Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy

Clinical characteristics and treatment of delirium in palliative care settings

Delirium 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.

Delirium screening in patients in a palliative care ward: a best practice implementation project

OBJECTIVES

The objective was to promote evidence-based practice in screening for delirium in patients in the palliative care ward of a cancer hospital in Shanghai.

INTRODUCTION

Delirium is common but under recognized among patients in palliative care settings. Early detection is essential for timely management. Practice guidelines recommend an initial screening at first contact, followed by continuous screening.

METHODS

The Joanna Briggs Institute's three-phase Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback tool were used to enhance evidence-based practice. In phase 1, four audit criteria were developed and a baseline audit was conducted. In phase 2, barriers to compliance were identified, and strategies were adopted to promote best practice. In phase 3, a follow-up audit was conducted.

RESULTS

In the baseline audit, no delirium screening was performed, either on admission or regularly during hospitalization, hence compliance with these two audit criteria was 0%. Two out of 18 nurses had received training in delirium management, however neither had been trained to use the delirium screening tool. Compliance with the two criteria for nurse training was 11% and 0%, respectively. Four barriers were identified, including lack of a standardized screening tool, lack of a standardized screening procedure, inadequate knowledge on the part of the nurses, and potential inconsistencies between nurses in the rating of screening criteria. After applying strategies to address these barriers, compliance with the four audit criteria was 100%, 100%, 72%, and 72%, respectively, in the follow-up audit.

CONCLUSIONS

Best practice in delirium screening was successfully established in the ward.

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol)

BACKGROUND

Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).

OBJECTIVES

This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.

STUDY PLAN

A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).

An Advanced Practice Provider Initiative for Delirium Management in the ICU

Delirium is the most common neuropsychiatric challenge in cancer patients, particularly in the critically ill population. Without a screening method and constant vigilance by providers, delirium is often misdiagnosed. The purpose of our pilot study was to determine if an educational program targeting critical care medicine advanced practice providers (APPs) and fellows in an oncologic intensive care unit would increase APP knowledge of delirium and their level of comfort with delirium screening and management. Thirty-one APPs and fellows participated in the program. Scores on knowledge-based delirium assessments increased significantly after the intervention and at the 3-month follow-up (p < .0001 and p < .0225, respectively). Providers’ comfort with delirium screening and management also improved after the intervention (p = .0020 and p < .0001, respectively) and decreased slightly at the 3-month follow-up (p = .1764 and p = .9840, respectively). A brief and focused APP-led educational initiative successfully improved knowledge of delirium and comfort with screening and management.

Initiative for Prevention and Early Identification of Delirium in Medical-Surgical Units: Lessons Learned in the Past Five Years

BACKGROUND

Delirium is an acute change in mental status affecting 10%-64% of hospitalized patients, and may be preventable in 30%-40% of cases. In October 2013, a task force for delirium prevention and early identification in medical-surgical units was formed at our hospital. We studied whether our standardized protocol prevented delirium among high-risk patients.

METHODS

We studied 105,455 patient encounters between November 2013 and January 2018. Since November 2013, there has been ongoing education to decrease deliriogenic medications use. Since 2014, nurses screen all patients for presence or absence of delirium using the Confusion Assessment Method (CAM). Since 2015, nurses additionally screen all patients for risk of delirium. In 2015, a physician order set for delirium was created. Nonpharmacological measures are implemented for high-risk or CAM positive patients.

RESULTS

98.8% of patient encounters had CAM screening, and 99.6% had delirium risk screening. Since 2013, odds of opiate use decreased by 5.0% per year (P < .001), and odds of benzodiazepine use decreased by 8.0% per year (P < .001). There was no change in anticholinergic use. In the adjusted analysis, since 2015, odds of delirium decreased by 25.3% per year among high-risk patients (n = 21,465; P < .001). Among high-risk patients or those diagnosed with delirium (n = 22,121), estimated length of stay decreased by 0.13 days per year (P < .001), odds of inpatient mortality decreased by 16.0% per year (P = .011), and odds of discharge to a nursing home decreased by 17.1% per year (P < .001).

CONCLUSION

With high clinician engagement and simplified workflows, our delirium initiative has shown sustained results.

Delirium superimposed on dementia

PURPOSE

Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia.

METHODS

This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD.

RESULTS

There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia.

