A prospective study of delirium and prolonged hospital stay. Exploratory study

Geriatric care-related outcomes in patients 75 years and older admitted to a pulmonary disease center and predictors for hospital-related complications

Objective

The primary aim of this study was to evaluate the influence of targeted interventions, administered through comprehensive geriatric assessments on the incidence of hospitalization-related complications among older adults diagnosed with pulmonary diseases.

Methods

A retrospective analysis of medical records encompassed individuals aged 75 years and older who were admitted to a lung center during the period spanning from March to June 2023. These admissions occurred in a context where standardized geriatric management protocols were systematically implemented. This study's scope extended to assessing the prevalence of hospital-related complications, encompassing delirium and pressure ulcers. A rigorous multivariate logistic regression analysis was conducted to discern and characterize associated factors.

Results

The integration of comprehensive geriatric assessment yielded a substantial reduction in in-hospital complications among the cohort of 118 patients (mean age : 82.1 ± 5.6 years, 44.5% women). The incidence of delirium decreased from 53.3% to 21.8% [odds ratio (OR): 0.246, 95% confidence interval (CI): 0.134-0.450, p < 0.001], whereas the presence of pressure ulcers decreased from 43.9% to 25% (OR: 0.395, 95% CI: 0.217-0.715, p < 0.001). The multivariate analysis uncovered independent associations between delirium and variables including community-acquired pneumonia (OR: 4.417, 95% CI : 1.574-12.395, p = 0.005), severe disability (OR: 2.981, 95% CI: 1.140-7.798, p = 0.026), and hearing loss (OR: 3.219, 95% CI : 1.260-8.170, p = 0.014). Prolonged hospital stays emerged as the sole factor significantly associated with pressure ulcers (OR: 1.071, 95% CI: 1.033-1.109). Furthermore, an intricate bidirectional relationship was evident between delirium and pressure ulcers (OR: 7.158, 95% CI: 2.962-17.300, p < 0.01).

Conclusion

In conjunction with its consequent interventions, geriatric evaluation assumes a pivotal role in ameliorating adverse outcomes stemming from hospitalization among older adults afflicted with pulmonary ailments. This role gains particular salience among subpopulations characterized by heightened susceptibility, such as individuals coping with hearing loss and severe disability.

Electroencephalogram measured functional connectivity for delirium detection: a systematic review

Objective

Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional connectivity, but the requirement to lay still may limit measurement with existing functional imaging modalities in this population. Electroencephalography (EEG) may allow for a more feasible approach to the study of potential connectivity disturbances in delirium. We conducted a systematic review to investigate whether there are EEG-measurable differences in brain functional connectivity in the resting state associated with delirium.

Methods

Medline, PubMed, PsychInfo, Embase and CINAHL were searched for relevant articles containing original data studying EEG functional connectivity measures in delirium.

Results

The search yielded 1,516 records. Following strict inclusion criteria, four studies were included in the review. The studies used a variety of EEG measures including phase lag index, coherence, entropy, shortest path length, minimum spanning tree, and network clustering coefficients to study functional connectivity between scalp electrodes. Across connectivity measures, delirium was associated with decreased brain functional connectivity. All four studies found decreased alpha band connectivity for patients with delirium. None of the studies directly compared the different motor subtypes of delirium.

Significance

This systematic review provides converging evidence for disturbances in oscillatory-based functional connectivity in delirium.

Association of silodosin, tamsulosin, and naftopidil with delirium: analysis of the pharmacovigilance database in Japan

BACKGROUND

An association between adrenergic alpha-1 receptor antagonists and delirium has been suggested, but the details are unclear.

AIM

This study investigated the association between adrenergic alpha-1 receptor antagonists and delirium in patients with benign prostatic hyperplasia using the Japanese Adverse Drug Event Report database.

METHOD

First, disproportionality analysis compared the frequency of delirium in the adrenergic alpha-1 receptor antagonists silodosin, tamsulosin, and naftopidil. Next, multivariate logistic analysis was performed to examine the association between delirium and adrenergic alpha-1 receptor antagonists where disproportionality was detected.

RESULTS

A disproportionality in delirium was observed in patients receiving tamsulosin (reporting odds ratio [ROR] 1.85, 95% confidence interval [CI] 1.38-2.44, P < 0.01) compared with those who did not, and also in patients receiving naftopidil (ROR 2.23, 95% CI 1.45-3.28, P < 0.01) compared with those who did not. Multivariate logistic analysis revealed that in addition to previously reported risk factors for delirium, delirium in patients receiving tamsulosin was significantly increased with concomitant use of anticholinergics (odds ratio 2.73, 95% CI 1.41-5.29, P < 0.01) and delirium in patients receiving naftopidil was significantly increased with concomitant use of beta3-adrenergic receptor agonists (odds ratio 4.19, 95% CI 1.66-10.6, P < 0.01).

CONCLUSION

Anticholinergics or beta3-adrenergic receptor agonists to treat overactive bladder in patients receiving tamsulosin and naftopidil was strongly associated with delirium. Confirming the medical history and concomitant medications of patients receiving tamsulosin or naftopidil may contribute to preventing delirium in patients with benign prostatic hyperplasia and to improving their outcomes.

