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Kneihsl M, Berger N, Sumerauer S, Asenbaum-Nan S, Höger FS, Gattringer T, Enzinger C, Aigner M, Ferrari J, Lang W. Management of delirium in acute stroke patients: a position paper by the Austrian Stroke Society on prevention, diagnosis, and treatment. Ther Adv Neurol Disord 2024; 17:17562864241258788. [PMID: 39161955 PMCID: PMC11331472 DOI: 10.1177/17562864241258788] [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: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 08/21/2024] Open
Abstract
Delirium is a common complication in acute stroke patients, occurring in 15-35% of all stroke unit admissions and is associated with prolonged hospital stay and a poor post-stroke prognosis. Managing delirium in acute stroke patients necessitates an intensive and multiprofessional therapeutic approach, placing a significant burden on healthcare staff. However, dedicated practical recommendations for delirium management developed for the population of acute stroke patients are lacking. For this purpose, the Austrian Stroke Society, in cooperation with the Austrian Society of Neurology, the Austrian Society of Neurorehabilitation, and the Austrian Society of Psychiatry, Psychotherapy, and Psychosomatics has formulated an evidence-based position paper addressing the management of delirium in acute stroke patients. The paper outlines practical recommendations on the three pillars of care in stroke patients with delirium: (a) Key aspects of delirium prevention including stroke-specific delirium risk factors and delirium prediction scores are described. Moreover, a non-pharmacological delirium prevention bundle is presented. (b) The paper provides recommendations on timing and frequency of delirium screening to ensure early diagnosis of delirium in acute stroke patients. Moreover, it reports on the use of different delirium screening tools in stroke populations. (c) An overview of non-pharmacological and pharmacological treatment strategies in patients with delirium and acute stroke is presented and summarized as key recommendation statements.
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Affiliation(s)
- Markus Kneihsl
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, Graz A-8036, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Natalie Berger
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Stefan Sumerauer
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Martin Aigner
- Department of Psychiatry and Psychotherapy, Karl Landsteiner University for Health and Science, Tulln, Austria
| | - Julia Ferrari
- Department of Neurology, Hospital Barmherzige Brüder Vienna, Vienna, Austria
| | - Wilfried Lang
- Medical Faculty, Sigmund Freud University, Vienna, Austria
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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [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: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Gao X, Lin C, Feng Y, You Y, Jin Z, Li M, Zhou Y, Chen K. Akkermansia muciniphila-derived small extracellular vesicles attenuate intestinal ischemia-reperfusion-induced postoperative cognitive dysfunction by suppressing microglia activation via the TLR2/4 signaling. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2024; 1871:119630. [PMID: 37967793 DOI: 10.1016/j.bbamcr.2023.119630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023]
Abstract
Akkermansia muciniphila (AKK) bacteria improve the functions of theere intestinal and blood-brain barriers (BBB) via their extracellular vesicles (AmEvs). However, their role in postoperative cognitive dysfunction (POCD) and its underlying mechanisms remain unclear. To investigate, we used C57BL/6 J mice divided into five groups: Sham, POCD, POCD+Akk, POCD+Evs, and POCD+Evs + PLX5622. POCD was induced through intestinal ischemia-reperfusion (I/R). The mice's cognitive function was assessed using behavioral tests, and possible mechanisms were explored by examining gut and BBB permeability, inflammation, and microglial function. Toll-like receptor (TLR) 2/4 pathway-related proteins were also investigated both in vitro and in vivo. PLX5622 chow was employed to eliminate microglial cells. Our findings revealed a negative correlation between AKK abundance and POCD symptoms. Supplementation with either AKK or AmEvs improved cognitive function, improved the performance of the intestinal barrier and BBB, and decreased inflammation and microglial activation in POCD mice compared to controls. Moreover, AmEvs treatment inhibited TLR2/4 signaling in the brains of POCD mice and LPS-treated microglial cells. In microglial-ablated POCD mice, however, AmEvs failed to protect BBB integrity. Overall, AmEvs is a potential therapeutic strategy for managing POCD by enhancing gut and BBB integrity and inhibiting microglial-mediated TLR2/4 signaling.
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Affiliation(s)
- Xiang Gao
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Fuzhou, 350000, China; College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
| | - Chuantao Lin
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Fuzhou, 350000, China; College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
| | - Yebin Feng
- Department of Science and Education, Fujian Maternity and Child Health Hospital, Fuzhou, 350000, China; College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
| | - Yi You
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Fuzhou, 350000, China; College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
| | - Zhe Jin
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Mengyun Li
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yufeng Zhou
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Kai Chen
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Ren Y, Zhang Y, Zhan J, Sun J, Luo J, Liao W, Cheng X. Machine learning for prediction of delirium in patients with extensive burns after surgery. CNS Neurosci Ther 2023; 29:2986-2997. [PMID: 37122154 PMCID: PMC10493655 DOI: 10.1111/cns.14237] [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: 01/03/2023] [Revised: 02/23/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023] Open
Abstract
AIMS Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns. METHODS Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital. RESULTS Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%). CONCLUSION The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Yu Zhang
- Medical Innovation CenterThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Junfeng Sun
- Medical Center of Burns and PlasticGanzhou People's HospitalGanzhouChina
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
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Matsuura Y, Ohno Y, Toyoshima M, Ueno T. Effects of non-pharmacologic prevention on delirium in critically ill patients: A network meta-analysis. Nurs Crit Care 2023; 28:727-737. [PMID: 35624556 DOI: 10.1111/nicc.12780] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 04/22/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients. AIM This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients. STUDY DESIGN A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI. RESULTS We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001). CONCLUSION This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS. RELEVANCE TO CLINICAL PRACTICE These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.
