1
|
den Boogaard MV, Leenders M, Pop-Purceleanu M, Tilburgs B. Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study. Intensive Crit Care Nurs 2024; 83:103627. [PMID: 38301387 DOI: 10.1016/j.iccn.2024.103627] [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: 10/19/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools. OBJECTIVE The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity. RESEARCH METHOD CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed. DESIGN A prospective observational study performed between October and December 2020. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity. RESULTS In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively. CONCLUSION Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98. IMPLICATIONS FOR CLINICAL PRACTICE Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.
Collapse
Affiliation(s)
- Mark van den Boogaard
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands.
| | - Margot Leenders
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands
| | - Monica Pop-Purceleanu
- Radboud University Medical Center, Department of Psychiatrie, Nijmegen, the Netherlands
| | - Bram Tilburgs
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands
| |
Collapse
|
2
|
Richardson SJ, Cropp AD, Ellis SW, Gibbon J, Sayer AA, Witham MD. The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review. Age Ageing 2024; 53:afae120. [PMID: 38965032 PMCID: PMC11223896 DOI: 10.1093/ageing/afae120] [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: 06/15/2023] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium. METHODS Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines. RESULTS After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively. CONCLUSION Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.
Collapse
Affiliation(s)
- Sarah Joanna Richardson
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria Northumberland Tyne and Wear NHS Foundation Trust and Faculty of Medical Sciences Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | | | | | - Jake Gibbon
- South Tyneside and Sunderland NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Avan Aihie Sayer
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria Northumberland Tyne and Wear NHS Foundation Trust and Faculty of Medical Sciences Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Miles David Witham
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria Northumberland Tyne and Wear NHS Foundation Trust and Faculty of Medical Sciences Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| |
Collapse
|
3
|
Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
Collapse
Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Brown CH, Kim AS, Yanek L, Lewis A, Mandal K, Le L, Tian J, Neufeld KJ, Hogue C, Moghekar A. Association of perioperative plasma concentration of neurofilament light with delirium after cardiac surgery: a nested observational study. Br J Anaesth 2024; 132:312-319. [PMID: 38114355 PMCID: PMC10808824 DOI: 10.1016/j.bja.2023.10.043] [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: 01/04/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Neurofilament light is a blood-based biomarker of neuroaxonal injury that can provide insight into perioperative brain vulnerability and injury. Prior studies have suggested that increased baseline and postoperative concentrations of neurofilament light are associated with delirium after noncardiac surgery, but results are inconsistent. Results have not been reported in cardiac surgery patients, who are among those at highest risk for delirium. We hypothesised that perioperative blood concentrations of neurofilament light (both baseline and change from baseline to postoperative day 1) are associated with delirium after cardiac surgery. METHODS This study was nested in a trial of arterial blood pressure targeting during cardiopulmonary bypass using cerebral autoregulation metrics. Blood concentrations of neurofilament light were measured at baseline and on postoperative day 1. The primary outcome was postoperative delirium. Regression models were used to examine the associations between neurofilament light concentration and delirium and delirium severity, adjusting for age, sex, race, logistic European System for Cardiac Operative Risk Evaluation, bypass duration, and cognition. RESULTS Delirium occurred in 44.6% of 175 patients. Baseline neurofilament light concentration was higher in delirious than in non-delirious patients (median 20.7 pg ml-1 [IQR 16.1-33.2] vs median 15.5 pg ml-1 [IQR 12.1-24.2], P<0.001). In adjusted models, greater baseline neurofilament light concentration was associated with delirium (odds ratio, 1.027; 95% confidence interval, 1.003-1.053; P=0.029) and delirium severity. From baseline to postoperative day 1, neurofilament light concentration increased by 42%, but there was no association with delirium. CONCLUSIONS Baseline neurofilament light concentration, but not change from baseline to postoperative day 1, was associated with delirium after cardiac surgery.
Collapse
Affiliation(s)
- Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Alexander S Kim
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Highland Hospital-Alameda Health System, Oakland, CA, USA
| | - Lisa Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandria Lewis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kaushik Mandal
- Department of Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Lan Le
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Emergent Biosolutions Company, Gaithersburg, MD, USA
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, ON, Canada
| | - Charles Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
6
|
Oldham MA. Describing the features of catatonia: A comparative phenotypic analysis. Schizophr Res 2024; 263:82-92. [PMID: 35995651 PMCID: PMC9938840 DOI: 10.1016/j.schres.2022.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Catatonia is widely under-detected, and the many differences across catatonia rating scales and diagnostic criteria could be a key reason why clinicians have a hard time knowing what catatonia looks like and what constitutes each of its features. METHODS This review begins by discussing the nature of catatonia diagnosis, its evolution in ICD and DSM, and different approaches to scoring. The central analysis then provides a descriptive survey of catatonia's individual signs across scales and diagnostic criteria. The goal of this survey is to characterize distinctions across scales and diagnostic criteria that can introduce variance into catatonia caseness. RESULTS Diagnostic criteria for catatonia in DSM-5-TR and ICD-11 are broadly aligned in terms of which items are included, item definitions and number of items required for diagnosis; however, the lack of item thresholds is a fundamental limitation. Many distinctions across scales and criteria could contribute to diagnostic discordance. DISCUSSION Clear, consistent definitions for catatonia features are essential for reliable detection. Of available scales, Bush-Francis and Northoff can be converted to diagnostic criteria with limited modification. Bush-Francis is the most efficient, with a screening instrument, videographic resources and standardized clinical assessment. Northoff offers the most detailed assessment and uniquely emphasizes emotional and volitional disturbances in catatonia. CONCLUSIONS The field's understanding of the catatonia phenotype has advanced considerably over the past few decades. However, this review reveals many important limitations in the ICD and DSM as well as differences across scales and criteria that stand in the way of reliable catatonia detection.
Collapse
Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, 300 Crittenden Blvd. Box PSYCH, Rochester, NY 14642.
| |
Collapse
|
7
|
Nicholas M, Wittmann J, Norena M, Ornowska M, Reynolds S. A randomized, clinical trial investigating the use of a digital intervention to reduce delirium-associated agitation. NPJ Digit Med 2023; 6:202. [PMID: 37903857 PMCID: PMC10616287 DOI: 10.1038/s41746-023-00950-4] [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: 10/18/2023] [Indexed: 11/01/2023] Open
Abstract
We aimed to determine if a novel digital therapeutic intervention could reduce agitation and unscheduled medication use in an adult delirious acute care population. Delirious participants were randomly allocated (1:1) to receive standard of care plus a single 4-hour exposure to the digital intervention "MindfulGarden", which uses a screen-based delivery to display a nature landscape with dynamic adjustment of screen content in response to movement and sound or standard of care only. Between March 2021 and January 2022, 73 participants were enrolled with 70 completing the trial protocol and included in the final analysis with a mean age of 61 years and 68% being male (35 intervention, 35 control). Mean RASS was significantly lower across the 4-hour study period in the intervention arm 0.3 (0.85) vs 0.9 (0.93), p = 0.01. Exposure to a nature-based dynamic digital intervention showed benefits in agitation reduction.
Collapse
Affiliation(s)
- Michelle Nicholas
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Jessica Wittmann
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, V6Z 1Y6, Canada
| | - Marlena Ornowska
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Steven Reynolds
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada.
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada.
| |
Collapse
|
8
|
Kotake K, Matsunuma S, Takahashi T, Kitamura N, Kawakami Y. Yokukansan (TJ-54) in patients undergoing surgery: A systematic review and meta-analysis. Geriatr Nurs 2023; 52:8-15. [PMID: 37196515 DOI: 10.1016/j.gerinurse.2023.04.014] [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: 03/22/2023] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of Yokukansan (TJ-54) in patients undergoing surgery. METHODS Efficacy was assessed by the onset of delirium, delirium rating scales, anxiety evaluated by Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score, and safety was assessed by any reported adverse events. RESULTS Six studies were included. There were no significant differences between the groups in the onset of delirium (risk ratio 1.15, 95% confidence interval [CI] 0.77-1.72), delirium rating scales (early postoperative period: standardized mean difference [SMD] -0.24, 95% CI -1.11 to 0.63; late postoperative period: SMD -0.06, 95% CI -1.56 to 1.45), HADS-A score (mean difference -0.47, 95% CI -1.90 to 0.96), and any adverse events (risk ratio 1.18, 95% CI 0.35-4.00). CONCLUSIONS The use of TJ-54 in patients undergoing surgery is not an effective strategy for postoperative delirium and anxiety. Further research considering target patients and durations of administration should be conducted.