Machine learning for prediction of delirium in patients with extensive burns after surgery

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of Dezocine on the Reduction of Emergence Delirium after Laparoscopic Surgery: A Retrospective Propensity Score-Matched Cohort Study

In China, dezocine is commonly employed as a partial agonist of mu/kappa opioid receptors during anesthesia induction for surgical patients, yet evidence supporting its causal association with emergence delirium is limited. The objective of this investigation was to evaluate the impact of intravenous dezocine administered during anesthesia induction on emergence delirium. The retrospective studied existing data containing medical records of patients undergoing an elective laparoscopy procedure and the study was conducted with ethics-board approval. The primary outcome was the incidence of emergence delirium. Secondary outcomes included the VAS in the PACU and 24 h after surgery, the RASS score in the PACU, postoperative MMSE, hospital stay, and ICU stay. A total of 681 patients were analyzed, after being propensity score-matched, the dezocine and non-dezocine group each had 245 patients. Emergence delirium occurred in 26/245 (10.6%) of patients who received dezocine and 41/245 (16.7%) of patients did not receive dezocine. Patients on whom dezocine was used were associated with a significantly lower incidence of emergence delirium (absolute risk difference, −6.1%, 95% CI, −12% to −0.2%; relative risk [RR], 0.63; 95% CI, 0.18–0.74). All secondary outcome measures and adverse outcomes were not significantly different. The use of dezocine during anesthesia induction was associated with a decreased incidence of emergence delirium after elective laparoscopic surgeries.

Robot-assisted laparoscopic staging compared to conventional laparoscopic staging and laparotomic staging in clinical early stage ovarian carcinoma

PURPOSE OF REVIEW

Robot-assisted laparoscopic staging (RALS) is increasingly used for staging epithelial ovarian cancer (EOC). Evidence of its safety is limited. The aim of this review is to compare the efficacy and safety of RALS in clinical early-stage EOC to conventional laparoscopy and laparotomy and to assess the level of evidence that is currently available to adopt this surgical technique.

RECENT FINDINGS

Only retrospective studies comparing staging by minimally invasive surgery (MIS) to laparotomy are available. Both RALS and conventional laparoscopic staging shorten length of hospital stay (LHS, mean -2.9 days) and decrease estimated blood loss (EBL, mean -79 ml less) compared to laparotomy. Complication rates and number of lymph nodes collected are similar in all surgical staging techniques. Survival outcomes after staging by MIS cannot be compared to staging by laparotomy because of the lack of evidence but RALS is probably noninferior to conventional laparoscopic staging.

SUMMARY

RALS probably improves perioperative outcomes in patients with clinical early stage EOC similar to conventional laparoscopic staging. Whether oncologic outcomes of RALS are comparable to open and conventional approaches is uncertain as there is only level C evidence and randomized controlled trials are urgently needed to confirm the current retrospective findings.

Validating the Mandarin version of the Memorial delirium assessment scale in general medical hospital patients

INTRODUCTION

Delirium is a common neuropsychiatric condition in the general hospital population. Thus, the goal of the present study is to extend the use of diagnostic tools for delirium by developing and validating a Mandarin version of the Memorial Delirium Assessment Scale (MDAS).

METHODS

Participants were sampled from two general Mackay Memorial Hospital locations in Taipei and Danshui. Board-certified psychiatrists assessed patients using the MDAS, confusion assessment method (CAM), and Mini-Mental State Examination (MMSE). Another consultation-liaison psychiatrist confirmed the diagnosis of delirium. We assessed the reliability and validity of the MDAS, and the receiver operating characteristic curve was used to determine the optimal cut-off point for identifying delirium.

RESULTS

Of the 61 patients assessed, 29 were diagnosed with delirium. The mean MDAS score was 16.7 for delirium patients and 4.1 for nondelirium patients. The MDAS has good internal consistency, with a Cronbach's alpha coefficient of 0.912. Interrater reliability was 0.996 (95% confidence interval [CI]: 0.992-0.998). The diagnostic cut-off value for the Mandarin version of the MDAS was 9, with a high sensitivity (93.1%) and specificity (96.9%). Factor analysis revealed a two-factor structure; these factors accounted for 58.37% and 14.42% of the variance. A high correlation was found between the MDAS and the CAM scores (r = -0.849, p < .001) as well as the MMSE (r = -0.875, p < .001).

DISCUSSION

The Mandarin MDAS exhibited good reliability and validity for assessing general hospital patients.

Research progress on risk factors of delirium in burn patients: A narrative review

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.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Midazolam Premedication Immediately Before Surgery Is Not Associated With Early Postoperative Delirium

BACKGROUND

Postoperative delirium is common among older surgical patients and may be associated with anesthetic management during the perioperative period. The aim of this study is to assess whether intravenous midazolam, a short-acting benzodiazepine used frequently as premedication, increased the incidence of postoperative delirium.

METHODS

Analyses of existing data were conducted using a database created from 3 prospective studies in patients aged 65 years or older who underwent elective major noncardiac surgery. Postoperative delirium occurring on the first postoperative day was measured using the confusion assessment method. We assessed the association between the use or nonuse of premedication with midazolam and postoperative delirium using a χ2 test, using propensity scores to match up with 3 midazolam patients for each control patient who did not receive midazolam.