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Affiliation(s)
- Yutaka Matsuura
- Division of Nursing, Mie University Graduate School of Medicine, Tsu, Japan
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Ohno
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
| | - Miki Toyoshima
- Department of Intensive Care Unit, Osaka City General Hospital, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
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Ryan SL, Liu X, McKenna V, Ghanta M, Muniz C, Renwick R, Westover MB, Kimchi EY. Associations between early in-hospital medications and the development of delirium in patients with stroke. J Stroke Cerebrovasc Dis 2023; 32:107249. [PMID: 37536017 PMCID: PMC10529367 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES Patients hospitalized with stroke develop delirium at higher rates than general hospitalized patients. While several medications are associated with existing delirium, it is unknown whether early medication exposures are associated with subsequent delirium in patients with stroke. Additionally, it is unknown whether delirium identification is associated with changes in the prescription of these medications. MATERIALS AND METHODS We conducted a retrospective cohort study of patients admitted to a comprehensive stroke center, who were assessed for delirium by trained nursing staff during clinical care. We analyzed exposures to multiple medication classes in the first 48 h of admission, and compared them between patients who developed delirium >48 hours after admission and those who never developed delirium. Statistical analysis was performed using univariate testing. Multivariable logistic regression was used further to evaluate the significance of univariately significant medications, while controlling for clinical confounders. RESULTS 1671 unique patients were included in the cohort, of whom 464 (27.8%) developed delirium >48 hours after admission. Delirium was associated with prior exposure to antipsychotics, sedatives, opiates, and antimicrobials. Antipsychotics, sedatives, and antimicrobials remained significantly associated with delirium even after accounting for several clinical covariates. Usage of these medications decreased in the 48 hours following delirium identification, except for atypical antipsychotics, whose use increased. Other medication classes such as steroids, benzodiazepines, and sleep aids were not initially associated with subsequent delirium, but prescription patterns still changed after delirium identification. CONCLUSIONS Early exposure to multiple medication classes is associated with the subsequent development of delirium in patients with stroke. Additionally, prescription patterns changed following delirium identification, suggesting that some of the associated medication classes may represent modifiable targets for future delirium prevention strategies, although future study is needed.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Mount Sinai Medical Center, India
| | - Xiu Liu
- Department of Neurology, Massachusetts General Hospital, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital, USA
| | - Vanessa McKenna
- Department of Neurology, Massachusetts General Hospital, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, USA
| | - Carlos Muniz
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, SUNY Upstate Medical University, USA
| | - Rachel Renwick
- Department of Neurology, Massachusetts General Hospital, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Beth Israel Deaconess Medical Center, USA
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Northwestern University, USA.
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Al Farsi RS, Al Alawi AM, Al Huraizi AR, Al-Saadi T, Al-Hamadani N, Al Zeedy K, Al-Maqbali JS. Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study. J Clin Med 2023; 12:3897. [PMID: 37373591 DOI: 10.3390/jcm12123897] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/12/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH). METHODS A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors. RESULTS The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital. CONCLUSIONS Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.
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Affiliation(s)
- Rajaa Saleh Al Farsi
- Oman Medical Specialty Board, Internal Medicine Residency Training Program, Muscat 130, Oman
| | | | | | - Taif Al-Saadi
- School of Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Noof Al-Hamadani
- School of Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Khalfan Al Zeedy
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
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Dodsworth BT, Reeve K, Falco L, Hueting T, Sadeghirad B, Mbuagbaw L, Goettel N, Schmutz Gelsomino N. Development and validation of an international preoperative risk assessment model for postoperative delirium. Age Ageing 2023; 52:7192246. [PMID: 37290122 DOI: 10.1093/ageing/afad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a frequent complication in older adults, characterised by disturbances in attention, awareness and cognition, and associated with prolonged hospitalisation, poor functional recovery, cognitive decline, long-term dementia and increased mortality. Early identification of patients at risk of POD can considerably aid prevention. METHODS We have developed a preoperative POD risk prediction algorithm using data from eight studies identified during a systematic review and providing individual-level data. Ten-fold cross-validation was used for predictor selection and internal validation of the final penalised logistic regression model. The external validation used data from university hospitals in Switzerland and Germany. RESULTS Development included 2,250 surgical (excluding cardiac and intracranial) patients 60 years of age or older, 444 of whom developed POD. The final model included age, body mass index, American Society of Anaesthesiologists (ASA) score, history of delirium, cognitive impairment, medications, optional C-reactive protein (CRP), surgical risk and whether the operation is a laparotomy/thoracotomy. At internal validation, the algorithm had an AUC of 0.80 (95% CI: 0.77-0.82) with CRP and 0.79 (95% CI: 0.77-0.82) without CRP. The external validation consisted of 359 patients, 87 of whom developed POD. The external validation yielded an AUC of 0.74 (95% CI: 0.68-0.80). CONCLUSIONS The algorithm is named PIPRA (Pre-Interventional Preventive Risk Assessment), has European conformity (ce) certification, is available at http://pipra.ch/ and is accepted for clinical use. It can be used to optimise patient care and prioritise interventions for vulnerable patients and presents an effective way to implement POD prevention strategies in clinical practice.
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Affiliation(s)
| | - Kelly Reeve
- Institute of Data Analysis and Process Design, Zurich University of Applied Sciences, Winterthur 8400, Switzerland
| | - Lisa Falco
- Zühlke Engineering AG, Zürcherstrasse 39J, Schlieren 8952, Switzerland
| | - Tom Hueting
- Evidencio, Irenesingel 19, Haaksbergen 7481 GJ, Netherlands
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Anesthesia, McMaster University, Hamilton ON L8S 4L8, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Anesthesia, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON L8S 4L8, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé 12117, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town 7600, South Africa
| | - Nicolai Goettel
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville FL 32610, USA
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
| | - Nayeli Schmutz Gelsomino
- PIPRA AG, Zurich 8005, Switzerland
- Department of Anaesthesia, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland
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Abstract
ABSTRACT Delirium is a common neurocognitive disorder among hospitalized older adults, and it can have devastating effects. The purpose of this article is to inform NPs in the hospital setting to recognize, prevent, and manage delirium in older adults. The roles of nonpharmacologic and pharmacologic interventions are described.
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Affiliation(s)
- Thomas J Blodgett
- Thomas J. Blodgett is an assistant professor at Duke University School of Nursing in Durham, N.C
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10
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Babine RL, Hyrkäs KE, Scott C, Wierman HR. Individuals Who Developed Delirium While Enrolled in the Hospital Elder Life Program: An Exploratory Study. J Gerontol Nurs 2023; 49:19-29. [PMID: 37126011 DOI: 10.3928/00989134-20230414-02] [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: 05/02/2023]
Abstract
Delirium prevention in hospitalized older adults is important due to delirium's high prevalence and negative impact on outcomes. Today, there are evidence-based programs with well-documented effectiveness aimed at preventing delirium, such as the Hospital Elder Life Program (HELP); however, approximately 4% to 5% of patients develop delirium regardless of implemented prevention interventions. It remains unknown why some patients develop delirium. The current retrospective exploratory chart review analyzed 98 records for clinical risk factors and outcomes of patients who developed delirium while enrolled in the HELP. On admission, immobility (86.7%) was the most common risk factor. Patients developed delirium approximately 70 hours after admission. Average length of stay was 8 days. Approximately one half (44.9%) of patients died within 1 year. Immobility (97.7% vs. 77.8%, p = 0.005) and renal disease (52.3% vs. 24.1%, p = 0.008) were more often found in patients who died. This study identifies risk factors that seem to require heightened attention during hospitalization to prevent the negative outcomes associated with delirium in older adults. [Journal of Gerontological Nursing, 49(5), 19-29.].
