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Giesa N, Haufe S, Menk M, Weiß B, Spies CD, Piper SK, Balzer F, Boie SD. Predicting postoperative delirium assessed by the Nursing Screening Delirium Scale in the recovery room for non-cardiac surgeries without craniotomy: A retrospective study using a machine learning approach. PLOS DIGITAL HEALTH 2024; 3:e0000414. [PMID: 39141688 PMCID: PMC11324157 DOI: 10.1371/journal.pdig.0000414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 07/04/2024] [Indexed: 08/16/2024]
Abstract
Postoperative delirium (POD) contributes to severe outcomes such as death or development of dementia. Thus, it is desirable to identify vulnerable patients in advance during the perioperative phase. Previous studies mainly investigated risk factors for delirium during hospitalization and further used a linear logistic regression (LR) approach with time-invariant data. Studies have not investigated patients' fluctuating conditions to support POD precautions. In this single-center study, we aimed to predict POD in a recovery room setting with a non-linear machine learning (ML) technique using pre-, intra-, and postoperative data. The target variable POD was defined with the Nursing Screening Delirium Scale (Nu-DESC) ≥ 1. Feature selection was conducted based on robust univariate test statistics and L1 regularization. Non-linear multi-layer perceptron (MLP) as well as tree-based models were trained and evaluated-with the receiver operating characteristics curve (AUROC), the area under precision recall curve (AUPRC), and additional metrics-against LR and published models on bootstrapped testing data. The prevalence of POD was 8.2% in a sample of 73,181 surgeries performed between 2017 and 2020. Significant univariate impact factors were the preoperative ASA status (American Society of Anesthesiologists physical status classification system), the intraoperative amount of given remifentanil, and the postoperative Aldrete score. The best model used pre-, intra-, and postoperative data. The non-linear boosted trees model achieved a mean AUROC of 0.854 and a mean AUPRC of 0.418 outperforming linear LR, well as best applied and retrained baseline models. Overall, non-linear machine learning models using data from multiple perioperative time phases were superior to traditional ones in predicting POD in the recovery room. Class imbalance was seen as a main impediment for model application in clinical practice.
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Affiliation(s)
- Niklas Giesa
- Institute of Medical Informatics, Charité – Universitätmedizin Berlin, Berlin, Germany
| | - Stefan Haufe
- Institute of Medical Informatics, Charité – Universitätmedizin Berlin, Berlin, Germany
- Berlin Center for Advanced Neuroimaging (BCAN), Charité – Universitätmedizin Berlin, Berlin, Germany
- Mathematical Modelling and Data Analysis Department, Physikalisch-Technische Bundesanstalt Braunschweig und Berlin, Berlin, Germany
- Uncertainty, Inverse Modeling and Machine Learning Group, Technische Universität Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Björn Weiß
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Sophie K. Piper
- Institute of Medical Informatics, Charité – Universitätmedizin Berlin, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité – Universitätmedizin Berlin, Berlin, Germany
| | - Sebastian D. Boie
- Institute of Medical Informatics, Charité – Universitätmedizin Berlin, Berlin, Germany
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Ingelson B, Dahlke S, O'Rourke H, Hunter KF. Nurses' knowledge and beliefs on pain management practices with hospitalised persons living with dementia: A qualitative descriptive study. J Clin Nurs 2024; 33:3224-3235. [PMID: 38590077 DOI: 10.1111/jocn.17164] [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: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024]
Abstract
AIM To understand nurses' knowledge, beliefs and experiences affect pain management practices in hospitalised persons living with dementia (PLWD). DESIGN Naturalistic inquiry using qualitative descriptive design. METHODS Semi-structured interviews were conducted with 12 registered nurses who worked in one acute care hospital in Southern California from October to November 2022. Data were analysed using content analysis to identify themes. RESULTS Two themes were developed: improvising pain assessment, which included how pain was documented, and administration hesitancy referring to nurse's concerns about PLWD's confusion. Nurses described the challenges of assessing pain in hospitalised PLWD particularly if they were non-verbal and/or demonstrating responsive behaviours. Nurse's years of experience, dementia stigma, and their unconscious biases affected nurses' pain management practices. CONCLUSIONS The study findings highlight the complex challenges of pain management in hospitalised PLWD that are exacerbated by nurses' knowledge deficits, negative stereotypical beliefs, dementia stigma and unconscious biases towards older people that contributes to undermanaged pain in hospitalised PLWD. IMPLICATIONS A comprehensive strategy using an implementation framework is needed to address nurse's knowledge gaps, unconscious bias, dementia stigma and techniques that enhance communication skills is suggested. Building a foundation in these areas would improve pain management in hospitalised PLWD. IMPACT Improving pain management in hospitalised PLWD would improve the quality of life, decrease hospital length of stay, prevent readmissions, and improve nurse satisfaction. REPORTING METHOD The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ). PATIENT CONTRIBUTIONS Improving pain management in hospitalised PLWD would prevent long term confusion, episodes of delirium and improve quality of life as they recover from their acute illness for which they required hospital care.
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Affiliation(s)
- Beverly Ingelson
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen F Hunter
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Zhang GB, Li HY, Yu WJ, Ying YZ, Zheng D, Zhang XK, Wang YG, Shi GZ, Huang HW. Occurrence and risk factors for post-stroke delirium: A systematic review and meta-analysis. Asian J Psychiatr 2024; 99:104132. [PMID: 38981150 DOI: 10.1016/j.ajp.2024.104132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/15/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES Delirium is a significant health concern in acute stroke patients. We aim to systematically summarize existing evidence to conduct a meta-analysis to quantify the occurrence and risk factors for delirium after acute stroke. METHOD PubMed, EMBASE and MEDLINE were searched from inception to Feb. 2023 for prospective observational studies that reported the incidence or prevalence of post-stroke delirium and/or evaluated potential risk factors. The search strategy was created using controlled vocabulary terms and text words for stroke and delirium. We performed a meta-analysis of the estimates for occurrence and risk factors using random-effects models. Meta-regression and subgroup meta-analyses were conducted to explore the sources of heterogeneity. Study quality and quality of evidence were assessed using the customized Newcastle-Ottawa Scale and GRADE, respectively. RESULTS Forty-nine studies that enrolled 12383 patients were included. The pooled occurrence rate of post-stroke delirium was 24.4 % (95 %CI, 20.4 %-28.9 %, I2=96.2 %). The pooled occurrence of hyperactive, hypoactive, and mixed delirium was 8.5 %, 5.7 % and 5.0 %, respectively. Study location, delirium assessment method and stroke type independently affected the heterogeneity of the pooled estimate of delirium. Statistically significant risk factors were older age, low education level, cigarette smoking, alcohol drinking, atrial fibrillation, lower ADL level, higher pre-stroke mRS score, premorbid cognitive impairment or dementia, aphasia, total anterior circulation impairment, higher National Institute of Health Stroke Scale score and infection. CONCLUSIONS Delirium affected 1 in 4 acute stroke patients, although reported rates may depend on assessment method and stroke type. Timely prevention, recognition and intervention require prioritizing patients with dominant risk factors.
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Affiliation(s)
- Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Hao-Yi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Wei-Jie Yu
- Department of Neurosurgery, The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Yu-Zhe Ying
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Dao Zheng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Xiao-Kang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Yong-Gang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Guang-Zhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Almuhairi ES, Badejo M, Peer A, Pitkanen M, McKenzie CA. The Validity and Applicability of the Revised Delirium Rating Scale (DRS-R98) for Delirium Severity Assessment in a Critical Care Setting. J Intensive Care Med 2024; 39:240-249. [PMID: 37670545 PMCID: PMC10845842 DOI: 10.1177/08850666231199986] [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] [Indexed: 09/07/2023]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome common in critical illness. Worsening delirium severity is associated with poorer clinical outcomes, yet its assessment remains under-reported with most severity assessment tools not validated for critical care. The DRS-R98 is a widely applied and validated tool. The aim of this project is to report the validation and utility of the DRS-R98 in critical illness. METHODS This prospective, cohort study was conducted in adults with delirium admitted to a critical care unit and predicted to stay for ≥ 24 h. We excluded patients with severe neurological or communication barriers that would have interfered with the DRS-R98 assessment. Patients were screened using a delirium detection algorithm and the Confusion Assessment Method for the Intensive Care Unit. Eligible patient informations were collected and reported to qualified assessor/s before visiting clinical areas, confirming delirium presence and undertaking DRS- R98 assessments. To assess the tool's construct validity, an intensivist completed the Clinical Global Impression-Scale (CGI-S). To calculate the inter-rater reliability (IRR) a subset of patients were simultaneously evaluated by two assessors. RESULTS We assessed 22 patients, 73% were male, with a median age of 65 years (IQR14). The DRS -R98 mean (SD) severity score was 24 (+/-7.7), total scale was 29 (+/18.0), and CGI-S 3.5 (+/11.5). Assessment duration was 90 min (+/-55) and 15 min (+/-5) for record data extraction and clinical assessment respectively. The CGI-S significantly correlated with DRS-R98 severity (r = 0.626) and total (r = 0.628) scales. The DRS-R98 Cronbach's alpha was 0.896 for severity scale and 0.886 for total scale. The inter-rater reliability (IRR) was assessed in six patients and reported an inter-correlation coefficient of 0.505 (p = 0.124) and 0.565 (p = 0.93) for the severity and total scale respectively. CONCLUSIONS In critical care, the Delirium Rating Scale R98 had good construct validity, excellent internal consistency, and moderate inter-rater reliability.