CONCLUSIONS

It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.

Outcome Differences by Delirium Motor Subtype in Patients with Ischemic Stroke

OBJECTIVE

This study evaluated the outcomes of ischemic stroke patients according to delirium motor subtype.

METHODS

This study included patients who were admitted to the stroke unit between August 2017 and March 2019 and met the DSM-5 diagnostic criteria for delirium. Patients were assessed twice weekly throughout their delirium episodes using the Korean version of the Delirium Motor Subtype Scale (K-DMSS) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). The clinical characteristics and short-term outcomes of the patients were also assessed.

RESULTS

A total of 943 stroke patients were included; the rate of incident delirium was 10.18%. Of the 95 delirium patients, 34 were classified as the hyperactive subtype, 30 as the mixed subtype, 25 as the hypoactive and six as no subtype. Among the subtype groups, the hypoactive subtype had the highest initial scores on the National Institutes of Health Stroke Scale (NIHSS; 6.72±4.75, p=0.02) and the modified Rankin Scale (mRS; 3.96±1.24, p<0.01). Additionally, the mixed and hypoactive subtypes had longer durations (p<0.01) and more severe symptoms of delirium (p=0.03) than the other motor subtypes, and the hypoactive subtype group had a significantly longer hospital stay (36.88±27.71 days, p<0.01) than the other subtype groups. After adjusting for baseline covariates in a multiple linear regression analysis, these differences remained significant.

CONCLUSION

The present results suggest that the motor subtype of delirium is associated with different characteristics and outcomes in ischemic stroke patients.

Dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phosphorylated neurofilament heavy subunit

BACKGROUND

Delirium is the most common postoperative complication of the central nervous system (CNS) that can trigger long-term cognitive impairment. Its underlying mechanism is not fully understood, but the dysfunction of the blood-brain barrier (BBB) has been implicated. The serum levels of the axonal damage biomarker, phosphorylated neurofilament heavy subunit (pNF-H) increase in moderate to severe delirium patients, indicating that postoperative delirium can induce irreversible CNS damage. Here, we investigated the relationship among postoperative delirium, CNS damage and BBB dysfunction, using pNF-H as reference.

METHODS

Blood samples were collected from 117 patients within 3 postoperative days. These patients were clinically diagnosed with postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit. We measured intercellular adhesion molecule-1, platelet and endothelial cell adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, and P-selectin as biomarkers for BBB disruption, pro-inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6), and pNF-H. We conducted logistic regression analysis including all participants to identify independent biomarkers contributing to serum pNF-H detection. Next, by multiple regression analysis with a stepwise method we sought to determine which biomarkers influence serum pNF-H levels, in pNF-H positive patients.

RESULTS

Of the 117 subjects, 41 were clinically diagnosed with postoperative delirium, and 30 were positive for serum pNF-H. Sensitivity and specificity of serum pNF-H detection in the patients with postoperative delirium were 56% and 90%, respectively. P-selectin was the only independent variable to associate with pNF-H detection (P < 0.0001) in all 117 patients. In pNF-H positive patients, only PECAM-1 was associated with serum pNF-H levels (P = 0.02).

CONCLUSIONS

Serum pNF-H could be an objective delirium biomarker, superior to conventional tools in clinical settings. In reference to pNF-H, P-selectin may be involved in the development of delirium-related CNS damage and PECAM-1 may contribute to the progression of delirium- related CNS damage.

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

BACKGROUND

Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).

METHODS

This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.

RESULTS

Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%).

CONCLUSIONS

The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.

TRIAL REGISTRATION

International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.

Methods of identifying delirium: A research protocol

Delirium is an acute disorder affecting up to 80% of intensive care unit (ICU) patients. It is associated with a 10-fold increase in cognitive impairment, triples the rate of in-hospital mortality, and costs $164 billion annually. Delirium acutely affects attention and global cognitive function with fluctuating symptoms caused by underlying organic etiologies. Early detection is crucial because the longer a patient experiences delirium the worse it becomes and the harder it is to treat. Currently, identification is through intermittent clinical assessment using standardized tools, like the Confusion Assessment Method for ICU. Such tools work well in clinical research but do not translate well into clinical practice because they are subjective, intermittent and have low sensitivity. As such, healthcare providers using these tools fail to recognize delirium symptoms as much as 80% of the time. Delirium-related biochemical derangement leads to electrical changes in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. However, continuous EEG monitoring is not feasible due to cost and need for skilled interpretation. Studies using limited-lead EEG show large differences between patients with and without delirium while discriminating delirium from other causes. The Ceribell is a limited-lead device that analyzes EEG. If it is capable of detecting delirium, it would provide an objective physiological monitor to identify delirium before symptom onset. This pilot study was designed to explore relationships between Ceribell and delirium status. Completion of this study will provide a foundation for further research regarding delirium status using the Ceribell data.