Collapse
Affiliation(s)
- Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Japan.
| | - Satoru Matsunuma
- Department of Pharmacy, Tokyo Medical University Hachioji Medical Center, Japan
| | | | - Naoya Kitamura
- Department of Neuropsychiatry, Okayama Saiseikai General Hospital, Japan
| | | |
Collapse
|
9
|
Oldham MA, Slooter AJC, Ely EW, Crone C, Maldonado JR, Rosenthal LJ. An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes. J Acad Consult Liaison Psychiatry 2023; 64:248-261. [PMID: 35840003 PMCID: PMC9839895 DOI: 10.1016/j.jaclp.2022.07.001] [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: 03/15/2022] [Revised: 05/10/2022] [Accepted: 07/04/2022] [Indexed: 01/17/2023]
Abstract
An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.
Collapse
Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education Clinical Center (GRECC), TN Valley Veterans Affairs Medical Center, Nashville, TN
| | - Cathy Crone
- Inova Health System, Behavioral Health, Falls Church, VA; George Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Washington, DC
| | - José R Maldonado
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, CA
| | - Lisa J Rosenthal
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
| |
Collapse
|
10
|
Delirium in Nursing Home Residents: A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10081544. [PMID: 36011202 PMCID: PMC9407867 DOI: 10.3390/healthcare10081544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Delirium is an important component of the geriatric syndromes and has been recognized to negatively influence the prognosis of older people in hospital and in a post-acute setting. About 2–5% of older people world-wide live in nursing homes and are characterized by functional impairment, cognitive decline, dementia, comorbidities, and polypharmacotherapy, all factors which influence the development of delirium. However, in this setting, delirium remains often understudied. Therefore, in this narrative review, we aimed to describe the latest evidence regarding delirium screening tools, epidemiology characteristics, outcomes, risk factors, and preventions strategies in nursing homes.
Collapse
|
11
|
Young M, Holmes N, Kishore K, Marhoon N, Amjad S, Serpa-Neto A, Bellomo R. Natural language processing diagnosed behavioral disturbance vs confusion assessment method for the intensive care unit: prevalence, patient characteristics, overlap, and association with treatment and outcome. Intensive Care Med 2022; 48:559-569. [PMID: 35322288 PMCID: PMC9050783 DOI: 10.1007/s00134-022-06650-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/15/2022] [Indexed: 12/19/2022]
Abstract
Purpose To compare the prevalence, characteristics, drug treatment for delirium, and outcomes of patients with Natural Language Processing (NLP) diagnosed behavioral disturbance (NLP-Dx-BD) vs Confusion Assessment Method for intensive care unit (CAM-ICU) positivity. Methods In three combined medical-surgical ICUs, we obtained data on demographics, treatment with antipsychotic medications, and outcomes. We applied NLP to caregiver progress notes to diagnose behavioral disturbance and analyzed simultaneous CAM-ICU. Results We assessed 2313 patients with a median lowest Richmond Agitation-Sedation Scale (RASS) score of − 2 (− 4.0 to − 1.0) and median highest RASS score of 1 (0 to 1). Overall, 1246 (53.9%) patients were NLP-Dx-BD positive (NLP-Dx-BDpos) and 578 (25%) were CAM-ICU positive (CAM-ICUpos). Among NLP-Dx-BDpos patients, 539 (43.3%) were also CAM-ICUpos. In contrast, among CAM-ICUpos patients, 539 (93.3%) were also NLP-Dx-BDpos. The use of antipsychotic medications was highest in patients in the CAM-ICUpos and NLP-Dx-BDpos group (24.3%) followed by the CAM-ICUneg and NLP-Dx-BDpos group (10.5%). In NLP-Dx-BDneg patients, antipsychotic medication use was lower at 5.1% for CAM-ICUpos and NLP-Dx-BDneg patients and 2.3% for CAM-ICUneg and NLP-Dx-BDneg patients (overall P < 0.001). Regardless of CAM-ICU status, after adjustment and on time-dependent Cox modelling, NLP-Dx-BD was associated with greater antipsychotic medication use. Finally, regardless of CAM-ICU status, NLP-Dx-BDpos patients had longer duration of ICU and hospital stay and greater hospital mortality (all P < 0.001). Conclusion More patients were NLP-Dx-BD positive than CAM-ICU positive. NLP-Dx-BD and CAM-ICU assessment describe partly overlapping populations. However, NLP-Dx-BD identifies more patients likely to receive antipsychotic medications. In the absence of NLP-Dx-BD, treatment with antipsychotic medications is rare. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06650-z.
Collapse
Affiliation(s)
- Marcus Young
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Natasha Holmes
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Sobia Amjad
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- School of Computing and Information Systems, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Ary Serpa-Neto
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia.
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, VIC, Australia.
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia.
| |
Collapse
|
12
|
Albanese AM, Ramazani N, Greene N, Bruse L. Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment. Geriatr Orthop Surg Rehabil 2022; 13:21514593211058947. [PMID: 35282299 PMCID: PMC8915233 DOI: 10.1177/21514593211058947] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a serious complication occurring in 4–53.3%
of geriatric patients undergoing surgeries for hip fracture. Incidence of
hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in
2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected
to increase, POD is also anticipated to increase. Signficance Postoperative delirium remains the most common complication of emergency hip
fracture surgery leading to high morbidity and mortality rates despite
significant research conducted regarding this topic. This study reviews
literature from 1990 to 2021 regarding POD in geriatric hip fracture
management. Results Potentially modifiable and non-modifiable risk factors for developing POD
include, but are not limited to, male gender, older age, multiple
comorbidities, specific comorbidities (dementia, cognitive impairment,
diabetes, vision impairment, and abnormal blood pressure), low BMI,
preoperative malnutrition, low albumin, low hematocrit, blunted preoperative
cytokines, emergency surgery, time to admission and surgery, preoperative
medical treatment, polypharmacy, delirium-inducing medications, fever,
anesthesia time, and sedation depth and type. Although the pathophysiology
remains unclear, the leading theories suggest neurotransmitter imbalance,
inflammation, and electrolyte or metabolic derangements as the underlying
cause of POD. POD is associated with increased length of hospital stay,
cost, morbidity, and mortality. Prevention and early recognition are key
factors in managing POD. Methods to reduce POD include utilizing
interdisciplinary teams, educational programs for healthcare professionals,
reducing narcotic use, avoiding delirium-inducing medications, and
multimodal pain control. Conclusion While POD is a known complication after hip fracture surgery, further
exploration in prevention is needed. Early identification of risk factors is
imperative to prevent POD in geriatric patients. Early prevention will
enhance delivery of health care both pre- and post-operatively leading to
the best possible surgical outcome and better quality of life after hip
fracture treatment.
Collapse
Affiliation(s)
- Anita M Albanese
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Noyan Ramazani
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Natasha Greene
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Laura Bruse
- Adjunct Clinical Assistant Professor Community Faculty, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| |
Collapse
|
13
|
Oh ES, Rosenberg PB, Wang N, Sieber FE, Neufeld KJ. Delirium detection methodologies: Implications for outcome measurement in clinical trials in postoperative delirium. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5695. [PMID: 35170079 PMCID: PMC9303755 DOI: 10.1002/gps.5695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Delirium is a common postoperative complication of hip fracture. Various methods exist to detect delirium as a reference standard. The goal of this study was to characterize the properties of the measures obtained in a randomized controlled trial, to document their relationship to the Diagnostic and Statistical Manual of Mental Disorders:Text Revision based diagnosis of postoperative delirium by a consensus panel, and to describe the method in detail to allow replication by others. METHODS A secondary analysis of the randomized trial STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) was conducted. Delirium assessments were performed in 200 consecutive hip fracture repair patients ≥65 years old. Assessors underwent extensive training in delirium assessment and the final delirium diagnosis was adjudicated by a consensus panel of three physicians with expertise in delirium assessment. RESULTS A total of 680 consensus panel delirium diagnoses were completed. There were only 19 (2.8%, 19/678) evaluations where the delirium adjudication by the consensus panel differed from delirium findings by the Confusion Assessment Method (CAM). In 16 (84%, 16/19) of the cases, CAM was negative but the consensus panel diagnosed the patient as having delirium based on all of the available information including the CAM. CONCLUSION The consensus panel diagnosis was more sensitive compared to CAM alone, however the magnitude of the difference was not large. When assessors are well trained and delirium assessments are closely supervised throughout the study, CAM may be adequate for delirium diagnosis in a clinical trial. Future studies are needed to test this hypothesis.
Collapse
Affiliation(s)
- Esther S. Oh
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Johns Hopkins University School of NursingBaltimoreMarylandUSA
| | - Paul B. Rosenberg
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nae‐Yuh Wang
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Frederick E. Sieber
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Johns Hopkins University School of NursingBaltimoreMarylandUSA
| |
Collapse
|
14
|
Urfer Dettwiler P, Zúñiga F, Bachnick S, Gehri B, de Jonghe JFM, Hasemann W. Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study. Eur Geriatr Med 2022; 13:917-931. [PMID: 35143027 PMCID: PMC9378321 DOI: 10.1007/s41999-022-00612-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
Aim The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard. Findings This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%. Message The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents. Purpose Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard. Methods This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult. Results 85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer. Conclusion The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.
