The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center

Routine comprehensive geriatric assessment is associated with improved detection of cognitive disorders in older people with giant cell arteritis

OBJECTIVES

Giant cell arteritis (GCA) carries an increased risk of stroke and blindness. International guidelines recommend older people receive routine comprehensive geriatric assessment (RCGA) during unplanned hospital admissions to improve health outcomes. This quality improvement study addressed the need for RCGA in older people with GCA at an Australian tertiary hospital. The aims of this study were to co-design, implement and evaluate a referral process for RCGA for hospitalised people 65 years or older with a new diagnosis of GCA and evaluate changes to the identification and management of falls and cognitive disorders (delirium, dementia and mild cognitive impairment).

METHODS

Hospital stakeholders co-designed an RCGA referral pathway as a quality improvement change initiative. An observational cohort design measured implementation and outcomes. Consecutive patients aged 65 years or older with a new diagnosis of GCA were recruited for 15 months (n = 18), and outcomes were compared with a retrospective cohort of similar patients (n = 55). Descriptive summaries were compared between groups using non-parametric tests.

RESULTS

Following implementation, all eligible patients received both RCGA and individualised interventions. Forty-four per cent of patients in the RCGA group were diagnosed with delirium, dementia or mild cognitive impairment compared to 18% in the usual care group (p = .03).

CONCLUSIONS

In this small population, implementation of an RCGA pathway was associated with increased detection of delirium, mild cognitive impairment and dementia, and allowed for implementation of individualised interventions.

Effect of intraoperative intravenous esketamine on postoperative delirium in older patients undergoing hip fracture surgery: protocol for a randomised, double-blind, placebo-controlled trial

INTRODUCTION

Postoperative delirium (POD) is a common complication after hip fracture surgery in older patients. Esketamine may be beneficial in alleviating the occurrence of POD. Our trial aim is to investigate whether the intravenous administration of esketamine can improve POD in older patients undergoing surgery for hip fracture.

METHODS AND ANALYSIS

This randomised controlled trial will be conducted at the Chengdu Integrated TCM & Western Medicine Hospital in Chengdu, China. A total of 260 older patients scheduled for hip fracture surgery under general anaesthesia will be randomly allocated to either an esketamine group (group E) or a control group (group C) at a 1:1 ratio (n=130 in each group). After tracheal intubation, group E will receive continuous infusion of esketamine at a rate of 0.3 mg/kg/h intraoperatively until the beginning of skin incision closure. Group C will receive equivalent volumes and rates of 0.9% normal saline; the injection methods are in accordance with those in group E. The primary outcome is the incidence of POD within 3 days after surgery, which will be evaluated using the confusion assessment method two times per day. Secondary outcomes are subtypes, duration of delirium, length of hospital stay, pain severity score within 3 days after surgery and 30-day all-cause mortality. Pain severity scores at rest will be evaluated using a numeric rating scale. Safety outcomes will include hallucination, dizziness, nightmares, nausea and vomiting. All analyses will be performed in line with the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Medical Ethics Committee of Chengdu integrated TCM & Western Medicine Hospital (2024KT022). All patients will provide written informed consent before enrolment. The results of the trial will be published in an appropriate journal or an oral presentation at academic meetings.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2400081681).

Practical prognostic tools to predict the risk of postoperative delirium in older patients undergoing cardiac surgery: visual and dynamic nomograms

PURPOSE

Postoperative Delirium (POD) has an incidence of up to 65% in older patients undergoing cardiac surgery. We aimed to develop two dynamic nomograms to predict the risk of POD in older patients undergoing cardiac surgery.

METHODS

This was a single-center retrospective cohort study, which included 531 older patients who underwent cardiac surgery from July 2021 to June 2022 at Nanjing First Hospital, China. Univariable and multivariable logistic regression were used to identify the significant predictors used when constructing the models. We evaluated the performances and accuracy, validated, and estimated the clinical utility and net benefit of the models using the receiver operating characteristic (ROC), the 10-fold cross-validation, and decision curve analysis (DCA).

RESULTS

A total of 30% of the patients developed POD, the significant predictors in the preoperative model were ASA ( p < 0.001 OR = 3.220), cerebrovascular disease (p < 0.001 OR = 2.326), Alb (p < 0.037 OR = 0.946), and URE (p < 0.001 OR = 1.137), while for the postoperative model they were ASA (p = 0.044, OR = 1.737), preoperative MMSE score (p = 0.005, OR = 0.782), URE (p = 0.017 OR = 1.092), CPB duration (p < 0.001 OR = 1.010) and APACHE II (p < 0.001, OR = 1.353). The preoperative and postoperative models achieved satisfactory predictive performances, with AUC values of 0.731 and 0.799, respectively. The web calculators can be accessed at https://xxh152.shinyapps.io/Pre-POD/ and https://xxh152.shinyapps.io/Post-POD/ .

CONCLUSION

We established two nomogram models based on the preoperative and postoperative time points to predict POD risk and guide the flexible implementation of possible interventions at different time points.

Prediction of delirium occurrence using machine learning in acute stroke patients in intensive care unit

Introduction

Delirium, frequently experienced by ischemic stroke patients, is one of the most common neuropsychiatric syndromes reported in the Intensive Care Unit (ICU). Stroke patients with delirium have a high mortality rate and lengthy hospitalization. For these reasons, early diagnosis of delirium in the ICU is critical for better patient prognosis. Therefore, we developed and validated prediction models to classify the real-time delirium status in patients admitted to the ICU or Stroke Unit (SU) with ischemic stroke.

