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Kappenschneider T, Meyer M, Maderbacher G, Parik L, Leiss F, Quintana LP, Grifka J. [Delirium-an interdisciplinary challenge]. DER ORTHOPADE 2022; 51:106-115. [PMID: 35037987 DOI: 10.1007/s00132-021-04209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients. DIAGNOSTIC Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential. TREATMENT In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.
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Affiliation(s)
- Tobias Kappenschneider
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Matthias Meyer
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Günther Maderbacher
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Lukas Parik
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Franziska Leiss
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Loreto Pulido Quintana
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Adam EH, Haas V, Lindau S, Zacharowski K, Scheller B. Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study. BMJ Open 2020; 10:e031212. [PMID: 31941763 PMCID: PMC7044931 DOI: 10.1136/bmjopen-2019-031212] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium. DESIGN Prospective observational study. SETTING Single-centre at a European academic hospital. PRIMARY AND SECONDARY OUTCOME MEASURES In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD. RESULTS A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD. CONCLUSIONS We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Victoria Haas
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simone Lindau
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Bertram Scheller
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
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Prokop A, Reinauer KM, Koebler M, Schwerb E, Keller L, Chmielnicki M. Community Service as Patients' Tutor to Avoid Delirium. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:625-629. [PMID: 31556077 DOI: 10.1055/a-0974-4175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Today, nearly two thirds of inpatients in trauma surgery hospitals are over 70 years old and at significant risk for comorbidities. These patients frequently suffer delirium. Delirium occurs in 15 - 30% of these trauma patients and increases the risk of mortality in up to 15 - 25% of cases. Conversation, attention, and activity significantly reduce this risk. OBJECTIVES Thus, the Centre for Geriatric Traumatology and the District Seniors Council have initiated a new project of a visiting service, to prevent delirium and anxiety conditions in elderly inpatients. Volunteers from the welfare program offer daily care for selected patients. METHODS They care for and interact with the patients for approximately one hour per day. They accompany the patients in the hospital and during mobilization, explain, read aloud, converse, or simply listen, and thus provide calm, support, and company. The attendants are volunteers who have been previously trained by the clinic, who regularly attend team meetings and draw up reports from each admission. All patients and relatives are informed prior to these visits and are notified with an accompanying letter. There are structured visiting plans for each week. RESULTS From July 17 to May 19, 4031 patients in our clinic and in three other hospitals have been accompanied in the program. None of the patients suffered delirium. The patients and attendants found the care very good and personally satisfying. Evaluations of the volunteers for the success of their work, using the German school-grading system, was an average 1.3. Noticeable was the markedly reduced frequency of patient calls to nursing, who were thus relieved. Travel expenses and insurance costs for the volunteers were reimbursed. CONCLUSION In times of skilled labour shortages, patient support provided by volunteer patient attendants enables innovative care for patients at risk for delirium. The assistance of the attendants alone reduced the workload on the nursing staff.
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Affiliation(s)
- Axel Prokop
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Kliniken Sindelfingen, Klinikverbund Südwest
| | - Karl Michael Reinauer
- Medizinische Klinik VI - Altersmedizin, Kliniken Sindelfingen, Klinikverbund Südwest
| | | | - Erna Schwerb
- Pflegegruppenleitung Unfallchirurgie, Kliniken Sindelfingen, Klinikverbund Südwest
| | | | - Marc Chmielnicki
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Kliniken Sindelfingen, Klinikverbund Südwest
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Abstract
BACKGROUND Opioids are increasingly used in the elderly. Side effects differ compared to other analgesics. PURPOSE In this review article, special aspects about using opioids for noncancer pain in older people and in geriatric patients are identified. CURRENT SITUATION So far randomized controlled trials for the indication of and comparison between various opioids have been performed in middle-aged patients and not exclusively in geriatric patients or elderly (> 75 years). Furthermore, the evidence for multimorbid elderly patients with respect to side effects is also very poor. RECOMMENDATIONS The indication for opioid therapy should be narrow. The patient and their caregivers must be provided patient information regarding opioid therapy. The principle "start low, go slow" is highly recommended. To reduce the risk of falls, longer acting opioids should be used and short acting opioids should be avoided. Everyday relevant negative effects on cognition are possible in opioid use and have to be observed. As recommended in the recently published German guideline for long-term use of opioids in noncancer pain a critical check after 3 months and in case of dosing over 120 mg morphine equivalents is advisable, especially for older patients. Liver and kidney function and drug interactions have to be taken into consideration like in every age group.