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Affiliation(s)
- Eiman Saeed Almuhairi
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
| | - Monica Badejo
- Department of Social, Therapeutic and Community Studies, Goldsmiths College, University of London, London, UK
| | - Aneesa Peer
- Lambeth Southeast Focussed Support, Clozapine Plus Service, Orchard House - Lambeth Hospital, London, UK
| | - Mervi Pitkanen
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
| | - Cathrine A McKenzie
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
- Department of Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- School of Medicine, University of Southampton, National Institute of Health and Care Research (NIHR), Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, Southampton, UK
- NIHR Applied Research Collaborative Wessex, Southampton, UK
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Chen S, Tang L, Chen J, Cai L, Liu C, Song J, Chen Y, Liu Y, Zheng S. Prevalence and risk factors of subsyndromal delirium among postoperative patients: A systematic review and meta-analysis. J Adv Nurs 2024; 80:924-934. [PMID: 37788076 DOI: 10.1111/jan.15871] [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: 04/03/2023] [Revised: 08/21/2023] [Accepted: 09/09/2023] [Indexed: 10/04/2023]
Abstract
AIM The aim of this study is to determine the prevalence and risk factors for subsyndromal delirium in the postoperative patient. DESIGN A systematic review and meta-analysis. METHODS The Review Manager 5.3 statistics platform and the Newcastle-Ottawa Scale were used for quality evaluation. DATA SOURCES The following databases were searched: PubMed, Web of Science, EMBASE, The Cochrane Library, Scopus and EBSCO from January 2000 to December 2021. Additional sources were found by looking at relevant articles' citations. RESULTS A total of 1744 titles were originally identified, and five studies including 962 patients were included in the systematic review, with a pooled prevalence of postoperative subsyndromal delirium (PSSD) of 30% (95% CI: 0.28-0.32). Significant risk variables for PSSD were older age, low levels of education (≤9 years), cognitive impairment, higher comorbidity score, and the duration of operation. CONCLUSION PSSD is prevalent and is associated with a variety of risk factors as well as low academic performance. IMPACT Identification and clinical management of patients with PSSD should be improved. Future research on PSSD risk factors should look at a wider range of intraoperative and postoperative risk factors that can be changed. PATIENT AND PUBLIC CONTRIBUTION No Patient or Public Contribution.
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Affiliation(s)
- Shunli Chen
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- School of Nursing, Southwest Medical University, Luzhou, China
| | - Lingyu Tang
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- School of Nursing, Southwest Medical University, Luzhou, China
| | - Jing Chen
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Luyao Cai
- School of Nursing, Southwest Medical University, Luzhou, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Janying Song
- School of Nursing, Southwest Medical University, Luzhou, China
| | - Yingyi Chen
- School of Nursing, Southwest Medical University, Luzhou, China
| | - Yan Liu
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Silin Zheng
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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6
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Tan ZS, Qureshi N, Roberts P, Guinto A, Escovedo C, Chung P, Spivack E, Nasmyth M, Kremen S, Sicotte NL. Alerting providers to hospitalized persons with dementia using the electronic health record. J Am Geriatr Soc 2024; 72:822-827. [PMID: 37937688 DOI: 10.1111/jgs.18673] [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: 08/02/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While patients with dementia entering the hospital have worse outcomes than those without dementia, early detection of dementia in the inpatient setting is less than 50%. We developed and assessed the positive predictive value (PPV) and feasibility of a novel electronic health record (EHR) banner to identify patients with dementia who present to the inpatient setting using data from the medical record. METHODS We developed and implemented an EHR algorithm to flag hospitalized patients age ≥65 years with potential cognitive impairment in the Epic EHR system using dementia ICD-10 codes, FDA-approved medications, and the use of the term "dementia" in the emergency department physician note. Medical records were reviewed for all patients who were flagged with an EHR banner from October 2022 to May 2023. RESULTS A total of 344 individuals were identified who had a banner on their chart of which 280 (81.4%) were either diagnosed with dementia or were on an FDA-approved dementia medication. Forty-three individuals who had confirmed dementia were identified by a medication only (15.4%). Of the patients without confirmed dementia, the majority (N = 33, 9.6%) had a diagnosis of altered mental status, cognitive dysfunction, or mild cognitive impairment. Only 31 individuals (9.0%) had no indication of dementia or cognitive decline in their problem list, past medical history, or medication list. CONCLUSIONS We found that it was feasible to implement an EHR algorithm for prospective dementia identification with a high PPV. These types of algorithms provide an opportunity to accurately identify hospitalized older individuals for inclusion in quality improvement projects, clinical trials, pay-for-performance programs, and other initiatives.
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Affiliation(s)
- Zaldy S Tan
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Nabeel Qureshi
- Cedars Sinai Medical Center, Los Angeles, California, USA
- RAND Corporation, Los Angeles, California, USA
| | - Pamela Roberts
- Cedars Sinai Medical Center, Los Angeles, California, USA
- California Rehabilitation Institute, Los Angeles, California, USA
| | | | | | - Phong Chung
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Erica Spivack
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mary Nasmyth
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Sarah Kremen
- Cedars Sinai Medical Center, Los Angeles, California, USA
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Shi X, Yang L, Bai W, Jing L, Qin L. Evaluating early lymphocyte-to-monocyte ratio as a predictive biomarker for delirium in older adult patients with sepsis: insights from a retrospective cohort analysis. Front Med (Lausanne) 2024; 11:1342568. [PMID: 38357643 PMCID: PMC10864594 DOI: 10.3389/fmed.2024.1342568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Background This study aims to explore the value of the Lymphocyte-to-Monocyte Ratio (LMR) in predicting delirium among older adult patients with sepsis. Methods Retrospective data were obtained from the MIMIC-IV database in accordance with the STROBE guidelines. Patients aged 65 and above, meeting the Sepsis 3.0 criteria, were selected for this study. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Demographic information, comorbid conditions, severity of illness scores, vital sign measurements, and laboratory test results were meticulously extracted. The prognostic utility of the Lymphocyte-to-Monocyte Ratio (LMR) in predicting delirium was assessed through logistic regression models, which were carefully adjusted for potential confounding factors. Results In the studied cohort of 32,971 sepsis patients, 2,327 were identified as meeting the inclusion criteria. The incidence of delirium within this subgroup was observed to be 55%. A univariate analysis revealed a statistically significant inverse correlation between the Lymphocyte-to-Monocyte Ratio (LMR) and the risk of delirium (p < 0.001). Subsequent multivariate analysis, which accounted for comorbidities and illness severity scores, substantiated the role of LMR as a significant predictive marker. An optimized model, achieving the lowest Akaike Information Criterion (AIC), incorporated 17 variables and continued to demonstrate LMR as a significant prognostic factor (p < 0.01). Analysis of the Receiver Operating Characteristic (ROC) curve indicated a significant enhancement in the Area Under the Curve (AUC) upon the inclusion of LMR (p = 0.035). Conclusion The Lymphocyte-to-Monocyte Ratio (LMR) serves as a significant, independent prognostic indicator for the occurrence of delirium in older adult patients with sepsis. Integrating LMR into existing predictive models markedly improves the identification of patients at elevated risk, thereby informing and potentially guiding early intervention strategies.
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Affiliation(s)
| | | | | | | | - Lijie Qin
- Department of Emergency, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, China
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Bradford CV, Fung MY, Wang A, Benefield EC, Bashqoy F, Neely SB, Johnson PN. Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study. J Pediatr Pharmacol Ther 2023; 28:540-552. [PMID: 38130349 PMCID: PMC10731945 DOI: 10.5863/1551-6776-28.6.540] [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: 11/01/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management. METHODS A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05. RESULTS The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed. CONCLUSIONS Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia, PA
| | - Mon-Yee Fung
- Department of Pharmacy (M-YF), University of Michigan MOTT Children’s Hospital, Ann Arbor, MI
| | - Alexander Wang
- Department of Pharmacy (AW), Children’s National Hospital, Washington, DC
| | | | - Ferras Bashqoy
- Department of Pharmacy (FB), Hassenfeld Children’s Hospital at NYU Langone Health, New York City, NY
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Goettel N, Wueest AS. Diagnosing delirium in perioperative and intensive care medicine. Curr Opin Anaesthesiol 2023; 36:491-499. [PMID: 37427443 DOI: 10.1097/aco.0000000000001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent findings to guide clinicians and researchers in choosing the most appropriate tools. RECENT FINDINGS The incidence of delirium in hospitalized patients ranges from 5% to over 50%, depending on the population of patients studied. Failure to diagnose delirium in a timely manner is associated with serious adverse outcomes, including death and institutionalization. Valid assessment tests are needed for delirium detection, as early identification and treatment of delirium may help to prevent complications. Currently, there are more than 30 available instruments, which have been developed to assist with the screening and diagnosis of delirium. However, these tools vary greatly in sensitivity, specificity, and administration time, and their overabundance challenges the selection of specific tool as well as direct comparisons and interpretation of results across studies. SUMMARY Overlooking or misdiagnosing delirium may result in poor patient outcomes. Familiarizing healthcare workers with the variety of delirium assessments and selecting the most appropriate tool to their needs is an important step toward improving awareness and recognition of delirium.
