Immunology of delirium: new opportunities for treatment and research

Management of delirium in acute stroke patients: a position paper by the Austrian Stroke Society on prevention, diagnosis, and treatment

Delirium is a common complication in acute stroke patients, occurring in 15-35% of all stroke unit admissions and is associated with prolonged hospital stay and a poor post-stroke prognosis. Managing delirium in acute stroke patients necessitates an intensive and multiprofessional therapeutic approach, placing a significant burden on healthcare staff. However, dedicated practical recommendations for delirium management developed for the population of acute stroke patients are lacking. For this purpose, the Austrian Stroke Society, in cooperation with the Austrian Society of Neurology, the Austrian Society of Neurorehabilitation, and the Austrian Society of Psychiatry, Psychotherapy, and Psychosomatics has formulated an evidence-based position paper addressing the management of delirium in acute stroke patients. The paper outlines practical recommendations on the three pillars of care in stroke patients with delirium: (a) Key aspects of delirium prevention including stroke-specific delirium risk factors and delirium prediction scores are described. Moreover, a non-pharmacological delirium prevention bundle is presented. (b) The paper provides recommendations on timing and frequency of delirium screening to ensure early diagnosis of delirium in acute stroke patients. Moreover, it reports on the use of different delirium screening tools in stroke populations. (c) An overview of non-pharmacological and pharmacological treatment strategies in patients with delirium and acute stroke is presented and summarized as key recommendation statements.

A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial

Aims and background

The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery.

Materials and methods

This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay.

Results

108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups.

Conclusion

This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate.

How to cite this article

Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.

Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment

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.

Low peripheral levels of insulin growth factor-1 are associated with high incidence of delirium among elderly patients: A systematic review and meta-analysis

INTRODUCTION

Delirium, a serious condition observed in critically ill patients, clinically presents with impaired cognition and consciousness. The relationship between delirium and peripheral levels of insulin growth factor-1 (IGF-1) is unclear. Thus we conducted a meta-analysis to address this issue.

METHODS

Seven major electronic databases were searched from inception until October 2, 2017 to obtain relevant clinical variables to compare the difference in IGF-1 levels between delirious and non-delirious elderly in-patients. A random effects meta-analysis was conducted.

RESULTS

We studies 10 articles involving 294 delirious patients (mean age 73.0 years) and 604 non-delirious patients (mean age 76.9 years). We found that peripheral levels of IGF-1 in patients with delirium were significantly lower than in those without delirium (Hedges' g = -0.209, 95% confidence interval [CI] = -0.393 to -0.026, p = 0.025). Meta-regression analyses found that no variables such as percentage of cognitive impairment, mean age, and female proportion contribute to heterogeneity in terms of the entire population.

CONCLUSIONS

Our data suggests that lower peripheral levels of IGF-1 could be associated with a higher incidence of delirium among elderly patients. Further prospective studies with larger sample sizes are needed to investigate the association between peripheral levels of IGF-1 and delirium.

Preventing dementia

Epidemiological evidence has identified key strategies that may be used in the prevention of both Alzheimer's disease and vascular dementia. These strategies may be loosely divided into three areas: treatment of vascular risk factors, neuroprotection and increasing neuronal reserves. Evidence from randomised controlled trials already exists for treatment of hypertension but results for statins have been disappointing. Most of the intervention trials currently in progress focus on one or two risk factors and include cognition or dementia only as a secondary outcome. The potential of intervention strategies awaits confirmation by randomised controlled trials that target multiple risk factors in at-risk people with mild cognitive impairment, with incident dementia as the primary outcome.

Remote ischemic preconditioning improves the cognitive function of elderly patients following colon surgery: A randomized clinical trial

BACKGROUND

Cognitive function impairment is one of the most common complications in elderly patients after surgery, and an ideal nonpharmacological therapy has not yet been identified. Thus, we hypothesized that remote ischemic preconditioning could improve cognitive functions in elderly patients after surgery and investigated the mechanism underlying this effect.

METHODS

Ninety patients classified as American Society of Anaesthesiologists (ASA) physical status of 2 or 3 and aged 65 to 75 years who were scheduled for elective colon surgery under general anesthesia were randomly allocated to either a remote ischemic preconditioning group (Group R, n = 45) or a control group (Group C, n = 45). Remote ischemic preconditioning was performed by applying a static pressure of 200 mm Hg with a blood pressure cuff wrapped around the right upper limb for 3 ischemia cycles of 5 minutes each.