Methods

A total of 84 delirium patients and 336 non-delirium patients in the ICU of Ajou University Hospital were included. The 8 fixed features [Age, Sex, Alcohol Intake, National Institute of Health Stroke Scale (NIHSS), HbA1c, Prothrombin time, D-dimer, and Hemoglobin] identified at admission and 12 dynamic features [Mean or Variability indexes calculated from Body Temperature (BT), Heart Rate (HR), Respiratory Rate (RR), Oxygen saturation (SpO2), Systolic Blood Pressure (SBP), and Diastolic Blood Pressure (DBP)] based on vital signs were used for developing prediction models using the ensemble method.

Results

The Area Under the Receiver Operating Characteristic curve (AUROC) for delirium-state classification was 0.80. In simulation-based evaluation, AUROC was 0.71, and the predicted probability increased closer to the time of delirium occurrence. We observed that the patterns of dynamic features, including BT, SpO2, RR, and Heart Rate Variability (HRV) kept changing as the time points were getting closer to the delirium occurrence time. Therefore, the model that employed these patterns showed increasing prediction performance.

Conclusion

Our model can predict the real-time possibility of delirium in patients with ischemic stroke and will be helpful to monitor high-risk patients.

Comprehensive geriatric assessment for predicting postoperative delirium in oral and maxillofacial surgery: a prospective cohort study

Identifying high-risk patients for developing postoperative delirium (POD) is essential for optimizing the medical field's human and financial resources through specialty-relevant geriatric assessments that can aid in establishing prehabilitation strategies. This study aims to identify geriatric screening tools to predict preoperative delirium and explore the high-risk elderly patients undergoing oral maxillofacial surgery. A comprehensive geriatric assessment encompassing 23 instruments was used to evaluate inpatients undergoing surgery under general anaesthesia, preoperatively and postoperatively. Selective intraoperative and postoperative variables were also assessed for their relation to POD occurrence. This prospective study included 90 patients (mean age 79.0 years) from August 2022 to August 2023. The POD rate in this cohort was (8.9% n = 8). The Clock-Drawing Test (CDT) was significantly associated with POD occurrence (p = 0.005). Significant associations were found between POD occurrence and operation type (p = 0.018), duration (p = 0.026), length of stay ( p = 0.002), and postoperative hemoglobin levels (p = 0.027). This study highlights the importance of comprehensive geriatric assessments in predicting POD in elderly patients. Future research should build on these findings to enhance preoperative care strategies and improve outcomes.Trial registration: German Register of Clinical Studies, DRKSID DRKS00028614.

Mortality-related factors in older adults with delirium: A prospective observational study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome characterized by acute changes in attention, cognition, and consciousness. It is frequently encountered in various clinical settings, including critical care units and postoperative care, and is associated with significant morbidity and mortality. Understanding the factors contributing to delirium-related mortality is crucial for improving patient outcomes and healthcare practices. However, the factors associated with mortality in delirium have not been well-defined in the literature.

OBJECTIVES

This study aimed to identify factors influencing 3-month mortality in older adults with delirium presenting to the emergency department (ED).

METHODS

The study was conducted prospectively and delirium was screened using the brief Confusion Assesment Method (bCAM). The primary outcome was 3-month mortality. Mann-Whitney U and Chi-square tests compared groups, Spearman correlation analyzed correlations, and multivariate logistic regression identified risk factors.

RESULTS

Among 243 patients, 29.6% experienced in-hospital mortality, and 56.4% had 3-month mortality. Factors associated with increased mortality risk included prior delirium history (3.32-fold increase, 95%CI: 1.51-7.30), active malignancy (3.49-fold increase, 95%CI: 1.61-7.56) and increased respiratory rate (1.18-fold increase, 95%CI: 1.08-1.29). An increase in mean arterial pressure (MAP) was associated with a 0.98-fold decrease in mortality risk (95%CI: 0.96-0.99), increase in body temperature was associated with a 0.48-fold decrease in mortality risk (95%CI:0.31-0.76).

CONCLUSION

In delirious older adults at the ED, higher respiratory rate, lower MAP, lower body temperature, active malignancy and prior delirium history signal elevated mortality risk.

The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study

BACKGROUND

Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.

AIM

To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.

DESIGN

A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.

SETTING/PARTICIPANTS

Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years.

RESULTS

A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).

CONCLUSION

The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings.

TRIAL REGISTRY

ISCRTN 97417474.

Delirium Diagnosis, Complication Recognition, and Treatment Knowledge among Nurses in an Italian Local Hospital: A Cross-Sectional Study

Delirium, a multifactorial condition with an acute onset and diverse clinical manifestations, poses a significant challenge in the care of hospitalized individuals aged 65 years and older. This study aimed to evaluate the level of knowledge among nursing healthcare personnel regarding the diagnosis, recognition of complications, and treatment of delirium. A paper questionnaire consisting of 18 multiple-choice questions was distributed to nurses in twelve operational units located in four facilities within a local hospital in a specific geographical region under the jurisdiction of the Romagna Local Health Authority in Italy. Out of 194 respondents, the overall acceptance rate was 64.2%. The findings revealed an insufficient understanding of delirium among the nursing staff, with more than 40% of respondents answering incorrectly to five out of nine questions related to delirium knowledge, diagnosis, prevention, and treatment. Notably, gender emerged as a significant determinant, with female participants exhibiting a substantial odds ratio (OR) of 3.50 (p = 0.011 and CI95% = 1.34-9.16) compared to their male counterparts, indicating a higher likelihood of receiving delirium training among females. Furthermore, prolonged tenure within the same work context was associated with a reduced likelihood of receiving delirium training compared to those with less than two years of experience (OR = 0.21, p = 0.034, and CI95% = 0.05-0.89 for 6-10 years of tenure; OR = 0.22, p = 0.038, and CI95% = 0.05-0.92 for over 10 years of tenure). This study underscores the urgent need for enhanced delirium education and improved strategies among nurses to effectively manage patients with delirium. The results advocate regular educational sessions utilizing diverse formats to comprehensively address knowledge gaps among nursing staff. This study was not registered.