RESULTS

A total of 1266 patients were included in this study. Intravenous midazolam was administered as premedication in 909 patients (72%), and 357 patients did not receive midazolam. Those who did and did not receive midazolam significantly differed in age, Charlson comorbidity scores, preoperative cognitive status, preoperative use of benzodiazepines, type of surgery, and year of surgery. Propensity score matching for these variables and American Society of Anesthesiology physical status scores resulted in propensity score-matched samples with 1-3 patients who used midazolam (N = 749) for each patient who did not receive midazolam (N = 357). After propensity score matching, all standardized differences in preoperative patient characteristics ranged from -0.07 to 0.06, indicating good balance on baseline variables between the 2 exposure groups. No association was found between premedication with midazolam and incident delirium on the morning of the first postoperative day in the matched dataset, with odds ratio (95% confidence interval) of 0.91 (0.65-1.29), P = .67.

CONCLUSIONS

Premedication using midazolam was not associated with higher incidence of delirium on the first postoperative day in older patients undergoing major noncardiac surgery.

Multidisciplinary Management of a Frequent Attender With Pyrexia of Unknown Origin and Psychotic Symptoms

This case report details the multidisciplinary management of a frequent attender in his early 50s with no fixed abode who presented with pyrexia of unknown origin, complicated by his noncooperation with intervention and treatment because of the development of psychotic symptoms. The case required the involvement of liaison psychiatry, anesthesia, cardiology, radiology, gastroenterology, rheumatology, respiratory, hematology, and social services, highlighting not just multidisciplinary intervention but the benefits of working with a multispeciality team. The patient had previously presented to the emergency department 47 times over an 18-month period. The management during his most recent inpatient stay resulted in the patient living independently and presenting to the hospital only once over the ensuing 7 months.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

STUDY OBJECTIVE

To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery.

PATIENTS

8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.

INTERVENTIONS

We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.

MEASUREMENTS

Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.

MAIN RESULTS

After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without.

CONCLUSIONS

After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium

OBJECTIVE

Till date, typical antipsychotic haloperidol is the treatment of choice for delirium. But, due to higher side effects with haloperidol, newer atypical antipsychotics (e.g., olanzapine) are increasingly being used in the treatment of delirious patients. The aim of the current research was to study the efficacy and tolerability of haloperidol and olanzapine in the treatment of delirium.

MATERIALS AND METHODS

This was an open-label, randomized controlled study carried out in a tertiary care hospital at Chandigarh, India. A total of 100 patients admitted in medicine, surgery, and orthopedic wards and diagnosed as having delirium on Confusion Assessment Method scale were included in the study. Patients were given either haloperidol (1-4 mg/day either orally or by nasogastric tube) or olanzapine (2.5-10 mg/day either orally or by nasogastric tube). Severity of delirium and pattern of symptom improvement were assessed by Memorial Delirium Assessment Scale (MDAS). Extrapyramidal side effects were assessed by Simpson-Angus Scale.

RESULTS

There was an improvement in delirium severity in both groups with treatment. Mean daily dose of haloperidol and olanzapine used per patient was 2.10 and 5.49 mg, respectively, and the mean duration of treatment in olanzapine group and haloperidol group was 3.57 days and 3.37 days, respectively. There was no significant difference in the mean duration of treatment in both groups. At the end of study period, the MDAS scores in olanzapine and haloperidol groups were 8.43 and 8.00, respectively, and the difference was not significant statistically with P = 0.765. Five patients experienced drug-related mild side effects.

CONCLUSION

Low-dose haloperidol and olanzapine were equally efficacious and well tolerated in delirium.

Statin and Its Association With Delirium in the Medical ICU

OBJECTIVES

To examine the association between statin use and the risk of delirium in hospitalized patients with an admission to the medical ICU.

DESIGN

Retrospective propensity-matched cohort analysis with accrual from September 1, 2012, to September 30, 2015.

SETTING

Hartford Hospital, Hartford, CT.

PATIENTS

An initial population of patients with an admission to a medical ICU totaling 10,216 visits were screened for delirium by means of the Confusion Assessment Method. After exclusions, a population of 6,664 was used to match statin users and nonstatin users. The propensity-matched cohort resulted in a sample of 1,475 patients receiving statin matched 1:1 with control patients not using statin.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Delirium defined as a positive Confusion Assessment Method assessment was the primary end point. The prevalence of delirium was 22.3% in the unmatched cohort and 22.8% in the propensity-matched cohort. Statin use was associated with a significant decrease in the risk of delirium (odds ratio, 0.47; 95% CI, 0.38-0.56). Considering the type of statin used, atorvastatin (0.51; 0.41-0.64), pravastatin (0.40; 0.28-0.58), and simvastatin (0.33; 0.21-0.52) were all significantly associated with a reduced frequency of delirium.

CONCLUSIONS

The use of statins was independently associated with a reduction in the risk of delirium in hospitalized patients. When considering types of statins used, this reduction was significant in patients using atorvastatin, pravastatin, and simvastatin. Randomized trials of various statin types in hospitalized patients prone to delirium should validate their use in protection from delirium.

Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit

As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.

Comparative Study of Delirium in Emergency and Consultation Liaison- A Tertiary Care Hospital Based Study in Northern India

INTRODUCTION

Delirium is an acute and often fluctuating disturbance in level of consciousness and thought process (cognition) that develops over a short period of time and is a significant change from previous level of functioning. Its prevalence increases with age, complexity of medical co- morbidities and number of medications prescribed.

AIM

To compare the cause and severity of delirium in patients in emergency and consultation liaison psychiatry group.