Association between Inpatient Delirium and Hospital Readmission in Patients ≥ 65 Years of Age: A Retrospective Cohort Study

BACKGROUND

Delirium affects more than seven million hospitalized adults in the United States annually. However, its impact on postdischarge healthcare utilization remains unclear.

OBJECTIVE

To determine the association between delirium and 30-day hospital readmission.

DESIGN

A retrospective cohort study.

SETTING

A general community medical and surgical hospital.

PATIENTS

All adults who were at least 65 years old, without a history of delirium or alcohol-related delirium, and were hospitalized from September 2010 to March 2015.

MEASUREMENTS

The patients deemed at risk for or displaying symptoms of delirium were screened by nurses using the Confusion Assessment Method with a followup by a staff psychiatrist for a subset of screen-positive patients. Patients with delirium confirmed by a staff psychiatrist were compared with those without delirium. The primary outcome was the 30-day readmission rate. The secondary outcomes included emergency department (ED) visits 30 days postdischarge, mortality during hospitalization and 30 days postdischarge, and discharge location.

RESULTS

The cohort included 718 delirious patients and 7,927 nondelirious patients. Using an unweighted multivariable logistic regression, delirium was determined to be significantly associated with the increased odds of readmission within 30 days of discharge (odds ratio (OR): 2.60; 95% CI, 1.96-3.44; P < .0001). Delirium was also significantly (P < .0001) associated with ED visits within 30 days postdischarge (OR: 2.18; 95% CI: 1.77-2.69) and discharge to a facility (OR: 2.52; 95% CI: 2.09-3.01).

CONCLUSIONS

Delirium is a significant predictor of hospital readmission, ED visits, and discharge to a location other than home. Delirious patients should be targeted to reduce postdischarge healthcare utilization.

Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions

OBJECTIVE

The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions.

METHODS

Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories.

RESULTS

Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]).

CONCLUSION

Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.

Risk Factors and Outcomes of Delirium in Older Patients Admitted to Postacute Care with and without Dementia

BACKGROUND

Delirium research is poorly studied in postacute care, a growing setting due to aging populations, as well as in dementia, a critical risk factor for delirium and particularly prevalent in postacute care. We investigated risk factors for delirium and its outcomes in older adults with and without dementia admitted to a subacute care unit (SCU) after exacerbated chronic conditions.

METHODS

This is a prospective cohort study including patients ≥65 years old admitted to an SCU for 12 months. We collected demographics, comprehensive geriatric assessments, and presence of dementia and delirium at admission. Outcomes included discharge to previous living situation, mortality, and functional evolution. Due to the high prevalence of dementia, a subgroup analysis was performed to investigate specific risk factors for delirium and related outcomes.

RESULTS

Of 909 patients (mean age [±SD] 85.8 ± 6.7; 60% women, 47.5% with dementia), 352 (38.7%) developed delirium. The main risk factor for delirium was dementia (HR [95% CI] 5.2 [3.5-7.7]); age, functional status, and urinary tract infections were also independently associated with delirium. In dementia patients, only age (HR [95% CI] 1.0 [1.004-1.1]) and being male (HR [95% CI] 1.7 [1.04-2.6]) were associated with delirium. Delirium was associated with greater mortality (10.8 vs. 3.9%; p < 0.001) and greater functional decline in the entire sample (-12.3 vs. -6.4 Barthel index points; p < 0.001). In the dementia subgroup, patients with delirium experienced greater functional loss (p = 0.013) and less functional recovery (p = 0.025).

CONCLUSIONS

In older patients admitted to postacute care, dementia is the main risk factor for delirium, and delirium carries worse clinical and functional outcomes. In patients with dementia, delirium is also relevant, since it entails a functional loss at admission and lower functional recovery.