Effect of hospital elder life program on the incidence of delirium: A systematic review and meta-analysis of clinical trials

OBJECTIVE

This meta-analysis aims to investigate the effect of the Hospital Elder Life Program (HELP) on the incidence of delirium, delirium scores, length of hospital stay, and incidence of falls.

METHODS

Four databases (PubMed, Embase, Cochrane Library, and Web of Science) were searched from inception until January 18, 2024. The search specifically targeted randomized controlled trials (RCTs). Two independent researchers conducted literature screening, quality assessment, and data extraction. The meta-analysis was performed using Review Manager 5.4.1 and Stata 15.1 software.

RESULTS

The final analysis included a total of 9 RCTs with 2583 patients. The findings from the meta-analysis indicated that HELP was found to considerably reduce the incidence of delirium and the length of hospital stay when compared to the control group. Nevertheless, no statistically significant differences were observed between the two groups in terms of delirium scores and fall rates.

CONCLUSION

In this meta-analysis, HELP can effectively reduce the incidence of delirium and lead to a shorter hospital stay.

Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review

INTRODUCTION

Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms.

CASE PRESENTATION

We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery.

CONCLUSION

RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.

Inflammatory and nutritional markers predict the risk of post-operative delirium in elderly patients following total hip arthroplasty

Objectives

This study intended to explore whether albumin-associated inflammatory and nutritional markers could predict post-operative delirium (POD) in older patients after total hip arthroplasty (THA). In addition, we established a nomogram model for POD prediction.

Methods

Totally, 254 elderly cases who received THA were included. Clinical and laboratory data of these patients were retrospectively collected. Albumin-associated inflammatory and nutritional markers included neutrophil-to-albumin ratio (NAR), CRP-to-albumin ratio (CAR), prognostic nutritional index (PNI), and systemic inflammation score (SIS). The LASSO, univariate and multivariate logistic regression analyses were utilized to screen risk factors. A nomogram model was developed according to the results of multivariate regression analyses.

Results

Among 254 patients, 49 cases had POD with an incidence of 19.3%. LASSO regression and multivariate logistic analyses suggested that preoperative NAR, preoperative PNI, preoperative SIS, and age >75 years were risk factors for POD. A nomogram model was developed according to the results of multivariate logistic analyses. The calibration curve suggested that the predicted probability of this nomogram model was in good line with the actual probability. The DCA showed that this nomogram model had net benefits for the prediction of POD for elderly patients following THA.

Conclusion

Albumin-associated inflammatory and nutritional markers including NAR, PNI, and SIS could predict POD in elderly patients following THA.

Delirium in oncological palliative care and clinical cardiology units: A comparative analysis

OBJECTIVE

The aim of this study was to compare the sociodemographic and clinical characteristics of delirium in patients treated in a clinical cardiology unit (CCU) and an oncological palliative care unit (OPCU) at a high-complexity institution.

CONTEXT

Delirium is a neuropsychiatric syndrome with multicausal etiology, associated with increased morbidity and mortality.

METHOD

This was a cross-sectional, analytical observational study. CCU and OPCU patients were evaluated for 480 days. The diagnosis was made according to DSM-V. Sociodemographic characteristics, the Karnofsky index, and the Charlson index were evaluated. Possible etiologies were verified. Severity was assessed with the Delirium Severity Scale (DRS-R98).

RESULTS

A total of 1,986 patients were evaluated, 205 were eligible, and 110 were included in the study (CCU: 61, OPCU: 49). Delirium prevalence was 11.35% in the CCU and 9.87% in the OPCU. CCU patients were 12 years older (p < 0.03) and a history of dementia (41 vs. 8.2%; p < 0.001). Organ failure was the most frequent etiology of delirium in the CCU (41.0%), and in the OPCU, the etiologies were neoplasms (28.6%), side effect of medication (22.4%), and infections (2.5%). Differences were found in the clinical characteristics of delirium evaluated by DRS-R98, with the condition being more severe and with a higher frequency of psychotic symptoms in OPCU patients.

CONCLUSION

Delirium was a common condition in hospitalized patients in the CCU and the OPCU. The clinical characteristics were similar in both groups; however, significant differences were found in OPCU patients in terms of age, personal history of dementia, and opioid use, as well as the severity of delirium and a greater association with psychotic symptoms. These findings have implications for the early implementation of diagnostic and therapeutic strategies.

Opioid-induced Neurotoxicity in Patients with Cancer Pain

OPINION STATEMENT

Opioid-induced neurotoxicity (OINT) is a neuropsychiatric syndrome observed with opioid therapy. The mechanism of OINT is thought to be multifactorial, and many risk factors may facilitate its development. If symptoms of OINT are seen, the prescriber should consider hydration, discontinuation of the offending opioid drug, or switching of opioid medication, or the use of some adjuvants. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations for opioid switching. Experience and clinical judgment in a specialistic palliative care setting should be used and individual patient characteristics considered when applying any conversion table.

Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients

Objective

Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium.

Methods

The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR).

Result

Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70).

Conclusion

UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.