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11
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Oldham MA, Slooter AJC, Ely EW, Crone C, Maldonado JR, Rosenthal LJ. An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes. J Acad Consult Liaison Psychiatry 2023; 64:248-261. [PMID: 35840003 PMCID: PMC9839895 DOI: 10.1016/j.jaclp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 07/04/2022] [Indexed: 01/17/2023]
Abstract
An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education Clinical Center (GRECC), TN Valley Veterans Affairs Medical Center, Nashville, TN
| | - Cathy Crone
- Inova Health System, Behavioral Health, Falls Church, VA; George Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Washington, DC
| | - José R Maldonado
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, CA
| | - Lisa J Rosenthal
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
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12
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Yu CL, Carvalho AF, Thompson T, Tsai TC, Tseng PT, Tu YK, Yang SN, Yang FC, Chang CH, Hsu CW, Hsu TW, Liang CS. Ramelteon for delirium prevention in hospitalized patients: An updated meta-analysis and trial sequential analysis of randomized controlled trials. J Pineal Res 2023; 74:e12857. [PMID: 36726202 DOI: 10.1111/jpi.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023]
Abstract
Although ramelteon has been examined as a relatively new therapeutic option for delirium prevention, current evidence to evaluate its efficacy is limited. We conducted an updated meta-analysis and examine the reliability of existing evidence regarding the effect of ramelteon on delirium prevention in hospitalized patients. Seven major electronic databases were systematically searched to identify randomized controlled trials examining the efficacy of ramelteon in delirium prevention. Data were pooled using a frequentist-restricted maximum-likelihood random-effects model. A trial sequential analysis was performed using relative risk reduction thresholds of 50%. The primary outcome was the incidence of delirium (reported as odds ratio with 95% confidence intervals). The secondary outcomes were the days of delirium, all-cause mortality, and all-cause discontinuation. Of 187 potentially eligible studies identified, 8 placebo-controlled randomized controlled trials (n = 587) were included. This updated meta-analysis showed that ramelteon was associated with lower odds of delirium occurrence than placebo (0.50; 0.29-0.86; I2 = 17.48%). In trial sequential analysis, the effect of ramelteon across the superiority boundary when using a relative risk reduction threshold ranging from 40% to 60%. In subgroup analyses, ramelteon compared with placebo was associated with lower odds of delirium occurrence in the elderly group (k = 5; 0.28; 0.09-0.85; I2 = 27.93%) and multiple dosage group (k = 5; 0.34; 0.14-0.82; I2 = 44.24%) but not in the non-elderly and non-multiple dosage groups. When considering surgical patients and medical patients separately, ramelteon showed a trend in the treatment of delirium prevention in both groups, while these findings were not statistically significant. No significant between-group differences were found in the secondary outcomes. The current meta-analysis provides updated and reliable evidence that ramelteon, in comparison with placebo, reduces the risk of delirium among hospitalized patients.
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Affiliation(s)
- Chia-Ling Yu
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Andre F Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Tzu-Cheng Tsai
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Nian Yang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
- Graduate Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, National Defense Medical Centre, Tri-Service General Hospital, Taipei, Taiwan
| | - Cheng-Ho Chang
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Wei Hsu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, National Defense Medical Centre, Taipei, Taiwan
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13
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Morandi A, Bellelli G. The case of B.M.: delirium across different settings of care. JOURNAL OF GERONTOLOGY AND GERIATRICS 2023. [DOI: 10.36150/2499-6564-n590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
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14
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An JY, Park JY, Cho J, Kim HE, Park J, Oh J. The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2023; 21:179-187. [PMID: 36700324 PMCID: PMC9889904 DOI: 10.9758/cpn.2023.21.1.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/19/2022] [Accepted: 05/02/2022] [Indexed: 01/27/2023]
Abstract
Objective The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties. Methods We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins. Results Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2. Conclusion The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.
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Affiliation(s)
- Jun Yong An
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jaesub Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Jooyoung Oh Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea, E-mail: , ORCID: https://orcid.org/0000-0001-6721-399X
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15
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Asymptomatic Aortic Stenosis in an Older Patient: How the Geriatric Approach Can Make a Difference. Diagnostics (Basel) 2023; 13:diagnostics13050909. [PMID: 36900053 PMCID: PMC10001207 DOI: 10.3390/diagnostics13050909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023] Open
Abstract
We present a case report of an older patient with aortic stenosis who was managed before and after transcatheter aortic valve implantation by a team of cardiologists but without the support of a geriatrician. We first describe the patient's post-interventional complications from a geriatric perspective and afterwards, discuss the unique approach that the geriatrician would have provided. This case report was written by a group of geriatricians working in an acute hospital, along with a clinical cardiologist who is an expert in aortic stenosis. We discuss the implications for modifying conventional practice in tandem with existing literature.
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16
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Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis. J Anesth 2023; 37:294-310. [PMID: 36788134 DOI: 10.1007/s00540-023-03170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.
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17
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Liu SB, Liu S, Gao K, Wu GZ, Zu G, Jie Liu J. Olanzapine for the treatment of ICU delirium: a systematic review and meta-analysis. Ther Adv Psychopharmacol 2023; 13:20451253231152113. [PMID: 36845642 PMCID: PMC9944192 DOI: 10.1177/20451253231152113] [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: 06/20/2022] [Accepted: 01/04/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND As an atypical antipsychotic drug, olanzapine is one of the most commonly used drugs for delirium control. There are no systematic evaluations or meta-analyses of the efficacy and safety of olanzapine for delirium control in critically ill adults. OBJECTIVES In this meta-analysis, we evaluated the efficacy and safety of olanzapine for delirium control in critically ill adults in the intensive care unit (ICU). DATA SOURCES AND METHODS From inception to October 2022, 12 electronic databases were searched. We retrieved randomized controlled trials (RCTs) and retrospective cohort studies of critically ill adults with delirium that compared the effects of olanzapine and other interventions, including routine care (no intervention), nonpharmaceutical interventions and pharmaceutical interventions. The main outcome measures were the (a) relief of delirium symptoms and (b) a decrease in delirium duration. Secondary outcomes were ICU and in-hospital mortality, ICU and hospital length of stay, incidence of adverse events, cognitive function, sleep quality, quality of life, mechanical ventilation time, endotracheal intubation rate and delirium recurrence rate. We applied a random effects model. RESULTS Data from 10 studies (four RCTs and six retrospective cohort studies) involving 7076 patients (2459 in the olanzapine group and 4617 in the control group) were included. Olanzapine did not effectively relieve delirium symptoms (OR = 1.36, 95% CI [0.83, 2.28], p = 0.21), nor did it shorten the duration of delirium [standardized mean difference (SMD) = 0.02, 95% CI [-1.04, 1.09], p = 0.97] when compared with other interventions. Pooled data from three studies showed that the use of olanzapine reduced the incidence of hypotension (OR = 0.44, 95% CI [0.20, 0.95], p = 0.04) compared with other pharmaceuticals. There was no significant difference in other secondary outcomes, including ICU or hospital length of stay, in-hospital mortality, extrapyramidal reactions, QTc interval prolongation, or overall incidence of other adverse reactions. The number of included studies was not sufficient for performing a comparison between olanzapine and no intervention. CONCLUSION Compared with other interventions, olanzapine has no advantage in alleviating delirium symptoms and shortening delirium duration in critically ill adults. However, there is some evidence that the rate of hypotension was lower in patients who received olanzapine than in those who received other pharmaceutical interventions. There was a nonsignificant difference in the length of ICU or hospital stay, in-hospital mortality, and other adverse reactions. This study provides reference data for delirium research and clinical drug intervention strategies in critically ill adults. REGISTRATION Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42021277232).
