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Shimura A, Seki T, Nishiguchi T, Yamanishi K, Ishii T, Aoyama B, Nguyen HD, Gorantla N, Inoue T, Shinozaki G. A web-based delirium detection application using bispectral electroencephalography (BSEEG). Gen Hosp Psychiatry 2024:S0163-8343(24)00159-2. [PMID: 39060191 DOI: 10.1016/j.genhosppsych.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024]
Affiliation(s)
- Akiyoshi Shimura
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; Department of Psychiatry, Tokyo Medical University, Japan
| | - Tomoteru Seki
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; Department of Psychiatry, Tokyo Medical University, Japan
| | - Tsuyoshi Nishiguchi
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; Department of Neuropsychiatry, Tottori University, Japan
| | - Kyosuke Yamanishi
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; Department of Neuropsychiatry, Hyogo Medical University, Japan
| | - Takaya Ishii
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; iPS Cell-Based Drug Discovery Group, Regenerative & Cellular Medicine Kobe Center, Sumitomo Pharma Co., Ltd., Japan
| | - Bun Aoyama
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America; Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Japan
| | - Hieu Dinh Nguyen
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America
| | - Nipun Gorantla
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Japan
| | - Gen Shinozaki
- Department of Psychiatry and Behavioral Sciences, Stanford University, United States of America.
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Lindroth H, Byrnes T, Fuchita M, Hetland B, Liu K, Maya K, McAndrew NS, Mulkey MA, Nydahl P, Palakshappa J, von Haken R, Psoter KJ, Oh ES. Delirium in the United States: Results From the 2023 Cross-Sectional World Delirium Awareness Day Prevalence Study. J Acad Consult Liaison Psychiatry 2024:S2667-2960(24)00067-3. [PMID: 38944277 DOI: 10.1016/j.jaclp.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/12/2024] [Accepted: 06/23/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia. OBJECTIVES To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day 2023. METHODS This is a sub-analysis of a prospective, cross-sectional, online, international survey. All health care settings were eligible, with the exception of operating rooms and outpatient clinics. Health care clinicians, administrators, and researchers completed the survey. The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to health care delivery. Descriptive statistics are reported. Differences between unit types (non-intensive care unit vs intensive care unit) were examined for all outcomes. RESULTS Ninety-one hospital units reported on 1318/1213 patients. The prevalence of clinically documented delirium was 16.4% (n = 216/1318) at 8:00 a.m. and 17.9% (n = 217/1213) at 8:00 p.m. (P = 0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-intensive care unit and intensive care unit settings in the use of delirium-related protocols, nonpharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care. CONCLUSIONS To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the United States. Delirium remains a significant burden and challenge for health care systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.
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Affiliation(s)
- Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN; Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, Indianapolis, IN; Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN.
| | - Tru Byrnes
- Department of Nursing, Atrium Health-Carolinas Medical Center, Charlotte, NC
| | - Mikita Fuchita
- Division of Critical Care, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Breanna Hetland
- College of Nursing, University of Nebraska Medical Center & Critical Care Division, Nebraska Medicine Omaha, NE
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Institute for Molecular Bioscience (IMB), The University of Queensland, Brisbane, Queensland, Australia; Non-Profit Organization ICU Collaboration Network (ICON), Tokyo, Japan
| | - Kerri Maya
- Department of Continuing Professional Development, Sutter Health System, Sacramento, CA
| | - Natalie S McAndrew
- University of Wisconsin-Milwaukee, School of Nursing, College of Health Professions & Sciences, Milwaukee, WI; Froedtert & the Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI
| | - Malissa A Mulkey
- Department of Biobehavioral and Nursing Science, College of Nursing, University of South Carolina, Columbia, SC
| | - Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Kiel Germany; Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Jessica Palakshappa
- Department of Internal Medicine, Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Kevin J Psoter
- Division of General Pediatrics, Department of Pediatrics, the Johns Hopkins University School of Medicine, Baltimore, MD
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Departments of Medicine, Psychiatry and Behavioral Sciences and Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD; The Johns Hopkins University School of Nursing, Baltimore, MD
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Abdelbaky AM, Eldelpshany MS. Patient Outcomes and Management Strategies for Intensive Care Unit (ICU)-Associated Delirium: A Literature Review. Cureus 2024; 16:e61527. [PMID: 38957260 PMCID: PMC11218465 DOI: 10.7759/cureus.61527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
Delirium is a significant public health concern, with tremendous implications for patient outcomes. Intensive care unit (ICU)-related delirium is gaining attention due to the higher prevalence of delirium in ICU-admitted patients. The most common negative outcomes of ICU delirium include cognitive impairments, functional dependence, high incidence of mortality, extended stay in the ICU, and high costs. So far, no single etiological factor has been identified as the sole cause of delirium. Several functional, neurotransmitter, or injury-causing hypotheses have been proposed for ICU delirium. Several risk factors contribute to the development of delirium in patients admitted to the ICU. These are age, gender, types of sedation, physical restraints, medical and surgical interventions, pain, and extended stay in the ICU. The most commonly used assessment modules for ICU delirium are the PREdiction of DELIRium in ICu patients (PRE-DELIRIC), Early PREdiction model for DELIRium in ICu patients (E-PRE-DELERIC), and Lanzhou Model, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), and Delirium Rating Scale (DRS). There is no proper treatment for ICU delirium; however, it can be managed through various pharmacological and non-pharmacological interventions. Healthcare providers should receive constant education and training on delirium recognition, prevention, and management to enhance patient care and outcomes in the ICU. Further research is needed on the effective prevention and management of ICU delirium.
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Ho VWT, Ling NMW, Anbarasan D, Chan YH, Merchant RA. Proof-of-concept for an automatable mortality prediction scoring in hospitalised older adults. Front Med (Lausanne) 2024; 11:1329107. [PMID: 38846139 PMCID: PMC11153690 DOI: 10.3389/fmed.2024.1329107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/24/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction It is challenging to prognosticate hospitalised older adults. Delayed recognition of end-of-life leads to failure in delivering appropriate palliative care and increases healthcare utilisation. Most mortality prediction tools specific for older adults require additional manual input, resulting in poor uptake. By leveraging on electronic health records, we aim to create an automatable mortality prediction tool for hospitalised older adults. Methods We retrospectively reviewed electronic records of general medicine patients ≥75 years at a tertiary hospital between April-September 2021. Demographics, comorbidities, ICD-codes, age-adjusted Charlson Comorbidity Index (CCI), Hospital Frailty Risk Score, mortality and resource utilization were collected. We defined early deaths, late deaths and survivors as patients who died within 30 days, 1 year, and lived beyond 1 year of admission, respectively. Multivariate logistic regression analyses were adjusted for age, gender, race, frailty, and CCI. The final prediction model was created using a stepwise logistic regression. Results Of 1,224 patients, 168 (13.7%) died early and 370 (30.2%) died late. From adjusted multivariate regression, risk of early death was significantly associated with ≥85 years, intermediate or high frail risk, CCI > 6, cardiovascular risk factors, AMI and pneumonia. For late death, risk factors included ≥85 years, intermediate frail risk, CCI >6, delirium, diabetes, AMI and pneumonia. Our mortality prediction tool which scores 1 point each for age, pneumonia and AMI had an AUC of 0.752 for early death and 0.691 for late death. Conclusion Our mortality prediction model is a proof-of-concept demonstrating the potential for automated medical alerts to guide physicians towards personalised care for hospitalised older adults.
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Affiliation(s)
- Vanda W. T. Ho
- Division of Geriatric Medicine, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Natalie M. W. Ling
- Division of Geriatric Medicine, Department of Medicine, National University Health System, Singapore, Singapore
| | - Denishkrshna Anbarasan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Reshma Aziz Merchant
- Division of Geriatric Medicine, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Soler-Sanchis A, Martínez-Arnau FM, Sánchez-Frutos J, Pérez-Ros P. The 4AT scale for rapid detection of delirium in emergency department triage. Front Med (Lausanne) 2024; 11:1345983. [PMID: 38808143 PMCID: PMC11130506 DOI: 10.3389/fmed.2024.1345983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the diagnostic accuracy and time impact of the 4AT scale in emergency department triage. Methods A Prospective diagnostic accuracy study was carried out. People aged ≥65 years presenting to the emergency department from 1 November 2021 to 30 June 2022 were included. Nurses opportunistically screened eligible patients using the 4AT scale during triage according to the Manchester Triage System Francesc de Borja Hospital emergency department, Gandía (Spain). Accuracy was compared with medical diagnosis of delirium. Time (seconds) spent in triage with and without screening was assessed. Results The study included 370 patients (55.1% men, mean age 81.8 years), of whom 58.4% (n = 216) were screened. A final diagnosis of delirium was made in 41.4% of those screened. The most frequently used presentational flow charts and discriminators were 'behaving strangely' (15%) and 'rapid onset' (33.3%). The highest accuracy was obtained for a score of 3 points or more (sensitivity 85.1%; specificity 66.9%; positive predictive value 52.8%; negative predictive value 71.7%). No significant differences were found in the time spent in triage according to the performance of screening. Conclusion A score of 3 points or more on the 4AT scale enables rapid detection of delirium in emergency department triage, without consuming more time than conventional triage.
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Affiliation(s)
- Angela Soler-Sanchis
- Department of Nursing, Universitat de València, Valencia, Spain
- Hospital Francesc de Borja, Generalitat Valenciana, Gandia, Valencia, Spain
| | - Francisco Miguel Martínez-Arnau
- Department of Nursing, Universitat de València, Valencia, Spain
- Department of Physiotherapy, Universitat de València, Valencia, Spain
| | | | - Pilar Pérez-Ros
- Department of Nursing, Universitat de València, Valencia, Spain
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Bu F, Cheng HT, Wang ZL, Hou YS, Zhuang Z, Li CY, Wang YQ, Zhang Y, Lyu J, Lyu QY. Effect of a fall within three months of admission on delirium in critically Ill elderly patients: a population-based cohort study. Aging Clin Exp Res 2024; 36:111. [PMID: 38743351 PMCID: PMC11093843 DOI: 10.1007/s40520-024-02740-8] [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: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Delirium is common among elderly patients in the intensive care unit (ICU) and is associated with prolonged hospitalization, increased healthcare costs, and increased risk of death. Understanding the potential risk factors and early prevention of delirium is critical to facilitate timely intervention that may reverse or mitigate the harmful consequences of delirium. AIM To clarify the effects of pre-admission falls on ICU outcomes, primarily delirium, and secondarily pressure injuries and urinary tract infections. METHODS The study relied on data sourced from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Statistical tests (Wilcoxon rank-sum or chi-squared) compared cohort characteristics. Logistic regression was employed to investigate the association between a history of falls and delirium, as well as secondary outcomes, while Kaplan-Meier survival curves were used to assess short-term survival in delirium and non-delirium patients. RESULTS Study encompassed 22,547 participants. Delirium incidence was 40%, significantly higher in patients with a history of falls (54.4% vs. 34.5%, p < 0.001). Logistic regression, controlling for confounders, not only confirmed that a history of falls elevates the odds of delirium (OR: 2.11; 95% CI: 1.97-2.26; p < 0.001) but also showed it increases the incidence of urinary tract infections (OR:1.50; 95% CI:1.40-1.62; p < 0.001) and pressure injuries (OR:1.36; 95% CI:1.26-1.47; p < 0.001). Elderly delirium patients exhibited lower 30-, 180-, and 360-day survival rates than non-delirium counterparts (all p < 0.001). CONCLUSIONS The study reveals that history of falls significantly heighten the risk of delirium and other adverse outcomes in elderly ICU patients, leading to decreased short-term survival rates. This emphasizes the critical need for early interventions and could inform future strategies to manage and prevent these conditions in ICU settings.