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Affiliation(s)
- Nicolai Goettel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Clinical Research, University of Basel
| | - Alexandra S Wueest
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel
- Memory Clinic, University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
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Dolan C, Mohd Zubir M, Melvin V, McCarthy G, Meagher D, Adamis D. Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study. Ir J Psychol Med 2023; 40:369-377. [PMID: 33455597 DOI: 10.1017/ipm.2020.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors. METHODS This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission. RESULTS Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium. CONCLUSIONS In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.
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Affiliation(s)
- C Dolan
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - M Mohd Zubir
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - V Melvin
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - G McCarthy
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
- Sligo Medical Academy, NUI Galway, The Mall, Rathquarter, Sligo, Ireland
| | - D Meagher
- Cognitive Impairment Research Group (CIRG), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - D Adamis
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
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Collet L, Lanore A, Alaterre C, Constantin JM, Martin GL, Caille A, James A, Dechartres A. Heterogeneity in the definition of delirium in ICUs and association with the intervention effect in randomized controlled trials: a meta-epidemiological study. Crit Care 2023; 27:170. [PMID: 37143091 PMCID: PMC10161412 DOI: 10.1186/s13054-023-04411-y] [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: 01/06/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023] Open
Abstract
PURPOSE To evaluate the heterogeneity in the definition of delirium in randomized controlled trials (RCTs) included in meta-analyses of delirium in intensive care units (ICUs) and to explore whether intervention effect depends on the definition used. METHODS We searched PubMed for meta-analyses including RCTs evaluating prevention or treatment strategies of delirium in ICU. The definition of delirium was collected from RCTs and classified as validated (DSM criteria, CAM-ICU, ICDSC, NEECHAM, DRS-R98) or non-validated (non-validated scales, set of symptoms, physician appreciation or not reported). We conducted a meta-epidemiological analysis to compare intervention effects between trials using or not a validated definition by a two-step method as primary analysis and a multilevel model as secondary analysis. A ratio of odds ratios (ROR) < 1 indicated larger intervention effects in trials using a non-validated definition. RESULTS Of 149 RCTs (41 meta-analyses), 109 (73.1%) used a validated definition and 40 (26.8%) did not (including 31 [20.8%] not reporting the definition). The primary analysis of 7 meta-analyses (30 RCTs) found no significant difference in intervention effects between trials using a validated definition and the others (ROR = 0.54, 95% CI 0.27-1.08), whereas the secondary multilevel analysis including 12 meta-analyses (67 RCTs) found significantly larger effects for trials using a non-validated versus a validated definition (ROR = 0.36, 95% CI 0.21-0.62). CONCLUSION The definition of delirium was heterogeneous across RCTs, with one-fifth not reporting how they evaluated delirium. We did not find a significant association with intervention effect in the primary analysis. The secondary analysis including more studies revealed significantly larger intervention effects in trials using a non-validated versus a validated definition.
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Affiliation(s)
- Lucie Collet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpetrière, Département de Santé Publique, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
- Sorbonne Université, GRC 29, DMU DREAM, AP-HP, Hôpital Pitié-Salpetrière, Département d'Anesthésie-Réanimation, Paris, France
| | - Aymeric Lanore
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpetrière, Département de Santé Publique, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
- CIC Neurosciences, Department of Neurology, Assistance Publique Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Camille Alaterre
- Sorbonne Université, GRC 29, DMU DREAM, AP-HP, Hôpital Pitié-Salpetrière, Département d'Anesthésie-Réanimation, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, DMU DREAM, AP-HP, Hôpital Pitié-Salpetrière, Département d'Anesthésie-Réanimation, Paris, France
| | - Guillaume L Martin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpetrière, Département de Santé Publique, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Agnès Caille
- Université́ de Tours, Université́ de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Arthur James
- Sorbonne Université, GRC 29, DMU DREAM, AP-HP, Hôpital Pitié-Salpetrière, Département d'Anesthésie-Réanimation, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpetrière, Département de Santé Publique, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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12
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Gajniak D, Mendrala K, Cyzowski T, Polak M, Gierek D, Krzych ŁJ. Efficacy of Lidocaine Infusion in High-Risk Vascular Surgery—A Randomized, Double-Blind, Placebo-Controlled Single-Center Clinical Trial. J Clin Med 2023; 12:jcm12062312. [PMID: 36983312 PMCID: PMC10053864 DOI: 10.3390/jcm12062312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 03/18/2023] Open
Abstract
Background: In perioperative pain control, adjuvants such as lidocaine can reduce opioid consumption in a specific type of surgery. The aim of this single-center prospective double-blinded randomized controlled trial was to determine opioid consumption in the perioperative period in patients receiving continuous lidocaine infusion. Methods: Patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive 1% lidocaine or placebo at the same infusion rate based on ideal body weight (bolus of 0.15 mL/kg during the induction of anesthesia followed by continuous infusion of 0.2 mL/kg/h during surgery; postoperatively 0.1 mL/kg/h for 24 h) additionally to standard opioid analgesia. Results: Total opioid consumption within 24 h after surgery was 89.2 mg (95%CI 80.9–97.4) in the lidocaine and 113.1 mg (95%CI 102.5–123.6) in the placebo group (p = 0.0007). Similar findings were observed in opioid consumption intraoperatively (26.7 mg (95%CI 22.2–31.3) vs. 35.1 mg (95%CI 29.1–41.2), respectively, p = 0.029) and six hours postoperatively (47.5 mg (IQR 37.5–59.5) vs. 60 mg (IQR 44–83), respectively, p = 0.01). Conclusions: In high-risk vascular surgery, lidocaine infusion as an adjunct to standard perioperative analgesia is effective. It may decrease opioid consumption by more than 20% during the first 24 h after surgery, with no serious adverse effects noted during the study period.
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Affiliation(s)
- Dariusz Gajniak
- Department of Anaesthesiology and Intensive Care, Upper Silesian Medical Centre, Medical University of Silesia, 40-752 Katowice, Poland
| | - Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence:
| | - Tomasz Cyzowski
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Michał Polak
- Department of Anaesthesiology and Intensive Care, Upper Silesian Medical Centre, Medical University of Silesia, 40-752 Katowice, Poland
| | - Danuta Gierek
- Department of Anaesthesiology and Intensive Care, Upper Silesian Medical Centre, Medical University of Silesia, 40-752 Katowice, Poland
| | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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13
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Ceppi MG, Rauch MS, Spöndlin J, Gantenbein AR, Meier CR, Sándor PS. Potential Risk Factors for, and Clinical Implications of, Delirium during Inpatient Rehabilitation: A Matched Case-Control Study. J Am Med Dir Assoc 2023; 24:519-525.e6. [PMID: 36828136 DOI: 10.1016/j.jamda.2023.01.012] [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: 09/02/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES To investigate the association between a wide set of baseline characteristics (age, sex, rehabilitation discipline), functional scores [Functional Independence Measure (FIM), cumulative Illness Rating Scale (CIRS)], diseases, and administered drugs and incident delirium in rehabilitation inpatients and, furthermore, to assess clinical implications of developing delirium during rehabilitation. DESIGN Matched case-control study based on electronic health record data. SETTING AND PARTICIPANTS We studied rehabilitation stays of inpatients admitted between January 1, 2015, and December 31, 2018, to ZURZACH Care, Rehaklinik Bad Zurzach, an inpatient rehabilitation clinic in Switzerland. METHODS We conducted unconditional logistic regression analyses to estimate adjusted odds ratios (AORs) with 95% CIs of exposures that were recorded in ≥5 cases and controls. RESULTS Among a total of 10,503 rehabilitation stays, we identified 125 validated cases. Older age, undergoing neurologic rehabilitation, a low FIM, and a high CIRS were associated with an increased risk of incident delirium. Being diagnosed with a bacterial infection (AOR 2.62, 95% CI 1.06-6.49), a disorder of fluid, electrolyte, or acid-base balance (AOR 2.76, 95% CI 1.19-6.38), Parkinson's disease (AOR 5.68, 95% CI 2.54-12.68), and administration of antipsychotic drugs (AOR 8.06, 95% CI 4.26-15.22), antiparkinson drugs (AOR 2.86, 95% CI 1.42-5.77), drugs for constipation (AOR 2.11, 95% CI 1.25-3.58), heparins (AOR 2.04, 95% CI 1.29-3.24), or antidepressant drugs (AOR 1.88, 95% CI 1.14-3.10) during rehabilitation, or an increased anticholinergic burden (ACB ≥ 3) (AOR 2.59, 95% CI 1.41-4.73) were also associated with an increased risk of incident delirium. CONCLUSIONS AND IMPLICATIONS We identified a set of factors associated with an increased risk of incident delirium during inpatient rehabilitation. Our findings contribute to detect patients at risk of delirium during inpatient rehabilitation.