[Development and content validity of a questionnaire to assess knowledge about delirium]

BACKGROUND

Delirium is a neuropsychiatric syndrome that can have serious consequences and is often overlooked by healthcare professionals. The level of knowledge about delirium is often insufficient among nursing and medical staff. At the current time there is no suitable questionnaire to record the level of knowledge in German-speaking countries.

AIM

Development of a questionnaire and evaluation of content validity.

METHODS

Following a literature search to identify current best practice, several questionnaires were identified. An already published questionnaire with the dimensions of basic knowledge of delirium and risk factors has been translated, adapted and extended by the dimension of nonpharmacological delirium prevention. Delirium experts assessed the relevance of the questionnaire items in two rounds of reviews. Content validity was calculated using the Content Validity Index (CVI) at item (I-CVI) and scale (S-CVI) level. Additionally, the modified Kappa (k*) was calculated using a lower 95% confidence interval (CI).

RESULTS

The original 30-item questionnaire was expanded to include 18 delirium prevention items. After the first round of scoring 30 out of 48 items showed good to excellent I‑CVI scores. Considering the comments, 6 items were discarded and 12 were adapted in terms of language and content. In the final version of the questionnaire 41 items with excellent scores remained. The total scale score increased from 0.88 in the first version to 1.0 in the final version. Nurses were identified as the target group, potentially also therapists and medical personnel.

CONCLUSION

The delirium knowledge questionnaire is content-valid.

Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis

INTRODUCTION

Despite common, serious, costly, and often fatal conditions affecting up to 50 % of older patients, delirium is often unrecognized and overlooked. We examine the accuracy of the 4AT for detecting older patients with delirium.

METHODS

We performed a systematic search of PubMed, Web of Science, PsycINFO, and EMBASE databases from inception to April 2020 and updated to January 2022. Four independently reviewers extracted study data and assessed the methodological quality using the revised quality assessment of diagnostic accuracy studies tool (QUADAS-2). Pooled estimates of sensitivity and specificity were generated using a bivariate random effects model. All statistical analyses were performed with STATA version 15.1 and Meta-DiSc version 1.4 software.

RESULTS

Eleven studies with 2789 participants were included. The pooled sensitivity and specificity were 0.87 (95 % CI: 0.81-0.91) and 0.87 (95 % CI: 0.79-0.92), respectively, and the positive and negative likelihood ratios were 6.66 (95 % CI: 4.12-10.74) and 0.15 (95 % CI: 0.10-0.23), respectively. Deeks' test indicated no significant publication bias (t = 0.83, P = 0.43). Univariable meta-regression showed that patient selection and flow and timing significantly influenced the pooled sensitivity (P < 0.05), settings significantly influenced the pooled specificity (P < 0.05).

CONCLUSION

Our meta-analysis demonstrates that 4AT is a sensitive and specific screening tool for delirium in older patients. Its brevity and simplicity support its use in routine clinical practice, particularly in time-poor settings. Clinicians should come to a conclusion based largely on the 4AT findings in conjunction with clinical judgment.

[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]

Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.

Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention

Objectives

The assessment of prevalence of delirium in advanced cancer patients admitted in hospice centre and outcome after palliative intervention. The possible related risk factors for development of delirium.

Material and Methods

This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019 - July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion criteria (all patient admitted to hospice centre above 18 years, with advance cancer disease and on best supportive care) and exclusion criteria (Lack of informed consent, Inability to participate in study due to mentally retard or coma). The following information were collected: age, gender, address, type of cancer, comorbidities, history of substance abuse, history of (h/o) palliative chemotherapy or radiotherapy within last 3month, general condition, ESAS (Edmonton symptom assessment scale), ECOG (Eastern cooperative oncology group), PaP score (palliative prognostic score), medication including opioids, NSAIDs (Non-steroidal anti-inflammatory drugs), steroids, antibiotic, adjuvant analgesic, PPI (Proton pump inhibitor), anti-emetic etc. Delirium diagnosis was based on diagnostic criterion of DSM-IV text revised and MDAS.

Results

In our study we found prevalence of delirium was 31.29% in advanced cancer patients admitted to hospice centre. We found most common type of delirium is hypoactive (34.7%) and mixed subtype (34.7%) followed by hyperactive (30.4%) delirium. Resolution of delirium was higher among hyperactive delirium (78.57%) followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%) followed by mixed (43.75%) and hyperactive delirium (14.28%).

Conclusion

An identification and assessment of delirium is vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalization, expanded time on a ventilator, and by and large more prominent medical services costs. Clinicians should utilize one of a few approved delirium assessment tools to help evaluate and archive cognitive function. Prevention and recognizing the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium. The study results demonstrate that multi component delirium management or projects are generally proficient to lessen the prevalence and negative outcomes of delirium. It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

A quality improvement project addressing the underreporting of delirium in hip fracture patients

INTRODUCTION

After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred.

METHODS

Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations.

RESULTS

The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001).

CONCLUSIONS

Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study

OBJECTIVE

This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner.

METHODS

This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic.

RESULTS

In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values.

CONCLUSION

Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.