MATERIALS AND METHODS

A cross-sectional, tertiary care hospital based study was conducted on the patients who presented with delirium from emergency department (50) and consultation-liaison psychiatry groups (50), over a period of one year. The diagnosis was made on the basis of DSM- 5 criteria. The Delirium Rating Scale (DRS-R-98) was applied to know the severity of delirium, cognitive and non-cognitive symptoms of delirium in patients. The results were subjected to appropriate statistical analysis.

RESULTS

In emergency group, 42% patients had metabolic abnormalities, while in consultation-liaison, 38% patients had hyponatremia and hypokalemia and the difference was found to be statistically non-significant (p>0.05). In emergency group, 21(42%) patients were diagnosed as delirium due to other medical condition, followed by 13 (26%) and 8(16%) patients, who were diagnosed as delirium due to multiple aetiologies and substance intoxication each respectively. In only 33(66%) cases in consultation liaison group patients had delirium secondary to other medical conditions. As per DRS-R98 Scale, mean severity score was found to be statistically significant (p<0.05) in consultation liaison group as compared to emergency department group (p> 0.05).

CONCLUSION

Delirium is multifactorial aetiological disease, with variable but preventable outcome. Approach should be aimed at finding the treatable causes to reduce morbidity and mortality.

Antimicrobial-induced cognitive side effects

Introduction

Antimicrobial-induced cognitive side effects are often overlooked or underreported. Literature often reports symptoms of antimicrobial-induced cognitive impairment under more general blanket terms, such as neuropsychiatric side effects, neurotoxicity, or drug-induced delirium or encephalopathy.

Methods

A PubMed search using terms including antibiotics, antifungals, antivirals, antimalarials, side effects, cognitive, neurotoxicity, encephalopathy, and delirium was conducted. Respectively, symptoms of cognitive impairment were teased out of the multiple neurologic complications presented for each case and reported based on antimicrobial class. Articles were excluded if they focused solely on neuropsychiatric side effects such as seizures, psychosis, hallucinations, or mood disturbances, were conducted in animals, or involved antiretroviral medication therapies.

Results

Of over 50 case reviews, case reports, retrospective chart reviews, and prospective cohort studies analyzed, 25 were deemed appropriate for purposes of this review. Common antimicrobial-induced cognitive side effects for all antimicrobial classes included confusion, delirium, encephalopathy, and impaired concentration or attention. Recurring risk factors included, but were not limited to, older age and renal impairment. Mechanisms of cognitive impairment were relatively specific to each antimicrobial class.

Discussion

Awareness of the potential for antimicrobial-induced cognitive side effects, including the general time frame of symptom onset and symptom presentation, is critical in challenging patient cases. This review article aims to summarize the risk factors, clinical symptoms, mechanisms, and management of antimicrobial-induced cognitive side effects. Pharmacists can play a key role in prevention through adjustment of medications for renal or hepatic dysfunction, avoidance of polypharmacy, and knowledge of critical drug interactions that may precipitate cognitive decline.

Predictors of Mortality for Delirium in Palliative Care

INTRODUCTION

Delirium has a high mortality rate. Understanding predictors of prognosis in patients with delirium will aid treatment decisions and communication. This study aimed to explore variables associated with death during an established episode of delirium in palliative care when haloperidol treatment had been commenced.

METHODS

A consecutive cohort of palliative care patients, from 14 centers across four countries, is reported. The outcome of interest was death within 14 days from commencement of haloperidol treatment for delirium. Clinicodemographic variables explored were delirium severity, age, gender, primary life limiting illness, body mass index (BMI), total daily haloperidol dose at baseline (mg), functional status, and comorbidities.

RESULTS

One hundred and sixteen palliative care patients where vital status was known were included in the analysis; 45% (n = 52) died within 10 days, and 56% (n = 65) died within 14 days. In multivariate analyses no clinical or demographic variables predicted death, apart from lower BMI in noncancer patients.

CONCLUSION

This study has shown a very high mortality rate within two weeks of commencing haloperidol for delirium in palliative care, with no clear clinical predictors for those with a higher chance of dying. Having a higher BMI offered some benefit in survival, but only in noncancer patients. When delirium occurs in advanced illness, discussion should be initiated about the gravity of the clinical situation.

Association between Serum IGF-I levels and Postoperative Delirium in Elderly Subjects Undergoing Elective Knee Arthroplasty

Evidence is mixed for an association between serum insulin-like growth factor-I (IGF-I) levels and postoperative delirium (POD). The current study assessed preoperative serum IGF-I levels as a predictor of incident delirium in non-demented elderly elective knee arthroplasty patients. Preoperative serum levels of total IGF-I were measured using a commercially available Human IGF-I ELISA kit. POD incidence and severity were determined using DSM-IV criteria and the Delirium Rating Scale-Revised-98 (DRS-R98), respectively. Median IGF-I levels in delirious (62.6 ng/ml) and non-delirious groups (65.9 ng/ml) were not significantly different (p = 0.141). The ratio (95% CI) of geometric means, D/ND, was 0.86 (0.70, 1.06). The Hodges-Lehmann median difference estimate was 7.23 ng/mL with 95% confidence interval (−2.32, 19.9). In multivariate logistic regression analysis IGF-I level was not a significant predictor of incident POD after correcting for medical comorbidities. IGF-I levels did not correlate with DRS-R98 scores for delirium severity. In conclusion, we report no evidence of association between serum IGF-I levels and incidence of POD, although the sample size was inadequate for a conclusive study. Further efforts to investigate IGF-I as a delirium risk factor in elderly should address comorbidities and confounders that influence IGF-I levels.

