Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, 37772Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
5
|
Ulsa MC, Xi Z, Li P, Gaba A, Wong PM, Saxena R, Scheer FAJL, Rutter M, Akeju O, Hu K, Gao L. Association of Poor Sleep Burden in Middle Age and Older Adults With Risk for Delirium During Hospitalization. J Gerontol A Biol Sci Med Sci 2022; 77:507-516. [PMID: 34558609 PMCID: PMC8893188 DOI: 10.1093/gerona/glab272] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Delirium is a distressing neurocognitive disorder recently linked to sleep disturbances. However, the longitudinal relationship between sleep and delirium remains unclear. This study assessed the associations of poor sleep burden, and its trajectory, with delirium risk during hospitalization. METHODS About 321 818 participants from the UK Biobank (mean age 58 ± 8 years [SD]; range 37-74 years) reported (2006-2010) sleep traits (sleep duration, excessive daytime sleepiness, insomnia-type complaints, napping, and chronotype-a closely related circadian measure for sleep timing), aggregated into a sleep burden score (0-9). New-onset delirium (n = 4 775) was obtained from hospitalization records during a 12-year median follow-up. About 42 291 (mean age 64 ± 8 years; range 44-83 years) had repeat sleep assessment on average 8 years after their first. RESULTS In the baseline cohort, Cox proportional hazards models showed that moderate (aggregate scores = 4-5) and severe (scores = 6-9) poor sleep burden groups were 18% (hazard ratio = 1.18 [95% confidence interval: 1.08-1.28], p < .001) and 57% (1.57 [1.38-1.80], p < .001), more likely to develop delirium, respectively. The latter risk magnitude is equivalent to 2 additional cardiovascular risks. These findings appeared robust when restricted to postoperative delirium and after exclusion of underlying dementia. Higher sleep burden was also associated with delirium in the follow-up cohort. Worsening sleep burden (score increase ≥2 vs no change) further increased the risk for delirium (1.79 [1.23-2.62], p = .002) independent of their baseline sleep score and time lag. The risk was highest in those younger than 65 years at baseline (p for interaction <.001). CONCLUSION Poor sleep burden and worsening trajectory were associated with increased risk for delirium; promotion of sleep health may be important for those at higher risk.
Collapse
Affiliation(s)
- Ma Cherrysse Ulsa
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zheng Xi
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Patricia M Wong
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Martin Rutter
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, UK
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
6
|
Hogg E, Frank S, Oft J, Benway B, Rashid MH, Lahiri S. Urinary Tract Infection in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:743-757. [PMID: 35147552 PMCID: PMC9108555 DOI: 10.3233/jpd-213103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/27/2022]
Abstract
Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson's disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.
Collapse
Affiliation(s)
- Elliot Hogg
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samuel Frank
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jillian Oft
- Department of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brian Benway
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Shouri Lahiri
- Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
7
|
Richardson SJ, Lawson R, Davis DHJ, Stephan BCM, Robinson L, Matthews FE, Brayne C, Barnes LE, Taylor JP, Parker SG, Allan LM. Hospitalisation without delirium is not associated with cognitive decline in a population-based sample of older people-results from a nested, longitudinal cohort study. Age Ageing 2021; 50:1675-1681. [PMID: 33945608 PMCID: PMC8437075 DOI: 10.1093/ageing/afab068] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute hospitalisation and delirium have individually been shown to adversely affect trajectories of cognitive decline but have not previously been considered together. This work aimed to explore the impact on cognition of hospital admission with and without delirium, compared to a control group with no hospital admissions. METHODS The Delirium and Cognitive Impact in Dementia (DECIDE) study was nested within the Cognitive Function and Ageing Study II (CFAS II)-Newcastle cohort. CFAS II participants completed two baseline interviews, including the Mini-Mental State Examination (MMSE). During 2016, surviving participants from CFAS II-Newcastle were recruited to DECIDE on admission to hospital. Participants were reviewed daily to determine delirium status.During 2017, all DECIDE participants and age, sex and years of education matched controls without hospital admissions during 2016 were invited to repeat the CFAS II interview. Delirium was excluded in the control group using the Informant Assessment of Geriatric Delirium Scale (i-AGeD). Linear mixed effects modelling determined predictors of cognitive decline. RESULTS During 2016, 82 of 205 (40%) DECIDE participants had at least one episode of delirium. At 1 year, 135 of 205 hospitalised participants completed an interview along with 100 controls. No controls experienced delirium (i-AGeD>4). Delirium was associated with a faster rate of cognitive decline compared to those without delirium (β = -2.2, P < 0.001), but number of hospital admissions was not (P = 0.447). CONCLUSIONS These results suggest that delirium during hospitalisation rather than hospitalisation per se is a risk factor for future cognitive decline, emphasising the need for dementia prevention studies that focus on delirium intervention.