Mental health care for older adults: recent advances and new directions in clinical practice and research

The world's population is aging, bringing about an ever-greater burden of mental disorders in older adults. Given multimorbidities, the mental health care of these people and their family caregivers is labor-intensive. At the same time, ageism is a big problem for older people, with and without mental disorders. Positive elements of aging, such as resilience, wisdom and prosocial behaviors, need to be highlighted and promoted, both to combat stigma and to help protect and improve mental health in older adults. The positive psychiatry of aging is not an oxymoron, but a scientific construct strongly informed by research evidence. We champion a broader concept of geriatric psychiatry - one that encompasses health as well as illness. In the present paper, we address these issues in the context of four disorders that are the greatest source of years lived with disability: neurocognitive disorders, major depression, schizophrenia, and substance use disorders. We emphasize the need for implementation of multidisciplinary team care, with comprehensive assessment, clinical management, intensive outreach, and coordination of mental, physical and social health services. We also underscore the need for further research into moderators and mediators of treatment response variability. Because optimal care of older adults with mental disorders is both patient-focused and family-centered, we call for further research into enhancing the well-being of family caregivers. To optimize both the safety and efficacy of pharmacotherapy, further attention to metabolic, cardiovascular and neurological tolerability is much needed, together with further development and testing of medications that reduce the risk for suicide. At the same time, we also address positive aging and normal cognitive aging, both as an antidote to ageism and as a catalyst for change in the way we think about aging per se and late-life mental disorders more specifically. It is in this context that we provide directions for future clinical care and research.

Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium

Background: Delirium can occur in cancer patients during an acute hospitalization or in the terminal stages of cancer. Iatrogenic delirium can complicate hospital stays for over 2.6 million older persons by increasing fall risk, restraint use, length of stay, postacute placement, and costs. The purpose of this evidence-based quality improvement project was to implement routine screening for delirium with a consistent instrument and adopt an interprofessional plan of care for delirium. Methods: This project was identified as an interprofessional improvement initiative. The project leader identified a deficiency in the screening for delirium, convened stakeholders, evaluated evidence, reviewed screening instruments, and developed a plan of care for delirium management. Practice changes incorporated routine delirium screening across the inpatient units. A delirium interprofessional plan of care was integrated into the electronic health record for ease of adoption and workflow modification. Results: Routine screening for delirium and early interprofessional interventions reduced length of stay by 2.27 days for patients screening positive for delirium. The percentage of inpatient falls that were linked to an episode of delirium during hospitalization reduced from 23.4% to 17%. Discussions: Routine screening and targeted interventions are a first step in prevention and identification of those inpatients at risk of developing delirium. Delirium prevention is the goal for potential associated iatrogenic conditions.

Intervention of Coordination by Liaison Nurse Where Ward Staff Struggled to Establish a Therapeutic Relationship with a Patient Because of Failure to Recognize Delirium: A Case Study

In this case study, ward staff found it difficult to establish a therapeutic relationship with a patient with advanced gastric cancer because they misdiagnosed delirium as a psychogenic reaction to the cancer diagnosis. This article reports on the process and effects of intervention by a liaison nurse. The liaison nurse recognized the misdiagnosis and approached the ward staff via a psychiatrist-led team. This enabled rapid revision of the treatment policy. The liaison nurse contributed to the continuation of treatment by enabling the ward staff and patient to understand each other better and to collaborate to build a relationship and control the patient’s mental health symptoms, including attention disorder and excessive demands. The patient and family had different views on discharge because of the patient’s mental health issues. The liaison nurse encouraged the ward staff to inform the family caregiver about the patient’s medical condition, the expected future course of the disease, and likely symptoms, and provide appropriate professional services. This enabled the patient to be discharged in line with their wishes. This case highlights the role of the liaison nurse in coordinating care and helping ward staff to recognize symptoms and provide appropriate care and support for patients and their families.

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study

Introduction: Delirium in end-of-life patients is reported to be between 13% and 42% and up to 80% in the terminal phase. It is a serious clinical situation, often a cause of death due to the frequent ineffectiveness of treatments. This study aimed to assess whether and how much precocity of diagnosis, hitherto little considered, could affect the outcomes and prognosis of delirium in palliative care settings.

Methods: Patients consecutively admitted to a palliative care unit (PCU) between October 2018 and December 2019, cared for both in hospice and home programs, were analyzed. All patients were subjected to a careful procedure aimed at recognizing the onset of delirium. The first step was the detection of prodromal "sentinel" symptoms related to incoming delirium. PCU staff and family members/caregivers were trained to observe the patients and immediately identify the appearance of even one symptom. The final diagnosis was performed with the 4AT (4 A’s test). Patients were then included in the categories of "early" or "slow" diagnosis (cut-off: four hours) depending on the time between sentinel symptom observation and the final diagnosis of delirium.

Results: Among 503 admitted patients, 95 developed delirium. Confusion was the most frequent sentinel symptom (49.5%). The early diagnosis was more frequent in hospice than in home care (p-value<0.0001). Delirium was positively resolved in 43 patients, of which 25 with an early diagnosis (p-value=0.038). Time to resolution was shorter in the case of early diagnosis (7.1 vs. 13.7 hours in hospice patients; p-value=0.018). Palliative sedation was performed on 25 patients, but only 8 of them had an early diagnosis.

Conclusion: Time of diagnosis was important in determining the clinical outcomes of patients in charge of PCU who experienced delirium. The early diagnosis reduced both mortality and the necessity of palliative sedation.

Nurse-Driven Assessment, Prevention, and Management of Delirium on an Acute Inpatient Neurology Unit

BACKGROUND

Delirium commonly affects hospitalized patients and is associated with increased hospital length of stay, discharge to skilled care, cost, morbidity, and mortality.

LOCAL PROBLEM

At our organization, there was no formal delirium assessment performed by the nursing staff outside of the intensive care unit.

METHODS

Assessment of nurses' knowledge about delirium, a nurse-driven delirium screening protocol, and patient education were implemented on an adult inpatient neurology unit. Knowledge change, protocol implementation, and patient-level outcomes were assessed.

INTERVENTIONS

Staff nurse delirium education and a nurse-driven delirium screening protocol were implemented.