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Affiliation(s)
- Marco G Ceppi
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland
| | - Marlene S Rauch
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Julia Spöndlin
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Andreas R Gantenbein
- Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland; Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph R Meier
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland; Boston Collaborative Drug Surveillance Program, Lexington, MA, USA
| | - Peter S Sándor
- Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland; Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
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14
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Jiang JL, Zhang L, He LL, Yu H, Li XF, Dai SH, Yu H. Volatile Versus Total Intravenous Anesthesia on Postoperative Delirium in Adult Patients Undergoing Cardiac Valve Surgery: A Randomized Clinical Trial. Anesth Analg 2023; 136:60-69. [PMID: 36301724 DOI: 10.1213/ane.0000000000006257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effect of anesthesia regimens on postoperative delirium after on-pump cardiac valve surgery is yet undetermined. This study aimed to evaluate the effect of volatile anesthesia compared with propofol-based total intravenous anesthesia (TIVA) on the occurrence of delirium after on-pump cardiac valve surgery. METHODS This randomized clinical trial was conducted at a university academic hospital in China, from February 2019 to January 2021. Patients scheduled for on-pump cardiac valve surgery or combined valve with coronary artery bypass grafting (CABG) surgeries were randomly assigned to receive anesthesia maintenance with either a volatile anesthetic (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was the incidence of delirium during the first 7 days after surgery, assessed using the confusion assessment method for the intensive care unit (ICU). The secondary outcomes included duration of delirium, subtypes of delirium, 30-day mortality, pain score, major morbidity (including cerebral infarction, respiratory failure, and pneumonia), duration of mechanical ventilation, and lengths of ICU and hospital stay. The statistical analysis of the primary outcome variable was by Pearson's χ 2 test. RESULTS Among the 684 patients analyzed (mean age, 53.8 years; 381 [55.7%] women), 676 were assessed for the primary outcome. Postoperative delirium occurred in 63 of 337 (18.7%) patients receiving volatile anesthesia versus 76 of 339 (22.4%) patients receiving propofol-based TIVA (relative risk, 0.80; 95% confidence interval [CI], 0.55-1.16; P = .231). There were no significant differences between the groups in any of the secondary outcomes. CONCLUSIONS Among patients undergoing on-pump cardiac valve surgery, anesthesia maintenance with a volatile agent did not result in significantly fewer occurrences of postoperative delirium than propofol-based TIVA.
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Affiliation(s)
- Jia-Li Jiang
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Zhang
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei-Lei He
- Department of Anesthesiology, Sichuan Jinxin Women and Children's Hospital, Chengdu, Sichuan, China
| | - Hong Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xue-Fei Li
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shun-Hui Dai
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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15
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Bloemberg D, Musters SCW, van der Wal‐Huisman H, Dieren S, Nieveen van Dijkum EJM, Eskes AM. Impact of family visit restrictions due to COVID-19 policy on patient outcomes: A cohort study. J Adv Nurs 2022; 78:4042-4053. [PMID: 35699245 PMCID: PMC9350069 DOI: 10.1111/jan.15325] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/21/2022] [Accepted: 05/29/2022] [Indexed: 11/27/2022]
Abstract
AIM To investigate the impact of family visit restrictions during the COVID-19 pandemic on deliriums, falls, pneumonia, pressure ulcers and readmissions among surgical inpatients with gastrointestinal (oncologic) diseases. DESIGN Cohort study. METHODS This study was conducted among adult inpatients undergoing gastrointestinal surgery in two academic hospitals. During the COVID-19 outbreak in 2020, over a 10-week period, one cohort was subjected to family visit restrictions. Per patient, one person per day was allowed to visit for a maximum of 30 min. This cohort was compared with another cohort in which patients were not subjected to such restrictions during a 10-week period in 2019. Logistic regression analyses were used to investigate the impact of the restrictions on deliriums, falls, pneumonia, pressure ulcers and readmissions. RESULTS In total, 287 patients were included in the 2020 cohort and 243 in the 2019 cohort. No differences were observed in the cohorts with respect to baseline characteristics. Logistic regression analyses showed no significant differences in deliriums, falls, pneumonia, pressure ulcers and readmissions between the cohorts. CONCLUSION We cautiously conclude that the family visit restrictions during the COVID-19 pandemic did not contribute to deliriums, falls, pneumonia, pressure ulcers or readmissions in surgical patients with gastrointestinal (oncologic) diseases. IMPACT COVID-19 influenced family-centred care due to family visit restrictions. Nurses need to continue monitoring outcomes known to be sensitive to family-centred care to gain insight into the effects of visit restrictions and share the results in order to include nurses' perspectives in COVID-19-decision-making. Re-implementing of family visit restrictions should be carefully considered in policy-making.
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Affiliation(s)
- Daphne Bloemberg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Selma C. W. Musters
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Anne M. Eskes
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith UniversityGold Coast, G40 Griffith Health Centre, Level 8.86 Gold Coast campus Griffith UniversityNathanQldAustralia
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16
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Vreeswijk R, Maier AB, Kalisvaart KJ. Recipe for primary prevention of delirium in hospitalized older patients. Aging Clin Exp Res 2022; 34:2927-2944. [PMID: 36131074 DOI: 10.1007/s40520-022-02249-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022]
Abstract
Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.
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Affiliation(s)
- Ralph Vreeswijk
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
| | - Kees J Kalisvaart
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands
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17
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Campbell A, Gustafsson L, Gullo H, Summers M, Rosbergen I, Grimley R. Uncharted territory: The feasibility of serial computerised cognitive assessment the first week post-stroke. J Stroke Cerebrovasc Dis 2022; 31:106614. [PMID: 35858514 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106614] [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: 01/25/2022] [Revised: 06/05/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cognitive impairment is common and problematic post-stroke, yet vital information to understand early cognitive recovery is lacking. To examine early cognitive recovery, it is first necessary to establish the feasibility of repeat cognitive assessment during the acute post-stroke phase. OBJECTIVE To determine if serial computerised testing is feasible for cognitive assessment in an acute post-stroke phase, measured by assessment completion rates. METHOD An observational cohort study recruited consecutive stroke patients admitted to an acute stroke unit within 48 hours of onset. Daily assessment with the Cambridge Neuropsychological Test Automated Battery (CANTAB) was performed for seven days, and single Montreal Cognitive Assessment (MoCA). RESULTS Seventy-one participants were recruited, mean age 74 years, with 67 completing daily testing. Participants had predominantly mild (85%; NIHSS ≤6), ischemic (90%) stroke, 32% demonstrated clinical delirium. The first day of testing, 76% of participants completed CANTAB batteries. Eighty-seven percent of participants completed MoCA a mean of 3.4 days post-stroke. The proportion of CANTAB batteries completed improved significantly from day 2 to day 3 post-stroke with test completion rates stabilizing ≥ 92% by day 4. Participants with incomplete CANTAB were older, with persisting delirium, and longer stay in acute care. CONCLUSION Serial computerised cognitive assessments are feasible the first week post-stroke and provide a novel approach to measuring cognitive change for both clinical and research purposes. Maximum completion rates by day four have clinical implications for optimal timing of cognitive testing.
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Affiliation(s)
- Alana Campbell
- Brisbane, Queensland, Australia; and Queensland Health (Sunshine Coast Hospital and Health Service), The University of Queensland (School of Health and Rehabilitation Sciences), Sunshine Coast, QLD, Australia.
| | - Louise Gustafsson
- Griffith University (School of Health Sciences and Social Work), Brisbane, QLD, Australia
| | - Hannah Gullo
- The University of Queensland (School of Health and Rehabilitation Sciences), Brisbane, QLD, Australia
| | - Mathew Summers
- University of the Sunshine Coast (School of Health and Behavioural Sciences), Sunshine Coast, QLD, Australia
| | - Ingrid Rosbergen
- Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Brisbane, QLD, Australia
| | - Rohan Grimley
- Griffith University and Queensland Health (Sunshine Coast Hospital and Health Service), Sunshine Coast, Queensland, Australia
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Affiliation(s)
- Yu-Chieh Chuang
- Department of General Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City
| | - Che-Yin Lin
- Department of Psychiatry, Shuang-Ho Hospital, Taipei Medical University, New Taipei City
| | - Jiunn-Kae Wang
- Department of Psychiatry, Shuang-Ho Hospital, Taipei Medical University, New Taipei City.,Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei
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19
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Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:1225-1235. [PMID: 34981431 DOI: 10.1007/s40520-021-02057-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU. AIM To examine the diagnostic accuracy of delirium screening tools used in the PACU. METHODS A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool. RESULTS A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU. CONCLUSION Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.
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20
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Ghosal MK, Ray AK. Assessment of Psychiatric Disorders in Consultation-Liaison Setting. Indian J Psychiatry 2022; 64:S211-S227. [PMID: 35602358 PMCID: PMC9122156 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_20_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Malay Kumar Ghosal
- Department of Psychiatry, Medical College, Kolkata, West Bengal, India E-mail:
| | - Anindya Kumar Ray
- Department of Psychiatry, Medical College, Kolkata, West Bengal, India E-mail:
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21
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Hu CH, Chiu YC, Liu SI, Ko KT. Validating the Mandarin version of the Memorial delirium assessment scale in general medical hospital patients. Asia Pac Psychiatry 2022; 14:e12468. [PMID: 33847072 DOI: 10.1111/appy.12468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/10/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Delirium is a common neuropsychiatric condition in the general hospital population. Thus, the goal of the present study is to extend the use of diagnostic tools for delirium by developing and validating a Mandarin version of the Memorial Delirium Assessment Scale (MDAS). METHODS Participants were sampled from two general Mackay Memorial Hospital locations in Taipei and Danshui. Board-certified psychiatrists assessed patients using the MDAS, confusion assessment method (CAM), and Mini-Mental State Examination (MMSE). Another consultation-liaison psychiatrist confirmed the diagnosis of delirium. We assessed the reliability and validity of the MDAS, and the receiver operating characteristic curve was used to determine the optimal cut-off point for identifying delirium. RESULTS Of the 61 patients assessed, 29 were diagnosed with delirium. The mean MDAS score was 16.7 for delirium patients and 4.1 for nondelirium patients. The MDAS has good internal consistency, with a Cronbach's alpha coefficient of 0.912. Interrater reliability was 0.996 (95% confidence interval [CI]: 0.992-0.998). The diagnostic cut-off value for the Mandarin version of the MDAS was 9, with a high sensitivity (93.1%) and specificity (96.9%). Factor analysis revealed a two-factor structure; these factors accounted for 58.37% and 14.42% of the variance. A high correlation was found between the MDAS and the CAM scores (r = -0.849, p < .001) as well as the MMSE (r = -0.875, p < .001). DISCUSSION The Mandarin MDAS exhibited good reliability and validity for assessing general hospital patients.