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Affiliation(s)
- Fan Bu
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Hong-Tao Cheng
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Zi-Lin Wang
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Yu-Shan Hou
- Department of Geriatric Psychology, Shandong Daizhuang Hospital, Jining, China
| | - Zhuang Zhuang
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Can-Yang Li
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Ya-Qi Wang
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Yue Zhang
- School of Nursing, Jinan University, Room 1015, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China.
| | - Qi-Yuan Lyu
- School of Nursing, Jinan University, Room 1015, Guangzhou, China.
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Oldham MA, Heinrich T, Luccarelli J. Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System. J Acad Consult Liaison Psychiatry 2024; 65:302-312. [PMID: 38503671 PMCID: PMC11179982 DOI: 10.1016/j.jaclp.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/21/2024]
Abstract
Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
| | - Thomas Heinrich
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI; Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Hamadah K, Velagapudi M, Navarro JJ, Pirotte A, Obersteadt C. Best Practices for Treating Blind and Visually Impaired Patients in the Emergency Department: A Scoping Review. West J Emerg Med 2024; 25:350-357. [PMID: 38801041 PMCID: PMC11112656 DOI: 10.5811/westjem.61686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/21/2023] [Accepted: 01/19/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Blind and visually impaired individuals, an under-represented population of the emergency department (ED), possess comorbidities and have a higher chance of in-hospital sequelae, including falls. This potentially vulnerable population, if not treated mindfully, can be subject to decreased quality of care, recurrent and/or longer hospitalizations, persistence of health issues, increased incidence of falls, and higher healthcare costs. For these reasons, it is crucial to implement holistic practices and train clinicians to treat blind and visually impaired patients in the ED setting. Methods We identified and used a comprehensive article describing best practices for the care of blind and visually impaired patients to establish the ED-specific recommendations presented in this paper. A scoping review of the literature was then performed using PubMed to identify additional articles to support each recommendation. To ensure that recommendations could be implemented in a representative, scalable, and sustainable manner, we consulted an advocate for the blind to help refine and provide additional suggestions. Results We identified 14 recommendations that focus on communication strategies, ED resource access, and continuity of care. The main recommendation is for the clinician to support the unique healthcare needs of the visually impaired individual and maintain the patient's autonomy. Another recommendation is the consistent use of assistive devices (eg, canes, guide dogs) to aid patients to safely ambulate in the ED. Also identified as best practices were discharge education with the use of a screen reader and timely follow-up with a primary care physician. Conclusion While we summarize a variety of recommendations in this article, it is important to implement only the strategies that work best for the patients, personnel, and environment specific to your ED. After implementation, it is vital to refine (as frequently as needed) the interventions to optimize the strategies. This will enable the provision of exceptional and equal care to blind and visually impaired patients in the ED.
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Affiliation(s)
- Kareem Hamadah
- University of Kansas School of Medicine, Kansas City, Kansas
- University of Kansas Medical Center, Kansas City, Kansas
| | - Mary Velagapudi
- University of Kansas Health System, Kansas City, Kansas
- University of Kansas Medical Center, Kansas City, Kansas
| | - Juliana J. Navarro
- University of Kansas Health System, Kansas City, Kansas
- University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew Pirotte
- University of Kansas Health System, Kansas City, Kansas
- University of Kansas Medical Center, Kansas City, Kansas
- University of Kansas Medical Center, Department of Emergency Medicine, Kansas City, Kansas
- University of Kansas Medical Center, Office of Student Affairs, Kansas City, Kansas
| | - Chris Obersteadt
- University of Kansas Health System, Kansas City, Kansas
- University of Kansas Medical Center, Kansas City, Kansas
- Rockhurst University, Kansas City, Kansas
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Peterson R, Bruti C, Doraiswamy V, Hall AM. Improving the adult hospital experience: Reducing trauma with pediatric pearls. J Hosp Med 2024; 19:421-423. [PMID: 37661588 DOI: 10.1002/jhm.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Rachel Peterson
- Departments of Internal Medicine and Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher Bruti
- Departments of Internal Medicine and Pediatrics, Rush Medical College, Chicago, Illinois, USA
| | - Vignesh Doraiswamy
- Department of Internal Medicine and Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Alan M Hall
- Departments of Internal Medicine and Pediatrics, University of Kentucky College of Medicine in Lexington, Lexington, Kentucky, USA
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van der Hoeven AE, Bijlenga D, van der Hoeven E, Schinkelshoek MS, Hiemstra FW, Kervezee L, van Westerloo DJ, Fronczek R, Lammers GJ. Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality. Intensive Crit Care Nurs 2024; 81:103603. [PMID: 38171236 DOI: 10.1016/j.iccn.2023.103603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/25/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024]
Abstract
AIM OF THE STUDY The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated. MATERIALS AND METHODS This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression. RESULTS Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070). CONCLUSIONS Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset. IMPLICATIONS FOR CLINICAL PRACTICE Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.
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Affiliation(s)
- Adrienne E van der Hoeven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Ernst van der Hoeven
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Mink S Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Floor W Hiemstra
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands; Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laura Kervezee
- Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands.
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Lauffer-Vogt SU, Hediger H, Lauener SK, Schubert M. [The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital]. Pflege 2024; 37:89-97. [PMID: 37997948 DOI: 10.1024/1012-5302/a000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital Abstract: Background: With a prevalence of 12-64%, delirium is a common complication in acute care, associated with negative outcomes such as increased mortality and prolonged length of stay. Many hospitals have guidelines to improve the delirium management. The Delirium Observation Screening Scale (DOS) Score is collected in the study hospital from all patients ≥ 70 years at each shift for at least 3 days. Delirium is diagnosed by a physician and coded according to ICD-10. Purpose: Evaluation of the delirium screening with the DOS according to internal guideline in terms of number of DOS assessments performed, prevalence of delirium (DOS score ≥ 3 points, CD-10 code delirium). Method: This retrospective quantitative single-centre longitudinal study used 2017 and 2018 data of 10046 cases. Statistical analysis methods were used to analyse prevalence of delirium and subgroup comparisons. Results: At least one DOS score was documented in 92% of cases aged ≥ 70-years (n = 5038). DOS implementation varied between 60% in the early, 49% in the late and 38% in the night shift. The prevalence of delirium was 12% according to DOS score ≥ 3 and 4% according to physician diagnosis of a delirium. Cases with a DOS score ≥ 3 were significantly older, more often female, had more comorbidities and were depressed. Conclusions: DOS is performed in most patients when indicated. The DOS implementation frequency varied depending on the shift.
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Affiliation(s)
- Stefan Urs Lauffer-Vogt
- Klinik für Plastische Chirurgie und Handchirurgie, Klinik für Traumatologie, Universitätsspital Zürich, Schweiz
| | - Hannele Hediger
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| | - Susanne Knüppel Lauener
- Abteilung für Praxisentwicklung und Forschung Pflege/MTT, Medizinische Direktion, Universitätsspital Basel, Schweiz
| | - Maria Schubert
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
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Ajmera Y, Paul K, Khan MA, Kumari B, Kumar N, Chatterjee P, Dey AB, Chakrawarty A. The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'. Asian J Psychiatr 2024; 94:103990. [PMID: 38447233 DOI: 10.1016/j.ajp.2024.103990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes. AIM To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults. METHODS A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge. RESULTS The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up. CONCLUSION Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.
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Affiliation(s)
- Yamini Ajmera
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Karandeep Paul
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Bharti Kumari
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nand Kumar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Prasun Chatterjee
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Aparajit Ballav Dey
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avinash Chakrawarty
- Department of Geriatric Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Morales-Puerto M, Ruiz-Díaz M, García-Mayor S, León-Campos Á, Morales-Asencio JM, Canca-Sánchez JC, Gavira-Guerra S, Toledo-Fernandez C, Aranda-Gallardo M. Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study. BMC Nurs 2024; 23:101. [PMID: 38321514 PMCID: PMC10845719 DOI: 10.1186/s12912-023-01638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 12/05/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED. METHODS A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument. RESULTS Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97. CONCLUSIONS The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.
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Affiliation(s)
- Marta Morales-Puerto
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - María Ruiz-Díaz
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Silvia García-Mayor
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Álvaro León-Campos
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain.
| | - José Miguel Morales-Asencio
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - José Carlos Canca-Sánchez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Sonia Gavira-Guerra
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Cecilia Toledo-Fernandez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Marta Aranda-Gallardo
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Instituto de Salud Carlos III, Bizkaia, Spain
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Doğan RB, Yavuz BG, Satilmis D, Afacan MA, Colak S. CRP/albumin, Glasgow prognostic score, and prognostic nutritional index as a predictor of mortality among delirium patients. Ir J Med Sci 2024; 193:469-476. [PMID: 37407872 DOI: 10.1007/s11845-023-03443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND With the older populations growing each year, high mortality rates make delirium a valuable topic. AIM We aimed to analyze the parameters that could predict 30 days of mortality of the patients diagnosed in the emergency department (ED) with delirium. METHODS This retrospective study included 85 patients with a diagnosis of delirium. Glasgow prognostic score (GPS), prognostic nutritional index (PNI), and C-reactive protein (CRP)/albumin values of the patients and 30-day mortality rate were computed. The effectiveness of GPS, PNI, and CRP/albumin parameters in predicting 30-day mortality was analyzed. RESULTS The findings showed that the optimal cut-off value for albumin as determined by Youden's index in estimation of 30-day mortality was ≤ 36.8 [AUC: 0.830 (95% CI: 0.733-0.903; p < 0.001), with a sensitivity of 85.71% and specificity of 76.36%], while cut-off value for CRP/albumin was > 0.974 [AUC: 0.753 (95% CI: 0.647-0.840; p < 0.001); with a sensitivity of 85.71% and specificity of 70.51%], and cut-off value for PNI was ≤ 39.05 [AUC: 0.850 (95% CI: 0.756-0.918; p < 0.001) sensitivity 71.43% and specificity 92.31%]. Significant effectiveness of the values of GPS (odds ratio (OR) = 6.69; 95% confidence interval (CI): 1.69-26.37), PNI (OR = 0.83; 95% CI: 0.74-0.95), albumin (OR = 0.82; 95% CI: 0.71-0.94), and CAD (OR = 10.5; 95% CI: 1.85-59.45) was observed for predicting mortality in univariate regression analysis. CONCLUSIONS The findings obtained in this study suggest that GPS, PNI, and albumin parameters could be used to guide the clinician in predicting the 30-day mortality of patients diagnosed with delirium.