Collapse
Affiliation(s)
- Sarah J Richardson
- Translational and Clinical Research Institute, Biomedical Research Building, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - Rachael Lawson
- Translational and Clinical Research Institute, Biomedical Research Building, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London WC1E 7HB, UK
| | - Blossom C M Stephan
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, Nottingham University, Nottingham NG7 2TU, UK
| | - Louise Robinson
- Population Health Sciences Institute, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Fiona E Matthews
- Population Health Sciences Institute, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, Cambridge CB2 0SR, UK
| | - Linda E Barnes
- Cambridge Public Health, University of Cambridge, Cambridge CB2 0SR, UK
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Biomedical Research Building, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - Stuart G Parker
- Population Health Sciences Institute, Campus for Ageing & Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Louise M Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter EX1 2LU, UK
| |
Collapse
|
8
|
Mychajliw C, Herrmann ML, Suenkel U, Brand K, von Thaler AK, Wurster I, Yilmaz R, Eschweiler GW, Metzger FG. Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years. Front Aging Neurosci 2021; 13:676734. [PMID: 34163350 PMCID: PMC8215445 DOI: 10.3389/fnagi.2021.676734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute medical illnesses, surgical interventions, or admissions to hospital in older individuals are frequently associated with a delirium. In this cohort study, we investigated the impact of specific cognitive domains and depression before the occurrence of delirium symptoms in an 8-year observation of older non-hospitalized individuals. METHODS In total, we included 807 participants (48-83 years). Deficits in specific cognitive domains were measured using the CERAD test battery, and depressive symptoms were measured using Beck Depression Inventory and the Geriatric Depression Scale (GDS) before the onset of a delirium. Delirium symptoms were retrospectively assessed by a questionnaire based on the established Nursing Delirium Screening Scale. RESULTS Fifty-eight of eight hundred seven participants (7.2%) reported delirium symptoms over the 8-year course of the study. Sixty-nine percent (n = 40) of reported delirium symptoms were related to surgeries. In multivariate regression analysis, impaired executive function was an independent risk factor (p = 0.034) for the occurrence of delirium symptoms. Furthermore, age (p = 0.014), comorbidities [captured by the Charlson Comorbidity Index (CCI)] (p < 0.001), and depression (p = 0.012) were significantly associated with reported delirium symptoms. CONCLUSION Especially prior to elective surgery or medical interventions, screening for impaired executive function and depression could be helpful to identify patients who are at risk to develop delirium symptoms.
Collapse
Affiliation(s)
- Christian Mychajliw
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Matthias L. Herrmann
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
- Department of Neurology and Neuroscience, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Suenkel
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Katharina Brand
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Anna-Katharina von Thaler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
- Department of Neurology, University Hospital of Tübingen, Tübingen, Germany
| | - Isabel Wurster
- Department of Neurology, University Hospital of Tübingen, Tübingen, Germany
- German Center of Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Rezzak Yilmaz
- Department of Neurology, University of Ankara Medical School, Ankara, Turkey
| | - Gerhard W. Eschweiler
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Florian G. Metzger
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
- Vitos Hospital for Psychiatry and Psychotherapy Haina, Haina, Germany
| |
Collapse
|
9
|
Richardson SJ, Davis DHJ, Stephan BCM, Robinson L, Brayne C, Barnes LE, Taylor JP, Parker SG, Allan LM. Recurrent delirium over 12 months predicts dementia: results of the Delirium and Cognitive Impact in Dementia (DECIDE) study. Age Ageing 2021; 50:914-920. [PMID: 33320945 PMCID: PMC8099011 DOI: 10.1093/ageing/afaa244] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Indexed: 11/19/2022] Open
Abstract
Background Delirium is common, distressing and associated with poor outcomes. Previous studies investigating the impact of delirium on cognitive outcomes have been limited by incomplete ascertainment of baseline cognition or lack of prospective delirium assessments. This study quantified the association between delirium and cognitive function over time by prospectively ascertaining delirium in a cohort aged ≥ 65 years in whom baseline cognition had previously been established. Methods For 12 months, we assessed participants from the Cognitive Function and Ageing Study II-Newcastle for delirium daily during hospital admissions. At 1-year, we assessed cognitive decline and dementia in those with and without delirium. We evaluated the effect of delirium (including its duration and number of episodes) on cognitive function over time, independently of baseline cognition and illness severity. Results Eighty two of 205 participants recruited developed delirium in hospital (40%). One-year outcome data were available for 173 participants: 18 had a new dementia diagnosis, 38 had died. Delirium was associated with cognitive decline (−1.8 Mini-Mental State Examination points [95% CI –3.5 to –0.2]) and an increased risk of new dementia diagnosis at follow up (OR 8.8 [95% CI 1.9–41.4]). More than one episode and more days with delirium (>5 days) were associated with worse cognitive outcomes. Conclusions Delirium increases risk of future cognitive decline and dementia, independent of illness severity and baseline cognition, with more episodes associated with worse cognitive outcomes. Given that delirium has been shown to be preventable in some cases, we propose that delirium is a potentially modifiable risk factor for dementia.