Collapse
Affiliation(s)
- Pia Urfer Dettwiler
- Nursing Home Frenkenbündten, Gitterlistrasse 10, 4410, Liestal, Switzerland.,Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Stefanie Bachnick
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Beatrice Gehri
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland.,University Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Jos F M de Jonghe
- Private Practice, DC VerzuimDiagnostiek , Tesselschadestraat 4, 1054 ET, msterdam, The Netherlands
| | - Wolfgang Hasemann
- University Department of Geriatric Medicine FELIX PLATTER, Burgfelderstrasse 101, 4002, Basel, Switzerland.
| |
Collapse
|
15
|
Montgomery A, Todd JA, Jones C, Koroitamana J, Grealish L, Wand A, Billett S, Teodorczuk A. The DEMS-DOSS study: validating a delirium monitoring tool in hospitalised older adults. Age Ageing 2022; 51:6530459. [PMID: 35192683 PMCID: PMC9171726 DOI: 10.1093/ageing/afac012] [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: 08/24/2021] [Revised: 11/28/2021] [Indexed: 11/15/2022] Open
Abstract
Objective to evaluate the sensitivity, specificity and test–retest reliability of the Delirium Early Monitoring System-Delirium Observation Screening Scale (DEMS-DOSS). Design prospective diagnostic accuracy study of a convenience sample of admitted older adults with DEMS-DOSS and reference standard assessments. Setting 60-bed aged care precinct at a metropolitan hospital in Sydney, Australia. Participants 156 patients (aged ≥65 years old) were recruited to participate between April 2018 and March 2020. One hundred participants were included in the analysis. Measurements Participants were scored on the DEMS-DOSS. Trained senior aged care nurses conducted a standardised clinical interview based on the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV delirium criteria, within two hours of DEMS-DOSS completion. The senior aged care nurse undertaking the DSM-IV interview was blinded to the results of the DEMS-DOSS. Results Participants’ mean age was 84 (SD ±7.3) years and 39% (n = 39) had a documented diagnosis of dementia. Delirium was detected in 38% (n = 38) according to the reference standard. The DEMS-DOSS had a sensitivity of 76.3% and a specificity of 75.8% for delirium. The area under the receiver operating characteristics curve for delirium was 0.76. The test–retest reliability of the DEMS-DOSS was found to be high (r = 0.915). Conclusion DEMS-DOSS is a sensitive and specific tool to assist with monitoring new onset and established delirium in hospitalised older adults. Further studies are required to evaluate the impact of the monitoring tool on health outcomes.
Collapse
Affiliation(s)
- Amy Montgomery
- School of Nursing , Faculty of Science, Medicine and Health, University of Wollongong, New South Wales, 2522, Australia
- Department of Aged Care , St. George Hospital, Kogarah, New South Wales 2217, Australia
- Illawarra Health and Medical Research Institute , University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Jo-Anne Todd
- Menzies Health Institute Queensland , Griffith University, Queensland 4111, Australia
| | - Cindy Jones
- Faculty of Health Sciences and Medicine , Bond University, Robina, Queensland 4226, Australia
- Healthcare Practice and Survivorship , Menzies Health Institute Queensland, Griffith University, Nathan, Queensland 4111, Australia
| | - June Koroitamana
- Department of Aged Care , St. George Hospital, Kogarah, New South Wales 2217, Australia
| | - Laurie Grealish
- Menzies Health Institute Queensland , Griffith University, Queensland 4111, Australia
- Gold Coast Health , Southport, Queensland 4215, Australia
| | - Anne Wand
- School of Psychiatry , Faculty of Medicine, University of New South Wales, Australia 2052, Australia
| | - Stephen Billett
- Education and Professional Studies , Griffith University, Brisbane, Queensland 4111, Australia
| | - Andrew Teodorczuk
- Metro North Mental Health , The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
- Faculty of Medicine , University of Queensland, Brisbane, Queensland 4072, Australia
- School of Medicine and Dentistry , Griffith University, Queensland 4111, Australia
| |
Collapse
|
16
|
Franks JA, Anderson JL, Bowman E, Li CY, Kennedy RE, Yun H. Inpatient Diagnosis of Delirium and Encephalopathy: Coding Trends 2011-2018. J Acad Consult Liaison Psychiatry 2022; 63:413-422. [PMID: 35017122 DOI: 10.1016/j.jaclp.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 12/18/2021] [Accepted: 12/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Ten medical societies have called for scientific literature to integrate research on delirium and encephalopathy, while physicians continually debate how to accurately document diagnoses of acute confusional states. To promote this integration, we evaluated trends in diagnoses of delirium and encephalopathy among hospitalized adults and physician specialties, incorporating transitions to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) and the International Classification of Disease-10 (ICD-10). METHODS Using 2011-2018 IBM MarketScan datasets, we identified delirium/encephalopathy patients ≥ 18 years using ICD-9/10 codes among hospitalized patients. We identified physician specialties associated with the hospitalization and comorbidities within one year prior to the diagnosis of delirium or encephalopathy. Log-binomial models were used to evaluate diagnostic trends, adjusting for age, gender, insurance and comorbidities. RESULTS We identified 10,509 hospitalized patients with diagnosis of delirium and 94,438 with encephalopathy between 2011-2018. Although the number of patients with either diagnosis increased over time, increased use of delirium diagnosis was less than it was for encephalopathy compared to 2011 after adjusting for covariates (ARR 0.45; 95% CI 0.43 to 0.48). During the 8 years, neurologists and internists increased their use of both diagnoses, whereas psychiatrists only increased their use of delirium. Family practice physicians and nurse practitioners presented no significant change in either diagnosis for this timeframe. CONCLUSIONS Our results suggest that refined diagnostic codes and criteria may alter trends among clinicians in diagnosing delirium and/or encephalopathy. Additional diagnostic clarity may be necessary to support refined diagnoses among family practice physicians and nurse practitioners.
Collapse
Affiliation(s)
- Jeffrey A Franks
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jami L Anderson
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL
| | - Ella Bowman
- Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Huifeng Yun
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
17
|
Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
Collapse
Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| |
Collapse
|
18
|
Nydahl P, Günther U, Hansen HC, Meyne J, Osterbrink J, Margraf NG. [Pitfalls in the diagnosis of delirium]. Med Klin Intensivmed Notfmed 2021; 117:615-622. [PMID: 34383103 DOI: 10.1007/s00063-021-00846-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/09/2021] [Accepted: 07/03/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis of delirium is challenging and requires precise definitions in both clinical routine and in studies. AIM To point out various pitfalls in the clinical diagnosis of delirium and discuss solutions. METHODS Review. RESULTS Common problems include (a) clinical judgment of staff vs. the use of valid assessment tools, (b) different lists of criteria for delirium that may consider the symptoms of delirium differently and thus lead to inclusion or exclusion of patients, (c) different assessment tools that test the symptoms of delirium to different extents and thus have different accuracy, (d) patients with limited communication abilities, such as aphasia, where common tests often fail and alternative procedures may be more effective; (e) the decision whether to test delirium once, twice, three times, or more frequently in 24 h has consequences on the incidence and duration of delirium, (f) the end of delirium, often defined retrospectively as a delirium-free interval or prospectively as the time of transfer or occurrence of an exclusion criterion, can lead to considerable measurement inaccuracies. CONCLUSIONS Although not all problems can be definitively answered, transparent definition, performance, and documentation of diagnostic procedures are recommended.
Collapse
Affiliation(s)
- Peter Nydahl
- Pflegeforschung, Abteilung für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Brunswiker Str. 10, 24105, Kiel, Deutschland.
| | - Ulf Günther
- Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie, Klinikum Oldenburg AöR, Oldenburg, Deutschland.,Oldenburger Forschungsnetzwerk Notfall- und Intensivmedizin, Fakultät VI - Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität, Oldenburg, Deutschland
| | - Hans-Christian Hansen
- Klinik für Neurologie, Friedrich-Ebert-Krankenhaus GmbH Neumünster/Universität Hamburg, Neumünster, Deutschland
| | - Johannes Meyne
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Jürgen Osterbrink
- Institut für Pflegewissenschaft und -praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.,Brooks College of Health, University of North Florida, Jacksonville, FL, USA
| | - Nils G Margraf
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| |
Collapse
|
19
|
Gupta N, Talathi S, Woolley A, Wilson S, Franklin M, Robbins J, Colston C, Hayes L. Performance of Cornell Assessment of Pediatric Delirium Scale in Mechanically Ventilated Children. J Pediatr Intensive Care 2021; 12:24-30. [PMID: 36742252 PMCID: PMC9894695 DOI: 10.1055/s-0041-1728784] [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: 03/01/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023] Open
Abstract
Accuracy of delirium diagnosis in mechanically ventilated children is often limited by their varying developmental abilities. The purpose of this study was to examine the performance of the Cornell Assessment of Pediatric Delirium (CAPD) scale in these patients. This is a single-center, prospective, observational study of patients requiring sedation and mechanical ventilation for 2 days or more. CAPD scale was implemented in our unit for delirium screening. Each CAPD assessment was accompanied by a physician assessment using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Sensitivity analysis was performed to determine the best cut-off score in our target population. We also evaluated ways to improve the accuracy of this scale in patients with and without developmental delay. A total of 837 paired assessments were performed. Prevalence of delirium was 19%. Overall, CAPD score ≥ 9 had sensitivity of 81.8% and specificity of 44.8%. Among typically developed patients, the sensitivity and specificity were 76.7 and 65.4%, respectively, whereas specificity was only 16.5% for developmentally delayed patients. The best cut-off value for CAPD was 9 for typically developed children and 17 for those with developmental delay (sensitivity 74.4%, specificity 63.2%). Some CAPD questions do not apply to patients with sensory and neurocognitive deficits; upon excluding those questions, the best cut-off values were 5 for typically developed and 6 for developmentally delayed children. In mechanically ventilated patients with developmental delay, CAPD ≥ 9 led to a high false-positive rate. This emphasizes the need for either a different cut-off score or development of a delirium scale specific to this patient population.