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Affiliation(s)
- Rümeysa Büşra Doğan
- Department of Neuroscience, Institute of Medical Science, Istanbul Medipol University, Istanbul, Turkey
- Department of Emergency Medicine, Çorlu State Hospital, Tekirdağ, Turkey
| | - Burcu Genc Yavuz
- Department of Emergency Medicine, University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.
| | - Dilay Satilmis
- Department of Emergency Medicine, University of Health Sciences, Sultan 2, Abdulhamit Han Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ahmet Afacan
- Department of Emergency Medicine, University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Sahin Colak
- Department of Emergency Medicine, University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
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Titlestad I, Haugarvoll K, Solvang SEH, Norekvål TM, Skogseth RE, Andreassen OA, Årsland D, Neerland BE, Nordrehaug JE, Tell GS, Giil LM. Delirium is frequently underdiagnosed among older hospitalised patients despite available information in hospital medical records. Age Ageing 2024; 53:afae006. [PMID: 38342753 PMCID: PMC10859244 DOI: 10.1093/ageing/afae006] [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: 04/28/2023] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND In-hospital delirium is associated with adverse outcomes and is underdiagnosed, limiting research and clinical follow-up. OBJECTIVE To compare the incidence of in-hospital delirium determined by chart-based review of electronic medical records (D-CBR) with delirium discharge diagnoses (D-DD). Furthermore, to identify differences in symptoms, treatments and delirium triggers between D-CBR and D-DD. METHOD The community-based cohort included 2,115 participants in the Hordaland Health Study born between 1925 and 1927. Between 2018 and 2022, we retrospectively reviewed hospital electronic medical records from baseline (1997-99) until death prior to 2023. D-DD and D-CBR were validated using The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for delirium. RESULTS Of the 2,115 participants, 638 had in-hospital delirium. The incidence rate (IR) of D-CBR was 29.8 [95% confidence interval 28, 32] per 1,000 person-years, whereas the IR by D-DD was 3.4 [2.8, 4.2]. The IR ratio was 9.14 (P < 0.001). Patients who received pharmacological treatment for delirium (n = 121, odds ratio (OR) 3.4, [2.1, 5.4], P < 0.001), who were affected by acute memory impairment (n = 149, OR 2.8, [1.8, 4.5], P < 0.001), or change in perception (n = 137, OR 2.9, [1.8, 4.6] P < 0.001) had higher odds for D-DD. In contrast, post-operative cases (OR 0.2, [0.1, 0.4], P < 0.001) had lower odds for D-DD. CONCLUSION Underdiagnosis of in-hospital delirium was a major issue in our study, especially in less severe delirium cases. Our findings emphasise the need for integrating systematic delirium diagnostics and documentation into hospital admission and discharge routines.
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Affiliation(s)
- Irit Titlestad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Kristoffer Haugarvoll
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stein-Erik H Solvang
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Tone Merete Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ragnhild E Skogseth
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ole A Andreassen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dag Årsland
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Grethe S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lasse M Giil
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Geetha J, Babu H, George C. Determinants of delirium in elderly in-patients in a general ward setting in a teaching hospital: A case control study. Ind Psychiatry J 2024; 33:41-47. [PMID: 38853788 PMCID: PMC11155642 DOI: 10.4103/ipj.ipj_16_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/15/2023] [Indexed: 06/11/2024] Open
Abstract
Background There is a dearth of research on risk factors of delirium among elderly inpatients in nonintensive low resource settings. Aim To determine the risk factors of delirium in elderly inpatients in a nonintensive care unit setting. Materials and Methods Sixty two elderly patients with delirium (cases) and 62 patients without delirium (controls) were administered a semi-structured proforma with socio-demographic variables and putative predisposing and precipitating risk factors and the Vellore screening instrument for dementia. Results On univariate analysis, factors such as past cognitive impairment, history of nocturnal confusion and delirium, diminished daily living activities, severe medical illness, history of psychiatric illness, presence of dementia, infection, fever above 1000F, abnormal electrolytes abnormal RFT, leukocytes in urine, hypoxia, anticholinergics and benzodiazepines, emergency admission, use of physical restraints, bladder catheterization, more than routine investigations, intensive care unit admission, surgery, and duration of hospital stay more than 10 days were found to be significantly associated with delirium. On multivariate analysis with binary logistic regression, bladder catheterization (odds ratio [OR] = 13.85; confidence interval [CI] = 1.44-133.14), abnormal electrolytes (OR = 5.12; CI = 1.11-23.69), and hypoxia (OR = 75.52; CI = 4.64-1.134E3) were detected to be independently associated with delirium. Conclusion Acute modifiable rather than long-term factors were risk factors for delirium among the elderly. An awareness of modifiable risk factors has the potential of developing targeted interventions for the early mitigation of delirium.
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Affiliation(s)
- Jitha Geetha
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
| | - Haritha Babu
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
| | - Christina George
- Department of Psychiatry, DR SMCSI Medical College, Karakonam, Trivandrum, Kerala, India
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Dayton K, Hudson M, Lindroth H. Stopping Delirium Using the Awake-and-Walking Intensive Care Unit Approach: True Mastery of Critical Thinking and the ABCDEF Bundle. AACN Adv Crit Care 2023; 34:359-366. [PMID: 38033207 PMCID: PMC11019856 DOI: 10.4037/aacnacc2023159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Kali Dayton
- Kali Dayton is ICU Sedation and Mobility Consultant, Dayton ICU Consulting, Washington
| | - Mark Hudson
- Mark Hudson is an ICU survivor and patient advocate for improved ICU care; podcaster of the ICU Life and Recovery podcast; and a student at the School of Psychology and Counselling, The Open University, Milton Keynes, United Kingdom
| | - Heidi Lindroth
- Heidi Lindroth is a clinician-nurse scientist, Department of Nursing, Mayo Clinic, 200 1st St SW, Mayo Clinic, Rochester, MN, 55902 ; and an affiliate scientist, Center for Innovation and Implementation Science and the Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, Indianapolis, Indiana
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Aggar C, Craswell A, Bail K, Compton R, Hughes M, Sorwar G, Baker J, Shinners L, Greenhill J. Partnering with carers in the management of delirium in general acute care settings: An integrative review. Australas J Ageing 2023; 42:638-648. [PMID: 37528556 DOI: 10.1111/ajag.13229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/31/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES Delirium is a common, preventable condition. However, delirium is poorly recognised and often missed because symptoms are misinterpreted, and risk factors overlooked by health-care professionals. Carers usually have intimate knowledge about the person they care for. Therefore, they are well placed within care teams to implement delirium prevention strategies, identify symptoms and support the early diagnosis of delirium. The aim of this integrative review was to synthesise findings from the published research reporting on partnering with carers in the management of delirium in general acute care settings. METHODS Five databases (Medline-EBSCO, PubMed, PsycINFO, ProQuest, CINAHL and SCOPUS) were searched to identify primary research regarding partnering with carers in the management of delirium in acute care settings, and results were synthesised. PRISMA guidelines were adhered to, and quality appraisal was conducted using the Mixed Methods Appraisal Tool. RESULTS All seven studies reported that partnering with carers was a viable strategy in the management of delirium to maximise outcomes for people at risk of or experiencing delirium and that increasing carers' knowledge of delirium was key. The synthesis of findings also identified two themes: Increasing knowledge and Effective partnerships. CONCLUSIONS A collaborative approach to increasing carers' and nurses' knowledge about the management of delirium, coupled with education on how to develop therapeutic nurse-carer relationships, is important for ongoing effective partnerships in the management of delirium. Good communication supported effective partnerships, which enabled both nurses and carers the opportunity to express their needs and concerns and negotiate collaborative involvement in the management of delirium.
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Affiliation(s)
- Christina Aggar
- Faculty of Health, Gold Coast Campus, Southern Cross University, Bilinga, Queensland, Australia
| | - Alison Craswell
- Caboolture Campus, University of Sunshine Coast, Caboolture, Queensland, Australia
| | - Kasia Bail
- University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Roslyn Compton
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mark Hughes
- Faculty of Health, Gold Coast Campus, Southern Cross University, Bilinga, Queensland, Australia
| | - Golam Sorwar
- Faculty of Health, Gold Coast Campus, Southern Cross University, Bilinga, Queensland, Australia
| | - James Baker
- Lismore Campus, Southern Cross University, Lismore, New South Wales, Australia
| | - Lucy Shinners
- Faculty of Health, Gold Coast Campus, Southern Cross University, Bilinga, Queensland, Australia
| | - Jennene Greenhill
- Faculty of Health, Gold Coast Campus, Southern Cross University, Bilinga, Queensland, Australia
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Alaterre C, Fazilleau C, Cayot-Constantin S, Chanques G, Kacer S, Constantin JM, James A. Monitoring delirium in the intensive care unit: Diagnostic accuracy of the CAM-ICU tool when performed by certified nursing assistants - A prospective multicenter study. Intensive Crit Care Nurs 2023; 79:103487. [PMID: 37451087 DOI: 10.1016/j.iccn.2023.103487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/05/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Monitoring delirium in critically ill patients is recognized as a major challenge. Although involving certified nursing assistants could be a valuable help in this field, such strategy has never been formally investigated. OBJECTIVES Following theoretical training, we conducted a prospective multicenter study assessing the diagnostic accuracy of a CAM-ICU delirium screening strategy performed by CNAs in clinical settings, compared to parallel blinded evaluations conducted by nurses and physicians. METHODS From October 2020 to June 2022, adult intensive care patients admitted in three French University teaching hospitals with Richmond Agitation Sedation Scale ≥-2 were independently assessed for delirium by the three members of the care team (clinical nursing assistant, nurse and physician) using CAM-ICU in a random order. Physician's assessment served as the reference standard for comparisons. RESULTS We analyzed results from 268 triplets of CAM-ICU assessments performed sequentially on 203 patients. Prevalence of delirium was 22%. Compared to physician's assessments, clinical nursing assistants demonstrated a sensitivity (Se) of 88% CI95% [80-96] and a specificity (Sp) of 95% [92-98] in detecting delirium. There was no significant difference in the performance of clinical nursing assistants and nurses (Se = 90 % [82-97] p = 0.77, Sp = 98 % [95-100] p = 0.19). We observed high agreement between results obtained by physicians and clinical nursing assistants (ĸ = 0.82) and clinical nursing assistants performance remained consistent in the subgroups at higher risk of delirium. CONCLUSION Evaluation of the CAM-ICU by clinical nursing assistants is feasible and should be seen as an opportunity to increase routine monitoring of delirium in intensive care patients. IMPLICATION FOR CLINICAL PRACTICE Delirium is a severe and underestimated complication of intensive care unit stay. This study results demonstrate the great performance of trained clinical nursing assistants in detecting delirium using the CAM-ICU. Further research is needed to define the most effective role for clinical nursing assistants in the routine management of delirium in intensive care patients.