Collapse
Affiliation(s)
- Sarah J Richardson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London WC1E 7HB, UK
| | - Blossom C M Stephan
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham NG7 2TU, UK
| | - Louise Robinson
- Institute of Population Health Sciences, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building, Newcastle upon Tyne NE4 5PL, UK
| | - Carol Brayne
- Cambridge Public Health, Cambridge Institute of Public Health, University of Cambridge, Cambridge CB2 0SR, UK
| | - Linda E Barnes
- Cambridge Public Health, Cambridge Institute of Public Health, University of Cambridge, Cambridge CB2 0SR, UK
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Stuart G Parker
- Institute of Population Health Sciences, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building, Newcastle upon Tyne NE4 5PL, UK
| | - Louise M Allan
- College of Medicine and Health, South Cloisters, University of Exeter, Exeter EX1 2LU, UK
| |
Collapse
|
10
|
Rawle MJ, McCue L, Sampson EL, Davis D, Vickerstaff V. Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study. Drugs Aging 2021; 38:233-242. [PMID: 33415708 PMCID: PMC7914229 DOI: 10.1007/s40266-020-00827-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population. OBJECTIVES Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients. METHODS We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality. RESULTS The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship. CONCLUSIONS ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.
Collapse
Affiliation(s)
- Mark James Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- Whipps Cross University Hospital, London, UK
| | - Laura McCue
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Research Department of Primary Care and Population Health, UCL, London, UK
| |
Collapse
|
11
|
Efraim NT, Zikrin E, Shacham D, Katz D, Makulin E, Barski L, Zeller L, Bartal C, Freud T, Lebedinski S, Press Y. Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes. Front Med (Lausanne) 2020; 7:581069. [PMID: 33195329 PMCID: PMC7604336 DOI: 10.3389/fmed.2020.581069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an “any symptoms of delirium” group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.
Collapse
Affiliation(s)
- Nirit Tzur Efraim
- Department of Psychiatry, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeniya Zikrin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - David Shacham
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Dori Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Evgeni Makulin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine F, Soroka Medical Center, Beer-Sheva, Israel
| | - Lior Zeller
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine C, Soroka Medical Center, Beer-Sheva, Israel
| | - Carmi Bartal
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Internal Medicine E, Soroka Medical Center, Beer-Sheva, Israel
| | - Tamar Freud
- Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Svetlana Lebedinski
- Clinical Pharmacy Services, Pharmacy Department, Clalit Health Services, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
12
|
MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
Collapse
Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| |
Collapse
|
13
|
Droś J, Kowalska K, Pasińska P, Szyper-Maciejowska A, Gorzkowska A, Klimkowicz-Mrowiec A. Delirium Post-Stroke-Influence on Post-Stroke Dementia (Research Study-Part of the PROPOLIS Study). J Clin Med 2020; 9:jcm9072165. [PMID: 32659885 PMCID: PMC7408906 DOI: 10.3390/jcm9072165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Previous research confirmed association between delirium and subsequent dementia in different clinical settings, but the impact of post-stroke delirium on cognitive functioning is still under-investigated. Therefore, we aimed to assess the risk of dementia among patients with stroke and in-hospital delirium. METHODS A total of 750 consecutive patients admitted to the stroke unit with acute stroke or transient ischemic attacks were screened for delirium, during the first seven days after admission. At the three- and twelve-month follow-up, patients underwent cognitive evaluation. The DSM-5 definition for dementia was used. Cases with pre-stroke dementia were excluded from the analysis. RESULTS Out of 691 included cases, 423 (61.22%) and 451 (65.27%) underwent cognitive evaluation, three and twelve months after stroke; 121 (28.61%) and 151 (33.48%) patients were diagnosed with dementia, respectively. Six (4.96%) patients with dementia, three months post-stroke did not meet the diagnostic criteria for dementia nine months later. After twelve months, 37 (24.50%) patients were diagnosed with dementia, first time after stroke. Delirium in hospital was an independent risk factor for dementia after three months (OR = 7.267, 95%CI 2.182-24.207, p = 0.001) but not twelve months after the stroke. CONCLUSIONS Patients with stroke complicated by in-hospital delirium are at a higher risk for dementia at three but not twelve months post-stroke.