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Affiliation(s)
- Si Bo Liu
- Intensive Care Unit, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Shan Liu
- Intensive Care Unit, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Kai Gao
- Intensive Care Unit, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Guo Zhi Wu
- Intensive Care Unit, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Guo Zu
- Department of Gastrointestinal Surgery, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Jin Jie Liu
- Department of No. 2 General Medicine, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian 116033, China.,Neurological Intensive Care Unit, Beijing Tiantan Hospital Affiliated Capital Medical University, Beijing 100050, China
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18
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Affiliation(s)
- Edward R Marcantonio
- From the Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School - both in Boston
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19
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Yamanashi T, Anderson ZEEM, Modukuri M, Chang G, Tran T, Marra PS, Wahba NE, Crutchley KJ, Sullivan EJ, Jellison SS, Comp KR, Akers CC, Meyer AA, Lee S, Iwata M, Cho HR, Shinozaki E, Shinozaki G. The potential benefit of metformin to reduce delirium risk and mortality: a retrospective cohort study. Aging (Albany NY) 2022; 14:8927-8943. [PMID: 36399107 PMCID: PMC9740381 DOI: 10.18632/aging.204393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Metformin has been reported to improve age-related disorders, including dementia, and to lower mortality. This study was conducted to investigate whether metformin use lower delirium risk, as well as long-term mortality. METHODS In this retrospective cohort study, previously recruited 1,404 subjects were analyzed. The relationship between metformin use and delirium, and the relationship between metformin use and 3-year mortality were investigated. MAIN FINDINGS 242 subjects were categorized into a type 2 diabetes mellitus (DM)-without-metformin group, and 264 subjects were categorized into a DM-with-metformin group. Prevalence of delirium was 36.0% in the DM-without-metformin group, and 29.2% in the DM-with-metformin group. A history of metformin use reduced the risk of delirium in patients with DM (OR, 0.50 [95% CI, 0.32 to 0.79]) after controlling for confounding factors. The 3-year mortality in the DM-without-metformin group (survival rate, 0.595 [95% CI, 0.512 to 0.669]) was higher than in the DM-with-metformin group (survival rate, 0.695 [95% CI, 0.604 to 0.770]) (p=0.035). A history of metformin use decreased the risk of 3-year mortality after adjustment for confounding factors (HR, 0.69 [95% CI, 0.48 to 0.98]). CONCLUSIONS Metformin use may lower the risk of delirium and mortality in DM patients.
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Affiliation(s)
- Takehiko Yamanashi
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA 94305, USA,University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA,Tottori University Faculty of Medicine, Department of Neuropsychiatry, Yonago-Shi, Tottori, Japan
| | - Zoe-Ella EM Anderson
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Manisha Modukuri
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Gloria Chang
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Tammy Tran
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Pedro S. Marra
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Nadia E. Wahba
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Kaitlyn J. Crutchley
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Eleanor J. Sullivan
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Sydney S. Jellison
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Katie R. Comp
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Cade C. Akers
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Alissa A. Meyer
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
| | - Sangil Lee
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, IA 52242, USA
| | - Masaaki Iwata
- Tottori University Faculty of Medicine, Department of Neuropsychiatry, Yonago-Shi, Tottori, Japan
| | - Hyunkeun R. Cho
- University of Iowa College of Public Health, Department of Biostatistics, Iowa City, IA 52242, USA
| | - Eri Shinozaki
- University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA 52242, USA
| | - Gen Shinozaki
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA 94305, USA,University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA 52242, USA
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20
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Jaworska N, Moss SJ, Krewulak KD, Stelfox Z, Niven DJ, Ismail Z, Burry LD, Fiest KM. A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings. BMC Health Serv Res 2022; 22:1272. [PMID: 36271347 PMCID: PMC9587627 DOI: 10.1186/s12913-022-08650-7] [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: 01/28/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08650-7.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Calgary, AB, Canada.
| | - Stephana J Moss
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Zara Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy, Sinai Health System, University of Toronto, Toronto, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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21
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Riester MR, Goyal P, Jiang L, Erqou S, Rudolph JL, McGeary JE, Rogus-Pulia NM, Madrigal C, Quach L, Wu WC, Zullo AR. New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:3368-3379. [PMID: 34981366 PMCID: PMC9550891 DOI: 10.1007/s11606-021-07233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge. OBJECTIVE Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge. DESIGN Retrospective cohort. PARTICIPANTS Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF. MAIN MEASURES Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge. KEY RESULTS Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge. CONCLUSIONS Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nicole M Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Caroline Madrigal
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lien Quach
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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22
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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23
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Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness. CHILDREN 2022; 9:children9071051. [PMID: 35884035 PMCID: PMC9316756 DOI: 10.3390/children9071051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/27/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022]
Abstract
An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.
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24
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Abstract
The care of the critically ill child often includes medications used for the relief of pain and anxiety. Children have key differences in pharmacokinetics and pharmacodynamics compared with adults that should always be considered to achieve safe medication use in this population. Pain must be addressed, and sedative use should be minimized when possible. Our understanding of sedation safety is evolving, and studies have shown that minimizing exposure to multiple medications can reduce the burden of delirium and iatrogenic withdrawal.
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Affiliation(s)
- Kevin Valentine
- Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Suite 4900, Indianapolis, IN 46202, USA.
| | - Janelle Kummick
- Butler University College of Pharmacy and Health Sciences, Riley Hospital for Children, 705 Riley Hospital Drive, Room W6111, Indianapolis, IN 46202, USA
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25
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Kinchin I, Edwards L, Hosie A, Agar M, Mitchell E, Trepel D. Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations. Acta Psychiatr Scand 2022; 147:430-459. [PMID: 35596552 DOI: 10.1111/acps.13457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium. METHODS Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%). CONCLUSION Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.