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Affiliation(s)
- Ching-Ho Hu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu-Chuan Chiu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, Taiwan
| | - Shen-Ing Liu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Kai-Ting Ko
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, Taiwan
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22
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Yaghoubi E, Shariat SV, Rashedi V, Ghanbari Jolfaei A. Repetitive Transcranial Magnetic Stimulation in Delirium: A Double-blind, Randomized, Sham-controlled, Pilot Study. Basic Clin Neurosci 2022; 13:237-246. [PMID: 36425946 PMCID: PMC9682314 DOI: 10.32598/bcn.2022.1830.1] [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: 05/14/2019] [Revised: 06/20/2020] [Accepted: 11/14/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Delirium is a fatal but potentially reversible disorder of the central nervous system that imposes high costs on health systems. This study aims to evaluate the effect of intermittent theta-burst stimulation on the severity and course of delirium disorder. METHODS This is a double-blind, randomized, sham-controlled pilot study. The study participants were randomly allocated into the active (active intermittent theta-burst stimulation) and sham groups. The severity of delirium was assessed 15 minutes before the intervention and 15 minutes after that by the Neelon and Champagne (NEECHAM) confusion scale. RESULTS In the active group, total and subscale scores of NEECHAM significantly decreased after intervention (P<0.05). Although no statistical difference was found in the control group regarding the subscale scores of NEECHAM, the difference in the total scores before and after the sham intervention was statistically significant. CONCLUSION Carrying one session of repetitive transcranial magnetic stimulation on the left dorsolateral prefrontal cortex can reduce the delirium severity in a short period, although it will not decrease the number of delirium cases three days after the intervention. HIGHLIGHTS Delirium is a CNS disorder;Delirium treatment is based on pharmacological and non-pharmacological;rTMS is quasi-modern treatment of neurocognitive disorders. PLAIN LANGUAGE SUMMARY Delirium is fatal but reversible disorder. regarding the restrictions of routine treatments of delirium and by considering the cognition disturbances as the core symptom of delirium, and the positive effect of rTMS on cognition functions. we hypothesized that rTMS could be effective in the treatment of delirium.
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Affiliation(s)
- Emad Yaghoubi
- Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Vahid Shariat
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Rashedi
- School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
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Ntalouka M, Arnaoutoglou E, Vrakas S, Staikou C, Angelis F, Papadopoulos G, Tzimas P. The effect of type 2 diabetes mellitus on perioperative neurocognitive disorders in patients undergoing elective noncardiac surgery under general anesthesia. A prospective cohort study. J Anaesthesiol Clin Pharmacol 2022; 38:252-262. [PMID: 36171952 PMCID: PMC9511857 DOI: 10.4103/joacp.joacp_292_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/13/2021] [Accepted: 05/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background and Aims: Preliminary evidence suggests a possible relationship between type 2 diabetes mellitus (T2DM) and perioperative neurocognitive disorders (NCD). We sought to investigate whether patients with T2DM, undergoing elective noncardiac surgery under general anesthesia, are at increased risk of perioperative NCD. Material and Methods: A prospective cohort study was designed. One-hundred and forty-four patients with T2DM and 144 healthy controls were recruited. Controls were matched for sex, age, type of operation, and educational background. Postoperative delirium (POD), delayed neurocognitive recovery and postoperative NCD were evaluated. Results: Two hundred twenty-eight patients were analyzed. Compared to controls, patients with T2DM were diagnosed with higher rates of NCD preoperatively (n = 96 vs. n = 26, P < 0.05) and higher POD up to 4 days postoperatively (n = 204 vs. n = 68, P < 0.05). Increased rates of delayed neurocognitive recovery and postoperative NCD were recorded in patients with T2DM up to 9 months postoperatively (n = 473 vs. n = 192, P < 0.05). Insulin-dependent patients had higher rates of POD on the second (n = 38 vs. n = 24, P < 0.05) and third day (n = 27 vs. n = 16, P < 0.05) when compared to noninsulin-dependent patients. Logistic multivariable analysis revealed that patients with T2DM are at increased risk for postoperative cognitive disorders. Conclusion: Patients with type 2 diabetes mellitus appear to be at a higher risk of perioperative NCDs up to 9 months after elective noncardiac surgery under general anesthesia.
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Selvaraj T, Thangavel P, Siddhaarth K. Delirium associated with buprenorphine use in cardiac surgery: A retrospective cohort study. Indian J Anaesth 2022; 66:266-271. [PMID: 35663209 PMCID: PMC9159403 DOI: 10.4103/ija.ija_780_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/11/2022] [Accepted: 03/28/2022] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: Methods: Results: Conclusion:
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Detecting Incident Delirium within Routinely Collected Inpatient Rehabilitation Data: Validation of a Chart-Based Method. Neurol Int 2021; 13:701-711. [PMID: 34940753 PMCID: PMC8705493 DOI: 10.3390/neurolint13040067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/30/2021] [Accepted: 11/15/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Delirium is a brain condition associated with poor outcomes in rehabilitation. It is therefore important to assess delirium incidence in rehabilitation. Purpose: To develop and validate a chart-based method to identify incident delirium episodes within the electronic database of a Swiss rehabilitation clinic, and to identify a study population of validated incident delirium episodes for further research purposes. Design: Retrospective validation study. Settings: Routinely collected inpatient clinical data from ZURZACH Care. Participants: All patients undergoing rehabilitation at ZURZACH Care, Rehaklinik Bad Zurzach between 2015 and 2018 were included. Methods: Within the study population, we identified all rehabilitation stays for which ≥2 delirium-predictive key words (common terms used to describe delirious patients) were recorded in the medical charts. We excluded all prevalent delirium episodes and defined the remaining episodes to be potentially incident. At least two physicians independently confirmed or refuted each potential incident delirium episode by reviewing the patient charts. We calculated the positive predictive value (PPV) with 95% confidence interval (95% CI) for all potential incident delirium episodes and for specific subgroups. Results: Within 10,515 rehabilitation stays we identified 554 potential incident delirium episodes. Overall, 125 potential incident delirium episodes were confirmed by expert review. The PPV of the chart-based method varied from 0.23 (95% CI 0.19–0.26) overall to 0.69 (95% CI 0.56–0.79) in specific subgroups. Conclusions: Our chart-based method was able to capture incident delirium episodes with low to moderate accuracy. By conducting an additional expert review of the medical charts, we identified a study population of validated incident delirium episodes. Our chart-based method contributes towards an automated detection of potential incident delirium episodes that, supplemented with expert review, efficiently yields a validated population of incident delirium episodes for research purposes.
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Kim S, Choi E, Jung Y, Jang I. Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: A systematic review and meta-analysis. J Clin Nurs 2021; 32:1691-1704. [PMID: 34881476 DOI: 10.1111/jocn.16157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify the most accurate postoperative delirium screening tools for detecting postoperative delirium among patients who underwent general anaesthesia surgery in general wards. BACKGROUND The lack of detection of postoperative delirium can negatively affect the patient's condition, along with their postoperative treatment and rehabilitation, and it can prolong their hospitalisation, persists cognitive dysfunction and increases mortality. Screening for postoperative delirium in hospitalised patients as nursing assessment is routine clinical practice for early detection. DESIGN A systematic review and meta-analysis. METHODS MEDLINE, Embase, CINAHL, KoreaMed and Cochrane electronic databases were searched using the key words delirium, postoperative, assessment or screening, and adult for articles published up to April 2020, with no limit on the year of publishing. Only prospective cohort studies reporting sensitivity and specificity values were included. We followed the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews and the PRISMA checklist. The Quality Assessment of the Diagnostic Accuracy Studies-2 tool was used for data extraction and quality assessment, while a bivariate random-effects meta-analysis model was used for pooling and comparing diagnostic accuracy and providing a summary of evidence. RESULTS Six delirium assessment tools were evaluated from nine papers including 3088 patients. Due to the limited number of papers, the meta-analysis included the Confusion Assessment Method (CAM) and its variants, Delirium Detection Score (DDS) and Nurses' Delirium Screening Checklist (NuDESC). Overall, NuDESC demonstrated higher sensitivity than CAM or DDS, while all showed high specificity (0.90 or greater). CONCLUSION This review suggested that NuDESC can be employed as an accurate screening tool with high specificity for assessing postoperative delirium during routine checkups. However, it is necessary to consider suitable cut-off values, which is the reference point, in accordance with the clinical setting and the patients' condition. RELEVANCE TO CLINICAL PRACTICE NuDESC reported the best evidence of diagnostic accuracy, and we recommend clinical nurses to employ this easy-to-use and validated tool for daily screening of postoperative delirium in general wards to facilitate its early detection and the accurate estimation of its prevalence.