RESULTS

No change in nursing knowledge occurred pre/postintervention. Falls, falls with injury, and restraint and sitter usage decreased. Changes in length of stay varied over the intervention period. The trend to discharge to home increased, while the trend to discharge to skilled nursing care decreased.

CONCLUSIONS

Formal delirium screening protocols may add organizational value by positively impacting patient outcomes.

The detection of delirium in admitted oncology patients: a scoping review

PURPOSE

Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection.

RESULTS

Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18-33% for general medical or oncology wards; 42-58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality.

CONCLUSION

The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population.

Implementation of Nurse-Led, Goal-Directed Lung Physiotherapy for Older Patients With Sepsis and Pneumonia in the ICU

Objectives: This study aimed to investigate the effect of nurse-led, goal-directed lung physiotherapy (GDLPT) on the prognosis of older patients with sepsis caused by pneumonia in the intensive care unit. Methods: We conducted a prospective, two-phase (before-and-after) study over 3 years called the GDLPT study. All patients received standard lung therapy for sepsis caused by pneumonia and patients in phase 2 also received GDLPT. In this study, 253 older patients (age ≥ 65 years) with sepsis and pneumonia were retrospectively analyzed. The main outcome was 28 day mortality. Results: Among 742 patients with sepsis, 253 older patients with pneumonia were divided into the control group and the treatment group. Patients in the treatment group had a significantly shorter duration of mechanical ventilation [5 (4, 6) vs. 5 (4, 8) days; P = 0.045], and a lower risk of intensive care unit (ICU) mortality [14.5% (24/166) vs. 28.7% (25/87); P = 0.008] and 28 day mortality [15.1% (25/166) vs. 31% (27/87); P = 0.005] compared with those in the control group. GDLPT was an independent risk factor for 28 day mortality [odds ratio (OR), 0.379; 95% confidence interval (CI), 0.187-0.766; P = 0.007]. Conclusions: Nurse-led GDLPT shortens the duration of mechanical ventilation, decreases ICU and 28-day mortality, and improves the prognosis of older patients with sepsis and pneumonia in the ICU.

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients

PURPOSE

The aim of this study is to establish the prevalence, associated factors, and clinical impact of delirium in newly referred palliative care patients and the percentage of delirium diagnoses missed by primary medical teams.

METHODS

Newly referred palliative care patients were evaluated and were reviewed for possible associated factors of delirium. Univariable and multivariable analysis were used to identify associated factors. Median overall survival and survival curves were analyzed. The percentage of missed diagnosis in IPD patients was identified.

RESULTS

We included 350 palliative care patients. Nearly all patients had cancer diagnosis (96.6%). The overall prevalence of delirium was 44.0%. The independent associated factors of delirium were age ≥ 63 years (adjusted odds ratio [aOR], 7.0; 95% CI, 2.2-22.9), palliative performance scale ≤ 20% (aOR, 54.5; 95% CI, 13.1-228.0), brain metastasis (aOR, 15.6; 95% CI, 3.7-66.7), urinary tract infection (aOR, 18.8; 95% CI, 4.7-75.5), sepsis (aOR, 59.0; 95% CI, 4.4-797.8), hyponatremia (aOR, 8.8; 95% CI, 2.6-29.8), and hypercalcemia (not applicable). Interestingly, opioids and benzodiazepines were not associated with delirium. Delirious patients had significantly shorter survival (median survival 11 days). Delirium diagnoses were missed for 76.1%.

CONCLUSION

Nearly half of the palliative care patients had delirium, which was associated with noticeably short survivals. We identified the independent factors associated with the delirium. Despite having a remarkably high prevalence rate and being a well-known poor prognostic factor, there was still a very high rate of missed delirium diagnoses. Effective, routine, delirium screening of palliative care patients needs to be emphasized.

Factors Influencing Pain Expression in Patients with Cancer: An Expert Opinion

Pain is a multidimensional experience that requires an appropriate assessment, and simple numbering may not be enough for the different components that are involved in the clinical expression. In consideration of the subjectivity of the symptom, each assessment should start from the way in which the patients perceive the pain and from how they deal with it. Some factors related to individual patient characteristics may make pain management difficult because of interference with the clinical pain expression. These factors may amplify the reporting of pain. Cognitive disorders and psychological distress seem to strongly influence pain expression and may render the analgesic treatment more difficult. Aberrant behaviors, such as alcoholism, smoking, and opioid misuse, may play a role, although geographic differences were found in terms of prevalence of the phenomenon, especially in some countries. Finally, the assessment of patients' expectation and the meaning of the personal feeling of changes in pain intensity provide new concepts in pain assessment, which may allow better personalization of the analgesic therapy. A modern pain assessment should include a multitude of factors influencing the phenotype of pain.

Screening and Assessment Tools for Measuring Delirium in Patients with Cancer in Hospice and Palliative Care: A Systematic Review

Purpose

This study reviewed screening and assessment tools that are used to measure delirium in patients with cancer in hospice and palliative care settings and examined their psychometric properties.

Methods

Four databases were searched for studies using related search terms (delirium, tools, palliative care, cancer, and others). The inclusion criteria were a) studies that included screening/assessment tools for measuring delirium in cancer patients receiving hospice/palliative care, and b) studies published in English or Korean. The exclusion criteria were a) studies that were conducted in an intensive care setting, and b) case studies, qualitative studies, systematic reviews, or meta-analyses.