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Affiliation(s)
- Irina Kinchin
- Centre for Health Policy and Management, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Layla Edwards
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Eileen Mitchell
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Dominic Trepel
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
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26
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Abe H, Sumitani M, Matsui H, Inoue R, Konishi M, Fushimi K, Uchida K, Yasunaga H. Gabapentinoid Use Is Associated With Reduced Occurrence of Hyperactive Delirium in Older Cancer Patients Undergoing Chemotherapy: A Nationwide Retrospective Cohort Study in Japan. Anesth Analg 2022; 135:362-369. [PMID: 35560025 DOI: 10.1213/ane.0000000000006093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is unclear whether gabapentinoids affect the development of delirium. We aimed to determine the association between gabapentinoid use and hyperactive delirium in older cancer patients undergoing chemotherapy. METHODS We conducted propensity score-matched analyses using data from a nationwide inpatient database in Japan. We included cancer patients with pain ≥70 years of age undergoing chemotherapy between April 2016 and March 2018. Patients receiving gabapentinoids were matched with control patients using propensity scores. The primary outcome was occurrence of hyperactive delirium during hospitalization, and the secondary outcomes were length of hospital stay, in-hospital fractures, and in-hospital mortality. Hyperactive delirium was identified by antipsychotic use or discharge diagnoses from the International Classification of Diseases, 10th Revision. RESULTS Among 143,132 identified patients (59% men; mean age, 76.3 years), 14,174 (9.9%) received gabapentinoids and 128,958 (90.1%) did not (control group). After one-to-one propensity score matching, 14,173 patients were included in each group. The occurrence of hyperactive delirium was significantly lower (5.2% vs 8.5%; difference in percent, -3.2% [95% confidence interval, -3.8 to -2.6]; odds ratio, 0.60 [0.54-0.66]; P < .001), the median length of hospital stay was significantly shorter (6 days [interquartile range, 3-15] vs 9 days [4-17]; subdistribution hazard ratio, 1.22 [1.19-1.25]; P < .001), and the occurrence of in-hospital mortality was significantly lower in the gabapentinoid group than in the control group (1.3% vs 1.8%; difference in percent, -0.6% [-0.9 to -0.3]; odds ratio, 0.69 [0.57-0.83]; P < .001). Gabapentinoid use was not significantly associated with the occurrence of in-hospital fractures (0.2% vs 0.2%; difference in percent, 0.0% [-0.1 to 0.1]; odds ratio, 1.07 [0.65-1.76]; P = .799). The results of sensitivity analyses using stabilized inverse probability of treatment weighting were consistent with the results of the propensity score-matched analyses. CONCLUSIONS Our findings suggest that gabapentinoid use is associated with reduced hyperactive delirium in older cancer patients undergoing chemotherapy, with no evidence of an increase in the fracture rate, length of hospital stay, or in-hospital death.
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Affiliation(s)
- Hiroaki Abe
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Mitsuru Konishi
- From theDepartment of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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27
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Ren Y, Zhang Y, Luo J, Liao W, Cheng X, Zhan J. Research progress on risk factors of delirium in burn patients: A narrative review. Front Psychiatry 2022; 13:989218. [PMID: 36405924 PMCID: PMC9666388 DOI: 10.3389/fpsyt.2022.989218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu Zhang
- Medical Innovation Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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28
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Oldham MA. Delirium disorder: Unity in diversity. Gen Hosp Psychiatry 2022; 74:32-38. [PMID: 34875568 DOI: 10.1016/j.genhosppsych.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing them through the model of delirium disorder. METHOD This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets. RESULTS Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies. CONCLUSIONS Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
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29
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Abe H, Sumitani M, Matsui H, Inoue R, Fushimi K, Uchida K, Yasunaga H. Use of naldemedine is associated with reduced incidence of hyperactive delirium in cancer patients with opioid-induced constipation: a nationwide retrospective cohort study in Japan. Pharmacotherapy 2021; 42:241-249. [PMID: 34967450 DOI: 10.1002/phar.2658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/10/2021] [Accepted: 11/24/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Medical benefits of peripherally-acting mu-opioid receptor antagonists other than improving opioid-induced constipation remain unclear. Our aim was to evaluate the association between the use of naldemedine and incidence of hyperactive delirium in cancer patients receiving chemotherapy and opioid therapy. METHODS We conducted a propensity score-matched analysis using a nationwide inpatient database in Japan. Cancer patients receiving both inpatient chemotherapy and opioid therapy from June 1, 2017 to March 31, 2018 were included. Patients receiving naldemedine were matched to control patients by propensity score. Our primary outcome was the incidence of hyperactive delirium during hospitalization, and secondary outcomes were the length of hospital stay, hospital costs, in-hospital mortality, and incidence of ileus. RESULTS Of 34,031 patients receiving inpatient chemotherapy and opioid therapy, 1905 (5.6%) were included in the naldemedine group. After one-to-four propensity score matching, 1904 patients were included in the naldemedine group and 7616 in the control group. Naldemedine users had significantly reduced incidence of hyperactive delirium compared with the control patients (19.4% vs 23.3%; risk difference, -3.9 [95% confidence interval, -5.9 - -1.9]; risk ratio, 0.83 [0.75-0.92]; P<0.001; subdistribution hazard ratio, 0.85 [0.75-0.97]; P=0.015). The median length of hospital stay was significantly shorter in the naldemedine group compared with the control group (12 days [interquartile range, 6-23] vs 14 days [6-26]; P=0.001). The median hospital costs were also significantly lower in the naldemedine group compared with the control group (US $6179 [3351-10,026] vs US $6576 [3436-11,107]; P<0.001). No significant differences were found for in-hospital mortality or incidence of ileus between the groups. CONCLUSIONS Our findings suggest that the use of naldemedine may have benefits in preventing hyperactive delirium, shortening hospital stay, and decreasing hospital costs in cancer patients receiving chemotherapy and opioid therapy.
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Affiliation(s)
- Hiroaki Abe
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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30
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El Hayek S, Kassir G, Zalzale H, Gonzalez-Diaz JM, Bizri M. Emerging Psychiatric Themes in Post-COVID-19 Patients on a Psychiatry Consultation-liaison Service. Psychiatr Q 2021; 92:1785-1796. [PMID: 34463904 PMCID: PMC8405712 DOI: 10.1007/s11126-021-09944-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 01/19/2023]
Abstract
The need for consultation-liaison psychiatry on COVID-19 wards has substantially increased since the start of the pandemic. In this cross-sectional study, we aimed to summarize the characteristics of patients admitted to the post-COVID-19 ward of the American University of Beirut Medical Center who received a psychiatric consultation. We collected relevant sociodemographic and medical data, information about past psychiatric history, psychiatry consultation details, hospital course, and disposition outcome. We also conducted chi-square and binary logistic regression analyses to assess the association between the different variables and disposition outcome. A total of 52 patients (mean age 57.33 years; equal gender distribution) were seen by the psychiatry consult-liaison team. Most had medical comorbidities and 21.2% required intubation. The most prevalent psychiatric diagnoses were delirium (30.8%), major depressive episode (15.4%), and other anxiety disorder (15.4%). Pharmacological management was implemented in 90.4% of cases and mainly included second-generation antipsychotics (36.5%). Non-pharmacological interventions consisted of those related to delirium and therapy for anxiety. Only intubation was significantly associated with disposition outcome (p = 0.004). This study highlights the various psychiatric themes emerging during the acute and post-acute periods of hospitalization for COVID-19. Hospitalized individuals recovering from the infection should be diligently screened and referred to the psychiatry consultation-liaison team to ensure the implementation of appropriate interventions.