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Affiliation(s)
- Sujeong Kim
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Eunju Choi
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Youngsun Jung
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Insil Jang
- Department of Nursing, Chung-Ang University, Seoul, Korea
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Grover S, Gupta BM. A scientometric study of publications on delirium from 2001 to 2020. Asian J Psychiatr 2021; 66:102889. [PMID: 34717112 DOI: 10.1016/j.ajp.2021.102889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/02/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aims to evaluate the publications on delirium by using bibliometric analysis. METHODOLOGY The Scopus database was evaluated for publications on delirium, during the period of 2001-20. The search results were analyzed for the origin of country, origin of institution, authorship, collaborations, type of article, source of funding, and number of citations. RESULTS The searches of Scopus database yielded 22,941 publications, originating from 139 countries. Compared to the decade of 2001-2010, the number of publications on delirium doubled in the decade of 2011-2020. The majority of the papers were research articles (58.26%), and the papers were cited for mean number of 20.53 times. Only a small proportion of the papers were based on funding (13.14%). Maximum number of papers emerged from United States of America. In terms of institutional affiliations, among the authors from top 20 institutes, 15 were from United States, 2 from Netherlands and 1 each from Canada, Germany and United Kingdom. In terms of authors, the research productivity of the top 20 most productive authors varied from 172 to 612 publications with 12 authors belonging to United States, 2 from Italy and 1 each from Canada, Greece, India, Ireland, Netherland and the United Kingdom. The maximum number of papers were published in Journal of the American Geriatric Society and based on the number of citations the New England Journal of Medicine was the most impactful journal. CONCLUSION Over the years number of publications on delirium have increased, majority of the publications have emerged from United States.
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Affiliation(s)
- Sandeep Grover
- Post Graduate Institute of Medical Education & Research, Chandigarh, India.
| | - B M Gupta
- Formerly with CSIR-NISTADS, New Delhi 11012, India
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Huang DD, Fischer PE. Management of Delirium in the Intensive Care Unit. Surg Clin North Am 2021; 102:139-148. [PMID: 34800382 DOI: 10.1016/j.suc.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the intensive care unit, delirium is a major contributor to morbidity and mortality in adult patients. Patients with delirium have been shown to have increased length of stay, decreased functional outcomes, and increased risk for requiring placement at the time of discharge. In addition, decreased cognitive function and dementia have been shown to be long-term complications from delirium. The mainstay of treatment and prevention include therapy- and behavioral-based interventions, including frequent orientation, cognitive stimulation, mobilization, sleep restoration, and providing hearing and visual aids. Refractory delirium may require pharmacologic intervention with antipsychotics or alpha-2 agonists.
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Affiliation(s)
- Dih-Dih Huang
- University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA.
| | - Peter E Fischer
- University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA
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Kappen P, Jeekel J, Dirven CMF, Klimek M, Kushner SA, Osse RJ, Coesmans M, Poley MJ, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial. BMJ Open 2021; 11:e048270. [PMID: 34598983 PMCID: PMC8488750 DOI: 10.1136/bmjopen-2020-048270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Delirium is a neurocognitive disorder characterised by an acute and temporary decline of mental status affecting attention, awareness, cognition, language and visuospatial ability. The underlying pathophysiology is driven by neuroinflammation and cellular oxidative stress.Delirium is a serious complication following neurosurgical procedures with a reported incidence varying between 4% and 44% and has been associated with increased length of hospital stay, increased amount of reoperations, increased costs and mortality.Perioperative music has been reported to reduce preoperative anxiety, postoperative pain and opioid usage, and attenuates stress response caused by surgery. We hypothesize that this beneficial effect of music on a combination of delirium eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. METHODS This protocol concerns a single-centred prospective randomised controlled trial with 6 months follow-up. All adult patients undergoing a craniotomy at the Erasmus Medical Center in Rotterdam are eligible. The music group will receive recorded music through an overear headphone before, during and after surgery until postoperative day 3. Patients can choose from music playlists, offered based on music importance questionnaires administered at baseline. The control group will receive standard of clinical careDelirium is assessed by the Delirium Observation Scale and confirmed by a delirium-expert psychiatrist according to the DSM-5 criteria. Risk factors correlated with the onset of delirium, such as cognitive function at baseline, preoperative anxiety, perioperative medication use, depth of anaesthesia and postoperative pain, and delirium-related health outcomes such as length of stay, daily function, quality of life (ie, EQ-5D, EORTC questionnaires), costs and cost-effectiveness are collected. ETHICS AND DISSEMINATION This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Center Rotterdam, The Netherlands, approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBERS NL8503 and NCT04649450.
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Affiliation(s)
- Pablo Kappen
- Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Neuroscience, Erasmus MC, Rotterdam, The Netherlands
- Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Klimek
- Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
- Medical Technology Assessment (iMTA), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. The validation of the Czech version of the Delirium Observation Scale and the Nursing Delirium Screening Scale for delirium screening in patients with locomotive apparatus trauma. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2021.12.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Purpose of Review Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge. Recent Findings This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged. Summary With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.
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Risk factors for postoperative delirium and subsyndromal delirium in older patients in the surgical ward: A prospective observational study. PLoS One 2021; 16:e0255607. [PMID: 34339463 PMCID: PMC8328296 DOI: 10.1371/journal.pone.0255607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
Postoperative delirium (POD) and subsyndromal delirium (SSD) among older patients is a common, serious condition associated with a high incidence of negative outcomes. However, there are few accurate methods for the early detection of POD and SSD in surgical wards. This study aimed to identify risk factors of POD and SSD in older patients who were scheduled for surgery in a surgical ward. This was a prospective observational study. Study participants were older than 65 years, underwent urology surgery, and were hospitalized in the surgical ward between April and September 2019. Delirium symptoms were assessed using the Confusion Assessment Method (CAM) on the preoperative day, the day of surgery, and postoperative days 1–3 by the surgical ward nurses. SSD was defined as the presence of one or more CAM criteria and the absence of a diagnosis of delirium based on the CAM algorithm. Personal characteristics, clinical data, cognitive function, physical functions, laboratory test results, medication use, type of surgery and anesthesia, and use of physical restraint and bed sensor were collected from medical records. Multiple logistic regression analyses were conducted to identify the risk factors for both POD and SSD. A total of 101 participants (mean age 74.9 years) were enrolled; 19 (18.8%) developed POD (n = 4) and SSD (n = 15). The use of bed sensors (odds ratio 10.2, p = .001) was identified as a risk factor for both POD and SSD. Our findings suggest that the use of bed sensors might be related to the development of both POD and SSD among older patients in surgical wards.
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Chu NM, Segev DL, McAdams-DeMarco MA. Delirium Among Adults Undergoing Solid Organ Transplantation. CURRENT TRANSPLANTATION REPORTS 2021; 8:118-126. [PMID: 35321347 PMCID: PMC8936706 DOI: 10.1007/s40472-021-00326-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/01/2023]
Abstract
Purpose of Review To summarize the research on post-operative delirium among patients undergoing solid organ transplantation in efforts to improve recognition, evaluation, and management, as well as highlight areas for future research. Recent Findings Delirium is a common complication in patients with organ failure before and after undergoing solid organ transplant (range: 4.7-47%). However, it is frequently unrecognized and underdiagnosed-even among those closely monitored after major surgery-given that its manifestation is often variable and inconsistent. Delirium has multifactorial etiologies comprising of a complex mix of predisposing recipient, donor, and transplant factors, as well as intraoperative and perioperative factors. Evidence suggests that delirium risk increases with presence of a greater number of such risk factors, and can lead to adverse outcomes such as increased hospital length of stay, time in the ICU, time on mechanical ventilators, graft dysfunction, graft loss, and mortality. Though no trials have been conducted among transplant populations specifically, delirium has been shown to be preventable among hospitalized older adults generally. Multicomponent, primary prevention strategies designed to target multiple risk factors of delirium, such as cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration, have been identified as most effective. Whether these approaches translate to improvements in quality of life and long-term health outcomes among patients with organ failure before and after transplantation is yet to be determined. Summary Delirium is an important, common, yet potentially preventable complication among patients with organ failure. Future studies are needed to test the efficacy of multicomponent, primary prevention strategies on long-term health outcomes among these vulnerable populations.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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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.
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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
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Henao Castaño ÁM, Baquero Lizarazo AC, Gonzalez Pabon N, Burgos Tulcán GF, Lozano Gonzalez L. Enfermería en la monitorización del delirium en cuidado intensivo adulto: una revisión de alcance. INVESTIGACIÓN EN ENFERMERÍA: IMAGEN Y DESARROLLO 2021. [DOI: 10.11144/javeriana.ie22.emdc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Introducción. El delirium es una alteración cognitiva secundaria a una situación clínica aguda que puede estar presente en el paciente crítico, y la enfermería juega un rol protagónico en la prevención, monitoreo y tratamiento no farmacológico del delirium en el paciente en unidad de cuidado intensivo. Objetivo. Identificar las investigaciones actuales que describen las estrategias que utilizan las enfermeras para la monitorización del delirium en la unidad de cuidado intensivo adulto. Método. Revisión de alcance, utilizando la pregunta orientadora ¿qué estrategias utiliza enfermería en la monitorización del delirium en la unidad de cuidado intensivo?, estudios obtenidos en las bases de datos PubMed, Biblioteca Virtual en Salud, Science Direct y Cochrane. Se realizó una revisión crítica con el instrumento CASPe, los datos se extrajeron, y se llevaron a cabo registros en tablas de gráficos elaboradas para condensar la información. Resultados. Trece estudios se consideraron relevantes y fueron analizados. Las estrategias de monitorización del delirium empleadas por enfermería son, principalmente, el juicio clínico, la observación de la agitación y, en menor medida, el empleo de instrumentos validados para la detección. Conclusión. La enfermería requiere comprender mejor el delirium, y para esto la educación es vital para mejorar su conocimiento, y aumentar la autoconfianza y competencia en la evaluación a través del uso correcto de instrumentos.