Early mortality after hip fracture: what matters?

BACKGROUND

Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high-risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30-day mortality. The secondary aim was to investigate factors related to early mortality.

METHODS

We examined 384 elderly patients with hip fracture. Multivariate logistic regression analysis was used to explore independent prognostic factors for 30-day mortality.

RESULTS

By the end of the 30-day follow-up period, 22 patients (6.4%) had died. Postoperative delirium was the only variable independently related to 30-day mortality after hip fracture. Older, male patients with a lower cognitive status had a higher chance of developing postoperative delirium.

DISCUSSION

Postoperative delirium is a strong independent marker of high risk for 30-day mortality. Older, male patients with more severe cognitive impairment are at increased risk of developing postoperative delirium. Identifying patients at risk for developing postoperative delirium upon admission and early detection of delirium enable the development of targeted prevention and intervention strategies in older patients with hip fracture.

Risk factors of delirium in patients undergoing total knee arthroplasty

Although postoperative delirium is a complicated disorder in elderly individuals, no study has been examined the risk factors associated with perioperative comorbidities and clinical laboratory data while specifically focusing on only total knee arthroplasty (TKA). In the present retrospective study, we aimed to evaluate the incidence and perioperative risk factors of postoperative delirium after TKA. Between April 2009 and May 2013, 287 patients (365 knees) aged >65 years who had undergone primary TKA were enrolled. These patients were assigned to the delirium group of 11 patients (11 knees) or the non-delirium group of 276 patients (354 knees). The incidence of delirium among the patients was 3.1% (11/365). Univariate logistic regression analysis indicated that a history of dementia, older age, lower body mass index (BMI) level, and a postoperative day 3 blood urea nitrogen (BUN) level of >14.9 mg/dL were risk factors. However, multivariate logistic regression analysis indicated that a history of dementia (adjusted odds ratio [AOR]: 10.4, [1.09, 100]), older age (AOR: 1.15, [1.01, 1.31]), and a postoperative day 3 BUN level of >14.9 mg/dL (AOR: 4.76, [1.15, 19.7]) were independent risk factors. Based on our findings, we believe that the surgeons should be careful to avoid the postoperative delirium and ensure the appropriate management for patients who have these risk factors.

The Mini-Mental State Examination as a diagnostic and screening test for delirium: systematic review and meta-analysis

OBJECTIVE

To analyse the evidence concerning the accuracy of the Mini-Mental State Examination (MMSE) as a diagnostic and screening test for the presence of delirium in adults.

METHOD

Two authors searched MEDLINE, PsychINFO and EMBASE from inception till March 2014. Articles were included that investigated the diagnostic validity of the MMSE to detect delirium against standardised criteria. A diagnostic validity meta-analysis was conducted.

RESULTS

Thirteen studies were included representing 2017 patients in medical settings of whom 29.4% had delirium. The meta-analysis revealed the MMSE had an overall sensitivity and specificity estimate of 84.1% and 73.0%, but this was 81.1% and 82.8% in a subgroup analysis involving robust high quality studies. Sensitivity was unchanged but specificity was 68.4% (95% CI = 50.9-83.5%) in studies using a predefined cutoff of <24 to signify a case. In high-risk samples where delirium was present in 25% of patients, then the Positive predictive value and Negative predictive value would be 50.9% (48.3-66.2%) and 93.2% (90.0-96.5%).

CONCLUSION

The MMSE cannot be recommended as a case-finding confirmatory test of delirium, but may be used as an initial screen to rule out high scorers who are unlikely to have delirium with approximately 93% accuracy.

Influence of psychiatric disorders on surgical outcomes and care resource use in Japan

OBJECTIVE

The aim of this study was to quantify the effects of psychiatric disorders on major surgery outcomes and care resource use.

METHODS

This study adopted a retrospective cohort study design. The samples consisted of hospital stays. Subjects were patients who had undergone major surgery. We used multilevel regression analysis to quantify the influence of psychiatric disorders on major surgery outcomes and care resource use.

RESULTS

The total number of hospital stays included in the study was 5569, of which 250 were patients with psychiatric disorders. Compared with those without psychiatric disorders, those with schizophrenia had a significantly higher risk of complications, and those with neurotic disorder tended to have fewer complications. Total cost was significantly higher for those with schizophrenia and mood disorder and significantly lower in those with neurotic disorder. Lengths of stay were significantly longer for those with schizophrenia and mood disorder but not for those with neurotic disorder. Post-surgical mortality was equivalent among those with any psychiatric disorder and among those without a psychiatric disorder.

CONCLUSION

The study revealed that surgical outcomes and care resource use are differentiated by psychiatric disorders.

Neuropathogenesis of delirium: review of current etiologic theories and common pathways

Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.

Incidence of postoperative delirium is high even in a population without known risk factors

PURPOSE

Postoperative delirium is a recognized complication in populations at risk. The aim of this study is to assess the prevalence of early postoperative delirium in a population without known risk factors admitted to the ICU for postoperative monitoring after elective major surgery. The secondary outcome investigated is to identify eventual independent risk factors among demographic data and anesthetic drugs used.