Collapse
Affiliation(s)
- Jakub Droś
- Doctoral School in Medical and Health Sciences, Jagiellonian University Medical College, 31-008 Kraków, Poland;
| | - Katarzyna Kowalska
- Department of Neurology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (K.K.); (P.P.)
| | - Paulina Pasińska
- Department of Neurology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (K.K.); (P.P.)
| | | | - Agnieszka Gorzkowska
- Department of Neurorehabilitation, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Aleksandra Klimkowicz-Mrowiec
- Department of Neurology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (K.K.); (P.P.)
- Correspondence: ; Tel.: +48-12-424-86-35
| |
Collapse
|
14
|
Koirala B, Hansen BR, Hosie A, Budhathoki C, Seal S, Beaman A, Davidson PM. Delirium point prevalence studies in inpatient settings: A systematic review and meta‐analysis. J Clin Nurs 2020; 29:2083-2092. [DOI: 10.1111/jocn.15219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Binu Koirala
- Johns Hopkins School of Nursing Baltimore Maryland
| | | | - Annmarie Hosie
- School of Nursing Sydney The University of Notre Dame Australia Darlinghurst NSW Australia
| | | | - Stella Seal
- Johns Hopkins University and Medicine Welch Medical Library Baltimore Maryland
| | - Adam Beaman
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| | - Patricia M. Davidson
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| |
Collapse
|
15
|
Sajjad MU, Blennow K, Knapskog AB, Idland AV, Chaudhry FA, Wyller TB, Zetterberg H, Watne LO. Cerebrospinal Fluid Levels of Interleukin-8 in Delirium, Dementia, and Cognitively Healthy Patients. J Alzheimers Dis 2020; 73:1363-1372. [DOI: 10.3233/jad-190941] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | | | - Ane-Victoria Idland
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
| | - Farrukh Abbas Chaudhry
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
| | - Leiv Otto Watne
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
16
|
Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. MAIN BODY The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). SHORT CONCLUSION In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
Collapse
Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy.
- Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
- Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy
- University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Geriatric Unit, S. Gerardo Hospital, Monza, Italy
| |
Collapse
|
17
|
Levy I, Attias S, Gavrieli S, Oliven R, Neerland BE, Devlin JW, Ben-Arye E, Greenberg D, Schiff E. The study protocol for a randomized, controlled trial of acupuncture versus a sham procedure versus standard care alone for the treatment of delirium in acutely hospitalized older adults with a medical illness. Maturitas 2019; 124:72-80. [PMID: 31097183 DOI: 10.1016/j.maturitas.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/13/2019] [Accepted: 03/02/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many hospitalized older adults experience delirium, but treatment options are limited. Acupuncture has been shown to improve cognitive function and reduce agitation in dementia. We hypothesize that acupuncture, when compared with a sham intervention, will reduce the duration and severity of delirium, normalize delirium biomarkers, and improve clinical outcomes related to delirium in acutely hospitalized older adults with a medical illness. METHODS This three-arm, prospective, randomized, clinical trial will evaluate adults aged over 65 years who are acutely hospitalized to an internal-medicine ward and diagnosed with delirium or subsyndromal delirium. The 288 patients (96 in each of three groups) will be randomly allocated to receive either daily true acupuncture with usual care, a daily sham procedure with usual care, or usual care only in a 1:1:1 distribution for up to one week or until the patient is delirium-free for over 48 h. Other delirium and clinical interventions will remain unchanged. Delirium will be diagnosed using DSM-5 criteria and its severity will be assessed using the long Confusion Assessment Method Severity (CAM-S) tool. OUTCOMES The primary study outcome will be the daily CAM-S score over 7 days between the three groups. Secondary outcomes will include time to first resolution of the delirium (over 7 days), the proportion of days spent delirium-free, daily antipsychotic use, daily pain scores, sleep quality, morning serum cortisol and T3 levels, and midnight urinary cortisol/creatinine ratio, all determined twice a week, and delirium-related complications. Hospital mortality, duration of hospital stay and functional status at discharge will also be compared between the three groups. Adverse events potentially related to acupuncture will be evaluated daily. The cost-effectiveness of acupuncture will be estimated. CONCLUSION This novel randomized study will evaluate both the specific and the non-specific effects of acupuncture on delirium, and related outcomes, and its safety. Potential mechanism(s) of action for acupuncture in reducing delirium will be explored and healthcare-related costs estimated. Positive study results may prove pivotal in facilitating a multimodal, non-pharmacologic, integrative approach to delirium treatment among older, medical inpatients.