Collapse
Affiliation(s)
- Neha Gupta
- Division of Pediatric Critical Care, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States,Address for correspondence Neha Gupta, MD 1200 Everette Drive, Suite 8305, Oklahoma City, OK 73104United States
| | - Saurabh Talathi
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, United States
| | - Allison Woolley
- Department of Family Services, Children's of Alabama, Birmingham, Alabama, United States
| | - Stephanie Wilson
- Department of Physical and Occupational Therapy, Children's of Alabama, Birmingham, Alabama, United States
| | - Mildred Franklin
- Department of Nursing, Children's of Alabama, Birmingham, Alabama, United States
| | - Johanna Robbins
- Department of Physical and Occupational Therapy, Children's of Alabama, Birmingham, Alabama, United States
| | - Candice Colston
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Leslie Hayes
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| |
Collapse
|
20
|
Abstract
OBJECTIVES This study sets out to ascertain if recognition of delirium impacts on patient outcomes. DESIGN Retrospective cohort study. SETTING Unscheduled admissions to acute care trust/secondary care UK hospitals. PARTICIPANTS Six hundred and fifty-six older adults aged ≥65 years admitted on 14 September 2018. MEASUREMENTS Delirium was ascertained retrospectively from case notes using medical notes. Documented delirium was classified as recognised delirium and retrospectively ascertained delirium was classified as unrecognised delirium. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measure: inpatient mortality. SECONDARY OUTCOME MEASURES length of stay, discharge destination. RESULTS Delirium was present in 21.1% (132/626) of patients at any point during admission. The presence of delirium was associated with increased mortality (HR 2.65, CI 1.40 to 5.01). Recognition of delirium did not significantly impact on outcomes. CONCLUSIONS Delirium is associated with adverse outcomes in hospitalised older adults. However, there is insufficient evidence that recognition of delirium affects outcomes. However, delirium recognition presents an opportunity to discuss a person's overall prognosis and discuss this with the patient and their family. Further research is needed to assess the pathophysiology of delirium to enable development of targeted interventions towards improved outcomes in patients with delirium.
Collapse
|
21
|
Abstract
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles (
n
= 81), and these were followed by, case reports (
n
= 58), review articles (
n
= 10), letter to the editor (not as case reports but as a communication;
n
= 13), editorials (
n
= 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
Collapse
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devakshi Dua
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
22
|
Torigoe T, Imanishi J, Yazawa Y, Koyama T, Kadono Y, Oda H, Saita K. Oncologic emergency in patients with skeletal metastasis of unknown primary. Acute Med Surg 2021; 8:e600. [PMID: 33552525 PMCID: PMC7860590 DOI: 10.1002/ams2.600] [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: 08/05/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Aim Patients with skeletal metastasis from prediagnosed primary malignancy sometimes have concurrent oncologic emergency (OE) during the first visit. This study aims to investigate the types of OEs and treatment outcome in such patients. Methods We have experienced 359 patients with skeletal metastasis from unknown primary malignancy. Among them, 130 patients required immediate admission for OE treatment (OE group), 229 patients had no OE and did not required immediate admission (non‐OE group). Results The recognized types of OE were spinal cord compression in 60 patients, cancer pain in 30, hypercalcemia in 19, delirium in 16, deep vein thrombosis in 13, acute renal failure in 6, respiratory failure in 3, gastrointestinal hemorrhage in 3, and disseminated intravascular coagulation in 1. The overall 5‐year survival rates were 28% and 37% in the OE and non‐OE groups, respectively (P < 0.001). The multivariate analysis revealed that delirium (hazard ratio 4.2; 95% confidence interval, 1.6–12.5; P < 0.005) and respiratory failure (hazard ratio 22.6; 95% confidence interval, 4.5–92.8; P < 0.001) were significant prognostic factors in patients with OEs, whereas other OEs did not confer a significant risk for patient outcomes. Conclusion In this study, OE was observed in as many as 36% of patients with skeletal metastasis from unknown primary malignancy. Delirium and respiratory failure were only two significant prognostic risk factors, which suggest that many of the OEs in untreated advanced cancer patients have probable chance to resolve. Early detection followed by appropriate treatment of such OEs is recommended.
Collapse
Affiliation(s)
- Tomoaki Torigoe
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Jungo Imanishi
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Yasuo Yazawa
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Tadaaki Koyama
- Division of Orthopedic Oncology Shizuoka Cancer Center Hospital Nagaizumi Japan
| | - Yuho Kadono
- Department of Orthopedic Surgery Saitama Medical University Moroyama Japan
| | - Hiromi Oda
- Department of Orthopedic Surgery Saitama Medical University Moroyama Japan
| | - Kazuo Saita
- Department of Orthopedic Surgery Saitama Medical Center Saitama Medical University Kawagoe Japan
| |
Collapse
|
23
|
Bacellar A, Assis TRD, Pedreira BB, CÔrtes L, Santana S, Nascimento OJMD. Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:687-694. [PMID: 33263637 DOI: 10.1590/0004-282x20200062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures. METHODS We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors. RESULTS The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014). CONCLUSION Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.
Collapse
Affiliation(s)
- Aroldo Bacellar
- Hospital São Rafael, Department of Neurology, D'Or Institute for Research and Education, Salvador BA, Brazil
| | - Telma Rocha de Assis
- Hospital São Rafael, Department of Neurology, D'Or Institute for Research and Education, Salvador BA, Brazil
| | - Bruno Bacellar Pedreira
- Hospital São Rafael, Department of Neurology, D'Or Institute for Research and Education, Salvador BA, Brazil
| | - Luan CÔrtes
- Resident of the Department of Neurology, Hospital São Rafael, Monte Tabor Foundation, Italian-Brazilian Centre for Health Promotion, Salvador BA, Brazil
| | - Silas Santana
- Resident of the Department of Neurology, Hospital São Rafael, Monte Tabor Foundation, Italian-Brazilian Centre for Health Promotion, Salvador BA, Brazil
| | | |
Collapse
|
24
|
Eeles E, Ward S, Teodorczuk A, Dissanayaka N, Burianová H. Consciousness and the rabbit holes of delirium. Med Hypotheses 2020; 144:110260. [PMID: 33254566 DOI: 10.1016/j.mehy.2020.110260] [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: 08/09/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/24/2022]
Abstract
Delirium is a common disorder in hospitalized older adults and the defining characteristic is a disturbance of consciousness. Unfortunately, there are currently no testable measures of consciousness as pertains to its disruption in delirium. Not surprisingly rates of recognition of delirium suffer. Arguably, a greater understanding of the quantum of consciousness may improve delirium diagnosis through better diagnostic tools. Candidate dimensions of consciousness derived from fields of psychology, psychiatry, and philosophy are discussed and relevance to delirium explored. Based upon existing literature in the field of consciousness we identify the pre-reflective state, experiential awareness, and functional networks as candidate sites that may be affected in delirium. Opportunities for clinical instrument development and how these tools can be tested are discussed. We conclude that consciousness content may not hold to a unitary measurement, but facets of its integrity that are impacted in delirium are open to further exploration. Disorders in pre-reflective status, experiential awareness, and functional networks may represent the measurable "rabbit holes" of consciousness disturbance.