RESULTS

The Montreal Cognitive Assessment (MoCA) scores between the 2 groups were not significantly different on the day before surgery or the seventh day after surgery, but the scores on the first day after surgery (26.87 ± 0.84 vs 25.96 ± 0.85, P < .001) and third day after surgery (27.49 ± 0.66 vs 27.02 ± 0.92, P = .009) were significantly higher for Group R than those for Group C. Moreover, remote ischemic preconditioning markedly decreased the serum concentrations of the interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and S100B proteins compared with the control group (P < .001).

CONCLUSION

Remote ischemic preconditioning improves postoperative cognitive function in elderly patients following colon surgery. The cognitive protective effects of remote ischemic preconditioning are partially related to the inhibition of inflammation.

The Interaction between HIV and Intestinal Helminth Parasites Coinfection with Nutrition among Adults in KwaZulu-Natal, South Africa

In South Africa few studies have examined the effects of the overlap of HIV and helminth infections on nutritional status. This cross-sectional study investigated the interaction between HIV and intestinal helminths coinfection with nutritional status among KwaZulu-Natal adults. Participants were recruited from a comprehensive primary health care clinic and stratified based on their HIV, stool parasitology, IgE, and IgG4 results into four groups: the uninfected, HIV infected, helminth infected, and HIV-helminth coinfected groups. The nutritional status was assessed using body mass index, 24-hour food recall, micro-, and macronutrient biochemical markers. Univariate and multivariate multinomial probit regression models were used to assess nutritional factors associated with singly and dually infected groups using the uninfected group as a reference category. Biochemically, the HIV-helminth coinfected group was associated with a significantly higher total protein, higher percentage of transferrin saturation, and significantly lower ferritin. There was no significant association between single or dual infections with HIV and helminths with micro- and macronutrient deficiency; however general obesity and low micronutrient intake patterns, which may indicate a general predisposition to micronutrient and protein-energy deficiency, were observed and may need further investigations.

Delirium in Acute Stroke: A Review

Background

Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation.

Summary of review

Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke.

Conclusion

This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.

Effect of the overlap syndrome of depressive symptoms and delirium on outcomes in elderly adults with hip fracture: a prospective cohort study

OBJECTIVES

To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study.

MEASUREMENTS

Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded.

RESULTS

Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002).

CONCLUSION

Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.

Systemic inflammation impairs attention and cognitive flexibility but not associative learning in aged rats: possible implications for delirium

Delirium is a common and morbid condition in elderly hospitalized patients. Its pathophysiology is poorly understood but inflammation has been implicated based on a clinical association with systemic infection and surgery and preclinical data showing that systemic inflammation adversely affects hippocampus-dependent memory. However, clinical manifestations and imaging studies point to abnormalities not in the hippocampus but in cortical circuits. We therefore tested the hypothesis that systemic inflammation impairs prefrontal cortex function by assessing attention and executive function in aged animals. Aged (24-month-old) Fischer-344 rats received a single intraperitoneal injection of lipopolysaccharide (LPS; 50 μg/kg) or saline and were tested on the attentional set-shifting task (AST), an index of integrity of the prefrontal cortex, on days 1-3 post-injection. Plasma and frontal cortex concentrations of the cytokine TNFα and the chemokine CCL2 were measured by ELISA in separate groups of identically treated, age-matched rats. LPS selectively impaired reversal learning and attentional shifts without affecting discrimination learning in the AST, indicating a deficit in attention and cognitive flexibility but not learning globally. LPS increased plasma TNFα and CCL2 acutely but this resolved within 24-48 h. TNFα in the frontal cortex did not change whereas CCL2 increased nearly threefold 2 h after LPS but normalized by the time behavioral testing started 24 h later. Together, our data indicate that systemic inflammation selectively impairs attention and executive function in aged rodents and that the cognitive deficit is independent of concurrent changes in frontal cortical TNFα and CCL2. Because inattention is a prominent feature of clinical delirium, our data support a role for inflammation in the pathogenesis of this clinical syndrome and suggest this animal model could be useful for studying that relationship further.

Postoperative complications: delirium

Delirium is a common feature of the postoperative period, leading to increased morbidity and mortality and significant costs. Multiple factors predispose a patient to delirium in its hypoactive, hyperactive, or mixed forms. Tools have been validated for its quick and accurate identification to ensure timely and effective multidisciplinary intervention and treatment. A significant percentage of patients may require placement in skilled nursing facilities or similar care environments because of the long-lasting effects. The physician must be vigilant in the search for and identification of all forms of delirium and must effectively treat the underlying medical condition and symptoms.

A systematic literature review of cerebrospinal fluid biomarkers in delirium

BACKGROUND

Cerebrospinal fluid (CSF) analysis has great potential to advance understanding of delirium pathophysiology.