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Affiliation(s)
- Samer El Hayek
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ghida Kassir
- Department of Psychiatry, American University of Beirut, Beirut, Lebanon
| | - Hussein Zalzale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Jairo M Gonzalez-Diaz
- UR Center for Mental Health - CERSAME, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
- Clínica Nuestra Señora de La Paz, Bogota, Colombia
- Barcelona Clínic Schizophrenia Unit, Neurosciences Institute, Barcelona University, Barcelona, Spain
| | - Maya Bizri
- Department of Psychiatry, American University of Beirut, Beirut, Lebanon.
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31
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Blodgett TJ, Blodgett NP. Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: An umbrella review. Geriatr Nurs 2021; 42:1562-1568. [PMID: 34749057 DOI: 10.1016/j.gerinurse.2021.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Alterations in circadian rhythm play an important role in the development of delirium. In this umbrella review, we examined the efficacy of melatonin and ramelteon for delirium prevention in hospitalized older adults. METHODS Umbrella review methodology from the Joanna Briggs Institute guided the review process. Only meta-analyses were included. Risk of bias was evaluated using the AMSTAR-2 checklist. RESULTS Three meta-analyses were included in this review. The quality of studies was low-to-moderate. Two meta-analyses reported a significant reduction in delirium using melatonin or ramelteon (pooled OR and 95% confidence intervals ranged from 0.41 [0.19-0.86] to 0.63 [0.46-0.87]). Melatonergics significantly reduced delirium on medical units (OR = 0.25, 95% CI 0.07-0.88) but not surgical units (OR = 0.62, 0.16-2.43). Heterogenity was high, with I2 ranging from 72.14% to 84%. CONCLUSIONS Melatonergics appear to prevent delirium among hospitalized older adults, particularly those on medical units. Based on these results, providers may consider using melatonergics as complements to high-quality multicomponent delirium prevention.
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Affiliation(s)
- Thomas J Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710.
| | - Nicole P Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710
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Abstract
Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Mount Sinai Medical Center, New York, New York
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Henjum K, Godang K, Quist-Paulsen E, Idland AV, Neerland BE, Sandvig H, Brugård A, Raeder J, Frihagen F, Wyller TB, Hassel B, Bollerslev J, Watne LO. Cerebrospinal fluid catecholamines in delirium and dementia. Brain Commun 2021; 3:fcab121. [PMID: 34423298 PMCID: PMC8374970 DOI: 10.1093/braincomms/fcab121] [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] [Accepted: 04/27/2021] [Indexed: 11/28/2022] Open
Abstract
Dopamine and noradrenaline are functionally connected to delirium and have been targets for pharmacological interventions but the biochemical evidence to support this notion is limited. To study the CSF levels of dopamine, noradrenaline and the third catecholamine adrenaline in delirium and dementia, these were quantified in three patient cohorts: (i) cognitively normal elderly patients (n = 122); (ii) hip fracture patients with or without delirium and dementia (n = 118); and (iii) patients with delirium precipitated by another medical condition (medical delirium, n = 26). Delirium was assessed by the Confusion Assessment Method. The hip fracture cohort had higher CSF levels of noradrenaline and adrenaline than the two other cohorts (both P < 0.001). Within the hip fracture cohort those with delirium (n = 65) had lower CSF adrenaline and dopamine levels than those without delirium (n = 52, P = 0.03, P = 0.002). Similarly, the medical delirium patients had lower CSF dopamine levels than the cognitively normal elderly (P < 0.001). Age did not correlate with the CSF catecholamine levels. These findings with lower CSF dopamine levels in hip fracture- and medical delirium patients challenge the theory of dopamine excess in delirium and question use of antipsychotics in delirium. The use of alpha-2 agonists with the potential to reduce noradrenaline release needs further examination.
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Affiliation(s)
- Kristi Henjum
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | | | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Heidi Sandvig
- Medical Department, Kristiansund Hospital, Møre og Romsdal Hospital Trust, 6508 Kristiansund, Norway
| | - Anniken Brugård
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Johan Raeder
- Department of Anesthesiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, 0424 Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Bjørnar Hassel
- Department of Neurohabilitation, Oslo University Hospital, 0424 Oslo, Norway
| | - Jens Bollerslev
- Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway.,Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
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Wilson JE, Andrews P, Ainsworth A, Roy K, Ely EW, Oldham MA. Pseudodelirium: Psychiatric Conditions to Consider on the Differential for Delirium. J Neuropsychiatry Clin Neurosci 2021; 33:356-364. [PMID: 34392693 PMCID: PMC8929410 DOI: 10.1176/appi.neuropsych.20120316] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The phenotypes of several psychiatric conditions can very closely resemble delirium; the authors describe such presentations as pseudodelirium. However, because the clinical management of these conditions differs markedly from that of delirium, prompt differentiation is essential. The authors provide an educational review to assist clinicians in identifying and managing psychiatric conditions that may be especially challenging to differentiate from delirium. METHODS Based on clinical experience, the authors identified four psychiatric conditions as among the most difficult to differentiate from delirium: disorganized psychosis, Ganser syndrome, delirious mania, and catatonia. An overview of each condition, description of clinical features, differentiation of specific phenotypes from delirium, and review of clinical management are also provided. RESULTS The thought and behavioral disorganization in disorganized psychosis can be mistaken for the clouded sensorium and behavioral dysregulation encountered in delirium. The fluctuating alertness and apparent confusion in Ganser syndrome resemble delirium's altered arousal and cognitive features. As its name suggests, delirious mania presents as a mixture of hyperactive delirium and mania; additional features may include psychosis, autonomic activation, and catatonia. Both delirium and catatonia have hypokinetic and hyperkinetic variants, and the two syndromes can also co-occur. CONCLUSIONS The clinical presentations of several psychiatric conditions can blend with the phenotype of delirium, at times even co-occurring with it. Detailed evaluation is often required to differentiate such instances of pseudodelirium from delirium proper.