Results

Out of the 81 studies identified, only 10 examined the psychometric properties of tools for measuring delirium, and 8 tools were ultimately identified. The psychometric properties of the Memorial Delirium Assessment Scale (MDAS) were the most frequently examined (n=5), and the MDAS showed good reliability, concurrent validity, and diagnostic accuracy. The Delirium Rating Scale had good reliability and diagnostic accuracy. The Delirium Rating Scale-Revised 98 also showed good reliability and structural validity, but its diagnostic performance was not examined in hospice/palliative care settings. The Nursing Delirium Screening Scale showed relatively low diagnostic accuracy.

Conclusion

The MDAS showed evidence of being a valid assessment tool for assessing delirium in patients with cancer in palliative care. Few studies examined the diagnostic performance of delirium tools. Therefore, further studies are needed to examine the diagnostic performance of screening/assessment tools for the optimal detection of delirium in patients with cancer in hospice/palliative care.

Delirium in Palliative Care

Simple Summary

Delirium is a generalized cerebral dysfunction that occurs frequently near the end of life. In palliative care, delirium is frequently a sign of impending death; it is distressing for patients, families, and caregivers; and the goals of management, assessment, and treatment are controversial. We provide an update on these topics mainly focusing on patients with cancer.

Abstract

Delirium, a widespread neuropsychiatric disorder in patients with terminal diseases, is associated with increased morbidity and mortality, profoundly impacting patients, their families, and caregivers. Although frequently missed, the effective recognition of delirium demands attention and commitment. Reversibility is frequently not achievable. Non-pharmacological and pharmacological interventions are commonly used but largely unproven. Palliative sedation, although controversial, should be considered for refractory delirium. Psychological assistance should be available to patients and their families at all times.

Frequency and characteristics of advanced cancer patients with COVID + ve status among inpatient supportive care consults during the pandemic: experience from a tertiary cancer center

Purpose

There is limited literature available regards the frequency and characteristics of COVID-19 + ve status among advanced cancer patients referred to an inpatient supportive care consultation(PC) at a tertiary cancer center. Our study aimed to determine the frequency and characteristics of COVID-19 + ve cancer patients seen by PC.

Methods

Advanced cancer patients seen as a consult by PC between June 15 and September 25, 2020, at MD Anderson Cancer Center were eligible for the study. We evaluated the patient demographics, clinical characteristics including symptoms(ESAS), delirium(MDAS), COVID + status prior to, and after PC referral(converters), and type of PC delivery(in person or virtual care).

Results

Sixty-six out of 1380 (4.8%) PC consults were COVID-19 + ve: 42 prior to PC (79%), and 14 (21%) were COVID-19 + ve after the PC (converters). COVID-19 + PC patients had lower depression (P = .035), spiritual distress (P = .003), and were more seen frequently virtually (P < 0.001). There was no significant difference between COVID-19-ve patients and converters. Converters had higher symptom distress (P = 0.007), lower delirium (P = 0.014), and were referred earlier (P = .011) compared to COVID + PC patients diagnosed prior to PC consult. Overall, patients seen virtually compared in-person by PC were younger (P = 0.02) and had lower delirium (P = 0.007).

Conclusion

The burden of COVID-19 + status among patients referred to PC was low. COVID-19 + ve patients had more frequent virtual visits, lower depression, and spiritual distress scores. Patient seen virtually were significantly younger and had lower delirium. During a new pandemic, universal virtual care might be emphasized especially at initial encounters after admission and further research is needed on the potential efficacy of this intervention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06525-x.

How to deal with the consent of adults with cognitive impairment involved in European geriatric living labs?

BACKGROUND

Living labs are realistic environments designed to create links between technology developers and end-users (i.e. mostly older adults). Research in LLH (Living labs in health) covers a wide range of studies from non-interventional studies to CT (clinical trials) and should involve patients with neurocognitive disorders. However, the ethical issues raised by the design, development, and implementation of research and development projects in LLH have been the subject of only little interest thus far.

OBJECTIVE

Our aim was to determine a pragmatic, ethical and regulatory correct approach to seek the informed consent of patients with neurocognitive disorders according to the different types of studies carried out in European LLH, with a focus on the French context.

METHODS

A narrative review of regulatory texts and clinical articles was conducted, and a pragmatic procedure to determine the decision-making capacity of older adults in LLH was proposed.

RESULTS

Individuals must be adequately informed and freely agree to participate in CT. The capacity to consent should be assessed in CT including cognitively impaired older adults. We propose the following steps: first to assess for delirium using the 4 'A's Test (4AT) or the 3-min Diagnostic interview for Confusion Assessment Method (3D-CAM), second to search for medical history of major neurocognitive disorder, and third to assess the decision capacity using the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC).

CONCLUSIONS

Including individuals with neurocognitive disorders in research implies using an efficient and pragmatic strategy to inform participants and obtain their consent. The tool we offer here may be useful in the routine operation of LLH but can also be extended to all CT with this population.

Natural language processing to assess the epidemiology of delirium-suggestive behavioural disturbances in critically ill patients