METHODS

A systematic literature review of CSF studies of DSM or ICD delirium was performed.

RESULTS

In 8 studies of 235 patients, delirium was associated with: elevated serotonin metabolites, interleukin-8, cortisol, lactate and protein, and reduced somatostatin, β-endorphin and neuron-specific enolase. Elevated acetylcholinesterase predicted poor outcome after delirium and higher dopamine metabolites were associated with psychotic features.

CONCLUSIONS

No clear conclusions emerged, but the current literature suggests multiple areas for further investigation with more detailed studies.

Insulin-like growth factor I and the pathogenesis of delirium: a review of current evidence

Delirium is a frequent complication in medically ill elderly patients that is associated with serious adverse outcomes including increased mortality. Delirium risk is linked to older age, dementia, and illness that involves activation of inflammatory responses. IGF-I is increasingly postulated as a key link between environmental influences on body metabolism with a range of neuronal activities and has been described as the master regulator of the connection between brain and bodily well-being. The relationships between IGF-I and ageing, cognitive impairment and inflammatory illness further support a possible role in delirium pathogenesis. Five studies of IGF-I in delirium were identified by a systematic review. These conflicting findings, with three of the five studies indicating an association between IGF-1 and delirium occurrence, may relate to the considerable methodological differences in these studies. The relevance of IGF-I and related factors to delirium pathogenesis can be clarified by future studies which account for these issues and other confounding factors. Such work can inform therapeutic trials of IGF-I and/or growth hormone administration.

Nursing care, delirium, and pain management for the hospitalized older adult

Delirium is a reversible cognitive disorder that has a rapid onset. Delirium risk factors include older age, severity of illness, poorer baseline functional status, comorbid medical conditions, and dementia. There are adverse consequences of delirium, including increased length of stay and increased mortality. Therefore, it is important for nurses to identify clients at risk and prevent and manage delirium in the hospitalized older client. Once high-risk clients are identified, prevention strategies may be used to reduce the incidence. Examples of prevention strategies include providing glasses and working hearing aids and effective pain management. This article discusses various assessment instruments that detect the presence of delirium. With this information, nurses are better equipped to evaluate the best assessment options for their work setting. Early detection is crucial to reduce the adverse consequences of delirium. Once a client is found to be experiencing delirium, a treatment plan can be established using both nonpharmacologic and pharmacologic interventions. In addition, the identification and the correction of etiologies of delirium can shorten the course of delirium.

Pharmacological treatment for the prevention of delirium: review of current evidence

OBJECTIVE

Delirium is a very common and serious disorder with high morbidity and mortality. Despite symptomatic treatment the outcome can be poor for some especially when no underlying cause is identified. As a result, various strategies for delirium prevention have been assessed. Pharmacological agents such as antipsychotics, acetylcholinesterase inhibitors, sleep-wake cycle regulators, anti-inflammatories and others have been advocated for a potential role in delirium prevention. The aim of this paper is to review the available evidence for their use in the prevention of delirium.

METHODS

An electronic search was carried out using Medline, EMBASE and Cochrane for randomised controlled trials (RCTs) and other studies. The words delirium, prevention, intervention, pharmacological, prophylactic, antipsychotics, acetylcholinesterase inhibitors, sleep and anti-inflammatories were used. References from selected papers were also searched.

RESULTS

No multi-centre RCT has been identified. Few trials and other studies have been published so far assessing the prophylactic role of antipsychotics, acetylcholinesterase inhibitors, hypnotics, melatonin, and gabapentin. As these studies tested different drugs, regimes and protocols in diverse populations no meaningful comparison can be made.

CONCLUSION

To date there is conflicting and inconsistent data regarding the efficacy of pharmacological treatment for delirium prevention. Positive reports in few of the studies justify further assessment of the potential for some pharmacological agents in the prevention of delirium. Well designed and appropriately powered RCTs are now needed. However, based on available evidence so far, no recommendation can be made to justify the routine clinical prophylactic use of any pharmacological agent in the prevention of delirium.

[Delirium in the elderly]

Delirium is a common, serious medical and often life-threatening condition in elderly in-patients. Delirium can develop primarily or secondarily related to other medical conditions and lead to hospital admission. The pathogenesis is still not fully known and is usually addressed as multifactorial. Alterations in neurotransmitters have a key role in this process. The incidence varies by setting up to 90%. Delirium is associated with increased short- and long-term mortality, iatrogenic complications, functional decline, and future development of cognitive impairment or dementia. Delirium is also associated with longer hospital stays, higher hospital and total health system costs, and an increasing rate of nursing home admissions. A structured diagnostic and therapeutic process is recommended. Delirium should become a quality indicator for hospital medicine; however, many research questions still exist.

Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence

Deficits in cholinergic function have been postulated to cause delirium and cognitive decline. This review examines current understanding of the cholinergic deficiency hypothesis in delirium by synthesizing evidence on potential pathophysiological pathways. Acetylcholine synthesis involves various precursors, enzymes, and receptors, and dysfunction in these components can lead to delirium. Insults to the brain, like ischemia and immunological stressors, can precipitously alter acetylcholine levels. Imbalances between cholinergic and other neurotransmitter pathways may result in delirium. Furthermore, genetic, enzymatic, and immunological overlaps exist between delirium and dementia related to the cholinergic pathway. Important areas for future research include identifying biomarkers, determining genetic contributions, and evaluating response to cholinergic drugs in delirium. Understanding how the cholinergic pathway relates to delirium may yield innovative approaches in the diagnosis, prevention, and treatment of this common, costly, and morbid condition.

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation

OBJECTIVE

Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae.

DESIGN AND SETTING

Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers.

PATIENTS AND PARTICIPANTS

16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls.

MEASUREMENTS AND RESULTS

Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores.

CONCLUSIONS

Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.

APOE and cytokines as biological markers for recovery of prevalent delirium in elderly medical inpatients

BACKGROUND

Delirium frequently occurs in the context of infection and other inflammatory conditions associated with elevated levels of cytokines. Cytokines used therapeutically can induce symptoms of delirium as an adverse effect. We hypothesized that a causal relationship might exist between delirium and cytokine production during illness. Further, we speculated that the APOE genotype of patients might influence their rate of recovery from delirium given that APOE is associated with amyloid deposition, increased susceptibility to exogenous neurotoxins, and can affect the immune response.

METHODS

A cohort of 164 acutely ill patients, 70 years or older, admitted to an elderly medical unit were studied within 3 days of hospital admission and re-assessed twice weekly until their discharge, to identify and follow the clinical course of delirium. The APOE genotype and the level of circulating cytokines were determined for 116 and 60 patients respectively.

RESULTS

Prevalent delirium was significantly (p < 0.05) associated with a previous history of dementia, age, illness severity, disability and low levels of circulating IGF-I. Recovery was significantly associated (p < 0.05) with lack of APOE 4 allele and higher initial IFN-gamma. A model incorporating gender, APOE epsilon 4 status and IGF-I levels predicted recovery or not from delirium in 76.5% of cases, with a sensitivity 0.77 and specificity 0.75.

CONCLUSIONS

A relationship between delirium with APOE genotype, IFN-gamma, and IGF-I, but not with IL-6, IL-1, TNF-alpha, and LIF was found. A predictive model of recovery was derived from gender, APOE status, and IGF-I levels. This model needs replication with further studies.

Impact of delirium on cognition, distress, and health-related quality of life after hematopoietic stem-cell transplantation

PURPOSE

To determine the impact of delirium during the acute phase of myeloablative hematopoietic stem-cell transplantation (HSCT) on health-related quality of life (HRQOL), distress, and neurocognitive functioning 30 and 80 days after transplantation.

PATIENTS AND METHODS

Ninety patients completed a battery assessing HRQOL, distress, and neuropsychological functioning before receiving their first HSCT. Delirium was assessed three times per week using the Delirium Rating Scale and the Memorial Delirium Assessment Scale from 7 days before transplantation through 30 days after transplantation. At 30 days after transplantation, distress and neurocognitive functioning were assessed. At 80 days after transplantation, HRQOL, distress, and neuropsychological functioning were re-evaluated.

RESULTS

After adjusting for confounding factors, patients who experienced a delirium episode, versus patients who did not, reported significantly worse depression, anxiety, and fatigue symptoms at 30 days (linear regression beta(s) = 0.2, 0.3, and 0.5, respectively; P < .04). At 80 days, patients with a delirium episode had significantly worse executive functioning (beta = -1.1; P < .02), attention and processing speed (beta(s) = -4.7 and -5.4, respectively; P < .03), mental health on the Medical Outcomes Study Health Survey, 12-item short form (beta = -6.5; P < .02), and anxiety, fatigue, and cancer and treatment distress symptoms (beta(s) = 0.4, 0.6, and 0.3, respectively; P < .03).

CONCLUSION

Patients with a malignancy who experience delirium during myeloablative HSCT showed impaired neurocognitive abilities and persistent distress 80 days after transplantation. Effective prevention or treatment of delirium during HSCT may improve both cognitive and psychological outcomes.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES

To examine key aspects of delirium in a sample of hospitalized older patients with cancer.