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q₁ = 72.15; Q₃ = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Neurological Symptoms in Palliative Care Patients

Background

Neurological expertise in palliative care may be required not only for patients with primary neurological disorders but also for patients with non-neurological diseases suffering from burdensome neurological symptoms. The aim of this study was to determine the prevalence of neurological diagnoses and symptoms in palliative care patients, as well as the related burden and impact on everyday life.

Methods

We analyzed retrospectively the medical records of 255 consecutive patients from a tertiary medical center, at the time point of referral to an inpatient palliative care consultation service. In addition, 100 patients prospectively answered a questionnaire which included the assessment of neurological symptoms, as well as numeric rating scales for quality of life, symptom-specific burden, and restrictions in everyday life.

Results

Forty-one patients (16%) suffered from a primary neurological disease. Most decisions regarding the termination of life-sustaining measures concerned this group (20/22, 91%). Neurological symptoms (excluding pain) were documented in 122 patients (48%) with an underlying non-neurological disease. In the questionnaire study, 98/100 patients reported at least one neurological or neuropsychiatric symptom, most frequently sleeping problems (N = 63), difficulty concentrating (N = 55), and sensory symptoms (N = 50). Vertigo/dizziness (N = 19) had the greatest impact on everyday life (7.57/10 ± 2.17) and the highest symptom-specific burden (7.14 ± 2.51). Difficulty concentrating (restrictions in everyday life/burden) and pain intensity were the only symptoms significantly correlated with quality of life (r = -0.36, p = 0.009/r = -0.32; p = 0.04; r = -0.327, p = 0.003).

Conclusion

Neurological diseases and symptoms are frequent among palliative care patients and are often associated with a high symptom burden, which may severely affect the patients' lives. It is thus of paramount importance to implement neurological expertise in palliative care.

An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study

Background

Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium.

Methods

Using a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation.

Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests.

Focus groups were conducted to explore clinicians’ experiences of the OPTA role.

Results

Three thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9.

The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group.

Focus group interviews described mixed responses and support for the OPTA role.

Conclusions

An assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED.

Trial registration

Australian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.

Identification of delirium and dementia in older medical inpatients in Tanzania: A comparison of screening and diagnostic methods

BACKGROUND

In sub-Saharan Africa, there are no validated screening tools for delirium in older adults. This study assesses clinical utility of two instruments, the IDEA cognitive screen and the Confusion Assessment Method (CAM) for identification of delirium in older adults admitted to medical wards of a tertiary referral hospital in Tanzania.

METHOD

The IDEA cognitive screen and CAM were administered to a consecutive cohort of older individuals on admission to Kilimanjaro Christian Medical Centre using a blinded protocol. Consensus diagnosis for delirium was established against DSM-5 criteria and dementia by DSM-IV criteria.

RESULTS

Of 507 admission assessments, 95 (18.7%) had DSM-5 delirium and 95 (18.7%) had DSM-IV dementia (33 (6.5%) delirium superimposed on dementia). The CAM and IDEA cognitive screen had very good diagnostic accuracy for delirium (AUROC curve 0.94 and 0.87 respectively). However, a number of participants (10.5% and 16.4% respectively) were unable to complete these screening assessments due to reduced consciousness, or other causes of reduced verbal response and were excluded from this analysis; many of whom met DSM-5 criteria for delirium. Secondary analysis suggests that selected cognitive and observational items from the CAM and IDEA cognitive screen may be as effective as the full screening tools in identifying delirium even in unresponsive patients.

CONCLUSION

Both instruments appeared useful for delirium screening in this inpatient setting, but had significant limitations. The combination of assessment items identified may form the basis of a brief, simple delirium screening tool suitable for use by non-specialist clinicians. Further development work is needed.