Collapse
Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel.
| | - Samuel Attias
- Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel; School of Public Health, University of Haifa, Haifa, Israel
| | - Sagi Gavrieli
- Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel
| | - Ron Oliven
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Internal Medicine C Department, Bnai Zion Medical Center, Haifa, Israel; Geriatric Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Bjorn E Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - John W Devlin
- Northeastern University, School of Pharmacy, Boston, MA, United States; Tufts Medical Center, 1867, Boston, MA, United States
| | - Eran Ben-Arye
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Integrative Oncology Program, The Oncology Service and Lin Medical Center, Clalit Health Services, Haifa, Israel
| | - Dan Greenberg
- Department of Health Systems Management, Faculty of Health Sciences, School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Schiff
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel; Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
18
|
Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of Duration of Surgery With Postoperative Delirium Among Patients Receiving Hip Fracture Repair. JAMA Netw Open 2019; 2:e190111. [PMID: 30794305 PMCID: PMC6484601 DOI: 10.1001/jamanetworkopen.2019.0111] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks. OBJECTIVE To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019. EXPOSURE Surgery duration, measured as the total time in the operating room. MAIN OUTCOMES AND MEASURES A diagnosis of postoperative delirium during hospitalization. RESULTS Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01). CONCLUSIONS AND RELEVANCE Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.
Collapse
Affiliation(s)
- Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David N. Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Donald A. Redelmeier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Tsui A, Kuh D, Richards M, Davis D. Delirium symptoms are associated with decline in cognitive function between ages 53 and 69 years: Findings from a British birth cohort study. Alzheimers Dement 2018; 14:617-622. [PMID: 29161540 PMCID: PMC5948100 DOI: 10.1016/j.jalz.2017.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/23/2017] [Accepted: 08/30/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Few population studies have investigated whether longitudinal decline after delirium in mid-to-late life might affect specific cognitive domains. METHODS Participants from a birth cohort completing assessments of search speed, verbal memory, and the Addenbrooke's Cognitive Examination at age 69 were asked about delirium symptoms between ages 60 and 69 years. Linear regression models estimated associations between delirium symptoms and cognitive outcomes. RESULTS Period prevalence of delirium between 60 and 69 years was 4% (95% confidence interval 3.2%-4.9%). Self-reported symptoms of delirium over the seventh decade were associated with worse scores in the Addenbrooke's Cognitive Examination (-1.7 points; 95% confidence interval -3.2, -0.1; P = .04). In association with delirium symptoms, verbal memory scores were initially lower, with subsequent decline in search speed by the age of 69 years. These effects were independent of other Alzheimer's risk factors. DISCUSSION Delirium symptoms may be common even at relatively younger ages, and their presence may herald cognitive decline, particularly in search speed, over this time period.
Collapse
Affiliation(s)
- Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK.
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| |
Collapse
|
20
|
Prevalence and risk factors for delirium diagnosis in patients followed in general practices in Germany. Int Psychogeriatr 2018; 30:511-518. [PMID: 29235430 DOI: 10.1017/s1041610217002587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED ABSTRACTBackground:The aim of this study is to identify the prevalence and risk factors of documented delirium in general practices in Germany. METHODS The present study includes 2,194 patients over the age of 65 years with delirium and 2,194 controls without delirium from a sample of 6,180,042 patients from 1,262 general practices. Multivariate logistic regression models were fitted with delirium as a dependent variable and other disorders and drugs as potential predictors. RESULTS A five-year-prevalence of 0.08% and an average of 0.7 (SD: 1.5) patients per practice per year were found. Among the study participants, 43.0% were men, and the mean age was 82.2 years (SD = 7.1 years). 24.2% of delirium patients and 10.3% of controls lived in nursing homes. Delirium was found to be positively associated with nursing home residence (OR: 1.69), dementia (OR = 3.45), epilepsy (OR = 2.16), stroke (OR = 1.80), Parkinson's disease (OR = 1.78), sleep disorder (OR = 1.64), renal insufficiency (OR = 1.57), fractures (OR = 1.56), and the prescription of benzodiazepines (OR = 1.62) and antiepileptics (OR = 1.53). Finally, the number of different drug classes prescribed within one year prior to the index date was positively associated with a risk of delirium. Compared to patients without medication therapy, the OR for delirium was 3.21 when more than four drug classes were prescribed. CONCLUSIONS In primary care, neuropsychiatric risk factors and polymedication were particularly important for the diagnosis of delirium compared to inpatient care. The methodological limitations of the analysis of data from routine care must be considered. Delirium is rarely diagnosed in primary care. Risk factors in primary care differ from those found in inpatient care. The reasons for this need to be further investigated.