Collapse
Affiliation(s)
- Eamonn Eeles
- Internal Medicine Service, The Prince Charles Hospital, Brisbane, QLD, Australia; School of Medicine, Northside Clinical School, The University of Queensland, The Prince Charles Hospital, QLD, Australia; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD.
| | - S Ward
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD; Redcliffe Hospital, Redcliffe, QLD, Australia
| | - A Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia; Metro North Mental Health, The Prince Charles Hospital, Brisbane, Australia
| | - N Dissanayaka
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD; Department of Neurology, Royal Brisbane & Women's Hospital, Herston, Brisbane, QLD, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - H Burianová
- Department of Psychology, Bournemouth University, Fern Barrow, Poole, Dorset UK
| |
Collapse
|
25
|
Thiercelin N, Plat A, Garin A, Azuar J. [Alcohol withdrawal delirium: What's new for an old disease?]. Rev Med Interne 2020; 42:330-337. [PMID: 33218791 DOI: 10.1016/j.revmed.2020.10.383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/08/2020] [Accepted: 10/28/2020] [Indexed: 10/23/2022]
Abstract
The management of alcohol withdrawal syndrome is a frequent work in both community medicine and hospital wards. One of the most severe complications of alcohol withdrawal is Delirium Tremens (DT). The purpose of this development is to update knowledge on this complication in terms of diagnosis, evaluation and therapeutic approaches. It also proposes a reflection on the trajectory of care during and after DT.
Collapse
Affiliation(s)
- N Thiercelin
- Centre hospitalier des quatre villes, unité d'addictologie, 141 grande rue, 91570 Sèvres, France.
| | - A Plat
- Clinique des Epinettes, 51, bis rue des Epinettes, 75017 Paris, France
| | - A Garin
- Service de réanimation, centre hospitalier général de Dreux, 44, avenue J.F.-Kennedy, 28100 Dreux, France
| | - J Azuar
- APHP GHU Nord, Site Lariboisière Fernand-Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France; Inserm UMRS-1144 Optimisation thérapeutique en neuropsychopharmacologie, Université de Paris, Paris, France; FHU NOR-SUD, Paris, France
| |
Collapse
|
26
|
Franco JG, Trzepacz PT, Sepúlveda E, Ocampo MV, Velásquez-Tirado JD, Zaraza DR, Restrepo C, Giraldo AM, Serna PA, Zuluaga A, López C. Delirium diagnostic tool-provisional (DDT-Pro) scores in delirium, subsyndromal delirium and no delirium. Gen Hosp Psychiatry 2020; 67:107-114. [PMID: 33091783 DOI: 10.1016/j.genhosppsych.2020.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate whether the Delirium Diagnostic Tool-Provisional (DDT-Pro), a 0-9 point scale with three items each representing symptoms from delirium's three core domains, differentiates subsyndromal delirium (SSD) from delirium and no delirium. METHODS We applied cluster analyses of DDT-Pro scores from 200 consecutive inpatients using three reference standards for delirium diagnosis to determine DDT-Pro cutoff values for delirium, SSD and no delirium groups. Clinical validators and DDT-Pro item scores were compared among groups. RESULTS DDT-Pro SSD range was 6-7 (n = 54), with no delirium having higher scores (n = 98) and delirium lower (n = 48). Dementia prevalence in the SSD group (40.7%) was intermediate between no delirium (20.4%) and delirium (66.7%). SSD and delirium groups were more affected than no delirium regarding medical comorbidities, hospital stay (no delirium <1 week, SSD and delirium >1 week) and mortality (SSD = 7.4%, delirium = 18.8%, no delirium = 1%). Values for motor subtypes, frontal lobe signs, and DRS-R98 in the SSD group were intermediate between no delirium and delirium, as well as for the DDT-Pro items (all p < 0.05). CONCLUSIONS All DDT-Pro items, which represent the three delirium core domains, are important for SSD diagnosis. Patients scoring in the SSD 6-7 range have significant clinical and prognostic features and deserve clinical attention.
Collapse
Affiliation(s)
- José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Esteban Sepúlveda
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain
| | - María V Ocampo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Juan D Velásquez-Tirado
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Daniel R Zaraza
- Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Cristóbal Restrepo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Alejandra M Giraldo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paola A Serna
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Adolfo Zuluaga
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carolina López
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| |
Collapse
|
27
|
Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care. Aust Crit Care 2020; 34:226-234. [PMID: 33909556 DOI: 10.1016/j.aucc.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity. DESIGN This is a prospective observational study. SETTING The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital. PATIENTS The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h. INTERVENTIONS No interventions were provided in the study. MEASUREMENTS AND MAIN RESULTS Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01). CONCLUSIONS Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.
Collapse
|
28
|
MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
Collapse
Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| |
Collapse
|
29
|
Adamis D, Coada I, Eikelenboom P, Chu CS, Finn K, Melvin V, Williams J, Meagher DJ, McCarthy G. Delirium, insulin-like growth factor I, growth hormone in older inpatients. World J Psychiatry 2020; 10:212-222. [PMID: 33014722 PMCID: PMC7515747 DOI: 10.5498/wjp.v10.i9.212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 06/16/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Delirium is a common disorder in elderly medical inpatients with serious adverse outcomes and is characterized by sudden onset, disturbance in attention, awareness, consciousness and cognition, and often with behavioural disturbances. Central to understanding delirium, is understanding mechanisms by which body and brain wellbeing are linked and in particular how brain responses to bodily homeostatic stress is mediated. A number of studies have investigated the relationship between insulin-like growth factor I (IGF-I) and delirium in medically ill hospitalised patients with conflicting results. However, none have investigated growth hormone (GH) which is related to IGF-I via negative feedback.
AIM To investigate the relationship between serum levels of IGF-I and GH, and the occurrence of delirium.
METHODS Prospective, longitudinal, observational study. Consecutive elderly inpatients (aged 70+), were assessed twice weekly with Montreal cognitive assessment (MoCA), Confusion assessment method (CAM), Acute Physiology and Chronic Health Evaluation II. Delirium was defined using CAM. Previous history of dementia was evaluated with the Informant Questionnaire on Cognitive Decline in the Elderly. IGF-I and GH levels were estimated with the ELISA method. Generalized estimating equations (GEE) model was applied for the first five assessments to analyze those longitudinal data.
RESULTS The sample consisted of 198 participants (mean age 80.63 ± 6.81; range 70-97). Of these 92 (46.5%) were females. Eighty six (43.4%) were identified with a history of dementia. Incident or prevalent delirium during hospitalisation was identified with CAM in 40 participants (20.2%). Evaluation of missing values with Little's MCAR test indicated that they were missing completely at random (MCAR χ2 = 12.24, u: 9, P = 0.20). Using GEE for the analysis we found that low MoCA scores, low levels of IGF-I and high levels of GH were significantly associated with any delirium (prevalence, incident, or fluctuating , during the study period (Wald χ2 = 12.231; u: 1, P < 0.001, Wald χ2 = 7.196, u: 1, P = 0.007, Wald χ2 = 6.210; : u: 1, P = 0.013 respectively).
CONCLUSION The results show that low levels of IGF-I, high levels of GH and low scores in cognition are independently associated with the occurrence of any delirium during the hospitalisation of medically ill older people. The results of the study supports the hypothesis that deficits in the immunoreactivity of the brain (low cerebral reserve) may be associated with delirium.
Collapse
Affiliation(s)
- Dimitrios Adamis
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
- Department of Psychiatry, Research and Academic Institute of Athens, Athens 11742, Greece
- Department of Psychiatry, University Hospital Limerick, Limerick V94 F858, Ireland
| | - Iulian Coada
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
| | - Piet Eikelenboom
- Department of Psychiatry, GGZinGeest and VuMC, Amsterdam 1081 HV, the Netherlands
| | - Che-Sheng Chu
- Department of Psychiatry and Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan
| | - Karen Finn
- Department of Biopharmaceutical and Medical Science, School of Science and Computing, Galway-Mayo Institute of Technology, Galway H91 T8NW, Ireland
| | - Vincent Melvin
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
| | - John Williams
- Department of Pathology, Sligo University Hospital, Sligo F91 H684, Ireland
| | - David James Meagher
- Department of Psychiatry, University Hospital Limerick, Limerick V94 F858, Ireland
| | - Geraldine McCarthy
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
| |
Collapse
|
30
|
Edwards DA, Medhavy A, Hoffman OG, Hoffman GR. Postoperative Delirium is Associated With Prolonged Head and Neck Resection and Reconstruction Surgery: An Institutional Study. J Oral Maxillofac Surg 2020; 79:249-258. [PMID: 32898481 DOI: 10.1016/j.joms.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Delirium is a recognized complication of surgery. It has a deleterious effect on a patient's postoperative recovery and well-being. The purpose of this study was to estimate the frequency and identify the risk factors for the development of postoperative delirium (POD) in a cohort of patients who underwent extensive head and neck surgery (HNS) of greater than five hours duration. MATERIALS AND METHODS The authors undertook a retrospective cohort study of patients who underwent HNS of greater than five hours duration. The primary predictor variables comprised a set of risk factors (sociodemographic, disease-specific, duration of surgery, and duration of inpatient stay) that were thought to be associated with the development of POD. The primary outcome variable was the development of POD. Descriptive, bivariate, and multivariate statistical analysis was undertaken, and significance was set at P < .05. RESULTS One hundred and seventy patients were included in the study. There were 124 males and 46 females. Forty patients (23.53%) developed POD: 30 documented and 10 inferred. The mean age of the POD cohort was 65 years (SD 13), with a median age of 69 years. The occurrence of POD was statistically related to increased age, mental health status, American Society of Anesthesiologists (ASA) score, and drug dependence (either illicit or prescription). POD and operative duration were statistically associated. POD and length of stay were not statistically associated. CONCLUSION Delirium did occur postoperatively in 23.53% of our patients who underwent extensive and prolonged HNS. POD may go unrecognized by treating teams. As POD has a deleterious effect on the cognitive function, it is important to identify and aggressively treat episodes of POD that occur during a patient's postoperative recovery.