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Affiliation(s)
- Camille Alaterre
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital Pitié-Salpetrière, Department of Anesthesiology, Critical Care and Perioperative Medicine, Paris, France.
| | - Claire Fazilleau
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital Pitié-Salpetrière, Department of Anesthesiology, Critical Care and Perioperative Medicine, Paris, France
| | - Sophie Cayot-Constantin
- Department of Perioperative Medicine, Adult Intensive Care Unit, University Hospital of Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Gerald Chanques
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Samia Kacer
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital Pitié-Salpetrière, Department of Anesthesiology, Critical Care and Perioperative Medicine, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital Pitié-Salpetrière, Department of Anesthesiology, Critical Care and Perioperative Medicine, Paris, France
| | - Arthur James
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital Pitié-Salpetrière, Department of Anesthesiology, Critical Care and Perioperative Medicine, Paris, France
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Snigurska UA, Ser SE, Solberg LM, Prosperi M, Magoc T, Chen Z, Bian J, Bjarnadottir RI, Lucero RJ. Application of a practice-based approach in variable selection for a prediction model development study of hospital-induced delirium. BMC Med Inform Decis Mak 2023; 23:181. [PMID: 37704994 PMCID: PMC10500854 DOI: 10.1186/s12911-023-02278-1] [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: 05/08/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Prognostic models of hospital-induced delirium, that include potential predisposing and precipitating factors, may be used to identify vulnerable patients and inform the implementation of tailored preventive interventions. It is recommended that, in prediction model development studies, candidate predictors are selected on the basis of existing knowledge, including knowledge from clinical practice. The purpose of this article is to describe the process of identifying and operationalizing candidate predictors of hospital-induced delirium for application in a prediction model development study using a practice-based approach. METHODS This study is part of a larger, retrospective cohort study that is developing prognostic models of hospital-induced delirium for medical-surgical older adult patients using structured data from administrative and electronic health records. First, we conducted a review of the literature to identify clinical concepts that had been used as candidate predictors in prognostic model development-and-validation studies of hospital-induced delirium. Then, we consulted a multidisciplinary task force of nine members who independently judged whether each clinical concept was associated with hospital-induced delirium. Finally, we mapped the clinical concepts to the administrative and electronic health records and operationalized our candidate predictors. RESULTS In the review of 34 studies, we identified 504 unique clinical concepts. Two-thirds of the clinical concepts (337/504) were used as candidate predictors only once. The most common clinical concepts included age (31/34), sex (29/34), and alcohol use (22/34). 96% of the clinical concepts (484/504) were judged to be associated with the development of hospital-induced delirium by at least two members of the task force. All of the task force members agreed that 47 or 9% of the 504 clinical concepts were associated with hospital-induced delirium. CONCLUSIONS Heterogeneity among candidate predictors of hospital-induced delirium in the literature suggests a still evolving list of factors that contribute to the development of this complex phenomenon. We demonstrated a practice-based approach to variable selection for our model development study of hospital-induced delirium. Expert judgement of variables enabled us to categorize the variables based on the amount of agreement among the experts and plan for the development of different models, including an expert-model and data-driven model.
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Affiliation(s)
- Urszula A Snigurska
- College of Nursing, Department of Family, Community, and Health Systems Science, University of Florida, 1225 Center Drive, PO Box 100197, Gainesville, FL, 32610, United States of America.
| | - Sarah E Ser
- College of Public Health and Health Professions & College of Medicine, Department of Epidemiology, University of Florida, 2004 Mowry Rd, Gainesville, FL, 32610, United States of America
| | - Laurence M Solberg
- College of Nursing, Department of Family, Community, and Health Systems Science, University of Florida, 1225 Center Drive, PO Box 100197, Gainesville, FL, 32610, United States of America
- Geriatrics Research, Education, and Clinical Center (GRECC), North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville, FL, 32608, United States of America
- College of Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL, 32827, United States of America
| | - Mattia Prosperi
- College of Public Health and Health Professions & College of Medicine, Department of Epidemiology, University of Florida, 2004 Mowry Rd, Gainesville, FL, 32610, United States of America
| | - Tanja Magoc
- Clinical and Translational Science Institute (CTSI), Integrated Data Repository Research Services, University of Florida, 3300 SW Williston Rd, Gainesville, FL, 32608, United States of America
| | - Zhaoyi Chen
- College of Medicine, Department of Health Outcomes & Biomedical Informatics, University of Florida, 2004 Mowry Rd, Gainesville, FL, 32610, United States of America
| | - Jiang Bian
- College of Medicine, Department of Health Outcomes & Biomedical Informatics, University of Florida, 2004 Mowry Rd, Gainesville, FL, 32610, United States of America
| | - Ragnhildur I Bjarnadottir
- College of Nursing, Department of Family, Community, and Health Systems Science, University of Florida, 1225 Center Drive, PO Box 100197, Gainesville, FL, 32610, United States of America
| | - Robert J Lucero
- College of Nursing, Department of Family, Community, and Health Systems Science, University of Florida, 1225 Center Drive, PO Box 100197, Gainesville, FL, 32610, United States of America
- School of Nursing, University of California Los Angeles, 700 Tiverton Ave, Los Angeles, CA, 90095, United States of America
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Shahabi Raberi V, Solati Kooshk Qazi M, Zolfi gol A, GhorbaniNia R, Kahourian O, Faramarz Zadeh R. Postoperative Delirium and Dementia in Patients Undergoing Cardiac Surgery: A Review of Randomized Controlled Trials. Galen Med J 2023; 12:1-9. [PMID: 38774845 PMCID: PMC11108672 DOI: 10.31661/gmj.v12i.3045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Indexed: 05/24/2024] Open
Abstract
Delirium and dementia are considered to be the most significant postoperative neurocognitive complications in patients undergoing cardiac surgery, particularly those aged 60 years and older, which reduces the post-surgery quality of life, prolongs hospitalization, increases costs, and elevated the rates of mortality. Nevertheless, the etiology, risk factors, and predictive biomarkers, have not been well elucidated particularly, in patients with unmanifested underline cognitive impairments. The present study aimed to review the findings on the etiology, factors increasing the risk of incidence, and predictive biomarkers of postoperative delirium and dementia after cardiac surgery, and to describe the suggested pharmacological and non-pharmacological interventions.
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Affiliation(s)
- Venus Shahabi Raberi
- Seyed-Al-Shohada cardiology Hospital, Urmia University of Medical Sciences, Urmia,
Iran
| | | | - Ali Zolfi gol
- Department of Pediatric Cardiology, Shahid Motahari Hospital, Hospital, Urmia
University of Medical Sciences, Urmia, Iran
| | - Rahil GhorbaniNia
- Noncommunicable Diseases Research Center, Bam University of Medical Sciences, Bam,
Iran
| | - Ozra Kahourian
- Seyed-Al-Shohada cardiology Hospital, Urmia University of Medical Sciences, Urmia,
Iran
| | - Reza Faramarz Zadeh
- Seyed-Al-Shohada cardiology Hospital, Urmia University of Medical Sciences, Urmia,
Iran
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22
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Al Huraizi AR, Al-Maqbali JS, Al Farsi RS, Al Zeedy K, Al-Saadi T, Al-Hamadani N, Al Alawi AM. Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study. J Clin Med 2023; 12:5346. [PMID: 37629388 PMCID: PMC10455146 DOI: 10.3390/jcm12165346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes. METHODS A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM). RESULTS During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively. CONCLUSIONS Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.
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Affiliation(s)
- Aisha Ramadhan Al Huraizi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
| | - Rajaa Saleh Al Farsi
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
| | - Khalfan Al Zeedy
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
| | - Taif Al-Saadi
- College of Medicine, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Noof Al-Hamadani
- College of Medicine, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Abdullah M. Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman; (A.R.A.H.); (K.A.Z.); (A.M.A.A.)
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman;
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23
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Snigurska UA, Liu Y, Ser SE, Macieira TGR, Ansell M, Lindberg D, Prosperi M, Bjarnadottir RI, Lucero RJ. Risk of bias in prognostic models of hospital-induced delirium for medical-surgical units: A systematic review. PLoS One 2023; 18:e0285527. [PMID: 37590196 PMCID: PMC10434879 DOI: 10.1371/journal.pone.0285527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/25/2023] [Indexed: 08/19/2023] Open
Abstract
PURPOSE The purpose of this systematic review was to assess risk of bias in existing prognostic models of hospital-induced delirium for medical-surgical units. METHODS APA PsycInfo, CINAHL, MEDLINE, and Web of Science Core Collection were searched on July 8, 2022, to identify original studies which developed and validated prognostic models of hospital-induced delirium for adult patients who were hospitalized in medical-surgical units. The Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies was used for data extraction. The Prediction Model Risk of Bias Assessment Tool was used to assess risk of bias. Risk of bias was assessed across four domains: participants, predictors, outcome, and analysis. RESULTS Thirteen studies were included in the qualitative synthesis, including ten model development and validation studies and three model validation only studies. The methods in all of the studies were rated to be at high overall risk of bias. The methods of statistical analysis were the greatest source of bias. External validity of models in the included studies was tested at low levels of transportability. CONCLUSIONS Our findings highlight the ongoing scientific challenge of developing a valid prognostic model of hospital-induced delirium for medical-surgical units to tailor preventive interventions to patients who are at high risk of this iatrogenic condition. With limited knowledge about generalizable prognosis of hospital-induced delirium in medical-surgical units, existing prognostic models should be used with caution when creating clinical practice policies. Future research protocols must include robust study designs which take into account the perspectives of clinicians to identify and validate risk factors of hospital-induced delirium for accurate and generalizable prognosis in medical-surgical units.
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Affiliation(s)
- Urszula A. Snigurska
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, United States of America
| | - Yiyang Liu
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Sarah E. Ser
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Tamara G. R. Macieira
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, United States of America
| | - Margaret Ansell
- Health Science Center Libraries, George A. Smathers Libraries, University of Florida, Gainesville, FL, United States of America
| | - David Lindberg
- Department of Statistics, College of Liberal Arts and Sciences, University of Florida, Gainesville, FL, United States of America
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ragnhildur I. Bjarnadottir
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, United States of America
| | - Robert J. Lucero
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, United States of America
- School of Nursing, University of California Los Angeles, Los Angeles, CA, United States of America
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Ang HP, Makpol S, Nasaruddin ML, Ahmad NS, Tan JK, Wan Zaidi WA, Embong H. Lipopolysaccharide-Induced Delirium-like Behaviour in a Rat Model of Chronic Cerebral Hypoperfusion Is Associated with Increased Indoleamine 2,3-Dioxygenase Expression and Endotoxin Tolerance. Int J Mol Sci 2023; 24:12248. [PMID: 37569622 PMCID: PMC10418785 DOI: 10.3390/ijms241512248] [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: 06/15/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
Indoleamine 2,3-dioxygenase (IDO) and the tryptophan-kynurenine pathway (TRP-KP) are upregulated in ageing and could be implicated in the pathogenesis of delirium. This study evaluated the role of IDO/KP in lipopolysaccharide (LPS)-induced delirium in an animal model of chronic cerebral hypoperfusion (CCH), a proposed model for delirium. CCH was induced by a permanent bilateral common carotid artery ligation (BCCAL) in Sprague Dawley rats to trigger chronic neuroinflammation-induced neurodegeneration. Eight weeks after permanent BCCAL, the rats were treated with a single systemic LPS. The rats were divided into three groups: (1) post-BCCAL rats treated with intraperitoneal (i.p.) saline, (2) post-BCCAL rats treated with i.p. LPS 100 μg/kg, and (3) sham-operated rats treated with i.p. LPS 100 μg/kg. Each group consisted of 10 male rats. To elucidate the LPS-induced delirium-like behaviour, natural and learned behaviour changes were assessed by a buried food test (BFT), open field test (OFT), and Y-maze test at 0, 24-, 48-, and 72 h after LPS treatment. Serum was collected after each session of behavioural assessment. The rats were euthanised after the last serum collection, and the hippocampi and cerebral cortex were collected. The TRP-KP neuroactive metabolites were measured in both serum and brain tissues using ELISA. Our data show that LPS treatment in CCH rats was associated with acute, transient, and fluctuated deficits in natural and learned behaviour, consistent with features of delirium. These behaviour deficits were mild compared to the sham-operated rats, which exhibited robust behaviour impairments. Additionally, heightened hippocampal IDO expression in the LPS-treated CCH rats was associated with reduced serum KP activity together with a decrease in the hippocampal quinolinic acid (QA) expression compared to the sham-operated rats, suggested for the presence of endotoxin tolerance through the immunomodulatory activity of IDO in the brain. These data provide new insight into the underlying mechanisms of delirium, and future studies should further explore the role of IDO modulation and its therapeutic potential in delirium.