2-18F-fluoro-2-deoxyglucose positron emission tomography in delirium

Delirium is a common, serious, yet poorly understood syndrome. Growing evidence suggests cerebral metabolism is fundamentally disturbed; however, it has not been investigated using 2-¹⁸F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) in delirium. This prospective study thus explored FDG PET patterns of cerebral glucose metabolism in older inpatients with delirium. A particular emphasis was on the posterior cingulate cortex (PCC), a key region for attention, which is a central feature of delirium. Delirium scans were compared with post-delirium scans using visual analysis and semi-quantitative analysis with NeuroQ; 13 participants (8 female, median 84 y) were scanned during delirium, and 6 scanned again after resolution. On visual analysis, cortical hypometabolism was evident in all participants during delirium (13/13), and improved with delirium resolution (6/6). Using NeuroQ, glucose metabolism was higher post-delirium in the whole brain and bilateral PCC compared to during delirium ( p < 0.05). Greater metabolism in both PCCs correlated with better performance on a neuropsychological test of attention, the WAIS-IV Digit Span Test forwards, and with shorter delirium duration. This research found widespread, reversible cortical hypometabolism during delirium and PCC hypometabolism was associated with inattention during delirium.

Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions

BACKGROUND

Cognitive impairment of various kinds is common in older people admitted to hospital, but previous research has usually focused on single conditions in highly-selected groups and has rarely examined associations with outcomes. This study examined prevalence and outcomes of cognitive impairment in a large unselected cohort of people aged 65+ with an emergency medical admission.

METHODS

Between January 1, 2012, and June 30, 2013, admissions to a single general hospital acute medical unit aged 65+ underwent a structured specialist nurse assessment (n = 10,014). We defined 'cognitive spectrum disorder' (CSD) as any combination of delirium, known dementia, or Abbreviated Mental Test (AMT) score < 8/10. Routine data for length of stay (LOS), mortality, and readmission were linked to examine associations with outcomes.

RESULTS

A CSD was present in 38.5% of all patients admitted aged over 65, and in more than half of those aged over 85. Overall, 16.7% of older people admitted had delirium alone, 7.9% delirium superimposed on known dementia, 9.4% known dementia alone, and 4.5% unspecified cognitive impairment (AMT score < 8/10, no delirium, no known dementia). Of those with known dementia, 45.8% had delirium superimposed. Outcomes were worse in those with CSD compared to those without - LOS 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year death or readmission 62.4% vs. 51.5% (all P < 0.01). There was relatively little difference by CSD type, although people with delirium superimposed on dementia had the longest LOS, and people with dementia the worst mortality at 1 year.

CONCLUSIONS

CSD is common in older inpatients and associated with considerably worse outcomes, with little variation between different types of CSD. Healthcare systems should systematically identify and develop care pathways for older people with CSD admitted as medical emergencies, and avoid only focusing on condition-specific pathways such as those for dementia or delirium alone.

Direct evidence of central nervous system axonal damage in patients with postoperative delirium: A preliminary study of pNF-H as a promising serum biomarker

INTRODUCTION

Approximately 50-80% patients experience postoperative delirium, an acute cognitive dysfunction associated with prolonged hospitalization, increased mortality, excess healthcare costs, and persistent cognitive impairment. Elucidation of the mechanism of delirium and associated diagnostic and therapeutic measures are urgently required. Here we investigated the role of phosphorylated neurofilament heavy subunit (pNF-H), a major structural protein in axons, as a predictive maker of postoperative delirium.

MATERIAL AND METHODS

Twenty-three patients who underwent surgery for abdominal cancer were screened for postoperative delirium, and they were assessed for its severity using the memorial delirium assessment scale (MDAS) at and 48h after delirium onset. Serum pNF-H levels were also measured at both time points. The patients were divided into two groups according to the presence or absence of pNF-H. Clinical variables were compared between groups using the Mann-Whitney U test, and the relationship between pNF-H levels and delirium severity was analyzed using the exponential curve fitting.

RESULTS

Fifteen of the 23 (65.2%) patients tested positive for pNF-H, and these patients exhibited significantly higher MDAS scores compared with the pNF-H-negative patients only at the onset of delirium. Although the MDAS score significantly improved over time in the positive group, pNF-H positivity persisted. There was a correlation between the maximum pNF-H level and maximum MDAS score (R²=0.31, p=0.013).

CONCLUSIONS

More severe postoperative delirium was directly related to higher serum pNF-H levels, suggesting the potential application of pNF-H as a quantitative biomarker of neural damage in postoperative delirium.