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Castro VM, Sacks CA, Perlis RH, McCoy TH. Development and External Validation of a Delirium Prediction Model for Hospitalized Patients With Coronavirus Disease 2019. J Acad Consult Liaison Psychiatry 2021; 62:298-308. [PMID: 33688635 PMCID: PMC7933786 DOI: 10.1016/j.jaclp.2020.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/27/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022]
Abstract
Background The coronavirus disease 2019 pandemic has placed unprecedented stress on health systems and has been associated with elevated risk for delirium. The convergence of pandemic resource limitation and clinical demand associated with delirium requires careful risk stratification for targeted prevention efforts. Objectives To develop an incident delirium predictive model among coronavirus disease 2019 patients. Methods We applied supervised machine learning to electronic health record data for inpatients with coronavirus disease 2019 at three hospitals to build an incident delirium diagnosis prediction model. We validated this model in three different hospitals. Both hospital cohorts included academic and community settings. Results Among 2907 patients across 6 hospitals, 488 (16.8%) developed delirium. Applying the predictive model in the external validation cohort of 755 patients, the c-index was 0.75 (0.71–0.79) and the lift in the top quintile was 2.1. At a sensitivity of 80%, the specificity was 56%, negative predictive value 92%, and positive predictive value 30%. Equivalent model performance was observed in subsamples stratified by age, sex, race, need for critical care and care at community vs. academic hospitals. Conclusion Machine learning applied to electronic health records available at the time of inpatient admission can be used to risk-stratify patients with coronavirus disease 2019 for incident delirium. Delirium is common among patients with coronavirus disease 2019, and resource constraints during a pandemic demand careful attention to the optimal application of predictive models.
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Affiliation(s)
- Victor M Castro
- Center for Quantitative Health, Massachusetts General Hospital, Boston, MA
| | - Chana A Sacks
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Roy H Perlis
- Center for Quantitative Health, Massachusetts General Hospital, Boston, MA
| | - Thomas H McCoy
- Center for Quantitative Health, Massachusetts General Hospital, Boston, MA.
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Abstract
PURPOSE OF REVIEW Nervous system tissues have high metabolic demands and other unique vulnerabilities that place them at high risk of injury in the context of critical medical illness. This article describes the neurologic complications that are commonly encountered in patients who are critically ill from medical diseases and presents strategies for their diagnosis, prevention, and treatment. RECENT FINDINGS Chronic neurologic disability is common after critical medical illness and is a major factor in the quality of life for survivors of critical illness. Studies that carefully assessed groups of patients with general critical illness have identified a substantial rate of covert seizures, brain infarcts, muscle wasting, peripheral nerve injuries, and other neurologic sequelae that are strong predictors of poor neurologic outcomes. As the population ages and intensive care survivorship increases, critical illness-related neurologic impairments represent a large and growing proportion of the overall burden of neurologic disease. SUMMARY Improving critical illness outcomes requires identifying and managing the underlying cause of comorbid neurologic symptoms.
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Development of a Simple and Practical Delirium Screening Tool for Use in Surgical Wards. J Nurs Res 2021; 28:e90. [PMID: 32073481 DOI: 10.1097/jnr.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Delirium is an important and common medical condition, particularly in hospitalized patients, that is associated with adverse outcomes. The identification, prevention, and treatment of delirium are increasingly regarded as major public health priorities. PURPOSE The aim of this study was to create a simple-to-use screening tool for delirium in hospitalized patients using clinical manifestations of delirium regularly observed by nurses. METHODS This study was conducted using data on 2,168 patients who had been admitted to the surgical ward between January 2011 and December 2014. Data were collected retrospectively from medical records. Univariate and multivariate analyses were performed, and a logistic regression model was constructed for the development of a predictive screening tool. After constructing a new screening tool for delirium, a receiver operating characteristic curve was drawn, the most appropriate cutoff value was decided, and the area under the curve was obtained. Bootstrapping was used for the internal model validation. RESULTS A screening tool for delirium (Subjective Delirium Screening Scale by Nurse) with a total score of 5 points was constructed as follows: 2 points for disorientation and 1 point each for restlessness, somnolence, and hallucination. The area under the curve for the Subjective Delirium Screening Scale by Nurse was 81.9% (95% CI [77.9%, 85.8%]), and the most appropriate cutoff value was determined to be 2 (sensitivity of 61.0% and specificity of 96.7%). Bootstrapped validation beta coefficients of the predictive factors were similar to the original cohort beta coefficients. CONCLUSIONS We created a screening tool for delirium using factors that were regularly observed and recorded by nurses. This tool is simple and practical and has adequate diagnostic accuracy.
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Delirium Triage Screen/Brief Confusion Assessment Method in Adult Orthopaedic and Hematological Patients: A Validation Study. Orthop Nurs 2021; 40:16-22. [PMID: 33492905 DOI: 10.1097/nor.0000000000000726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Delirium in the hospitalized orthopaedic patient is associated with numerous negative outcomes. Assessing for the presence of delirium using an accurate and reliable tool is essential. However, the number of validated screening tools is limited. The purpose of this study was to validate and test the reliability of the Delirium Triage Screening and brief Confusion Assessment Method (DTS/bCAM) to screen for delirium in non-intensive care (ICU) orthopaedic and hematological patients. This was a prospective, observational study. Seventy-six delirium assessments were completed on 19 orthopaedic patients and 10 hematological patients. The clinical nurse performed the DTS/bCAM during every 12-hour shift. Within 2 hours of this assessment, a research investigator performed both the DTS/bCAM and the Confusion Assessment Method (CAM). Each patient had a maximum of three assessments by a research investigator. Interrater reliability for the clinical nurse and the researcher was measured through comparison of positive and negative DTS/bCAM results. Validity was measured by comparing the matched DTS/bCAM and CAM results, both performed by the researcher. The DTS/bCAM and CAM results had 100% agreement. Two patients (7%) screened positive for delirium. Sensitivity of the DTS/bCAM was 100% (95% CI [15.8-100]) and specificity was 100% (95% CI [95.1, 100]). There was 86% agreement (43/50) between the clinical nurse and the researcher for the DTS/bCAM. In adult orthopaedic and hematological patients not receiving intensive care, the DTS/bCAM may be a valid, reliable, and rapid screening tool for delirium.
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Joo C, Lee S, Kang JW, Lee JD. Acupuncture for postoperative delirium (POD): A systematic review and meta-analysis protocol. Medicine (Baltimore) 2021; 100:e23822. [PMID: 33545947 PMCID: PMC7837831 DOI: 10.1097/md.0000000000023822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a form of delirium that is newly diagnosed after a surgical procedure. This study aims to examine the effectiveness and safety of acupuncture treatment for POD in patients who underwent surgery. METHODS Randomized controlled trials for patients diagnosed with POD using validated delirium assessment scales will be included in this review. Electronic databases, such as MEDLINE, EMBASE, CENTRAL, CINAHL (English DB), CNKI, Wanfang, VIP (Chinese database), KoreaMed, RISS, KISS, DBpia, OASIS (Korean DB), and J-STAGE (Japanese DB) will be searched without language limitation from their inception to October 2020. The intervention group will include patients who have received any type of acupuncture treatment for POD. The control group will include individuals with no treatment, sham acupuncture treatment, and conventional treatment. The primary outcome is the incidence of POD in each study. Quality assessment will be performed using the Cochrane risk of bias tool. A meta-analysis will be performed to pool the estimated effect. CONCLUSION This study will provide evidence for acupuncture as a potential treatment for POD, in researchers, patients, and policy makers. DISSEMINATION The result of the study will be disseminated through posters, press releases, conference presentations, and peer-reviewed papers. TRIAL REGISTRATION NUMBER OSF 2020: (https://osf.io/usvdg).
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Affiliation(s)
- Chanwoo Joo
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University
- Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital
| | - Seunghoon Lee
- Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital
- Department of Acupuncture and Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Jung Won Kang
- Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital
- Department of Acupuncture and Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Jae-Dong Lee
- Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital
- Department of Acupuncture and Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
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Urso D, Gnoni V, Filardi M, Logroscino G. Delusion and Delirium in Neurodegenerative Disorders: An Overlooked Relationship? Front Psychiatry 2021; 12:808724. [PMID: 35115974 PMCID: PMC8804700 DOI: 10.3389/fpsyt.2021.808724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/24/2021] [Indexed: 12/04/2022] Open
Abstract
Delusions are part of the neuropsychiatric symptoms that patients suffering from neurodegenerative conditions frequently develop at some point of the disease course and are associated with an increased risk of cognitive and functional decline. Delirium is a syndrome characterized by acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over a short time period. Delusions and delirium are frequently observed in the context of neurodegeneration, and their presence can easily mislead clinicians toward a misdiagnosis of psychiatric disorder further delaying the proper treatment. Risk factors for developing delusion and delirium in neurodegenerative conditions have been investigated separately while the possible interplay between these two conditions has not been explored so far. With this study, we aim to achieve a more comprehensive picture of the relationship between delusions and delirium in neurodegeneration by analyzing prevalence and subtypes of delusions in different neurodegenerative disorders; providing an overview of clinical tools to assess delusions in neurodegenerative patients and how delusions are covered by delirium assessment tools and discussing the possible common pathophysiology mechanisms between delusion and delirium in neurodegenerative patients. A more extensive characterization of the relationship between delusions and delirium may help to understand whether delusions may constitute a risk factor for delirium and may ameliorate the management of both conditions in patients with neurodegenerative disorders.