Collapse
|
21
|
Davis D, Richardson S, Hornby J, Bowden H, Hoffmann K, Weston-Clarke M, Green F, Chaturvedi N, Hughes A, Kuh D, Sampson E, Mizoguchi R, Cheah KL, Romain M, Sinha A, Jenkin R, Brayne C, MacLullich A. The delirium and population health informatics cohort study protocol: ascertaining the determinants and outcomes from delirium in a whole population. BMC Geriatr 2018; 18:45. [PMID: 29426299 PMCID: PMC5807842 DOI: 10.1186/s12877-018-0742-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/05/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Delirium affects 25% of older inpatients and is associated with long-term cognitive impairment and future dementia. However, no population studies have systematically ascertained cognitive function before, cognitive deficits during, and cognitive impairment after delirium. Therefore, there is a need to address the following question: does delirium, and its features (including severity, duration, and presumed aetiologies), predict long-term cognitive impairment, independent of cognitive impairment at baseline? METHODS The Delirium and Population Health Informatics Cohort (DELPHIC) study is an observational population-based cohort study based in the London Borough of Camden. It is recruiting 2000 individuals aged ≥70 years and prospectively following them for two years, including daily ascertainment of all inpatient episodes for delirium. Daily inpatient assessments include the Memorial Delirium Assessment Scale, the Observational Scale for Level of Arousal, and the Hierarchical Assessment of Balance and Mobility. Data on delirium aetiology is also collected. The primary outcome is the change in the modified Telephone Interview for Cognitive Status at two years. DISCUSSION DELPHIC is the first population sample to assess older persons before, during and after hospitalisation. The cumulative incidence of delirium in the general population aged ≥70 will be described. DELPHIC offers the opportunity to quantify the impact of delirium on cognitive and functional outcomes. Overall, DELPHIC will provide a real-time public health observatory whereby information from primary, secondary, intermediate and social care can be integrated to understand how acute illness is linked to health and social care outcomes.
Collapse
Affiliation(s)
- Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Joanne Hornby
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Helen Bowden
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | - Fenella Green
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Alun Hughes
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | | | | | - Abhi Sinha
- Royal Free London NHS Foundation Trust, London, UK
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | | |
Collapse
|
22
|
Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Knowledge of Australian hospital pharmacists regarding delirium in elderly patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gizat M. Kassie
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; Sansom Institute for Health Research; University of South Australia; Adelaide Australia
| |
Collapse
|
23
|
Harrison JK, Reid J, Quinn TJ, Shenkin SD. Using quality assessment tools to critically appraise ageing research: a guide for clinicians. Age Ageing 2017; 46:359-365. [PMID: 27932357 PMCID: PMC5405751 DOI: 10.1093/ageing/afw223] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/10/2016] [Indexed: 01/05/2023] Open
Abstract
Evidence based medicine tells us that we should not accept published research at face value. Even research from established teams published in the highest impact journals can have methodological flaws, biases and limited generalisability. The critical appraisal of research studies can seem daunting, but tools are available to make the process easier for the non-specialist. Understanding the language and process of quality assessment is essential when considering or conducting research, and is also valuable for all clinicians who use published research to inform their clinical practice.We present a review written specifically for the practising geriatrician. This considers how quality is defined in relation to the methodological conduct and reporting of research. Having established why quality assessment is important, we present and critique tools which are available to standardise quality assessment. We consider five study designs: RCTs, non-randomised studies, observational studies, systematic reviews and diagnostic test accuracy studies. Quality assessment for each of these study designs is illustrated with an example of published cognitive research. The practical applications of the tools are highlighted, with guidance on their strengths and limitations. We signpost educational resources and offer specific advice for use of these tools.We hope that all geriatricians become comfortable with critical appraisal of published research and that use of the tools described in this review - along with awareness of their strengths and limitations - become a part of teaching, journal clubs and practice.