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Affiliation(s)
- Jo Ellen Wilson
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
- Center for Critical Illness, Brain Dysfunction, and Survivorship, Vanderbilt University Medical Center, Nashville, TN
| | - Patricia Andrews
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
- Center for Critical Illness, Brain Dysfunction, and Survivorship, Vanderbilt University Medical Center, Nashville, TN
| | | | - Kamalika Roy
- Oregon Health and Science University, Portland, OR
| | - E. Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN
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Pal S, Sharma N, Singh SM, Kumar S, Pannu AK. A prospective cohort study on predictors of mortality of delirium in an emergency observational unit. QJM 2021; 114:246-251. [PMID: 32483589 DOI: 10.1093/qjmed/hcaa183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delirium is often an underdiagnosed and underestimated neuropsychiatric syndrome, especially in low- and middle-income countries. AIM To document the prevalence and clinical profile of delirium and to detect the baseline parameters associated with in-hospital mortality. DESIGN A prospective cohort study conducted between January 2016 to December 2016 at an adult medical emergency observational unit of an academic hospital in north India. METHODS Confusion Assessment Method for the intensive care unit was used for screening and diagnosis of delirium. Subtypes of delirium and severity were defined with the Richmond agitation-sedation scale and Delirium Rating Scale-Revised-98 (DRS-R-98). RESULTS Out of 939 screened patients, 312 (33.2%) had delirium, including 73.7% unrecognized cases. The mean age was 49.1 ± 17.3 years (range 17-90), and only 33.3% of the patients were above 60 years. The prevalence of hypoactive, mixed and hyperactive delirium was 39.1, 33.7 and 27.2%, respectively. Usual predisposing factors were alcohol use disorder (57.4%) and hypertension (51.0%), and infections remain the most common precipitating factors (42.0%). In total, 96.1% of patients received midazolam before delirium onset, and physical restraints were used in 73.4%. Mortality was higher in delirium (19.9% vs. 6.4%). The independent predictors of death in delirium were low diastolic blood pressure (P-value = 0.000), Glasgow coma scale score <15 (P = 0.026), high Acute Physiology and Chronic Health Evaluation II score (P = 0.007), high DRS-R-98 severity score (P = 0.000) and hyperactive delirium (P = 0.024). CONCLUSION Rapid screening with Confusion Assessment Method for the intensive care unit detected a high prevalence of delirium (even in young patients), and it associated with high mortality.
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Affiliation(s)
- S Pal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S M Singh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, 3rd Floor, Cobalt Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
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Bellelli G, Brathwaite JS, Mazzola P. Delirium: A Marker of Vulnerability in Older People. Front Aging Neurosci 2021; 13:626127. [PMID: 33994990 PMCID: PMC8119654 DOI: 10.3389/fnagi.2021.626127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | | | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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Thanapluetiwong S, Ruangritchankul S, Sriwannopas O, Chansirikarnjana S, Ittasakul P, Ngamkala T, Sukumalin L, Charernwat P, Saranburut K, Assavapokee T. Efficacy of quetiapine for delirium prevention in hospitalized older medical patients: a randomized double-blind controlled trial. BMC Geriatr 2021; 21:215. [PMID: 33789580 PMCID: PMC8010962 DOI: 10.1186/s12877-021-02160-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
Background Delirium is a common disorder among hospitalized older patients and results in increased morbidity and mortality. The prevention of delirium is still challenging in older patient care. The role of antipsychotics in delirium prevention has been limited. Therefore, we conducted a trial to investigate the efficacy of quetiapine use to prevent delirium in hospitalized older medical patients. Methods This study was a randomized double-blind controlled trial conducted at Ramathibodi Hospital, Bangkok, Thailand. Patients aged ≥65 years hospitalized in the internal medicine service were randomized to quetiapine 12.5 mg or placebo once daily at bedtime for a maximum 7-day duration. The primary end point was delirium incidence. Secondary end points were delirium duration, length of hospital stay, ICU admission, rehospitalization and mortality within 30 and 90 days. Results A total of 122 patients were enrolled in the study. Eight (6.6%) left the trial before receiving the first dose of the intervention, whereas 114 (93.4%) were included in an intention-to-treat analysis allocated to the quetiapine or placebo group (n = 57 each). The delirium incidence rates in the quetiapine and placebo groups were 14.0 and 8.8% (OR = 1.698, 95% CI 0.520–5.545, P = 0.381), respectively. Other endpoints in the quetiapine and placebo groups were the median length of hospital stay, 6 (4–8) days versus 5 (4–8) days (P = 0.133), respectively; delirium duration, 4 (2.3–6.5) versus 3 (1.5–4.0) days (P = 0.557), respectively; ICU admission, 3 (5.3%) patients from both groups (P = 1.000); and mortality in the quetiapine and placebo groups, 1 (1.8%) versus 2 (3.5%) at 30 days (P = 0.566) and 7 (12.3%) versus 9 (15.8%) days at 90 days (P = 0.591). There were no significant differences in other outcomes. None of the participants reported adverse events. Conclusions Quetiapine prophylaxis did not reduce delirium incidence in hospitalized older medical patients. The use of quetiapine to prevent delirium in this population group should not be recommended. Trial registration This trial was retrospectively registered with the Thai clinical trials registry (TCTR) at clinicaltrials.in.th (TCTR20190927001) on September 26, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02160-7.
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Affiliation(s)
- Saran Thanapluetiwong
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Orapitchaya Sriwannopas
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sirintorn Chansirikarnjana
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Pichai Ittasakul
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tipanetr Ngamkala
- Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lalita Sukumalin
- Ramathibodi School of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piangporn Charernwat
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Krittika Saranburut
- Cardiovascular and Metabolic Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Taweevat Assavapokee
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
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Khera T, Mathur PA, Banner-Goodspeed VM, Narayanan S, Mcgourty M, Kelly L, Palihnich K, Novack L, Davis R, Talmor D, Marcantonio ER, Subramaniam B. Scheduled Prophylactic 6-Hourly IV AcetaminopheN to Prevent Postoperative Delirium in Older CaRdiac SurgicAl Patients (PANDORA): protocol for a multicentre randomised controlled trial. BMJ Open 2021; 11:e044346. [PMID: 33692183 PMCID: PMC7949372 DOI: 10.1136/bmjopen-2020-044346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/03/2020] [Accepted: 02/08/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Postoperative delirium is common among older cardiac surgery patients. Often difficult to predict and address prophylactically, delirium complicates the postoperative course by increasing morbidity and mortality as well as prolonging both hospital and intensive care unit (ICU) lengths of stay. Based on our pilot trial, we intend to study the effect of scheduled 6-hourly acetaminophen administration for 48 hours post-cardiac surgery with cardiopulmonary bypass (CPB) on the incidence of in-hospital delirium and long-term neurocognitive outcomes. Additionally, effect on duration and severity of delirium, rescue analgesic consumption, acute and chronic pain scores and lengths of hospital and ICU stay will also be explored. METHODS AND ANALYSIS This multicentre, randomised, placebo-controlled, quadruple-blinded trial will include 900 older (>60 years) cardiac surgical patients requiring CPB. Patients meeting the inclusion criteria and not meeting any exclusion criteria will be enrolled at seven centres across the USA with Beth Israel Deaconess Medical Center (BIDMC), Boston, as the central coordinating centre. Additional sites may be included to broaden or speed accrual. The primary outcome measure is the incidence of in-hospital delirium till day 30. Secondary outcomes include the duration and severity of in-hospital delirium, hospital and ICU lengths of stay, postoperative pain scores, postoperative rescue analgesic consumption, postoperative cognitive function and chronic sternal pain. Creation of a biorepository and the use of intraoperative-blinded electroencephalogram (EEG) and cerebral oximetry data will support exploratory endpoints to determine mechanistic predictors of postoperative delirium. ETHICS AND DISSEMINATION This trial is approved and centrally facilitated by the Institutional Review Board at BIDMC. An independent Data Safety and Monitoring Board is responsible for maintaining safety oversight. Protocol # 2019 P00075, V.1.4 (dated 20 October 2020). TRIAL REGISTRATION NUMBER NCT04093219.