METHODS

An observational, prospective study was conducted on a consecutive cohort of patients admitted to our ICU within and for at least 24 h after major surgical procedures. Exclusion criteria were any preexisting predisposing factor for delirium or other potentially confounding neurological dysfunctions. Patients were assessed daily using the confusion assessment method for the ICU scale for 3 days after the surgical procedure. Early postoperative delirium incidence risk factors were then assessed through three different multiple regression models.

RESULTS

According to the confusion assessment method for the ICU scale, 28 % of patients were diagnosed with early postoperative delirium. The use of thiopentone was significantly associated with an eight-fold-higher risk for delirium compared to propofol (57.1% vs. 7.1%, RR = 8.0, χ2 = 4.256; df = 1; 0.05 < p < 0.02).

CONCLUSION

In this study early postoperative delirium was found to be a very common complication after major surgery, even in a population without known risk factors. Thiopentone was independently associated with an increase in its relative risk.

Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice

Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.

Short-term clinical outcomes in delirious older patients: a study at general medical wards in a university hospital in Thailand

AIM

Delirium, a common disorder in hospitalized older patients, frequently results in unfavorable consequences. Previous studies in different settings have provided conflicting results regarding clinical outcomes and mortality. We aimed to study three clinical outcomes--length of stay (LOS), in-hospital mortality and 3-month mortality--among delirious Thai older patients.

METHODS

A prospective observational study was carried out in a university hospital in Thailand. All patients aged older than 70 years admitted to general medical wards were included. Delirium assessments were undertaken within the first 24 h of admission and serially until discharge. Subsequent assessments were carried out at 3 months after discharge. Delirium was diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria. Factors associated with mortality were determined by using logistic regression models.

RESULTS

LOS was significantly longer in the delirium group (10 and 8 days, P = 0.001). Furthermore, the delirium group had higher in-hospital and 3-month mortality (P < 0.001). Factors significantly associated with in-hospital mortality in multivariate analysis were age more than 80 years (AOR 2.74, 95% CI 1.05-7.15), malignancy (AOR 3.11, 95% CI 1.16-8.33), severe illness (AOR 3.75, 95% CI 1.38-10.20) and delirium (AOR 7.34, 95% CI 1.51-35.69). Delirium remained a strong predictor for 3-month mortality in multivariate analysis with AOR of 3.33 (95% CI 1.45-7.62) CONCLUSIONS: Delirium was associated with prolonged hospital-stay and was the strongest predictor for mortality among older hospitalized patients. It requires serious attention from physicians, healthcare administrators and policy makers to implement an appropriate management plan for this high-burden issue.

Screening for delirium within the interRAI acute care assessment system

OBJECTIVES

To develop and validate a screening strategy for delirium within the inter RAI acute care comprehensive assessment system.

DESIGN

Prospective validation cohort study.

SETTING

Acute general medical wards in two acute care metropolitan hospitals in Brisbane, Australia.

PARTICIPANTS

Two hundreds thirty-nine subjects with and without delirium, aged 70 and older.

MEASUREMENTS

Trained research nurses assessed subjects within 36 hours of hospital admission using the inter-RAI acute care (AC) system which includes four observational delirium items: Acute change mental status from baseline (ACMS), mental function varies over the course of the day (MFV), episode of disorganised speech (EDS), and easily distracted (ED). Geriatricians assessed subjects face to face within 4 hours of nurses' assessment using the Diagnostic and statistical manual of mental disorders (DSM IV) criteria and clinical judgement to determine delirium presence. Based on the performance of each delirium feature and to achieve highest predictive accuracy, a combination algorithm of either ACMS or MFV was developed and compared with the reference standard diagnosis determined by geriatricians.

RESULTS

Geriatricians diagnosed delirium in 52 of 239 (21.7%) subjects aged 70-102 years. The area under the receiver operator characteristics (AUC) for interRAI-AC delirium screener algorithm was 0.87 (95% CI; 0.80, 0.93), sensitivity 82%, specificity 91%, positive and negative predictive value of 0.72% and 95%, and likelihood ratio of 9.6 achieving the highest predictive accuracy of all possible combination of 4 delirium features. Underlying pre-morbid cognitive impairment did not undermine validity of the screening strategy, AUC 0.85 (95% CI; 0.74, 0.95), sensitivity 90% and specificity 69%.

CONCLUSION

The interRAI AC delirium screening strategy is a valid measure of delirium in older subjects in acute medical wards.

Protracted delirium with Sheehan's syndrome

OBJECTIVE

Delirium is a common problem, but often misdiagnosed and unidentified. Apart from the manifold clinical picture variable durations can also be an obstacle for its diagnosis.

METHODS

We present a case of protracted delirium that has developed after severe somatic illness in association with previously undiagnosed Sheehan's syndrome.

RESULTS

The variety of psychiatric symptoms with initial psychotic disorder and the long run of the disease delayed the diagnosis of delirium and meantime gave reason to assume personality change.

CONCLUSION

This case report calls attention to the possibility of protracted delirium in patients with neuropsychiatric deficit symptoms that persist subsequent to somatic illness.

Postoperative complications: delirium

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

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

An ACE unit with a delirium room may improve function and equalize length of stay among older delirious medical inpatients

BACKGROUND

Patients with delirium, compared with those without, are at increased risk for loss of function, longer hospital stays, and increased mortality. We studied the effect that an Acute Care of the Elderly Unit, which includes a delirium room, has on patients with delirium.