Collapse
Affiliation(s)
- Jennifer Kirsty Harrison
- University of Edinburgh,Centre for Cognitive Ageing and Cognitive Epidemiology & The Alzheimer Scotland Dementia Research Centre
, Edinburgh, United Kingdom
| | - James Reid
- Queen Elizabeth University Hospital, Medicine for the Elderly
, Glasgow, United Kingdom
| | - Terry J Quinn
- University of Glasgow, Institute of Cardiovascular and Medical Sciences
, Glasgow, United Kingdom
| | - Susan Deborah Shenkin
- University of Edinburgh, Geriatric Medicine, Department of Clinical and Surgical Sciences
, Edinburgh, United Kingdom
- University of Edinburgh, Centre for Cognitive Ageing and Cognitive Epidemiology
, Edinburgh, United Kingdom
| |
Collapse
|
24
|
Levy I, Attias S, Ben-Arye E, Bloch B, Schiff E. Complementary medicine for treatment of agitation and delirium in older persons: a systematic review and narrative synthesis. Int J Geriatr Psychiatry 2017; 32:492-508. [PMID: 28239906 DOI: 10.1002/gps.4685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/24/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions. METHODS Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness. RESULTS Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported. CONCLUSION Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Ilana Levy
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel
| | - Samuel Attias
- Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Eran Ben-Arye
- Integrative Oncology Program, The Oncology Service, Lin Medical Center, Clalit Health Services, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Boaz Bloch
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Psychiatric Department, HaEmek Medical Center, Afula, Israel
| | - Elad Schiff
- Internal Medicine B Department, Bnai Zion Medical Center, Haifa, Israel.,Complementary Medicine Department, Bnai Zion Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
25
|
Richardson SJ, Davis DHJ, Stephan B, Robinson L, Brayne C, Barnes L, Parker S, Allan LM. Protocol for the Delirium and Cognitive Impact in Dementia (DECIDE) study: A nested prospective longitudinal cohort study. BMC Geriatr 2017; 17:98. [PMID: 28454532 PMCID: PMC5410072 DOI: 10.1186/s12877-017-0479-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/05/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Delirium is common, affecting at least 20% of older hospital inpatients. It is widely accepted that delirium is associated with dementia but the degree of causation within this relationship is unclear. Previous studies have been limited by incomplete ascertainment of baseline cognition or a lack of prospective delirium assessments. There is an urgent need for an improved understanding of the relationship between delirium and dementia given that delirium prevention may plausibly impact upon dementia prevention. A well-designed, observational study could also answer fundamental questions of major importance to patients and their families regarding outcomes after delirium. The Delirium and Cognitive Impact in Dementia (DECIDE) study aims to explore the association between delirium and cognitive function over time in older participants. In an existing population based cohort aged 65 years and older, the effect on cognition of an episode of delirium will be measured, independent of baseline cognition and illness severity. The predictive value of clinical parameters including delirium severity, baseline cognition and delirium subtype on cognitive outcomes following an episode of delirium will also be explored. METHODS Over a 12 month period, surviving participants from the Cognitive Function and Ageing Study II-Newcastle will be screened for delirium on admission to hospital. At the point of presentation, baseline characteristics along with a number of disease relevant clinical parameters will be recorded. The progression/resolution of delirium will be monitored. In those with and without delirium, cognitive decline and dementia will be assessed at one year follow-up. We will evaluate the effect of delirium on cognitive function over time along with the predictive value of clinical parameters. DISCUSSION This study will be the first to prospectively elucidate the size of the effect of delirium upon cognitive decline and incident dementia. The results will be used to inform future dementia prevention trials that focus on delirium intervention.
Collapse
Affiliation(s)
- Sarah J Richardson
- Institute of Neuroscience, 3rd floor Biomedical Research Building, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK.