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Affiliation(s)
- Tanvi Khera
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Pooja A Mathur
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Valerie M Banner-Goodspeed
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shilpa Narayanan
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marie Mcgourty
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lauren Kelly
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kerry Palihnich
- Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lena Novack
- Soroka University Medical Center, Beer Sheva, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Roger Davis
- Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Daniel Talmor
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Balachundhar Subramaniam
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Seo CL, Park JY, Park J, Kim HE, Cho J, Seok JH, Kim JJ, Shin CS, Oh J. Neutrophil-Lymphocyte Ratio as a Potential Biomarker for Delirium in the Intensive Care Unit. Front Psychiatry 2021; 12:729421. [PMID: 34912245 PMCID: PMC8667224 DOI: 10.3389/fpsyt.2021.729421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Recognition and early detection of delirium in the intensive care unit (ICU) is essential to improve ICU outcomes. To date, neutrophil-lymphocyte ratio (NLR), one of inflammatory markers, has been proposed as a potential biomarker for brain disorders related to neuroinflammation. This study aimed to investigate whether NLR could be utilized in early detection of delirium in the ICU. Methods: Of 10,144 patients who admitted to the ICU, 1,112 delirium patients (DE) were included in the current study. To compare among inflammatory markers, NLR, C-reactive protein (CRP), and white blood cell (WBC) counts were obtained: the mean NLR, CRP levels, and WBC counts between the initial day of ICU admission and the day of initial delirium onset within DE were examined. The inflammatory marker of 1,272 non-delirium patients (ND) were also comparatively measured as a supplement. Further comparisons included a subgroup analysis based on delirium subtypes (non-hypoactive vs. hypoactive) or admission types (elective vs. emergent). Results: The NLR and CRP levels in DE increased on the day of delirium onset compared to the initial admission day. ND also showed increased CRP levels on the sixth day (the closest day to average delirium onset day among DE) of ICU admission compared to baseline, while NLR in ND did not show significant difference over time. In further analyses, the CRP level of the non-hypoactive group was more increased than that of the hypoactive group during the delirium onset. NLR, however, was more significantly increased in patients with elective admission than in those with emergent admission. Conclusion: Elevation of NLR was more closely linked to the onset of delirium compared to other inflammatory markers, indicating that NLR may play a role in early detection of delirium.
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Affiliation(s)
- Chai Lee Seo
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, South Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Jaesub Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeong-Ho Seok
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheung Soo Shin
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Jooyoung Oh
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
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Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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44
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FitzGerald JM, Price A. Delirium in the acute hospital setting: the role of psychiatry. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2020.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
SUMMARYIn this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.
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45
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McCoy TH, Castro VM, Hart KL, Perlis RH. Stratified delirium risk using prescription medication data in a state-wide cohort. Gen Hosp Psychiatry 2021; 71:114-120. [PMID: 34091195 PMCID: PMC8249339 DOI: 10.1016/j.genhosppsych.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list. METHOD Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort. RESULTS The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender. CONCLUSION Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.
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Affiliation(s)
- Thomas H McCoy
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Victor M Castro
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Kamber L Hart
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Roy H Perlis
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
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46
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 414] [Impact Index Per Article: 103.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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47
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Abstract
Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called acute brain failure, acute brain dysfunction, or altered mental status. All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.
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Affiliation(s)
- Melissa L P Mattison
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (M.L.M.)
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48
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Abstract
Geriatric patients are not just older adult patients. Aging brings about unique physiologic, psychological, and sociologic changes within individuals. Recognition of these unique characteristics and measuring for their impact; instituting mitigating strategies; using age-specific anesthetic measures; and performing a systematic, algorithmic care model in the postoperative period overseen by a multidisciplinary team brings about enhanced outcomes and improved quality of care for this expanding group of patients.
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Affiliation(s)
- Teresa S Jones
- Rocky Mountain Regional Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045.
| | - John T Moore
- Department of Surgery, Rocky Mountain Regional Medical Center Veterans Administration Healthcare, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045, USA
| | - Thomas N Robinson
- Rocky Mountain Regional Medical Center Veterans Affairs Medical Center, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045, USA
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49
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Clinical characteristics and treatment of delirium in palliative care settings. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2020. [DOI: 10.1007/s12254-020-00641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
SummaryDelirium is commonly seen in palliative care. It usually develops over a short period of time and is characterized by a disturbance of attention and awareness. As delirium is associated with increased mortality, prevention and early identification of this severe neurocognitive disorder is of high clinical relevance. This paper provides a brief overview of risk factors, preventive measures, current screening and diagnostic procedures, as well as nonpharmacological and pharmacological treatment options of delirium in the palliative care setting.
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50
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Oldham MA, Holloway RG. Delirium disorder. Neurology 2020; 95:173-178. [DOI: 10.1212/wnl.0000000000009949] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
ObjectiveAs the US population ages and with no definitive delirium treatments on the horizon, the delirium epidemic is on course to expand over the coming decades. Recognizing the import of this condition, a recent position statement from 10 medical societies—among whom the American Academy of Neurology was represented—issued recommendations on preferred nomenclature of delirium and acute encephalopathy: it concluded by preferring both terms. Urgently needed is an integrated model that addresses the near-total segregation of these separate bodies of literature, ideally one that offers an interdisciplinary framework to bring these 2 terms and those who use them together.MethodsWe review the historical forces that have led these terms to diverge and consider the unique benefits of each approach as well as their liabilities when considered in isolation. We then explore the potential implications of integrating these concepts and propose a hybrid model to capitalize on the strengths of both the model of delirium and that of acute encephalopathy.ResultsThe model we propose—delirium disorder—builds on the recommendations of this recent position statement and provides a unifying framework designed to have clinical utility and interdisciplinary appeal. It also broadens the translational landscape by identifying 4 distinct treatment targets: underlying causes, procognitive factors, delirium (phenotype alone), and neurophysiologic targets.ConclusionsThis person-centered model aims to integrate delirium and acute encephalopathy within a single framework and shared nomenclature. It is hoped that this model aids in harmonizing research efforts and advancing clinical practice.
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