METHODS

Retrospective observational study. Charts of 148 patients (≥65 years) admitted to an Acute Care of the Elderly Unit with a delirium room during a 4-month period were reviewed. Delirium on admission (prevalence) was based on physician-performed Confusion Assessment Method; delirium during hospital stay (incidence) was based on nurse-performed Confusion Assessment Method. Patients with delirium were compared with those without delirium regarding change in function between admission and discharge (activities of daily living), hospital length of stay, and mortality.

RESULTS

The prevalence of delirium was 16.2% (24/148), and the incidence was 16.1% (20/124). There were no significant differences between delirious and non-delirious patients in demographics or comorbidity scores. A significant interaction effect (p < .001) indicated improved activities of daily living (mean ± SD; scale 0-12) between admission and discharge among delirious patients (4.1 ± 4.6 and 6.1 ± 3.9) compared with non-delirious patients (7.4 ± 4.7 and 6.9 ± 4.5). There were no differences between delirious and non-delirious patients with reference to mean length of stay (6.4 ± 3.1 vs 5.9 ± 3.6 days, respectively; p = .461) and mortality (2 [4.5%] versus 2 [1.9%], respectively; p = .582).

CONCLUSIONS

Although this study sample was small, the results suggest that an Acute Care of the Elderly Unit with a delirium room may improve function among delirious patients and may equalize other outcomes compared with non-delirious patients.

Delirium, a 'confusing' condition in general hospitals: The experience of a Consultation-Liaison Psychiatry Unit in Greece

BACKGROUND/AIMS

A plethora of studies showed that delirium is common in hospitalized populations. We aimed to examine the characteristics of delirium patients referred to our Consultation-Liaison Psychiatry Unit (CLPU).

METHODS

Our CLPU database was used to obtain data of all referred patients admitted to our hospital and diagnosed with delirium. All referred nondelirious patients served as controls.

RESULTS

During one year, 483 patients were referred to the CLPU. Ninety-three (19.3%) were diagnosed with delirium. Delirious patients were older than nondelirious patients (P < 0.001), with 76.3% aged over 70 years. The majority of the referrals came from surgical specialties. Common etiological factors were fluid and electrolyte imbalance (29%), fractures (28%) and infections (24%), but laboratory tests for the investigation of the etiology prior to the consultation had been performed in only 12 patients (12.9%). The syndrome resulted in prolonged hospitalization and greater use of CLPU services.

CONCLUSIONS

Referrals for delirium are frequent in CLPUs in Greece. Although delirium is common, it remains a 'confusing' condition for health practitioners. The under-diagnosis of delirium, the prolonged hospitalization and the time that the CLPU dedicated to these patients underlines the role of the CLPU psychiatrists in the management of the syndrome.

Postoperative Delirium is Associated with Postoperative Cognitive Dysfunction at One Week after Cardiac Surgery with Cardiopulmonary Bypass

Postoperative delirium with cognitive impairment frequently occurs after cardiac surgery. It was hypothesized that delirium is associated with residual postoperative cognitive dysfunction in patients after surgery using cardiopulmonary bypass. Male cardiac surgical patients ( M age = 66 yr., SD = 8; M education = 13 yr., SD = 2) and nonsurgical controls ( M age = 62, SD = 7; M education = 12, SD = 2) 55 years of age or older were balanced on age and education. Delirium was assessed by the Intensive Care Delirium Screening Checklist preoperatively and for up to 5 days postoperatively. Recent verbal and nonverbal memory and executive functions were assessed (as scores on particular tests) before and 1 wk. after surgery. In 56 patients studied ( n = 28 Surgery; n=28 Nonsurgery), nine patients from the Surgery group developed delirium. In the Surgery group, the proportion of patients having postoperative cognitive dysfunction was significantly greater in those who experienced delirium (89%) compared with those who did not (37%). The odds of developing this dysfunction in patients with delirium were 14 times greater than those who did not. Postoperative delirium is associated with scores for residual postoperative cognitive dysfunction 1 wk. after cardiac surgery.

Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment

Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.

The opportunity for psychiatry in palliative care

The need for psychiatrists to work with patients and families living with chronic life-threatening illnesses has never been greater. Further, psychiatrists may find exciting work within the relatively new field of palliative care, which is devoted to the prevention and relief of all suffering. Increasingly, individuals are living longer with multiple issues that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To ensure state-of-the-art care for patients and families throughout an illness and any ensuing bereavement period, many experienced psychiatrists are needed as consultants to, and as members of, interdisciplinary palliative care teams. This need presents limitless opportunities for psychiatrists to care for patients, provide education, and engage in research. The potential to make a difference is great.

Differing management of people with advanced cancer and delirium by four sub-specialties

INTRODUCTION

Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer.

METHODS

A questionnaire was designed to identify investigations and treatment used, in relation to two cases.

RESULTS

Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists.

INVESTIGATIONS

85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium.

TREATMENT

Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium.

