Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study

Multilevel factors influencing falls of older patients in hospital: The risk of hospital-induced delirium and the impact of nurse staffing

OBJECTIVE

This study aimed to explore the individual and organizational factors influencing falls among older inpatients, with a particular focus on the risk posed by hospital-induced delirium and the effect of nurse staffing levels.

METHODS

This retrospective cohort study utilized data from a national healthcare database to examine falls in hospitalized older adults, applying a mixed-effect logistic regression model RESULTS: Data from 391,902 patients across 580 hospitals revealed that 1.2 % of older inpatients experienced falls. Influential factors for falls included advanced age, the use of multiple medications and treatments, impaired mobility, and hospital-induced delirium. Nurse staffing levels markedly influenced the reduction of fall risks among older patients.

CONCLUSION

Falls among hospitalized older adults are a frequent consequence of multifaceted risk components, highlighting the need for comprehensive fall prevention strategies and adequate.

Postoperative Delirium and Neurocognitive Disorders: A Comprehensive Review of Pathophysiology, Risk Factors, and Management Strategies

Postoperative delirium (POD) and neurocognitive disorders (NCDs) are common and serious complications that can occur after surgery, particularly in older adults and those with preexisting cognitive impairments. These conditions are associated with significant morbidity, increased healthcare costs, and reduced quality of life. Understanding the underlying mechanisms, risk factors, and effective management strategies for POD and NCDs is critical for improving patient outcomes and reducing the burden on healthcare systems. This comprehensive review aims to synthesize current knowledge on the pathophysiology, risk factors, and management strategies for POD and NCDs. It explores the neurobiological and molecular mechanisms contributing to these conditions, identifies the patient-related, surgical, and environmental factors that increase risk, and evaluates pharmacological and non-pharmacological approaches to prevention and treatment. A thorough literature review was conducted using recent studies, clinical guidelines, and expert consensus to provide a detailed overview of the pathophysiology, risk factors, clinical presentation, prevention, and management of POD and NCDs. The pathophysiology of POD and NCDs involves complex interactions between neuroinflammatory processes, neurotransmitter imbalances, and brain network disruptions. Risk factors include advanced age, preexisting cognitive impairment, type and duration of surgery, and perioperative complications. Management strategies emphasize a multidisciplinary approach, incorporating preoperative optimization, careful intraoperative management, and postoperative interventions. Pharmacological treatments, such as antipsychotics, and non-pharmacological approaches, including environmental modifications and cognitive rehabilitation, play crucial roles in management. Postoperative delirium and NCDs are multifactorial conditions with significant impacts on surgical outcomes. Effective management requires a comprehensive understanding of their pathophysiology and risk factors and the implementation of targeted prevention and treatment strategies. Future research should focus on personalized approaches to prevention and treatment, further elucidation of mechanisms, and developing predictive models to enhance care for patients at risk of these neurocognitive complications.

Diagnosing Late-Onset Psychosis in a Medically Complex Patient: A Diagnostic Challenge

This case report explores various possible causes of late-onset psychosis and highlights the importance of follow-up care. We report the case of a 65-year-old female with minimal available medical history or contacts, who presented to the hospital after being found unconscious after three weeks of strange behaviors, including partition delusions, multiple phone calls and texts to her friend, and lack of sleep. In the following days, she had various symptoms consistent with delirium, psychosis, and mania. However, she was also found to have a dural calcification and urinary tract infection on imaging and laboratories, respectively. We attempted to distinguish these possible etiologies and understand the best course of action for such a patient with a limited medical history who was subsequently lost to medical follow-up. Utilizing the psychiatric interview, mental status examination, laboratory work, imaging, and available medical and psychiatric history can all help narrow down the most likely etiologies. However, the lack of data given during follow-up visits, regarding patient response to treatment, their full medical and psychiatry history, as well as their understanding of their diagnosis, poses a significant challenge in reaching a definitive diagnosis in such a patient. This underscores the critical need for follow-up care, especially for patients treated for psychosis in acute settings.

Inappropriate Polypharmacy and the Need for Comprehensive Medication Management Service

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Impact of delirium on acute stroke outcomes: A systematic review and meta-analysis

Delirium is a common complication in acute stroke patients. A 2011 meta-analysis showed an increased risk of in-hospital mortality and mortality within 12 months post-stroke, longer hospitalization durations, and increased likelihood of being discharged to a nursing home for patients experiencing post-stroke delirium. There is a need for an updated meta-analysis with several new studies having been since published. The PubMed and Scopus databases were screened for relevant studies. Inclusion criteria were as follows: retrospective or prospective studies reporting on the effects of delirium accompanying acute stroke on mortality, functional outcomes, length of hospital stay and need for re-admission. Strength of association was presented as pooled adjusted relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Statistical analysis was done using STATA version 16.0. The meta-analysis included 22 eligible articles. Eighteen of the 22 studies were prospective follow ups. Included studies were of good quality. Post-stroke delirium was associated with increased risk of in-hospital mortality, as well as mortality within 12 months post-stroke. Patients with delirium experienced increased hospital stay durations, were at greater risk for hospital readmission, and showed elevated risk for poor functional outcome. Compared to those who did not have delirium, stroke patients with delirium were 42% less likely to be discharged to home. Acute stroke patients with delirium are at an increased risk for poor short- and long-term outcomes. More research is needed to identify the best set of interventions to manage such patients and improve outcomes.

Low CRB-65 Scores Effectively Rule out Adverse Clinical Outcomes in COVID-19 Irrespective of Chest Radiographic Abnormalities

Background: CRB-65 (Confusion; Respiratory rate ≥ 30/min; Blood pressure ≤ 90/60 mmHg; age ≥ 65 years) is a risk score for prognosticating patients with COVID-19 pneumonia. However, a significant proportion of COVID-19 patients have normal chest X-rays (CXRs). The influence of CXR abnormalities on the prognostic value of CRB-65 is unknown, limiting its wider applicability. Methods: We assessed the influence of CXR abnormalities on the prognostic value of CRB-65 in COVID-19. Results: In 589 study patients (71 years (IQR: 57-83); 57% males), 186 (32%) had normal CXRs. On ROC analysis, CRB-65 performed similarly in patients with normal vs. abnormal CXRs for predicting inpatient mortality (AUC 0.67 ± 0.05 vs. 0.69 ± 0.03). In patients with normal CXRs, a CRB-65 of 0 ruled out mortality, NIV requirement and critical illness (intubation and/or ICU admission) with negative predictive values (NPVs) of 94%, 98% and 99%, respectively. In patients with abnormal CXRs, a CRB-65 of 0 ruled out the same endpoints with NPVs of 91%, 83% and 86%, respectively. Patients with low CRB-65 scores had better inpatient survival than patients with high CRB-65 scores, irrespective of CXR abnormalities (all p < 0.05). Conclusions: CRB-65, CXR and CRP are independent predictors of mortality in COVID-19. Adding CXR findings (dichotomised to either normal or abnormal) to CRB-65 does not improve its prognostic accuracy. A low CRB-65 score of 0 may be a good rule-out test for adverse clinical outcomes in COVID-19 patients with normal or abnormal CXRs, which deserves prospective validation.

Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study

BACKGROUND

Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes.

METHODS

A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM).

RESULTS

During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively.

CONCLUSIONS

Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.