DESIGN

Secondary analysis of data from studies on acute confusion in hospitalized older adults.

SETTING

Tertiary teaching hospital in the southeastern United States.

SAMPLE

76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses.

METHODS

Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission.

MAIN RESEARCH VARIABLES

Prevalent and incident delirium, etiologic risk patterns, and patient characteristics.

FINDINGS

Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium.

CONCLUSIONS

Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients.

IMPLICATIONS FOR NURSING

Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Psychiatric adjustment in the year after meningococcal disease in childhood

OBJECTIVE

To assess psychiatric status after meningococcal disease.

METHOD

Cohort study of 66 children (34 boys, 32 girls) ages 4 to 17 years admitted to pediatric hospitals with meningococcal disease. The main outcome measure was psychiatric disorder (1-year period and point prevalence on the Schedule for Affective Disorders and Schizophrenia for School-Age Children interview for children 6 years or older; point prevalence in younger children on the Behavior Screening Questionnaire).

RESULTS

During the course of the year after discharge from hospital, psychiatric disorders were identified in 23 of 40 (57%) children ages 6 years or older. The most common primary disorders were depressive, oppositional defiant, and anxiety disorders. At the time of 12-month follow-up, psychiatric disorders were present in 13 of 40 (32%) of those ages 6 or older and in 7 of 26 (26%) under 6 years old. Two children had a diagnosis of posttraumatic stress disorder. Logistic regression analysis showed that global meningococcal illness severity score, clinical shock on admission, and impairing premorbid emotional and behavioral problems in the child were independent predictors of psychiatric disorder at 12-month follow-up.

CONCLUSIONS

Psychiatric disorders are common in the year after meningococcal disease. Especially at risk are children who are severely medically ill and those with more impairing premorbid emotional and behavioral problems.

Delirium in the Hospitalized Elder and Recommendations for Practice

Delirium is a mental disorder of acute onset and fluctuating course, characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior. It occurs in up to 50% of elderly hospital inpatients, many with preexisting dementia, and is associated with significant increases in functional disability, length of hospital stay, rates of death, and health care costs. Despite its clinical importance, delirium often remains undetected or misdiagnosed as dementia or other psychiatric illness. Awareness of the etiologies and risk factors of delirium should enable nurses to focus on patients at risk and to recognize delirium symptoms early. Knowledge of pharmacological and nonpharmacological treatments for delirium will provide the nurse with an arsenal of potential interventions in the care of the delirious hospitalized elder.

Plasma insulin growth factor-1 and incident delirium in older people

BACKGROUND

A variety of demographic and clinical variables are acknowledged as risk factors for delirium; a syndrome thought to be mediated by abnormalities in a wide range of neurotransmitters. However, little research has been conducted in this field and the role of neuro-immunological factors as a mechanism of medication has received very little attention.

AIMS

To determine if low base line (on admission) IGF-1 levels (a protective cytokine released by brain cells in response to insult) is a risk factor for incident delirium in patients aged 75 and over admitted to an acute medical ward.

METHOD

Base line demographic and clinical variables and serum IGF-1 levels were measured in a consecutive series of 100 non-delirious subjects on inpatient admission. Subjects were assessed daily regarding the development of delirium during the inpatient episode.

RESULTS

Twelve patients developed incident delirium. IGF-1 (OR: 0.822, CI: 0.69, 0.97, p = 0.027), pre-admission cognitive deterioration (assessed by IQCODE) (OR; 3.26, CI: 1.18, 9.04, p = 0.023) and depression (GDS four item: cut-off score > or = 3) (OR; 8.99, CI 1.59,50.76, p = 0.013) were identified as risk factors for developing subsequent delirium.

CONCLUSIONS

Despite the small size of this study our findings suggest that low, pre-morbid IGF-1 is a risk factor for subsequent delirium in this population, emphasizing the potential protective role of this anabolic cytokine and the need for replication of these findings.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Southwestern Internal Medicine Conference. Etiology and management of delirium

Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.

Delirium in critically ill patients

Delirium in the intensive care unit is a serious problem that has recently attracted much attention. User-friendly and reliable tools, such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), offer the clinician the opportunity to identify delirium in patients better. Diagnosis of delirium in a critical care population is often a difficult task because classical psychiatric evaluation is impossible for a number of reasons. The CAM-ICU makes use of nonverbal assessments to evaluate the cardinal features of delirium (i.e. acute or fluctuating onset, inattention, disorganized thinking and altered level of consciousness). Its development for use in the critical care setting represents a significant advance that could lead to better care for such patients.