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, 33 Bedford Place, London, WC1B 5JU, UK
| | - Blossom Stephan
- Institute for Ageing, 2nd floor Biomedical Research Building, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| | - Louise Robinson
- Institute for Ageing, 2nd floor Biomedical Research Building, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| | - Carol Brayne
- Institute of Public Health, Forvie Site, School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Linda Barnes
- Institute of Public Health, Forvie Site, School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Stuart Parker
- Institute of Neuroscience, 3rd floor Biomedical Research Building, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| | - Louise M Allan
- Institute of Neuroscience, 3rd floor Biomedical Research Building, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| |
Collapse
|
26
|
Davis DHJ, Muniz-Terrera G, Keage HAD, Stephan BCM, Fleming J, Ince PG, Matthews FE, Cunningham C, Ely EW, MacLullich AMJ, Brayne C. Association of Delirium With Cognitive Decline in Late Life: A Neuropathologic Study of 3 Population-Based Cohort Studies. JAMA Psychiatry 2017; 74:244-251. [PMID: 28114436 PMCID: PMC6037291 DOI: 10.1001/jamapsychiatry.2016.3423] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Delirium is associated with accelerated cognitive decline. The pathologic substrates of this association are not yet known, that is, whether they are the same as those associated with dementia, are independent, or are interrelated. OBJECTIVE To examine whether the accelerated cognitive decline observed after delirium is independent of the pathologic processes of classic dementia. DESIGN, SETTING, AND PARTICIPANTS Harmonized data from 987 individual brain donors from 3 observational cohort studies with population-based sampling (Vantaa 85+, Cambridge City Over-75s Cohort, Cognitive Function and Ageing Study) performed from January 1, 1985, through December 31, 2011, with a median follow-up of 5.2 years until death, were used in this study. Neuropathologic assessments were performed with investigators masked to clinical data. Data analysis was performed from January 1, 2012, through December 31, 2013. Clinical characteristics of brain donors were not different from the rest of the cohort. Outcome ascertainment was complete given that the participants were brain donors. EXPOSURES Delirium (never vs ever) and pathologic burden of neurofibrillary tangles, amyloid plaques, vascular lesions, and Lewy bodies. Effects modeled using random-effects linear regression and interactions between delirium and pathologic burden were assessed. OUTCOMES Change in Mini-Mental State Examination (MMSE) scores during the 6 years before death. RESULTS There were 987 participants (290 from Vantaa 85+, 241 from the Cambridge City Over-75s Cohort, and 456 from the Cognitive Function and Ageing Study) with neuropathologic data; mean (SD) age at death was 90 (6.4) years, including 682 women (69%). The mean MMSE score 6 years before death was 24.7 points. The 279 individuals with delirium (75% women) had worse initial scores (-2.8 points; 95% CI, -4.5 to -1.0; P < .001). Cognitive decline attributable to delirium was -0.37 MMSE points per year (95% CI, -0.60 to -0.13; P < .001). Decline attributable to the pathologic processes of dementia was -0.39 MMSE points per year (95% CI, -0.57 to -0.22; P < .001). However, the combination of delirium and the pathologic processes of dementia resulted in the greatest decline, in which the interaction contributed an additional -0.16 MMSE points per year (95% CI, -0.29 to -0.03; P = .01). The multiplicative nature of these variables resulted in individuals with delirium and the pathologic processes of dementia declining 0.72 MMSE points per year faster than age-, sex-, and educational level-matched controls. CONCLUSIONS AND RELEVANCE Delirium in the presence of the pathologic processes of dementia is associated with accelerated cognitive decline beyond that expected for delirium or the pathologic process itself. These findings suggest that additional unmeasured pathologic processes specifically relate to delirium. Age-related cognitive decline has many contributors, and these findings at the population level support a role for delirium acting independently and multiplicatively to the pathologic processes of classic dementia.
Collapse
Affiliation(s)
- Daniel H J Davis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England2Medical Research Council Unit for Lifelong Health and Ageing at University College London, London, England
| | | | - Hannah A D Keage
- School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | | | - Jane Fleming
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
| | - Paul G Ince
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, England
| | - Fiona E Matthews
- Institute of Health and Society, Newcastle University, Newcastle, England
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity College, Dublin, Ireland
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee9Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center, Nashville
| | | | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
| |
Collapse
|
27
|
Muraleedharan A, Palappallil DS, Gangadhar R, Das S. Valproate Induced Hyperammonemic Delirium. J Clin Diagn Res 2015; 9:FR01-3. [PMID: 26816916 DOI: 10.7860/jcdr/2015/15562.6883] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/16/2015] [Indexed: 01/09/2023]
Abstract
Sodium valproate induced hyperammonaemic delirium with normal liver function tests is a relatively uncommon adverse effect. It may be mistaken for psychosis or worsening of mania leading to wrong diagnosis and improper management. Plasma ammonia levels should be monitored in all patients developing altered mental status after receiving valproate therapy. This is a case series of hyperammonaemic delirium due to valproate reported to the Department of Pharmacology from Department of Psychiatry over a period of one year.
Collapse
Affiliation(s)
- Anupama Muraleedharan
- Junior Resident, Department of Pharmacology, Government TDMC , Alappuzha, Kerala, India
| | | | - Reneega Gangadhar
- Professor, Department of Pharmacology, Sree Mookambika Institute of Medical Science , Kulasekharam, Tamil Nadu, India
| | - Soumitra Das
- Junior Resident, Department of Psychiatry, Government TDMC , Alappuzha, Kerala, India
| |
Collapse
|
28
|
Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14:823-832. [PMID: 26139023 DOI: 10.1016/s1474-4422(15)00101-5] [Citation(s) in RCA: 338] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 02/02/2023]
Abstract
Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.
Collapse
Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Matthew E Growdon
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| |
Collapse
|