Infrared pupillometry helps to detect and predict delirium in the post-anesthesia care unit

This study evaluates the capability of pupillary parameters to detect and predict delirium in the post-anesthesia care unit (PACU-D) following general anesthesia. PACU-D may complicate and prolong the patient's postoperative course, consequently increasing hospital costs. After institutional approval, 47 patients undergoing surgical interventions with general anesthesia were included in the study. We measured the pupillary reflexes at signing of informed consent, during surgery 20 min after intubation and when the primary inhaled anesthetic was turned off, and 15 and 45 min after PACU admittance and upon discharge from the PACU. We evaluated patients for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) score after 15 and 60 min in the PACU. We chose receiver operating curve (ROC) and area under the curve (AUC) to compare the performance of non-pupillary parameters to pupillary parameters, such as pupil diameter, percent constriction, and dilation velocity, to detect and predict PACU-D. Percent constriction (AUC = 0.93, optimal threshold = 18.5%) and dilation velocity (AUC = 0.93, optimal threshold = 0.35 mm/s) showed excellent ability to detect and predict delirium persisting throughout the PACU stay. These pupillary measures showed superior performance compared to other pupillary measures and features commonly associated with delirium, e.g., age (AUC = 0.73), total opioids (AUC = 0.56), or length of surgery (AUC = 0.40). Our results suggest that pupillometry and the parameters derived from the recording may identify delirious patients in the PACU. This information can help to efficiently structure their care in a timely manner, and potentially avoid adverse complications for the patient and financial consequences for the hospital.

Optimising non-invasive mechanical ventilation: Which unit should care for these patients? A cohort study

BACKGROUND

Use of noninvasive ventilation (NIV) has extended beyond intensive care units (ICUs), becoming usual practice in emergency departments (EDs) and general wards.

OBJECTIVE

To analyse the relationship between nursing care and NIV outcome in different hospital units.

DESIGN AND SETTINGS

Three university hospitals and one community hospital participated in a prospective observational cohort study.

PARTICIPANTS

Ten units participated: 4 ICUs (1 surgical, 3 medical-surgical), 3 recovery (1 postsurgical, 2 EDs, 3 general wards).

METHOD

Treatment success/failure, interface intolerance and complications were evaluated according to patient characteristics, nursing care provided, and procedures used. Complications analysed included bronchoaspiration, pneumothorax, skin lesions, inability to manage secretions, eye irritations, deteriorating level of consciousness, gastric distension, and excessive air losses around the mask.

RESULTS

Of 387 patients, 194 (50.1%) were treated in ICU, 121 (31.3%) in ED, 38 (9.8%) postsurgery, and 34 (8.8%) in general wards. Regression analysis, adjusted for APACHE score and NIV indication, showed 3.3 times greater risk of NIV failure (95% CI [1.2-9.2]) in a university-hospital ICU with <50 NIV cases/year, compared to a community hospital ICU. In ICUs and general wards, NIV was suspended in 12% of patients due to interface intolerance. Acute-on-chronic lung diseases (ACLD) had lower risk of NIV failure (OR 0.2 [95% CI 0.06-0.69]) and lack of humidification was not associated with treatment failure (OR 0.2 [95% CI 0.1-0.4]). Poor secretion management was linked to pneumonia (OR 2.5 [95% CI 1.1-5.9]) and early weaning/extubation (OR 3.3 [95% CI 1.2-8.9]). Interface intolerance was associated with conventional ICU ventilators (OR 4.4 [95% CI 2.1-9.2]) and nasal skin lesions with excessive air losses (OR 2.4 [95% CI 1.1-5.3]), especially with oronasal masks (OR 3.5 [95% CI 1.1-11.3]).

CONCLUSIONS

Acute respiratory failure patients with pneumonia admitted to general wards had increased interface intolerance and NIV failure. Rotating mask types could improve NIV success in any unit administering this therapy.

Nurses' and physicians' perceptions of Confusion Assessment Method for the intensive care unit for delirium detection: focus group study

BACKGROUND

Delirium in the intensive care unit (ICU) has received more attention in the past decade. Early detection, prevention and treatment of delirium are important, and the most commonly used tool for delirium assessment is the Confusion Assessment Method for the ICU (CAM-ICU).

AIM

The aim of this study was to identify nurses' and physicians' perceived professional barriers to using the CAM-ICU in Danish ICUs.

METHODS

This study uses a qualitative explorative multicentre design using focus groups and a semi-structured interview guide. Five focus groups with nurses (n = 20) and four with physicians (n = 14) were conducted. Strategic sampling was used to include participants with varying CAM-ICU experience at units, with variable implementation of the tool.