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Affiliation(s)
- M Schuler
- Klinik für Geriatrie und Palliativmedizin, Diakonissenkrankenhaus, Speyerer Str. 91-93, 68163, Mannheim, Deutschland.
| | - N Grießinger
- Schmerzambulanz, Anästhesiologische Klinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
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Krupp S, Seebens A, Kasper J, Willkomm M, Balck F. [Validation of the German version of the 6‑item screener : Brief cognitive test with broad application possibilities]. Z Gerontol Geriatr 2017; 51:275-281. [PMID: 28093627 DOI: 10.1007/s00391-016-1177-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 09/29/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Especially during admission the detection of cognitive deficits relevant to everyday life should burden patient and examiner as little as possible. The 6‑item screener (SIS) takes approximately 1 min, is easy to learn, does not require any material and is independent of the patient's visual and fine motor skills. The test was first published in 2002 by Callahan who approved the present German translation. OBJECTIVE We checked the convergent and discriminant validity, reliability and sensitivity to change of the German translation among geriatric patients. MATERIAL AND METHODS A total of 165 patients in an acute geriatric department performed the SIS (4 times), the mini mental state examination (MMSE, 2 times), clock-drawing test according to Shulman (2 times), the Regensburg verbal fluency test (2 times) and the Montgomery-Åsberg depression rating scale within a period of 16 days. The overall judgment of a physician blinded to the test results served as the reference standard. RESULTS The SIS closely correlated with the medical judgment (-0.729). The retest reliability was 0.705 and the internal consistency 0.821 (Cronbach's alpha). The sensitivity to detect cognitive deficits relevant to activities of daily living was 100% if a threshold of 5 points was chosen. The achievement of maximum points largely rules out even mild cognitive impairment. CONCLUSION The SIS is a valid, reliable short cognitive test. Using a threshold of 5 points the SIS detects cognitive deficits relevant to daily living with a higher sensitivity than the MMSE with a threshold of 25. When the maximum score is achieved there are no medical indications for further cognitive assessment of clinically unremarkable geriatric patients. The brevity and simple application of the SIS also enable its application outside geriatric wards.
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Affiliation(s)
- S Krupp
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.
| | - A Seebens
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.,Psychosoziale Medizin und Entwicklungsneurowissenschaften, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland.,Universität zu Lübeck, Lübeck, Deutschland
| | - J Kasper
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland
| | - M Willkomm
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland
| | - F Balck
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.,Psychosoziale Medizin und Entwicklungsneurowissenschaften, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
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[Aortic valve replacement in the elderly]. Z Gerontol Geriatr 2016; 49:639-656. [PMID: 27518151 DOI: 10.1007/s00391-016-1112-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/27/2016] [Accepted: 06/29/2016] [Indexed: 11/27/2022]
Abstract
The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.
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Neuerburg C, Gosch M, Böcker W, Blauth M, Kammerlander C. [Proximal femoral fractures in the elderly]. Z Gerontol Geriatr 2015; 48:647-59; quiz 660-1. [PMID: 26286076 DOI: 10.1007/s00391-015-0939-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.
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Affiliation(s)
- Carl Neuerburg
- Klinik für Allgemeine, Unfall-, Hand- und Plastische Chirurgie, Klinikum der Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland.
| | - M Gosch
- Paracelus Medizinische Privatuniversität, Medizinische Klinik 2 - Geriatrie, Klinikum Nürnberg, Nürnberg, Deutschland
| | - W Böcker
- Klinik für Allgemeine, Unfall-, Hand- und Plastische Chirurgie, Klinikum der Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - M Blauth
- Universitätsklinik für Unfallchirurgie, Zentrum Operative Medizin, Innsbruck, Österreich
| | - C Kammerlander
- Klinik für Allgemeine, Unfall-, Hand- und Plastische Chirurgie, Klinikum der Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland.,Universitätsklinik für Unfallchirurgie, Zentrum Operative Medizin, Innsbruck, Österreich
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Müller D, Hallmeyer-Elgner S. [Diverse seizures, unusual EEG seizure pattern and episodic organic brain syndrome. A case report]. DER NERVENARZT 2015; 86:887-890. [PMID: 25777133 DOI: 10.1007/s00115-015-4280-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- D Müller
- -, Heideflügel 3, 01324, Dresden, Deutschland,
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Abstract
Delirium in older patients is also associated with persistent functional and cognitive impairment. Nevertheless, it frequently remains unrecognized or misinterpreted by treating physicians and this is particularly true in cases of hypoactive delirium. Screening and assessment instruments are helpful in the identification of patients with delirium. A multifactorial model of a combination of predisposing and precipitating factors best explains the etiology of delirium and avoidance is crucial for its prevention. Whenever delirium is suspected, immediate diagnosis and therapy of the precipitating condition are of primary importance. Non-pharmacological interventions, for example environmental modifications, play an important role in managing behavioral symptoms of delirium. Pharmacological interventions are merely symptomatic and should be limited to patients with severe symptoms when non-pharmacological means fail.
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Affiliation(s)
- K Singler
- Institut für Biomedizin des Alterns, Friedrich-Alexander Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nürnberg, Deutschland,
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