Collapse
Affiliation(s)
- Delyth A Edwards
- Consultant (Attending) Anaesthetist, Department of Anaesthetics, John Hunter Hospital, Newcastle, Australia
| | - Aditi Medhavy
- Resident Medical Officer, Liverpool Hospital, Liverpool, Australia
| | - Olivia G Hoffman
- First year Medical Student, The University of Melbourne, Melbourne, Australia
| | - Gary R Hoffman
- Consultant (Attending) in Head and Neck Surgery, Department of Maxillofacial Surgery, John Hunter Hospital, Newcastle, Australia; Professor, Medical School, The University of Newcastle, Newcastle, Australia.
| |
Collapse
|
31
|
Opioid use is Associated with ICU Delirium in Mechanically Ventilated Children. J Crit Care Med (Targu Mures) 2020; 6:167-174. [PMID: 32864462 PMCID: PMC7430359 DOI: 10.2478/jccm-2020-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/27/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Pediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated. Aim of the study To identify factors associated with delirium in mechanically ventilated children in an ICU. Material and Methods This is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines. Results 95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007). Conclusions Age, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.
Collapse
|
32
|
Nacul FE, Paul N, Spies CD, Sechting H, Hecht T, Dullinger JS, Piper SK, Luetz A, Balzer FS, Wernecke KD, Sa AK, Barros Ferreira da Costa C, Eymold L, Chenitir C, Weiss B. Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU-An International, Prospective, Bi-Center Observational Study (IDeAS). ACTA ACUST UNITED AC 2020; 56:medicina56080411. [PMID: 32823781 PMCID: PMC7466203 DOI: 10.3390/medicina56080411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors “level of sedation” and “mechanical ventilation” impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/−1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/−1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs.
Collapse
Affiliation(s)
- Flavio E. Nacul
- Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil; (F.E.N.); (A.K.S.); (C.B.F.d.C.)
| | - Nicolas Paul
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Henriette Sechting
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Thomas Hecht
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Jörn S. Dullinger
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Sophie K. Piper
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (S.K.P.); (K.-D.W.)
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Alawi Luetz
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
- Department of Healthcare Management, Technische Universität Berlin, 10623 Berlin, Germany
| | - Felix S. Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Klaus-Dieter Wernecke
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (S.K.P.); (K.-D.W.)
| | - Anna Karinina Sa
- Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil; (F.E.N.); (A.K.S.); (C.B.F.d.C.)
| | | | - Lisa Eymold
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Chokri Chenitir
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
- Correspondence: ; Tel.: +49-30-450-631-027
| |
Collapse
|
33
|
Roh HS, Park YC, Jo YG, Kim JC. The Incidence and Impact of Abdominal Surgery on Delirium in Abdominal Trauma Patients. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
34
|
Brown CH, Neufeld KJ, Tian J, Probert J, LaFlam A, Max L, Hori D, Nomura Y, Mandal K, Brady K, Hogue CW, Shah A, Zehr K, Cameron D, Conte J, Bienvenu OJ, Gottesman R, Yamaguchi A, Kraut M. Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial. JAMA Surg 2020; 154:819-826. [PMID: 31116358 DOI: 10.1001/jamasurg.2019.1163] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). Conclusions and Relevance The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. Trial Registration ClinicalTrials.gov identifier: NCT00981474.
Collapse
Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Andrew LaFlam
- Medical Student, School of Medicine, Tufts University, Medford Massachusetts
| | - Laura Max
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Ken Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles W Hogue
- Bluhm Cardiovascular Institute, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ashish Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - O Joseph Bienvenu
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Michael Kraut
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
35
|
Reif SJ, Layon AJ. A pilot volunteer reader programme decreases delirium days in critically ill, adult ICU patients. BMJ Open Qual 2020; 9:e000761. [PMID: 32690546 PMCID: PMC7373306 DOI: 10.1136/bmjoq-2019-000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 05/30/2020] [Accepted: 06/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - A Joseph Layon
- Department of Anesthesiology, University of Central Florida College of Medicine, Orlando, Florida, United States
- Professor of Anesthesiology, UniCamillus -International Medical University, Via di Sant'Alessandro, Rome, Italy
| |
Collapse
|
36
|
Oldham MA, Holloway RG. Delirium disorder. Neurology 2020; 95:173-178. [DOI: 10.1212/wnl.0000000000009949] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
ObjectiveAs the US population ages and with no definitive delirium treatments on the horizon, the delirium epidemic is on course to expand over the coming decades. Recognizing the import of this condition, a recent position statement from 10 medical societies—among whom the American Academy of Neurology was represented—issued recommendations on preferred nomenclature of delirium and acute encephalopathy: it concluded by preferring both terms. Urgently needed is an integrated model that addresses the near-total segregation of these separate bodies of literature, ideally one that offers an interdisciplinary framework to bring these 2 terms and those who use them together.MethodsWe review the historical forces that have led these terms to diverge and consider the unique benefits of each approach as well as their liabilities when considered in isolation. We then explore the potential implications of integrating these concepts and propose a hybrid model to capitalize on the strengths of both the model of delirium and that of acute encephalopathy.ResultsThe model we propose—delirium disorder—builds on the recommendations of this recent position statement and provides a unifying framework designed to have clinical utility and interdisciplinary appeal. It also broadens the translational landscape by identifying 4 distinct treatment targets: underlying causes, procognitive factors, delirium (phenotype alone), and neurophysiologic targets.ConclusionsThis person-centered model aims to integrate delirium and acute encephalopathy within a single framework and shared nomenclature. It is hoped that this model aids in harmonizing research efforts and advancing clinical practice.
Collapse
|
37
|
Gibb K, Seeley A, Quinn T, Siddiqi N, Shenkin S, Rockwood K, Davis D. The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Age Ageing 2020; 49:352-360. [PMID: 32239173 PMCID: PMC7187871 DOI: 10.1093/ageing/afaa040] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. METHODS We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. RESULTS We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19-26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. DISCUSSION The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.
Collapse
Affiliation(s)
- Kate Gibb
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Acute Medical Unit, University College London Hospitals NHS Foundation Trust, UK
| | - Anna Seeley
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Department of Medicine for the Elderly, University College London Hospitals NHS Foundation Trust, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, UK
| | - Susan Shenkin
- Department of Geriatric Medicine, University of Edinburgh, UK
| | - Kenneth Rockwood
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Acute Medical Unit, University College London Hospitals NHS Foundation Trust, UK
- Department of Medicine for the Elderly, University College London Hospitals NHS Foundation Trust, UK
| |
Collapse
|
38
|
Reznik ME, Daiello LA, Thompson BB, Wendell LC, Mahta A, Potter NS, Yaghi S, Levy MM, Fehnel CR, Furie KL, Jones RN. Fluctuations of consciousness after stroke: Associations with the confusion assessment method for the intensive care unit (CAM-ICU) and potential undetected delirium. J Crit Care 2020; 56:58-62. [PMID: 31855707 DOI: 10.1016/j.jcrc.2019.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/22/2019] [Accepted: 12/09/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To examine associations between fluctuating consciousness and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessments in stroke patients compared to non-neurological patients. MATERIALS AND METHODS We linked all recorded CAM-ICU assessments with corresponding Richmond Agitation Sedation Scale (RASS) measurements in patients with stroke or sepsis from a single-center ICU database. Fluctuating consciousness was defined by RASS variability using standard deviations (SD) over 24-h periods; regression analyses were performed to determine associations with RASS variability and CAM-ICU rating. RESULTS We identified 16,509 paired daily summaries of CAM-ICU and RASS measurements in 546 stroke patients and 1586 sepsis patients. Stroke patients had higher odds of positive (OR 4.2, 95% CI 3.3-5.5) and "unable to assess" (UTA; OR 5.2, 95% CI 4.0-6.8) CAM-ICU ratings compared to sepsis patients, and CAM-ICU-positive and UTA assessment-days had higher RASS variability than CAM-ICU-negative assessment-days, especially in stroke patients. Based on model-implied associations of RASS variability (OR 2.0 per semi-IQR-difference in RASS-SD, 95% CI 1.7-2.2) and stroke diagnosis (OR 2.7, 95% CI 2.0-3.7) with CAM-ICU-positive assessments, over one-third of probable delirium cases among stroke patients were potentially missed by the CAM-ICU. CONCLUSIONS Post-stroke delirium may frequently go undetected by the CAM-ICU, even in the setting of fluctuating consciousness.