RESULTS

Using a hermeneutical approach, three main themes and nine sub-themes emerged. The main themes were (1) Professional role issues: CAM-ICU screening affected nursing care, clinical judgment and professional integrity; (2) Instrument reliability: nurses and physicians expressed concerns about CAM-ICU assessment in non-sedated patients, patients with multi-organ failure or patients influenced by residual sedatives/opioids; and (3) Clinical consequence: after CAM-ICU assessment, physicians lacked evidence-based treatment options, and nurses lacked physician acknowledgment and guidelines for disclosing CAM-ICU results to patients.

CONCLUSION

In this study, ICU nurses and physicians raised a number of concerns regarding the use of the CAM-ICU for delirium detection. It might be necessary to revalidate the instrument as ICU care has changed in recent years, with lighter sedation and early mobilization of patients. We recommend that nurses and physicians receive more training in the use of the CAM-ICU to address some of the issues identified in our study.

RELEVANCE TO CLINICAL PRACTICE

There is a need for ongoing training and clearer guidelines on how to proceed with the delirium screening of non-sedated patients.

Therapeutic effects of dog visits in nursing homes for the elderly

BACKGROUND

Previous studies have suggested that visiting dogs can have positive effects on elderly people in nursing homes. We wanted to study the effects of biweekly dog visits on sleep patterns and the psychiatric well-being of elderly people.

METHODS

A total of 100 residents (median age: 85.5 years; [79; 90]) from four nursing homes were randomly assigned to receive biweekly visits for 6 weeks from a person accompanied by either a dog, a robot seal (PARO), or a soft toy cat. Sleep patterns were measured using actigraphy technology before, during (the third and sixth week), and after the series of visits. The participants were weighed and scored on the Geriatric Depression Scale, the Gottfries-Bråne-Steen Scale, and the Mini-Mental State Examination before and after the visit period.

RESULTS

We found that sleep duration (min) increased in the third week when visitors were accompanied by a dog rather than the robot seal or soft toy cat (dog: 610 ± 127 min; seal: 498 ± 146 min; cat: 540 ± 163 min; F2,37 = 4.99; P = 0.01). No effects were found in the sixth week or after the visit period had ended. We found that visit type had no effect on weight (F2,88 = 0.13; P > 0.05), body mass index (F2,86 = 0.33; P > 0.05), Geriatric Depression Scale (F2,82 = 0.85; P > 0.05), Gottfries-Bråne-Steen Scale (F2,90 = 0.41; P > 0.05), or Mini-Mental State Examination (F2,91 = 0.35; P > 0.05). Furthermore, we found a decrease in the Geriatric Depression Scale during the experimental period (S = -420; P < 0.05), whereas cognitive impairment worsened as shown by a decrease in Mini-Mental State Examination score (S = -483; P < 0.05) and an increase in the Gottfries-Bråne-Steen Scale (t = 2.06; P < 0.05).

CONCLUSION

Visit type did not affect the long-term mental state of the participants. The causal relationship between sleep duration and dog-accompanied visits remains to be explored.

Prevalence of Delirium and Coma In Mechanically Ventilated Patients Sedated With Dexmedetomidine or Propofol

OBJECTIVE

To assess the prevalence of delirium and coma in mechanically ventilated patients sedated with dexmedetomidine or propofol alone; to evaluate the hospital length of stay for both treatment groups; and to evaluate the level of sedation, adverse effects, and hospital outcomes.

METHODS

Medical records were reviewed retrospectively for patients who were admitted to the medical or surgical intensive care units (ICUs) in a 591-bed teaching hospital and who received either dexmedetomidine or propofol alone for 24 hours or more for sedation.

RESULTS

A total of 111 patients were included in the study, with 56 patients in the dexmedetomidine group and 55 patients in the propofol group. Results of the analysis showed that the propofol group had a higher prevalence of coma (43.6% versus 12.5%; P < 0.001). Dexmedetomidine patients had a longer median hospital length of stay of 23.5 days (interquartile range [IQR], 11.5-39.5 days) versus 15.0 days (IQR, 7.0-24.0 days; P = 0.01). The rates of delirium were similar in both groups, with 16% in dexmedetomidine-treated patients versus 20% in propofol-treated patients (P = 0.63).