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Affiliation(s)
- Daniele Urso
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Valentina Gnoni
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Marco Filardi
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Giancarlo Logroscino
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
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Fürst P, Lundström S, Klepstad P, Strang P. Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center. BMC Palliat Care 2020; 19:172. [PMID: 33172459 PMCID: PMC7657347 DOI: 10.1186/s12904-020-00681-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous subcutaneous infusion (CSCI) via ambulatory infusion pump (AIP) is a valuable method of pain control in palliative care. When using CSCI, low-dose methadone as add-on to other opioids might be an option in complex pain situations. This study aimed to investigate the effects, and adverse effects, of CSCI for pain control in dying patients, with particular interest in methadone use. METHODS This was an observational cohort study. Imminently dying patients with pain, admitted to specialized palliative inpatient wards and introduced on CSCI, were monitored daily by staff for symptoms (Integrated Palliative Care Outcome Scale - IPOS), sedation (Richmond Agitation and Sedation Scale - RASS), performance status (Eastern Cooperative Oncology Group - ECOG) and delirium (Confusion Assessment Method - CAM). RESULTS Ninety-three patients with a median survival of 4 days were included. Of the 47 patients who survived ≥3 days, the proportion of patients with severe/overwhelming pain decreased from 45 to 19% (p < 0.001) after starting CSCI, with only a moderate increase in morphine equivalent daily dose of opioids (MEDD). Alertness was marginally decreased (1 point on the 10-point RASS scale, p = 0.001), whereas performance status and prevalence of delirium, regardless of age, remained unchanged. Both patients with methadone as add-on (MET, n = 13) and patients with only other opioids (NMET, n = 34), improved in pain control (p < 0.05 and 0.001, respectively), despite that MET patients had higher pain scores at baseline (p < 0.05) and were on a higher MEDD (240 mg vs.133 mg). No serious adverse effects demanding treatment stop were reported. CONCLUSIONS CSCI via AIP is an effective way to reduce pain in dying patients without increased adverse effects. Add-on methadone may be beneficial in patients with severe complex pain.
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Affiliation(s)
- Per Fürst
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden. .,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden.
| | - Staffan Lundström
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden.,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,European Palliative Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Intensive Care medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Peter Strang
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden.,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Sanyaolu L, Scholz AFM, Mayo I, Coode-Bate J, Oldroyd C, Carter B, Quinn T, Hewitt J. Risk factors for incident delirium among urological patients: a systematic review and meta-analysis with GRADE summary of findings. BMC Urol 2020; 20:169. [PMID: 33109133 PMCID: PMC7590461 DOI: 10.1186/s12894-020-00743-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/14/2020] [Indexed: 12/02/2022] Open
Abstract
Background Post-operative delirium is an important, yet under-researched complication of surgery. Patients undergoing urological surgery may be at especially high risk of POD, as they are often older, and interventions can be associated with conditions that trigger delirium. The main aim of this systematic review was to evaluate the available evidence for risk factors in this patient group. Methods Five databases were searched (MEDLINE, Web of Science, EMBASE, CINAHL and PsychInfo) between January 1987 and June 2019. The Newcastle–Ottawa Scale was used to assess for risk of bias. Pooled odds ratio or mean difference (MD) for individual risk factors were estimated using the Mantel–Haenzel and inverse variance methods. Results Seven articles met the inclusion criteria, giving a total population of 1937. The incidence of POD ranged from 5 to 29%. Three studies were deemed low risk of bias and four at a high risk of bias. Nine risk factors were suitable for meta-analysis, with age (MD 4.314 95% CI 1.597, 7.032 p = 0.002) and the clock drawing test (MD − 2.443 95% CI − 3.029, − 1.857 p < 0.001) having a statistically significant association with POD in pooled analyses. Conclusion Delirium is common in urological patients. This review has identified a lack of studies in this surgical population, with wide heterogeneity and high risk of bias. It also highlights a number of potential risk factors for post-operative delirium, of which some are modifiable. However, the strength of evidence is weak at present and so future research should focus on assessing comparable risk factors in this patient group in order to inform future clinical practice. Review registration The review protocol was prospectively registered with the PROSPERO database (reference CRD42017054613)
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Affiliation(s)
- L Sanyaolu
- Division of Population Medicine, Cardiff University, Cardiff, UK.
| | - A F M Scholz
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - I Mayo
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - C Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - B Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Cochrane Skin Group, School of Medicine, The University of Nottingham, Nottingham, UK
| | - T Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - J Hewitt
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Yamanashi T, Iwata M, Crutchley KJ, Sullivan EJ, Malicoat JR, Anderson ZEM, Marra PS, Chang G, Kaneko K, Shinozaki E, Lee S, Shinozaki G. New Cutoff Scores for Delirium Screening Tools to Predict Patient Mortality. J Am Geriatr Soc 2020; 69:140-147. [PMID: 32905636 DOI: 10.1111/jgs.16815] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES Detecting delirium is important to identify patients with a high risk of poor outcomes. Although many different kinds of screening instruments for delirium exist, there is no solid consensus about which methods are the most effective. In addition, it is important to find the most useful tools in predicting outcomes such as mortality. DESIGN Retrospective cohort study. SETTING University of Iowa Hospitals and Clinics. PARTICIPANTS A total of 1,125 adult inpatients (mean age = 67.7; median age = 69). MEASUREMENTS Post hoc analyses were performed based on existing data from the Confusion Assessment Method for Intensive Care Unit (CAM-ICU), Delirium Rating Scale-Revised-98 (DRS), and the Delirium Observation Screening Scale (DOSS). Correlation among these scales and relationships between 365-day mortality and each scale were evaluated. RESULTS A positive result on the CAM-ICU ("CAM-ICU positive") was associated with higher DRS and DOSS scores. A DRS score = 9/10 was the best cutoff to detect CAM-ICU positive, and DOSS = 2/3 was the best cutoff to detect CAM-ICU positive. CAM-ICU positive was associated with high 365-day mortality. DRS score = 9/10 and DOSS score = 0/1 were found to differentiate mortality risk the most significantly. Higher DRS and DOSS scores significantly coincided with a decrease in a patient's survival rate at 365 days. CONCLUSION The best DRS and DOSS cutoff scores to differentiate 365-day mortality risk were lower than those commonly used to detect delirium in the literature. New cutoff scores for the DRS and DOSS might be useful in differentiating risk of mortality among hospital patients.
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Affiliation(s)
- Takehiko Yamanashi
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Masaaki Iwata
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Kaitlyn J Crutchley
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eleanor J Sullivan
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Johnny R Malicoat
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Zoe-Ella M Anderson
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Pedro S Marra
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Gloria Chang
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Koichi Kaneko
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Eri Shinozaki
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Gen Shinozaki
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, Iowa City, Iowa, USA.,Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, Iowa, USA
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Gonzalez MR, Miller RK, Michener AR. Overview of High Yield Geriatrics Assessment for Clinic and Hospital. Med Clin North Am 2020; 104:777-789. [PMID: 32773045 DOI: 10.1016/j.mcna.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Geriatric assessment is a comprehensive, multifaceted, and interdisciplinary evaluation of medical, socioeconomic, environmental, and functional concerns unique to older adults; it can be focused or broadened according to the needs of the patient and the concerns of clinical providers. Herein, the authors present a high-yield framework that can be used to assess older adult patients across a variety of settings.
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Affiliation(s)
- Mariana R Gonzalez
- Division of Geriatrics, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104, USA
| | - Rachel K Miller
- Division of Geriatrics, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104, USA.
| | - Alyson R Michener
- Division of Geriatrics, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104, USA
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Jeong E, Park J, Lee J. Diagnostic test accuracy of the Nursing Delirium Screening Scale: A systematic review and meta‐analysis. J Adv Nurs 2020; 76:2510-2521. [DOI: 10.1111/jan.14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eunhye Jeong
- College of Nursing Korea University Seoul Republic of Korea
| | - Jinkyung Park
- College of Nursing Korea University Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
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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
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Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [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] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
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Delp S, Mei W, Spies CD, Neuner B, Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Kramer S, Weiss B. Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology. J Int Med Res 2020; 48:300060520927207. [PMID: 32493149 PMCID: PMC7273774 DOI: 10.1177/0300060520927207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/27/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline. METHODS We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices. RESULTS In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment. CONCLUSION Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.
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Affiliation(s)
- Simon Delp
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Wei Mei
- Department of Anaesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Claudia D. Spies
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Bruno Neuner
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - César Aldecoa
- Department of Anesthesiology, Facultad de Medicina de Valladolid, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery; Department of Anaesthesia, Analgesia and Intensive Care, Italian National Research Centres on Aging/IRCCS, Ancona, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, ‘Sapienza’ University of Rome, Rome, Italy
| | - Robert D. Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, USA
| | - Sylvia Kramer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Bjoern Weiss
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
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Rapid evacuation of chronic subdural hematoma – A possible traumatic brain injury (TBI). Med Hypotheses 2020; 137:109539. [DOI: 10.1016/j.mehy.2019.109539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/18/2022]
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