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Affiliation(s)
- Hui Phing Ang
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia (N.S.A.)
| | - Suzana Makpol
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (M.L.N.); (J.K.T.)
| | - Muhammad Luqman Nasaruddin
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (M.L.N.); (J.K.T.)
| | - Nurul Saadah Ahmad
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia (N.S.A.)
| | - Jen Kit Tan
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (M.L.N.); (J.K.T.)
| | - Wan Asyraf Wan Zaidi
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Hashim Embong
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia (N.S.A.)
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25
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Gutowski M, Klimkiewicz J, Michałowski A, Ordak M, Możański M, Lubas A. ICU Delirium Is Associated with Cardiovascular Burden and Higher Mortality in Patients with Severe COVID-19 Pneumonia. J Clin Med 2023; 12:5049. [PMID: 37568451 PMCID: PMC10420272 DOI: 10.3390/jcm12155049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND COVID-19 can lead to functional disorders and complications, e.g., pulmonary, thromboembolic, and neurological. The neuro-invasive potential of SARS-CoV-2 may result in acute brain malfunction, which manifests as delirium as a symptom. Delirium is a risk factor for death among patients hospitalized due to critical illness. Taking the above into consideration, the authors investigated risk factors for delirium in COVID-19 patients and its influence on outcomes. METHODS A total of 335 patients hospitalized due to severe forms of COVID-19 were enrolled in the study. Data were collected from medical charts. RESULTS Delirium occurred among 21.5% of patients. In the delirium group, mortality was significantly higher compared to non-delirium patients (59.7% vs. 28.5%; p < 0.001). Delirium increased the risk of death, with an OR of 3.71 (95% CI 2.16-6.89; p < 0.001). Age, chronic atrial fibrillation, elevated INR, urea, and procalcitonin, as well as decreased phosphates, appeared to be the independent risk factors for delirium occurrence. CONCLUSIONS Delirium occurrence in patients with severe COVID-19 significantly increases the risk of death and is associated with a cardiovascular burden. Hypophosphatemia is a promising reversible factor to reduce mortality in this group of patients. However, larger studies are essential in this area.
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Affiliation(s)
- Mateusz Gutowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Jakub Klimkiewicz
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Andrzej Michałowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Michal Ordak
- Department of Pharmacotherapy and Pharmaceutical Care, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Marcin Możański
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Arkadiusz Lubas
- Department of Internal Diseases Nephrology and Dialysis, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland;
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26
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Kramer I, Schubert M. The use of patient sitters at a Swiss hospital: A retrospective observational study. PLoS One 2023; 18:e0287317. [PMID: 37315098 DOI: 10.1371/journal.pone.0287317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/04/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE Patient sitters are frequently used in acute care hospitals to provide one-to-one care for agitated or disorientated patients to assure the safety and well-being of patients. However, there is still a lack of evidence on the use of patient sitters, especially in Switzerland. Therefore, the aim of this study was to describe and explore the use of patient sitters in a Swiss acute care hospital. METHODS In this retrospective, observational study we included all inpatients who were hospitalized between January and December 2018 in a Swiss acute care hospital and required a paid or volunteer patient sitter. Descriptive statistics were used to describe the extent of patient sitter use, patient characteristics, and organizational factors. For the subgroup analysis between internal medicine and surgical patients Mann-Whitney U tests and chi-square tests were used. RESULTS Of the total of 27'855 included inpatients, 631 (2.3%) needed a patient sitter. Of these, 37.5% had a volunteer patient sitter. The median patient sitter duration per patient per stay was 18.0 hours (IQR = 8.4-41.0h). The median age was 78 years (IQR = 65.0-86.0); 76.2% of patients were over the age of 64. Delirium was diagnosed in 41% of patients, and 15% had dementia. Most of the patients showed signs of disorientation (87.3%), inappropriate behavior (84.6%), and risk of falling (86.6%). Patient sitter uses varied during the year and between surgical and internal medicine units. CONCLUSIONS These results add to the limited body of evidence concerning patient sitter use in hospitals, supporting previous findings related to patient sitter use for delirious or geriatric patients. New findings include the subgroup analysis of internal medicine and surgical patients, as well as analysis of patient sitter use distribution throughout the year. These findings may contribute to the development of guidelines and policies regarding patient sitter use.
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Affiliation(s)
- Iris Kramer
- Institute of Nursing, School of Health Sciences, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Maria Schubert
- Institute of Nursing, School of Health Sciences, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
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27
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Arneson ML, Oliveira J E Silva L, Stanich JA, Jeffery MM, Lindroth HL, Ginsburg AD, Bower SM, Mullan AF, Bellolio F. Association of delirium with increased short-term mortality among older emergency department patients: A cohort study. Am J Emerg Med 2023; 66:105-110. [PMID: 36738568 PMCID: PMC10038894 DOI: 10.1016/j.ajem.2023.01.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
STUDY OBJECTIVE To evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED). METHODS This was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity. RESULTS A total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68-26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46-8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44-19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45-5.46, p = 0.002). CONCLUSION Delirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families.
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Affiliation(s)
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jessica A Stanich
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Geriatric Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | | | - Alexander D Ginsburg
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Palliative Care, Mayo Clinic, Rochester, MN, USA
| | - Susan M Bower
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Geriatric Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA.
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28
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Zilezinski M, Lohrmann R, Hauß A, Bergjan M. [Development and content validity of a questionnaire to assess knowledge about delirium]. Z Gerontol Geriatr 2023; 56:132-138. [PMID: 35080647 PMCID: PMC8791090 DOI: 10.1007/s00391-022-02015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome that can have serious consequences and is often overlooked by healthcare professionals. The level of knowledge about delirium is often insufficient among nursing and medical staff. At the current time there is no suitable questionnaire to record the level of knowledge in German-speaking countries. AIM Development of a questionnaire and evaluation of content validity. METHODS Following a literature search to identify current best practice, several questionnaires were identified. An already published questionnaire with the dimensions of basic knowledge of delirium and risk factors has been translated, adapted and extended by the dimension of nonpharmacological delirium prevention. Delirium experts assessed the relevance of the questionnaire items in two rounds of reviews. Content validity was calculated using the Content Validity Index (CVI) at item (I-CVI) and scale (S-CVI) level. Additionally, the modified Kappa (k*) was calculated using a lower 95% confidence interval (CI). RESULTS The original 30-item questionnaire was expanded to include 18 delirium prevention items. After the first round of scoring 30 out of 48 items showed good to excellent I‑CVI scores. Considering the comments, 6 items were discarded and 12 were adapted in terms of language and content. In the final version of the questionnaire 41 items with excellent scores remained. The total scale score increased from 0.88 in the first version to 1.0 in the final version. Nurses were identified as the target group, potentially also therapists and medical personnel. CONCLUSION The delirium knowledge questionnaire is content-valid.
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Affiliation(s)
- Max Zilezinski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.,Universitätsmedizin Halle (Saale), AG Versorgungsforschung
- Pflege im Krankenhaus, Department für Innere Medizin, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.,Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Dorothea Erxleben Lernzentrum Halle (DELH), Projekt FORMAT, Magdeburger Straße 12, 06112, Halle (Saale), Deutschland
| | - Renée Lohrmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Armin Hauß
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Manuela Bergjan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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Kuntz AA, Stumm EK, Anderson TC, Ibarra SJ, Markart MR, Haske-Palomino M. Use of a nursing-led geriatrics consult service to deliver age-friendly care. Geriatr Nurs 2023; 50:58-64. [PMID: 36641857 DOI: 10.1016/j.gerinurse.2022.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
The Elder Veteran Program (EVP) is a nursing-led approach to deliver inpatient consultative geriatrics care at our academic Midwestern Veterans Hospital. From April to December of 2021, EVP modified its workflow using a Plan-Do-Study-Act approach to include previously under-addressed components of the IHI's "4M's" of Age-Friendly Care (Medication, Mobility, Mentation, and What Matters), with three months of retrospective data review as a Plan phase, three months of monthly Do and Study phases, and a three month Act phase to analyze post-intervention care. We found improvements in frequency of documentation of Medication, Mentation, and What Matters in EVP notes, and maintenance of Mobility documentation. Next steps include translating these documentation and workflow changes into other relevant outcome measures and outreach to other departments. Overall, our project demonstrates a novel way to integrate these Pillars into a hospital system, by leveraging an existing nursing-led geriatric consult service focused on prevention and education.
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Affiliation(s)
- Aaron A Kuntz
- Advanced Geriatrics Fellow, Geriatrics Research, Education, and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | - Eleanore K Stumm
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Tess C Anderson
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | | | - Megan R Markart
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Maureen Haske-Palomino
- Clinical Nurse Advisor for Geriatrics and Extended Care, Office of Nursing Services, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
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30
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Softy SJ, Rogers J, Voronina M, Brueckner AJ. Deliriogenic Medication Prescribing and Delirium in Hospitalized, Non-Critically Ill Older People. Sr Care Pharm 2023; 38:21-28. [PMID: 36751916 DOI: 10.4140/tcp.n.2023.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective Describe the incidence of delirium and associated outcomes among hospitalized, non-critically ill older people. Design Single-center, retrospective chart review. Setting A 217-bed academic teaching hospital in Cambridge, Massachusetts affiliated with Harvard Medical School. Patients People 65 years of age or older, admitted to a general medicine unit between January 1 and August 31, 2021, who were prescribed one or more deliriogenic medications prior to or during admission. Interventions Patient electronic medical records were reviewed for deliriogenic medications prescribed and administered during admission and associated clinical outcomes. Results The percentage of patients who developed delirium was 13% overall. The most implicated deliriogenic medications were benzodiazepines, antipsychotics, and histamine-2 receptor antagonists (H2RAs). Seventy-three percent of deliriogenic home medications were continued upon admission. Subgroup analyses of those with delirium had a mean length-of-stay of 20 days compared with 6 days in those who did not develop delirium. Those with delirium tended to have more deliriogenic medications used during admission. Conclusion This review describes the incidence of delirium for non-critically ill older people who were prescribed at least one deliriogenic medication. Of all the deliriogenic agents reviewed, moderate quality clinical evidence supports the association between use and development of delirium except for H2RAs, which have low-quality evidence. Pharmacist-driven efforts to deprescribe deliriogenic medications in at-risk patient populations may be better focused on agents with higher-quality evidence.