CONCLUSION

No difference in the prevalence of delirium was found when comparing the dexmedetomidine- and propofol-treated groups. Propofol was associated with more coma and oversedation; dexmedetomidine was associated with longer time to extubation, longer length of stay in the ICU, and longer hospital length of stay.

The Prevalence of Undiagnosed Presurgical Cognitive Impairment and Its Postsurgical Clinical Impact in Older Patients Undergoing Lumbar Spine Surgery

Objective

Because elderly patients are undergoing more surgeries, the importance of postoperative cognitive impairment (CI) evaluations is rising, especially for spine surgery, which is related to subjective pain. We investigated the prevalence of undiagnosed CI among elderly patients who underwent spine surgery and the impact of CI on postoperative outcomes.

Methods

The preoperative cognitive statuses of 129 patients over 65 who underwent lumbar spine surgery from 2012 to 2014 were determined with the Mini-Mental State Examination, and patients with scores under 24 were diagnosed with CI. The patients were then divided into a CI group (n=49) and non-cognitive impairment (NCI) group (n=80).

Results

Among the 129 patients, 49 (38.0%) were diagnosed with CI, and 9 (7.0%) had severe CI. The age of the CI group (72.88±6.20 years) was significantly greater than that of the NCI group (69.96±4.53 years). In contrast, the postoperative visual analog scale scores and performance statuses did not differ significantly. However, postoperative delirium was more frequent and the hospital stay length was longer in the CI group compared with the NCI group (p<0.05).

Conclusion

A high prevalence of undiagnosed CI was discovered among elderly patients undergoing spine surgery. The existence of CI was associated with higher rates of postoperative delirium and prolonged hospital stays, which affected clinical outcomes. Thus, CI assessments should be included in preoperative evaluations of elderly patients prior to spine surgery.

Impact of malnutrition on postoperative delirium development after on pump coronary artery bypass grafting

BACKGROUND & AIMS

Even though malnutrition is frequently observed in cardiac population outcome data after cardiac surgery in malnourished patients is very rare. No thorough research was done concerning the impact of malnutrition on neuropsychological outcomes after cardiac surgery. The aim of our study was to analyze the incidence of postoperative delirium development in malnourished patients undergoing on pump bypass grafting.

METHODS

We performed a cohort study of adults admitted to Vilnius University Hospital Santariskiu Clinics for elective coronary artery bypass grafting. The nutritional status of the patients was assessed by Nutritional Risk Screening 2002 (NRS-2002) questionnaire the day before surgery. Patients were considered as having no risk of malnutrition when NRS-2002 score was less than 3 and at risk of malnutrition when NRS-2002 score was ≥3. During ICU stay patients were screened for postoperative delirium development using the CAM-ICU method. and divided into two groups: delirium and non delirium. The statistical analysis was preformed to evaluate the differences between the two independent groups. The logistic regression model was used to evaluate the potential preoperative and intraoperative risk factors of postoperative delirium.

RESULTS

Ninety-nine patients were enrolled in the study. Preoperative risk of malnutrition was detected in 24 % (n = 24) of the patients. The incidence of early postoperative delirium in overall study population was 8.0 % (n = 8). The incidence of the patients at risk of malnutrition was significantly higher in the delirium group (5 (62.5 %) vs 19 (20.9 %), p <0.0191). In multivariate logistic regression analysis risk of malnutrition defined by NRS 2002 was an independent preoperative and intraoperative risk factor of postoperative delirium after coronary artery bypass grafting (OR: 6.316, 95 % CI: 1.384-28.819 p = 0.0173).

CONCLUSIONS

Preoperative malnutrition is common in patients undergoing elective coronary artery bypass grafting. Nutrition deprivation is associated with early postoperative delirium after on pump coronary artery bypass grafting.

Delirium diagnosis, screening and management

Purpose of review

Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care.

Recent findings

Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation.

Summary

Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.

Psychiatric care of the older adult: an overview for primary care

As the population ages, primary care providers will be frequently called on to manage psychiatric disorders suffered by their older patients. This overview of delirium, dementia, depression, and alcohol and substance misuse highlights the common presentations and suggests initial approaches to treatment. The challenges facing caregivers are also discussed.

Neurological complications of cardiac surgery

As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.