Collapse
Affiliation(s)
- Michael E Reznik
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America.
| | - Lori A Daiello
- Department of Neurology, Brown University, Alpert Medical School, United States of America
| | - Bradford B Thompson
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Linda C Wendell
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Ali Mahta
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - N Stevenson Potter
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Shadi Yaghi
- Department of Neurology, New York Langone Health, United States of America
| | - Mitchell M Levy
- Department of Medicine, Brown University, Alpert Medical School, United States of America
| | - Corey R Fehnel
- Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center, United States of America
| | - Karen L Furie
- Department of Neurology, Brown University, Alpert Medical School, United States of America
| | - Richard N Jones
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Psychiatry and Human Behavior, Brown University, Alpert Medical School, United States of America
| |
Collapse
|
39
|
Mu DL, Ding PP, Zhou SZ, Liu MJ, Sun XY, Li XY, Wang DX. Cross-cultural adaptation and validation of the 3D-CAM Chinese version in surgical ICU patients. BMC Psychiatry 2020; 20:133. [PMID: 32204700 PMCID: PMC7092439 DOI: 10.1186/s12888-020-02544-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Accurate diagnosis of delirium is very important for prevention and treatment. Present study was designed to validate the 3-Minute Diagnostic Interview for CAM-defined Delirium Chinese version (3D-CAM-CN) in surgical ICU patients. METHODS In this prospective diagnostic study, the 3D-CAM was translated into Chinese with culture adaption. Two interviewers (Roles A and B) independently administrated 3D-CAM-CN assessment in adult patients from postoperative days 1 to day 3. At the meantime, a panel of psychiatrists diagnosed delirium according to the Diagnostic and Statistical Manual of Mental Disorders-fifth edition as the reference standard. The sensitivity and specificity were calculated to analyze the diagnostic character of the 3D-CAM-CN. Kappa coefficient was used to evaluate interrater reliability. RESULTS Two hundred forty-five adult patients were assessed for at least 2 days, resulting a total of 647 paired-assessments. When compared with the reference standard, the sensitivity and specificity of the 3D-CAM-CN assessment were 87.2 and 96.7%, respectively, by Role A and 84.6 and 97.4%, respectively, by Role B, with good interrater reliability (Kappa coefficient = 0.82, P < 0.001). It also performed well in patients with mild cognitive impairment, with the sensitivity from 85.7 to 100% and the specificity from 95.7 to 96.4%. CONCLUSION Our results showed that the 3D-CAM-CN can be used as a reliable and accurate instrument for delirium assessment in surgical patients. TRIAL REGISTRATION This trail was approved by the Clinical Research Ethic Committee of Peking University First Hospital (No. 2017-1321) and registered on Chinese clinical trial registry on July 6, 2017 (ChiCTR-OOC-17011887).
Collapse
Affiliation(s)
- Dong-Liang Mu
- grid.411472.50000 0004 1764 1621Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Pan-Pan Ding
- grid.411472.50000 0004 1764 1621Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Shu-Zhe Zhou
- grid.459847.30000 0004 1798 0615Department of Geriatric Psychiatry, Peking University Sixth Hospital, Beijing, 100191 China
| | - Mei-Jing Liu
- grid.411472.50000 0004 1764 1621Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xin-Yu Sun
- Department of Geriatric Psychiatry, Peking University Sixth Hospital, Beijing, 100191, China.
| | - Xue-Ying Li
- grid.411472.50000 0004 1764 1621Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- grid.411472.50000 0004 1764 1621Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| |
Collapse
|
40
|
Nielsen RM, Urdanibia-Centelles O, Vedel-Larsen E, Thomsen KJ, Møller K, Olsen KS, Lauritsen AØ, Eddelien HS, Lauritzen M, Benedek K. Continuous EEG Monitoring in a Consecutive Patient Cohort with Sepsis and Delirium. Neurocrit Care 2020; 32:121-130. [PMID: 30891696 DOI: 10.1007/s12028-019-00703-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delirium is common during sepsis, although under-recognized. We aimed to assess the value of continuous electroencephalography (cEEG) to aid in the diagnosis of delirium in septic patients. METHODS We prospectively evaluated 102 consecutive patients in a medical intensive care unit (ICU), who had sepsis or septic shock, without evidence of acute primary central nervous system disease. We initiated cEEG recording immediately after identification. The median cEEG time per patient was 44 h (interquartile range 21-99 h). A total of 6723 h of cEEG recordings were examined. The Confusion Assessment Method for the ICU (CAM-ICU) was administered six times daily to identify delirium. We analyzed the correlation between cEEG and delirium using 1252 two-minute EEG sequences recorded simultaneously with the CAM-ICU scorings. RESULTS Of the 102 included patients, 66 (65%) had at least one delirium episode during their ICU stay, 30 (29%) remained delirium-free, and 6 (6%) were not assessable due to deep sedation or coma. The absence of delirium was independently associated with preserved high-frequency beta activity (> 13 Hz) (P < 10-7) and cEEG reactivity (P < 0.001). Delirium was associated with preponderance of low-frequency cEEG activity and absence of high-frequency cEEG activity. Sporadic periodic cEEG discharges occurred in 15 patients, 13 of whom were delirious. No patient showed clinical or electrographic evidence of non-convulsive status epilepticus. CONCLUSIONS Our findings indicate that cEEG can help distinguish septic patients with delirium from non-delirious patients.
Collapse
Affiliation(s)
- Rikke M Nielsen
- Department of Neuroanesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Neurophysiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olalla Urdanibia-Centelles
- Department of Clinical Neurophysiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Esben Vedel-Larsen
- Department of Clinical Neurophysiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten J Thomsen
- Department of Neuroscience, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karsten S Olsen
- Department of Neuroanesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Ø Lauritsen
- Department of Neuroanesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Heidi S Eddelien
- Department of Neuroanesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Lauritzen
- Department of Clinical Neurophysiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
- Department of Neuroscience, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark.
| | - Krisztina Benedek
- Department of Clinical Neurophysiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
41
|
Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review. Am J Emerg Med 2020; 38:349-357. [DOI: 10.1016/j.ajem.2019.158454] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
|
42
|
Ntalouka MP, Bareka M, Brotis AG, Chalkias A, Stamoulis K, Flossos A, Tzimas P, Arnaoutoglou E. Translation and cultural adaptation of the Greek version of the confusion assessment method diagnostic algorithm and the nursing delirium screening scale and their inter-rater reliability: A prospective cohort study. Hippokratia 2020; 24:8-14. [PMID: 33364733 PMCID: PMC7733361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The lack of standardized tools limits the diagnosis οf postoperative delirium (POD) in the Greek population. Our aim was the translation and the cultural adaptation of the confusion assessment method (CAM) diagnostic algorithm and the nursing delirium screening scale (nu-DESC) in the Greek surgical population, and the determination of their inter-rater reliability. METHODS After Ethical approval and registration as a clinical trial (NCT04154176), a prospective cohort study was conducted in the Department of Anesthesiology, University Hospital of Larissa, Greece. Patients at least 60 years old, undergoing elective non-cardiac surgery, under general anesthesia were included. RESULTS Data from 60 patients, 180 records in total, were analyzed. There was an "almost perfect agreement" between the raters with the use of CAM (Cohen's Kappa estimate: 0.960; 95 % CI: 0.905-1.000) and nu-DESC (Cohen's Kappa estimate: 0.981; 95 % CI: 0.944-1.000). The agreement on each specific question of CAM and nu-DESC ranged from "substantial" to "almost perfect agreement". Based on the CAM, the sensitivity and specificity of nu-DESC were 0.97 (95 % CI: 0.82-1.00) and 0.99 (95 % CI: 0.96-1.00), respectively. The Greek versions of CAM and nu-DESC showed a high inter-rater agreement. CONCLUSION With the translation, the cultural adaptation, and the determination of their inter-rater agreement, the CAM diagnostic algorithm and the nu-DESC may serve as reliable instruments for the detection of POD in the Greek population. HIPPOKRATIA 2020, 24(1): 8-14.