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Affiliation(s)
- Shane J Softy
- Department of Pharmacy, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Jessica Rogers
- Department of Pharmacy, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Maria Voronina
- Department of Pharmacy, Mount Auburn Hospital, Cambridge, Massachusetts
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31
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Tachibana M, Inada T. Poor prognostic impact of delirium: especially on mortality and institutionalisation. Psychogeriatrics 2023; 23:187-195. [PMID: 36416212 DOI: 10.1111/psyg.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022]
Abstract
The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.
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Affiliation(s)
- Masako Tachibana
- Department of Psychiatry, Nagoya University Hospital, Nagoya-shi, Japan.,Department of Psychiatry, Nagoya Ekisaikai Hospital, Nagoya-shi, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya-shi, Japan
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32
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Nitchingham A, Pereira JVB, Wegner EA, Oxenham V, Close J, Caplan GA. Regional cerebral hypometabolism on 18F-FDG PET/CT scan in delirium is independent of acute illness and dementia. Alzheimers Dement 2023; 19:97-106. [PMID: 35289980 PMCID: PMC10078760 DOI: 10.1002/alz.12604] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Delirium is associated with new onset dementia and accelerated cognitive decline; however, its pathophysiology remains unknown. Cerebral glucose metabolism previously seen in delirium may have been attributable to acute illness and/or dementia. We aimed to statistically map cerebral glucose metabolism attributable to delirium. METHODS We assessed cerebral glucose metabolism using 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) in sick, older patients with and without delirium, all without clinical dementia (N = 20). Strict exclusion criteria were adopted to minimize the effect of established confounders on FDG-PET. RESULTS Patients with delirium demonstrated hypometabolism in the bilateral thalami and right superior frontal, right posterior cingulate, right infero-lateral anterior temporal, and left superior parietal cortices. Regional hypometabolism correlated with delirium severity and performance on neuropsychological testing. DISCUSSION In patients with acute illness but without clinical dementia, delirium is accompanied by regional cerebral hypometabolism. While some hypometabolic regions may represent preclinical Alzheimer's disease (AD), thalamic hypometabolism is atypical of AD and consistent with the clinical features that are unique to delirium.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | | | - Eva A Wegner
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Department of Nuclear Medicine and PET, Prince of Wales Hospital, Sydney, Australia
| | - Vincent Oxenham
- Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Neurology, Royal North Shore Hospital, Sydney, Australia
| | - Jacqueline Close
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Luccarelli J, Kalinich M, McCoy TH, Fricchione G, Smith F, Beach SR. Co-Occurring Catatonia and COVID-19 Diagnoses Among Hospitalized Individuals in 2020: A National Inpatient Sample Analysis. J Acad Consult Liaison Psychiatry 2022; 64:209-217. [PMID: 36592693 PMCID: PMC9872966 DOI: 10.1016/j.jaclp.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/30/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND COVID-19 is associated with a range of neuropsychiatric manifestations. While case reports and case series have reported catatonia in the setting of COVID-19 infection, its rate has been poorly characterized. OBJECTIVE This study reports the co-occurrence of catatonia and COVID-19 diagnoses among acute care hospital discharges in the United States in 2020. METHODS The National Inpatient Sample, an all-payors database of acute care hospital discharges, was queried for patients of any age discharged with a diagnosis of catatonia and COVID-19 in 2020. RESULTS Among 32,355,827 hospitalizations in the 2020 National Inpatient Sample, an estimated 15,965 (95% confidence interval: 14,992-16,938) involved a diagnosis of catatonia without COVID-19 infection, 1,678,385 (95% confidence interval: 1,644,738-1,712,022) involved a diagnosis of COVID-19 without a co-occurring catatonia diagnosis, and 610 (95% confidence interval: 578-642) involved both catatonia and COVID-19 infection. In an adjusted model, a diagnosis of COVID-19, but not a diagnosis of catatonia or the combination of catatonia and COVID-19, was associated with increased mortality. Patients with catatonia and COVID-19 were frequently diagnosed with encephalopathy and delirium codes. CONCLUSIONS Catatonia and COVID-19 were rarely co-diagnosed in 2020, and catatonia diagnosis was not associated with increased mortality in patients with COVID-19. Further research is needed to better characterize the phenomenology of catatonia in the setting of COVID-19 infection and its optimal treatment.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA,Send correspondence and reprint requests to James Luccarelli, MD, DPhil, Massachusetts General Hospital, 32 Fruit Street Yawkey 6A, Boston, MA 02114
| | - Mark Kalinich
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Gregory Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Felicia Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Scott R. Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
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34
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Mulkey M, Albanese T, Kim S, Huang H, Yang B. Delirium detection using GAMMA wave and machine learning: A pilot study. Res Nurs Health 2022; 45:652-663. [PMID: 36321335 PMCID: PMC9649882 DOI: 10.1002/nur.22268] [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: 01/24/2022] [Revised: 09/13/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022]
Abstract
Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.
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Affiliation(s)
- Malissa Mulkey
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA
| | - Thomas Albanese
- College of Engineering and Technology, East Carolina University, Greenville, North Carolina, USA
| | - Sunghan Kim
- College of Engineering and Technology, East Carolina University, Greenville, North Carolina, USA
| | - Huyanting Huang
- Department of Computer and Information Technology, Purdue University, West Lafayette, Indiana, USA
| | - Baijain Yang
- Department of Computer and Information Technology, Purdue University, West Lafayette, Indiana, USA
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35
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Denk A, Müller K, Schlosser S, Heissner K, Gülow K, Müller M, Schmid S. Liver diseases as a novel risk factor for delirium in the ICU-Delirium and hepatic encephalopathy are two distinct entities. PLoS One 2022; 17:e0276914. [PMID: 36413529 PMCID: PMC9681112 DOI: 10.1371/journal.pone.0276914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. METHODS We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. RESULTS The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). CONCLUSIONS The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sophie Schlosser
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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Vardy ER, Lasserson D, Barker RO, Hanratty B. NEWS2 and the older person. Clin Med (Lond) 2022; 22:522-524. [PMID: 38589152 PMCID: PMC9761433 DOI: 10.7861/clinmed.2022-0426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The National Early Warning Score (NEWS), published in 2012, made no specific adjustments for older people. The updated NEWS2 (2017) incorporated new confusion as a category for consciousness. In this article, we consider the role of NEWS2 in detection of acute clinical deterioration in older people and how the score may be used to inform care, highlighting the additional aspects, such as care escalation decisions, that may ensue. We consider the evidence of NEWS and NEWS2 in assessment of the older person in different settings, including the potential benefits and limitations for care home residents. We suggest that NEWS2 may need adaptation for older people in future iterations, and that it should be used in conjunction with other clinical assessments, such as the Clinical Frailty Scale and the four 'A's test (4AT) for delirium.
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Affiliation(s)
- Emma Rlc Vardy
- Northern Care Alliance NHS Foundation Trust, Salford, UK and School of Health Sciences and NIHR Applied Research Collaboration Greater Manchester, Manchester, UK.
| | - Daniel Lasserson
- University of Warwick, Warwick, UK and clinical lead, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert O Barker
- Population Health Sciences Institute, Newcastle upon Tyne, UK and NIHR Applied Research Collaboration North East and North Cumbria, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle upon Tyne, UK and NIHR Applied Research Collaboration North East and North Cumbria, Newcastle upon Tyne, UK
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37
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Muzzana C, Mantovan F, Huber MK, Trevisani K, Niederbacher S, Kugler A, Ausserhofer D. Delirium in elderly postoperative patients: A prospective cohort study. Nurs Open 2022; 9:2461-2472. [PMID: 35716398 PMCID: PMC9374408 DOI: 10.1002/nop2.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN Prospective cohort study. METHODS Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.
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Affiliation(s)
- Chiara Muzzana
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | - Franco Mantovan
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy.,Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
| | | | - Katia Trevisani
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | | | - Alexander Kugler
- Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
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38
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Liu J, Li J, He J, Zhang H, Liu M, Rong J. The Age-adjusted Charlson Comorbidity Index predicts post-operative delirium in the elderly following thoracic and abdominal surgery: A prospective observational cohort study. Front Aging Neurosci 2022; 14:979119. [PMID: 36062155 PMCID: PMC9428551 DOI: 10.3389/fnagi.2022.979119] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Post-operative delirium (POD) presents as a serious neuropsychiatric syndrome in the elderly undergoing thoracic and abdominal surgery, which is mostly associated with poor prognosis. The Age-adjusted Charlson Comorbidity Index (ACCI) has been widely recognized as an independently predictive factor for overall survival rate and mortality in various surgeries. However, no studies demonstrated the potential relationship between ACCI and POD. The current study was to explore the correlation between ACCI and POD, and determine the predictive effect of ACCI on POD in the elderly after thoracic and abdominal surgery. Materials and methods Total 184 patients (≥60 years) who underwent thoracic and abdominal surgery from 2021.10 to 2022.5 were enrolled in this prospective observational cohort study. ACCI was calculated by weighting comorbidities and age. POD was diagnosed using Confusion Assessment Method (CAM) twice a day in the first 3 days after surgery. The Visual Analog Scale (VAS) was applied to measure pre-operative and post-operative pain at rest and in motion. All demographic and perioperative data were compared in patients with POD and without POD. ACCI and other variables were analyzed by univariate and multivariate logistic regression analysis. The characteristic curve of receiver operating characteristic (ROC) was used to further evaluate the accuracy of ACCI to predict POD. Results Post-operative delirium was diagnosed in 36 of 184 patients included in our study. The prevalence of POD in the elderly after thoracic and abdominal surgery was 19.6%. The outcomes by multivariate regression analysis showed the independent risk factors for POD were ACCI (OR: 1.834; 95%CI: 1.434–2.344; P < 0.001), pre-operative Mini-Mental State Examination (MMSE) scores (OR: 0.873; 95%CI: 0.767–0.994; P = 0.040), serum albumin (OR: 0.909; 95%CI: 0.826–1.000; P = 0.049) and pain scores in the post-operative third day (OR: 2.013; 95%CI: 1.459–2.778; P < 0.001). ACCI can predict POD more accurately with the largest area under curve (AUC) of 0.794 and sensitivity of 0.861, respectively. Conclusion Age-adjusted Charlson Comorbidity Index, pre-operative MMSE scores, serum albumin and post-operative pain were independently associated with POD in geriatric patients following thoracic and abdominal surgery. Moreover, ACCI may become an accurate indicator to predict POD early.