DISCUSSION

The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

Pathophysiology of delirium in the intensive care unit

Delirium, or acute brain dysfunction, is a life-threatening global disturbance in cognitive functioning that frequently manifests in critically ill patients. This review examines the current status of knowledge regarding the pathophysiology of delirium in the ICU, in particular, evaluating the role of iatrogenic factors such as sedatives and analgesic administration in brain dysfunction. This hypothesis is considered along with several other plausible mechanisms of ICU delirium, including sepsis, postoperative cognitive dysfunction, and changes in biomarkers and neurotransmitters. The review concludes by highlighting potential future directions in molecular genetics for the elucidation of delirium and its long-term consequences.

The relationship between psychiatric medication and course of hospital stay among intoxicated trauma patients

INTRODUCTION

The purpose of this study was to determine whether trauma patients requiring psychiatric medication who were admitted with positive alcohol or drug screen require more pain medications or sedation resulting in longer length of stay.

METHODS

Data were retrospectively collected from 1997 through 2003 on patients with positive alcohol or drug screen who also received psychiatric medication during their hospital stay in a trauma center. Patients were matched by age, injury severity score, and injury to controls who had negative alcohol and toxicology screens and no psychiatric medication. An additional group consisted of positive alcohol or drug-screen trauma patients without psychiatric medication during hospitalization. Each group had 25 patients.

RESULTS

No significant differences between the three groups regarding comorbidities or pain-medication doses given per day were found. The patients with positive alcohol and with psychiatric medication were more likely to have respiratory complications such as pneumonia or respiratory failure requiring ventilator support (36 versus 4%, P=0.005), to develop other infections (8 versus 0%), or other complications (26 versus 4%, P=0.0007) compared with the controls. A significant difference in hospital length of stay between the group with positive toxicity and psychiatric medication and that with negative toxicity and psychiatric medication (mean: 12.8 and 5.5 days, respectively; P=0.01) was found.

CONCLUSION

Psychiatric medication and positive drug or alcohol screens are associated with longer length of stay and increased respiratory complications. Factors influencing these outcomes need more clarification and prospective studies.

Insomnia among hospitalized older persons

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

WITHDRAWN: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus* . The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

AUTHORS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Distinguishing delirium and dementia

Delirium and dementia are syndromes with multiple cognitive impairments common to the elderly and to medically ill patients. While strides have been made in recognition of both delirium and dementia, underdiagnosis is common. Delirium and dementia cause great suffering in patients, families and caregivers. Both necessitate further advancement in assessment methods and treatment, especially when they overlap. Differentiating delirium and dementia requires recognizing that both may present with cognitive, behavioral and neuropsychiatric symptoms, but attentional disturbance and acute onset are cardinal discriminators in delirium. Superimposed delirium on dementia presents a particularly vexing problem in terms of recognition, treatment and prognosis. The pathophysiology of delirium results from diffuse cortical dysfunction or impairment in susceptible areas of the cortex and the reticular activating system. The pathophysiology of dementia is varied across dementias although several share histolological features. Treatment for both delirium and dementia includes antipsychotic medications and cholinesterase inhibitors, among others, although the disadvantages of pharmacological treatment are becoming better understood and demand caution. Nevertheless, there is an array of treatments and preventive strategies being explored for dementia, and to a lesser degree for delirium, that hold promise for the future.

Differences in Characteristics and Outcome of Delirium as Based on Referral Patterns

The authors studied factors associated with referral of delirium patients to psychiatry consultation and its outcome implications. Characteristics and treatment outcomes of delirium patients referred to psychiatry were compared with those not referred. Referred patients were younger, had a more hyperactive subtype, greater substance abuse, less comorbid dementia, were more likely to be recognized as having delirium, and be prescribed medications. Improvement in referred patients was indicated by lower readmission rate postdischarge. No differences were noted in length of stay, discharge status, or mortality within 1 year of the index episode. Psychiatric interventions were moderately helpful. Patients' characteristics and delirium subtypes may influence referral and should inform future liaison efforts.

Biperiden-induced delirium model in rats: a behavioral and electroencephalographic study

AIMS AND METHODS

In order to elucidate the neural mechanisms of delirium, we administered the anticholinergic drug, biperiden (40 mg/kg i.p.), to 10 adult male Wistar rats and examined the resulting polygraphic recordings, including electroencephalography (EEG), electrooculography (EOG), and electromyography (EMG), for 60 min following injection. EEG data were investigated quantitatively by power spectrum analyses using fast Fourier transformation. Ten male Wistar rats receiving saline (i.p.) were used as the control group.

RESULTS

Treated rats demonstrated two types of alternating behavioral change: a hyperactive and hypoactive state. In the hyperactive state, rapid walking, excessive random sniffing, and retropulsion were observed, with EEG desynchronization (significantly increased alpha1 (8.0-10.0 Hz), alpha2 (10.0-13.0 Hz), and beta (13.0-30.0 Hz) power values), as well as EEG slowing (significantly increased delta (0.5-4.0 Hz) and theta1 (4.0-6.0 Hz) power values): significantly marked rapid eye movement, and increased EMG activity. In the hypoactive state, motor arrest and drowsiness were observed, with prominent EEG slowing (significantly increased delta and theta1 power values): significantly decreased rapid eye movement and moderately decreased EMG activity. On the other hand, the control group did not show any behavioral or polygraphic changes.

CONCLUSIONS

The behavioral and polygraphic changes induced by biperiden administration in rats are similar to those of delirium in humans. Therefore, it is proposed that biperiden-treated rats are a good delirium model and the anticholinergic mechanism is one of the potent factors in the development of delirium in humans.