Collapse
Affiliation(s)
- M P Ntalouka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - M Bareka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - A G Brotis
- Department of Neurosurgery, University Hospital of Larissa, Thessaly, Greece
| | - A Chalkias
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - K Stamoulis
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - A Flossos
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - P Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Epirus, Greece
| | - E Arnaoutoglou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
43
|
Griton M, Dhaya I, Nicolas R, Raffard G, Periot O, Hiba B, Konsman JP. Experimental sepsis-associated encephalopathy is accompanied by altered cerebral blood perfusion and water diffusion and related to changes in cyclooxygenase-2 expression and glial cell morphology but not to blood-brain barrier breakdown. Brain Behav Immun 2020; 83:200-213. [PMID: 31622656 DOI: 10.1016/j.bbi.2019.10.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/02/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE) refers to brain dysfunction, including delirium, occurs during severe infection and is associated with development of post-traumatic stress disorder. SAE has been proposed to be related to reduced cerebral blood flow (CBF), blood-brain barrier breakdown (BBB), white matter edema and disruption and glia cell activation, but their exact relationships remain to be determined. In the present work, we set out to study CBF using Arterial Spin Labeling (ASL) and grey and white matter structure with T2- and diffusion magnetic resonance imaging (dMRI) in rats with cecal ligation and puncture (CLP)-induced encephalopathy. Using immunohistochemistry, the distribution of the vasoactive prostaglandin-synthesizing enzyme cyclooxygenase-2 (COX-2), perivascular immunoglobulins G (IgG), aquaporin-4 (AQP4) and the morphology of glial cell were subsequently assessed in brains of the same animals. CLP induced deficits in the righting reflex and resulted in higher T2-weighted contrast intensities in the cortex, striatum and at the base of the brain, decreased blood perfusion distribution to the cortex and increased water diffusion parallel to the fibers of the corpus callosum compared to sham surgery. In addition, CLP reduced staining for microglia- and astrocytic-specific proteins in the corpus callosum, decreased neuronal COX-2 and AQP4 expression in the cortex while inducing perivascular COX-2 expression, but did not induce widespread perivascular IgG diffusion. In conclusion, our findings indicate that experimental SAE can occur in the absence of BBB breakdown and is accompanied by increased water diffusion anisotropy and altered glia cell morphology in brain white matter.
Collapse
Affiliation(s)
- Marion Griton
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Service de Réanimation Anesthésie Neurochirurgicale, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Ibtihel Dhaya
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Laboratoire de Neurophysiologie Fonctionnelle et Pathologies, UR/11ES09, Faculté des Sciences Mathématiques, Physiques et Naturelles, Université de Tunis El Manar, Tunis, Tunisia
| | - Renaud Nicolas
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France
| | - Gérard Raffard
- CNRS, Résonance Magnétique des Systèmes Biologiques, UMR 5536, Bordeaux, France; Univ. Bordeaux, RMSB, UMR 5536, Bordeaux, France
| | - Olivier Periot
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Service de Médecine Nucléaire, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Bassem Hiba
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; CNRS UMR 5229, Centre de Neurosciences Cognitives Marc Jeannerod, Bron, France
| | - Jan Pieter Konsman
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France.
| |
Collapse
|
44
|
Translation and validation of the Tibetan confusion assessment method for the intensive care unit. Chin Med J (Engl) 2019; 132:1154-1158. [PMID: 30829717 PMCID: PMC6511416 DOI: 10.1097/cm9.0000000000000168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: At present, there is no available delirium translated assessment method for 3.3 million Tibetans. This study aimed to provide a method for delirium assessment for Tibetan patients speaking this language by validating a translation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Methods: The study was conducted between July 2018 and November 2018. Patients were screened for delirium by a neurologist using the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). Patients were subsequently screened by two nurses using Tibetan translations of the CAM-ICU. With DSM-IV criterion as the reference standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the validity of the CAM-ICU criterion. Interrater reliability was determined by comparing the CAM-ICU ratings of nurse 1 vs. nurse 2 using the κ coefficient. Results: Ninety-six patients were assessed independently by two nurses and one neurologist. According to DSM-IV standard, 42 out of 96 (43.8%) patients developed delirium. The sensitivities of Tibetan CAM-ICU were 90.5% for nurse 1 and 92.9% for nurse 2, respectively. Their specificities were 85.2% and 90.7%, respectively. The PPV were 82.6% for nurse 1 and 88.6% for nurse 2. Their NPV were 92.0% and 94.2%, respectively. The Tibetan CAM-ICU was done with good interrater reliability between nurse 1 and nurse 2 (κ = 0.91, P < 0.001). Conclusion: The Tibetan CAM-ICU shows good validity and might be incorporated into clinical practice in Tibetan Intensive Care Units. Clinical Trail Registry: www.chictr.org.cn (No. ChiCTR1800018231)
Collapse
|
45
|
Brown CH, Neufeld KJ, Tian J, Probert J, LaFlam A, Max L, Hori D, Nomura Y, Mandal K, Brady K, Hogue CW, Shah A, Zehr K, Cameron D, Conte J, Bienvenu OJ, Gottesman R, Yamaguchi A, Kraut M. Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial. JAMA Surg 2019. [PMID: 31116358 DOI: 10.1001/jamasurg.2019.1163.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). Conclusions and Relevance The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. Trial Registration ClinicalTrials.gov identifier: NCT00981474.
Collapse
Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Andrew LaFlam
- Medical Student, School of Medicine, Tufts University, Medford Massachusetts
| | - Laura Max
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Ken Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles W Hogue
- Bluhm Cardiovascular Institute, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ashish Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - O Joseph Bienvenu
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Michael Kraut
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
46
|
King CR, Escallier KE, Ju YES, Lin N, Palanca BJ, McKinnon SL, Avidan MS. Obstructive sleep apnoea, positive airway pressure treatment and postoperative delirium: protocol for a retrospective observational study. BMJ Open 2019; 9:e026649. [PMID: 31455698 PMCID: PMC6720237 DOI: 10.1136/bmjopen-2018-026649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 06/07/2019] [Accepted: 07/18/2019] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is common among older surgical patients, and delirium is a frequent and serious postoperative complication. Emerging evidence suggests that OSA increases the risk for postoperative delirium. We hypothesise that OSA is an independent risk factor for postoperative delirium, and that in patients with OSA, perioperative adherence to positive airway pressure (PAP) therapy decreases the incidence of postoperative delirium and its sequelae. The proposed retrospective cohort analysis study will use existing datasets to: (i) describe and compare the incidence of postoperative delirium in surgical patients based on OSA diagnosis and treatment with PAP; (ii) assess whether preoperatively untreated OSA is independently associated with postoperative delirium; and (iii) explore whether preoperatively untreated OSA is independently associated with worse postoperative quality of life (QoL). The findings of this study will inform on the potential utility and approach of an interventional trial aimed at preventing postoperative delirium in patients with diagnosed and undiagnosed OSA. METHODS AND ANALYSIS Observational data from existing electronic databases will be used, including over 100 000 surgical patients and ~10 000 intensive care unit (ICU) admissions. We will obtain the incidence of postoperative delirium in adults admitted postoperatively to the ICU who underwent structured preoperative assessment, including OSA diagnosis and screening. We will use doubly robust propensity score methods to assess whether untreated OSA independently predicts postoperative delirium. Using similar methodology, we will assess if untreated OSA independently predicts worse postoperative QoL. ETHICS AND DISSEMINATION This study has been approved by the Human Research Protection Office at Washington University School of Medicine. We will publish the results in a peer-reviewed venue. Because the data are secondary and high risk for reidentification, we will not publicly share the data. Data will be destroyed after 1 year of completion of active Institutional Review Board (IRB) approved projects.
Collapse
Affiliation(s)
- Christopher R King
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Krisztina E Escallier
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Yo-El S Ju
- Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Nan Lin
- Mathematics, Washington University in Saint Louis, St. Louis, Missouri, USA
- Division of Biostatistics, Washington Univiersity in Saint Louis, St. Louis, Missouri, USA
| | - Ben Julian Palanca
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Sherry Lynn McKinnon
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| | - Michael Simon Avidan
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, US
| |
Collapse
|
47
|
|
48
|
Abstract
Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.
Collapse
Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Consciousness Science, University of Michigan Medical School,, Ann Arbor, MI, USA
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| |
Collapse
|
49
|
Lawlor PG, Rutkowski NA, MacDonald AR, Ansari MT, Sikora L, Momoli F, Kanji S, Wright DK, Rosenberg E, Hosie A, Pereira JL, Meagher D, Rice J, Scott J, Bush SH. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. J Pain Symptom Manage 2019; 57:661-681.e12. [PMID: 30550832 DOI: 10.1016/j.jpainsymman.2018.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
CONTEXT Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.
Collapse
Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | | | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David K Wright
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Critical Care, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jose L Pereira
- Department of Family Medicine, University of Ottawa, Ontario, Canada; Division of Palliative Medicine, McMaster University, Ontario, Canada
| | - David Meagher
- University of Limerick School of Medicine, Limerick, Ireland
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Scott
- The Ottawa Hospital, Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
50
|
McCoy TH. Mapping the Delirium Literature Through Probabilistic Topic Modeling and Network Analysis: A Computational Scoping Review. PSYCHOSOMATICS 2019; 60:105-120. [DOI: 10.1016/j.psym.2018.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/09/2018] [Accepted: 12/13/2018] [Indexed: 01/21/2023]
|