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Affiliation(s)
- Jing Liu
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
- Graduate Faculty, Hebei North University, Zhangjiakou, China
| | - Jianli Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
- *Correspondence: Jianli Li,
| | - Jinhua He
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Huanhuan Zhang
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Meinv Liu
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Junfang Rong
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
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Tachibana M, Inada T, Ichida M, Ozaki N. Prevalence, clinical features, and risk factors of delusions in patients with delirium. Int J Geriatr Psychiatry 2022; 37. [PMID: 35603676 DOI: 10.1002/gps.5763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/12/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Delirium may be divided into multiple subtypes with different pathological factors. This study aimed to focus on the delirium subtype in which delusions are conspicuous and explore its prevalence, clinical characteristics, and risk factors. METHODS The subjects were 601 delirium cases referred to the department of psychiatry over 5 years at a general hospital. The Delirium Rating Scale-Revised-98 was used to assess the delusions in patients with delirium, and the features of delusions (delusional form, object, and content) were examined. Multiple regression analysis was applied to determine whether individual factors were associated with the delusions. RESULTS A total of 78 patients with delirium experienced delusions (13.0%). Most were classified as delusion of reference, such as persecution or poisoning, and 84.3% of patients believed that the persecutors were medical staff members. Older age (p < 0.001), female gender (p < 0.001), and living alone (p < 0.001) were significantly associated with delusions in patients with delirium. CONCLUSIONS The content of delusions was rooted in the distress caused by the patients' medical situation, and the features and risk factors of the delusions suggested a formal similarity with late paraphrenia and "lack-of-contact paranoia." Psychological interventions that consider the isolation, anxiety, and fear behind delusions may be necessary in the care and treatment of these patients.
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Affiliation(s)
- Masako Tachibana
- Department of Psychiatry, Nagoya University Hospital, Aichi, Japan.,Department of Psychiatry, Nagoya Ekisaikai Hospital, Aichi, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masaru Ichida
- Department of Psychiatry, Nagoya Ekisaikai Hospital, Aichi, Japan
| | - Norio Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Aichi, Japan
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Gaudet JG, Kull C, Eskenazi ML, Diaper J, Maillard J, Mollard F, Marti C, Marcantonio ER, Courvoisier DS, Walder B. Three-Minute Diagnostic Assessment for Delirium using the Confusion Assessment Method (3D-CAM): French translation and cultural adaptation. Can J Anaesth 2022; 69:726-735. [PMID: 35338453 PMCID: PMC9132814 DOI: 10.1007/s12630-022-02232-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The routine use of validated diagnostic instruments is key to identifying delirious patients early and expediting care. The 3-Minute Diagnostic Assessment for Delirium using the Confusion Assessment Method (3D-CAM) instrument is a brief, easy to use, sensitive, and specific delirium assessment tool for hospitalized patients. We aimed to translate the original English version into French, and then adapt it to older high-risk patients. METHODS Translation and adaptation of the questionnaire were guided by an expert committee and the 3D-CAM instrument developer. During the translation phase, we achieved semantic and conceptual equivalence of the instrument by conducting forward and backward translations. During the adaptation phase, we assessed the face validity, clarity of wording, and ease of use of the translated questionnaire by administering it to 30 patients and their caregivers in peri-interventional and medical intermediate care units. During both phases, we used qualitative (goal and adequacy of the questionnaire) and quantitative (Sperber score, clarity score) criteria. RESULTS Translation: four items were judged inadequate and were revised until all reached a Sperber score of < 3/7. Face validity: 91% of patients thought the questionnaire was designed to assess memory, thoughts, or reasoning. Clarity: eight items required adjustments until all scored ≥ 9/10 for clarity. Ease of use: all bedside caregivers reported that the questionnaire was easy to complete after receiving brief instructions. CONCLUSIONS We produced a culturally adapted French version of the 3D-CAM instrument that is well understood and well-received by older high-risk patients and their caregivers.
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Affiliation(s)
- John G Gaudet
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Corey Kull
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Marc L Eskenazi
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Julien Maillard
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Florence Mollard
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Christophe Marti
- Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Bernhard Walder
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.
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Salottolo K, Meinig R, Fine L, Kelly M, Madayag R, Ekengren F, Tanner A, Bar-Or D. Associations of Smoking With Delirium and Opioid Use in Older Adults With Traumatic Hip Fracture. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e21.00188. [PMID: 35576240 PMCID: PMC10566843 DOI: 10.5435/jaaosglobal-d-21-00188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 03/15/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Cigarette smoking is a risk factor for hip fractures, while risk factors for developing delirium include older age and preexisting cognitive impairment. We sought to determine whether smoking status is independently associated with delirium and pain outcomes. METHODS This was a prospective, observational cohort study of 442 older adults (65 to 90 years) admitted for traumatic hip fracture at five trauma centers. The primary exposure was smoking status (n = 43, 10%). Additional risk factors included demographics, injury characteristics, and medical interventions. Delirium (primary) and analgesia-related complications were examined with multivariable logistic regression, while analysis of covariance models were used to examine preoperative and postoperative pain scores and opioid consumption (oral morphine equivalents). RESULTS Smokers had significantly worse outcomes compared with nonsmokers: delirium incidence was 16.3% versus 5.0% (adjusted odds ratio, 4.23; P = 0.005), analgesia complications developed in 30.2% versus 14.8% (adjusted odds ratio, 2.63; P = 0.01), and postoperative opioid consumption was greater (53 mg versus 33 mg, adjusted P = 0.04). Adjusted pain scores were not different between groups. DISCUSSION Smoking status is associated with markedly worse outcomes in older adults with traumatic hip fracture. Smoking status should be considered in pain management protocols and for early screening and delirium prevention methods. DATA AVAILABILITY On reasonable request.
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Affiliation(s)
- Kristin Salottolo
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Richard Meinig
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Landon Fine
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Michael Kelly
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Robert Madayag
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Francie Ekengren
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - Allen Tanner
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
| | - David Bar-Or
- From the Trauma Research Department, Penrose Hospital, Colorado Springs, CO (Salottolo, Dr. Meinig, Kelly, Dr. Tanne II, and Dr. Bar-Or); the Trauma Research Department, St Anthony Hospital, Lakewood, CO (Salottolo, Dr. Madayag, and Dr. Bar-Or); the Trauma Research Department, Wesley Medical Center, Wichita, KS (Salottolo, Dr. Ekengren, and Dr. Bar-Or); the Trauma Research Department, St. Francis Medical Center, Colorado Springs, CO (Dr. Meinig); and the Trauma Research Department, Parker Adventist Hospital, Parker, CO (Dr. Fine)
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Predicting hospital mortality and length of stay: A prospective cohort study comparing the Intensive Care Delirium Screening Checklist versus Confusion Assessment Method for the Intensive Care Unit. Aust Crit Care 2022; 36:378-384. [PMID: 35272910 DOI: 10.1016/j.aucc.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare two tools, the Intensive Care Delirium Screening Checklist (ICDSC) and Confusion Assessment Method for the intensive care unit (ICU) (CAM-ICU), for their predictive validity for outcomes related to delirium, hospital mortality, and length of stay (LOS). METHODS The prospective study conducted in six medical ICUs at a tertiary care hospital in Taiwan enrolled consecutive patients (≥20 years) without delirium at ICU admission. Delirium was screened daily using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups. RESULTS Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ = 0.63; p < 0.001) was found between tools. Independent of age, Acute Physiology and Chronic Health Evaluation II score, and Charlson Comorbidity Index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio: 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI: 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared with the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (adjusted odds ratio: 2.97; 95% CI: 1.06 to 8.37 vs. 3.82; 95% CI: 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS. CONCLUSIONS The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients' arousal when deciding which tool to use to maximise the effects of delirium identification on patient mortality.
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Anand A, Cheng M, Ibitoye T, Maclullich AMJ, Vardy ERLC. Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions. Age Ageing 2022; 51:6548791. [PMID: 35292792 PMCID: PMC8923813 DOI: 10.1093/ageing/afac051] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 'A's Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). METHODS The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of $\sim$3 years were analysed using logistic regression models adjusted for age and sex. RESULTS 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99-6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98-3.87). Length of stay was more than double in patients with 4AT scores of 1-3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001). CONCLUSIONS Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment.
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Affiliation(s)
- Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michael Cheng
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Address correspondence to: Alasdair MacLullich, Professor of Geriatric Medicine, Ageing and Health, Usher Institute, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, Edinburgh, UK. Tel: 0131 650 1000. Email ; Emma Vardy, Consultant in Geriatric Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, Manchester, UK. Tel: 0161 789 7373.
| | - Emma R L C Vardy
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Manchester, UK
- Address correspondence to: Alasdair MacLullich, Professor of Geriatric Medicine, Ageing and Health, Usher Institute, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, Edinburgh, UK. Tel: 0131 650 1000. Email ; Emma Vardy, Consultant in Geriatric Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, Manchester, UK. Tel: 0161 789 7373.
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Grover S, Singh OP. Basics for Physicians and Psychiatrists for Effective Practice of Consultation-Liaison Psychiatry Services. Indian J Psychiatry 2022; 64:S228-S235. [PMID: 35602360 PMCID: PMC9122166 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_714_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/26/2021] [Accepted: 01/01/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - O P Singh
- West Bengal Medical Services, Kolkata, West Bengal, India E-mail:
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Cano-Escalera G, Graña M, Irazusta J, Labayen I, Besga A. Survival of Frail Elderly with Delirium. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042247. [PMID: 35206439 PMCID: PMC8872606 DOI: 10.3390/ijerph19042247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023]
Abstract
This study aims to determine when frailty increases the risks of delirium mortality. Hospital patients falling into the elderly frail or pre-frail category were recruited, some without delirium, some with delirium at admission, and some who developed delirium during admission. We screened for frailty, cognitive status, and co-morbidities whenever possible and extracted drug information and mortality data from electronic health records. Kaplan–Meier estimates of survival probability functions were computed at four times, comparing delirium versus non delirium patients. Differences in survival were assessed by a log-rank test. Independent Cox’s regression was carried out to identify significant hazard risks (HR) at 1 month, 6 months, 1 year, and 2 years. Delirium predicted mortality (log-rank test, p < 0.0001) at all four censoring points. Variables with significant HRs were frailty indicators, comorbidities, polypharmacy, and the use of specific drugs. For the delirium cohort, variables with the most significant 2-year hazard risks (HR(95%CI)) were: male gender (0.43 20 (0.26,0.69)), weight loss (0.45 (0.26,0.74)), sit and stand up test (0.67 (0.49,0.92)), readmission within 30 days of discharge (0.50 (0.30,0.80)), cerebrovascular disease (0.45 (0.27,0.76)), head trauma (0.54 22 (0.29,0.98)), number of prescribed drugs (1.10 (1.03,1.18)), and the use of diuretics (0.57 (0.34,0.96)). These results suggest that polypharmacy and the use of diuretics increase mortality in frail elderly patients with delirium.
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Affiliation(s)
- Guillermo Cano-Escalera
- Department of Computer Science and Artificial Intelligence, University of the Basque Country (UPV/EHU), Paseo Manuel de Lardizabal, 1, 20018 Donostia-San Sebastian, Spain;
- Computational Intelligence Group, University of the Basque Country (UPV/EHU), 20018 Donostia-San Sebastian, Spain
- Correspondence:
| | - Manuel Graña
- Department of Computer Science and Artificial Intelligence, University of the Basque Country (UPV/EHU), Paseo Manuel de Lardizabal, 1, 20018 Donostia-San Sebastian, Spain;
- Computational Intelligence Group, University of the Basque Country (UPV/EHU), 20018 Donostia-San Sebastian, Spain
| | - Jon Irazusta
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48013 Bilbao, Spain;
- BioCruces Health Research Institute, 48903 Barakaldo, Spain
| | - Idoia Labayen
- Institute for Innovation & Sustainable Development in Food Chain (IS-FOOD), Public University of Navarra, 31006 Pamplona, Spain;
| | - Ariadna Besga
- BioAraba, Health Research Institute, Hospital Universitario de Araba, Department of Medicine, 01004 Vitoria, Spain;
- Biomedical Research Centre in Mental Health Network (CIBERSAM) G10, Spain
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Taylor J, Parker M, Casey CP, Tanabe S, Kunkel D, Rivera C, Zetterberg H, Blennow K, Pearce RA, Lennertz RC, Sanders RD. Postoperative delirium and changes in the blood-brain barrier, neuroinflammation, and cerebrospinal fluid lactate: a prospective cohort study. Br J Anaesth 2022; 129:219-230. [PMID: 35144802 PMCID: PMC9465948 DOI: 10.1016/j.bja.2022.01.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Case-control studies have associated delirium with blood-brain barrier (BBB) permeability. However, this approach cannot determine whether delirium is attributable to high pre-existing permeability or to perioperative changes. We tested whether perioperative changes in cerebrospinal fluid/plasma albumin ratio (CPAR) and plasma S100B were associated with delirium severity. METHODS Participants were recruited to two prospective cohort studies of non-intracranial surgery (NCT01980511, NCT03124303, and NCT02926417). Delirium severity was assessed using the Delirium Rating Scale-98. Delirium incidence was diagnosed with the 3D-Confusion Assessment Method (3D-CAM) or CAM-ICU (CAM for the ICU). CSF samples from 25 patients and plasma from 78 patients were analysed for albumin and S100B. We tested associations between change in CPAR (n=11) and S100B (n=61) and delirium, blood loss, CSF interleukin-6 (IL-6), and CSF lactate. RESULTS The perioperative increase in CPAR and S100B correlated with delirium severity (CPAR ρ=0.78, P=0.01; S100B ρ=0.41, P<0.001), delirium incidence (CPAR P=0.012; S100B P<0.001) and CSF IL-6 (CPAR ρ=0.66 P=0.04; S100B ρ=0.75, P=0.025). Linear mixed-effect analysis also showed that decreased levels of S100B predicted recovery from delirium symptoms (P=0.001). Linear regression demonstrated that change in plasma S100B was independently associated with surgical risk, cardiovascular surgery, blood loss, and hypotension. Blood loss also correlated with CPAR (ρ=0.64, P=0.04), S100B (ρ=0.70, P<0.001), CSF lactate (R=0.81, P=0.01), and peak delirium severity (ρ=0.36, P=0.01). CONCLUSION Postoperative delirium is associated with a breakdown in the BBB. This increased permeability is dynamic and associated with a neuroinflammatory and lactate response. Strategies to mitigate blood loss may protect the BBB.
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Affiliation(s)
- Jennifer Taylor
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Margaret Parker
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron P Casey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Tanabe
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - David Kunkel
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron Rivera
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Robert A Pearce
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Richard C Lennertz
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
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Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System. J Am Med Dir Assoc 2022; 23:1322-1327.e2. [PMID: 35172165 PMCID: PMC9359928 DOI: 10.1016/j.jamda.2022.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services. DESIGN Pragmatic prospective cohort study of consecutive admissions to a large health care system. SETTING AND PARTICIPANTS A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014. METHODS Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI). RESULTS Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001). CONCLUSIONS AND IMPLICATIONS This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.
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Wong EKC, Watt J, Zou H, Chandraraj A, Wenyue Zhang A, Brookes J, Verduyn A, Berall A, Norman R, Piggott KL, Izukawa T, Straus SE, Liu BA. The association of typical and atypical symptoms with in-hospital mortality in older adults with COVID-19: a multicentre cohort study. Facets (Ott) 2022. [DOI: 10.1139/facets-2022-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Atypical disease presentations are common in older adults with COVID-19. The objective of this study was to determine the prevalence of atypical and typical symptoms in older adults with COVID-19 through progressive pandemic waves and the association of these symptoms with in-hospital mortality. This retrospective cohort study included consecutive adults aged over 65 years with confirmed COVID-19 infection who were admitted to seven hospitals in Toronto, Canada, from 1 March 2020 to 30 June 2021. The median age for the 1786 patients was 78.0 years and 847 (47.5%) were female. Atypical symptoms (as defined by geriatric syndromes) occurred in 1187 patients (66.5%), but rarely occurred in the absence of other symptoms ( n = 106; 6.2%). The most common atypical symptoms were anorexia ( n = 598; 33.5%), weakness ( n = 519; 23.9%), and delirium ( n = 449; 25.1%). Dyspnea (adjusted odds ratio [aOR] 2.05; 95% confidence interval [CI] 1.62–2.62), tachycardia (aOR 1.87; 95% CI 1.14–3.04), and delirium (aOR 1.52; 95% CI 1.18–1.96) were independently associated with in-hospital mortality. In a cohort of older adults hospitalized with COVID-19 infection, atypical presentations frequently overlapped with typical symptoms. Further research should be directed at understanding the cause and clinical significance of atypical presentations in older adults.
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Affiliation(s)
- Eric Kai-Chung Wong
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
| | - Jennifer Watt
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
| | - Hanyan Zou
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, M5G 1X5, Canada
| | - Arthana Chandraraj
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
| | - Alissa Wenyue Zhang
- Division of Geriatric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - Jahnel Brookes
- Kunin-Lunenfeld Centre for Applied Research & Evaluation, Rotman Research Institute, Baycrest Health Sciences Centre, Toronto, ON, M6A 2E1, Canada
| | - Ashley Verduyn
- Providence Healthcare and Houses of Providence, Unity Health Toronto, Toronto, ON, M1L 1W1, Canada
| | - Anna Berall
- Kunin-Lunenfeld Centre for Applied Research & Evaluation, Rotman Research Institute, Baycrest Health Sciences Centre, Toronto, ON, M6A 2E1, Canada
| | - Richard Norman
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, M5G 1X5, Canada
| | - Katrina Lynn Piggott
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Division of Geriatric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - Terumi Izukawa
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Kunin-Lunenfeld Centre for Applied Research & Evaluation, Rotman Research Institute, Baycrest Health Sciences Centre, Toronto, ON, M6A 2E1, Canada
- Division of Geriatric Medicine, Department of Medicine, Baycrest Health Sciences Centre, Toronto, ON, M6A 2E1, Canada
| | - Sharon E. Straus
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, M5B 1T8, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
| | - Barbara Arlena Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Division of Geriatric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
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Flaherty JH, Bloomstone JA, Vicents Sande E, Brantley A, Semien GA. An Inpatient Geriatrics Program with a Focus on Any Type of Cognitive Impairment Reduces Mortality. J Nutr Health Aging 2022; 26:103-109. [PMID: 35067711 DOI: 10.1007/s12603-021-1709-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND No matter what type of cognitive impairment an older hospitalized patient has, the risk of mortality is increased. OBJECTIVES To describe a hospital-based geriatrics program with a focus on any type of cognitive impairment and to determine whether this program was associated with reduced mortality over time. DESIGN, PARTICIPANTS AND SETTING Retrospective chart review of all patients age 70+ admitted during a 3-year period (2017-2019, N=20,401), to a 500-bed community-based hospital (Level 1 Trauma Center and Stroke Center). INTERVENTION A multicomponent geriatrics program was developed and implemented throughout 2018 and included: geriatric consultation, data collection, review of the data with hospital leaders, a geriatrics task force, clinician education and a Delirium Unit. MAIN OUTCOMES AND MEASURES Monthly mortality rates for patients with and without cognitive impairment over the 3-year period. To control for other variables associated with mortality, pre-post implementation analyses were performed (2017 versus 2019). RESULTS A linear regression analysis showed a significant downward trend in mortality over time for patients with cognitive impairment [R2=0.4, P<.0001, (correlation coefficient -0.6, 95% CI, -0.8 to -0.4)] but not among patients without cognitive impairment [R2=0.0, P=0.829, (correlation coefficient 0.0, 95% CI, -0.3 to 0.3)]. When controlling for other variables, there was still a decrease in mortality risk among patients with cognitive impairment. CONCLUSION Although there are limitations to this study, a multicomponent geriatrics program with an emphasis on any type of cognitive impairment, may be associated with improved mortality.
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Affiliation(s)
- J H Flaherty
- Joseph H. Flaherty, 13737 Noel Rd, Suite 1600, Dallas, TX, 75240. , Twitter: @flahertyinchina
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50
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Schnorr T, Fleiner T, Schroeder H, Reupke I, Woringen F, Trumpf R, Schroeder S, Zijlstra W, Haussermann P. Post-discharge Mortality in Patients With Delirium and Dementia: A 3-Year Follow Up Study. Front Psychiatry 2022; 13:835696. [PMID: 35295785 PMCID: PMC8918771 DOI: 10.3389/fpsyt.2022.835696] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delirium and dementia are prominent psychiatric diseases in old age and connected with poor outcomes for people affected. Nevertheless, there is a lack of knowledge concerning the long-term prognosis of patients with dementia and delirium. This study analyzes mortality, readmission rates and discharge destinations of patients with dementia or delirium superimposed on dementia (DSD) within 3 years after discharge from hospital. METHODS A cross-sectional, monocentric cohort study was conducted at the department of geriatric psychiatry of the LVR hospital cologne, using structured telephone interviews and analyses from the clinical information system. All patients with dementia and DSD, admitted between December 2014 and November 2015, were screened for eligibility. RESULTS In total, 113 patients were included, 49 patients with dementia (M 80 years, female 49%) and 64 with DSD (M 82 years, female 47%). Three years after discharge, 66 patients (58%) had died (95% CI 91.9-112.5; p = 0.53). Within the first 3 months, 9 patients (14%) with DSD deceased, but no patient from the dementia group (95% CI 11.3-12.7; p = 0.01). Out of all patients, 17 patients were readmitted and nursing homes were the predominant discharge destination (55%). CONCLUSIONS This analysis revealed a high post-discharge mortality rate of patients with dementia and DSD. For patients with DSD, a close clinical monitoring, mainly within the first 3 months after discharge, should challenge the significantly increased acute-mortality. These findings should set the pattern for a comprehensive analysis of long-term effects of dementia and DSD. More studies are required for better understanding and comparability in this field of research and healthcare.
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Affiliation(s)
- Thiemo Schnorr
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany.,Institute of Movement and Sport Gerontology, German Sport University Cologne, Cologne, Germany
| | - Tim Fleiner
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany.,Institute of Movement and Sport Gerontology, German Sport University Cologne, Cologne, Germany
| | - Henning Schroeder
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany
| | - Ira Reupke
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany
| | - Frank Woringen
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany
| | - Rieke Trumpf
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany.,Institute of Movement and Sport Gerontology, German Sport University Cologne, Cologne, Germany
| | - Stefan Schroeder
- Department of Psychiatry, KMG Kliniken, Güstrow, Germany.,Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Wiebren Zijlstra
- Institute of Movement and Sport Gerontology, German Sport University Cologne, Cologne, Germany
| | - Peter Haussermann
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Cologne, Germany
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