Background: There is no gold standard approach for delirium diagnosis, making the assessment of its epidemiology difficult. Delirium can only be inferred though observation of behavioural disturbance and described with relevant nouns or adjectives. Objective: We aimed to use natural language processing (NLP) and its identification of words descriptive of behavioural disturbance to study the epidemiology of delirium in critically ill patients. Study design: Retrospective study using data collected from the electronic health records of a university-affiliated intensive care unit (ICU) in Melbourne, Australia. Participants: 12 375 patients Intervention: Analysis of electronic progress notes. Identification using NLP of at least one of a list of words describing behavioural disturbance within such notes. Results: We analysed 199 648 progress notes in 12 375 patients. Of these, 5108 patients (41.3%) had NLP-diagnosed behavioural disturbance (NLP-Dx-BD). Compared with those who did not have NLP-Dx-DB, these patients were older, more severely ill, and likely to have medical or unplanned admissions, neurological diagnosis, chronic kidney or liver disease and to receive mechanical ventilation and renal replacement therapy (P < 0.001). The unadjusted hospital mortality for NLP-Dx-BD patients was 14.1% versus 9.6% for patients without NLP-Dx-BD. After adjustment for baseline characteristics and illness severity, NLP-Dx-BD was not associated with increased risk of death (odds ratio [OR], 0.94; 95% CI, 0.80-1.10); a finding robust to multiple sensitivity, subgroups and time of observation subcohort analyses. In mechanically ventilated patients, NLP-Dx-BD was associated with decreased hospital mortality (OR, 0.80; 95% CI, 0.65-0.99) after adjustment for baseline severity of illness and year of admission. Conclusions: NLP enabled rapid assessment of large amounts of data identifying a population of ICU patients with typical high risk characteristics for delirium. Moreover, this technique enabled identification of previously poorly understood associations. Further investigations of this technique appear justified.

Using Concept Unique Identifiers to Filter Electronic Health Records for Delirium Cases

Delirium, an acute mental status change associated with inattention, confusion, hypervigilance, or somnolence due to a medical cause, is considered a medical emergency. Unfortunately, screening and diagnosis of delirium in acute care are often inadequate. It is estimated that 60% of delirium cases are not identified, and in claims data, they are underreported. Using information technology, we investigated whether concept unique identifiers from the Unified Language Medical System Metathesaurus could be used as a method to filter electronic health records for possible delirium cases. This article provides the reader with an overview of delirium, the Unified Language Medical System Metathesaurus, and our method for retrospectively filtering electronic health records for delirium cases from our clinical research database. Using a retrospective observational approach, we randomly selected 150 electronic health records with narrative notes containing a delirium concept unique identifier. One hundred records were used for training and 50 were used for validation and interrater reliability. Our results validate electronic health record-selected concept unique identifiers and provide insights into their use. Refinement and application of this method on a larger scale can provide an initial filter for identifying patients with delirium from the electronic health record.

Incidence and Risk Factors for Delirium in Older Patients Following Intensive Care Unit Admission: A Prospective Observational Study

BACKGROUND

Both high prevalence and incidence rates of delirium occur frequently among patients aged 65 years or older in intensive care units (ICUs) and are accompanied by adverse outcomes. Because of lack of nursing staff resources and imperfect humanistic care, delirium is easily overlooked by both physicians and nurses in the ICU in Mainland China.

PURPOSE

This study aimed to explore the incidence rate of delirium and to determine the risk factors among critically ill older patients.

METHODS

A prospective observational study was conducted on patients aged 65 years and older who were admitted consecutively to two ICUs of a university-affiliated hospital in China. The Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale were used to assess delirium status twice daily. Patient demographic, laboratory, medical, therapeutic, and prognostic data were collected.

RESULTS

One hundred fifteen patients were included as participants, with a median age of 70 years (range 65-93 years). Seventy-six (66.1%) patients presented with delirium. Half of the sample had a hypoactive subtype. Patients who developed delirium had a longer mean length of ICU stay, greater chance of physical restraints use, greater use of fentanyl, and poorer sleep quality. A logistic regression analysis revealed that poor sleep quality (OR = 10.74, 95% CI [1.59, 72.47]) and physical restraints (OR = 13.04, 95% CI [1.57, 107.94]) were significantly associated with delirium.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Delirium is a common aggravation in older patients following ICU admission. The factors found in this study to be independently associated with delirium include poor sleep quality and physical restraints. Both critical care physicians and nurses should pay greater attention to the quality of the ICU stay experienced by their older patients.

Delirium researchers' perspectives of the challenges in delirium biomarker research: A qualitative study

Background

Despite the prevalence and impact of delirium, its pathophysiology remains unclear. In order to advance this field of research, robust scientific methodology is required, yet quality of reporting in this field of research has been highly inconsistent. Delirium biomarker research poses several challenges, none of which have been documented in the literature before. The aim of this study was to explore the perspectives of delirium researchers about key methodological issues in delirium biomarker research.

Methods

Following a Delphi study with delirium experts resulting in 60 recommendations for reporting delirium biomarker studies, semi-structured interviews with international delirium researchers were conducted. Interviews were audio-taped and transcribed verbatim, followed by thematic analysis of the qualitative data.

Results

Fifteen participants were interviewed between August and November 2019. Most were male (n = 12; 75%), clinician researchers (n = 13; 86%), and had more than ten years’ experience in conducting delirium research (n = 9; 60%). Analysis revealed two major themes and ten sub-themes, outlining key considerations to advance the field of delirium biomarker research. The major themes were: 1) Practical and scientific challenges of delirium biomarker research: stagnation versus driving improved methods and reporting; and 2) Valuing delirium research through investment and collaboration.

Conclusion

Findings identified a range of factors that contribute to the practical and ethical challenges of conducting delirium biomarker research, which have not previously been explicitly acknowledged or reported. A clear vision for collaborative efforts to enhance research quality for improved impact was also presented by the delirium researchers. This work complements the preceding Delphi and together these studies provide an in-depth understanding of what is needed in the field to inform and improve methods and reporting of delirium biomarker research.

A mobile app for delirium screening

OBJECTIVE

The objective of this study is to describe the algorithm and technical implementation of a mobile app that uses adaptive testing to assess an efficient mobile app for the diagnosis of delirium.

MATERIALS AND METHODS

The app was used as part of a NIH-funded project to assess the feasibility, effectiveness, administration time, and costs of the 2-step delirium identification protocol when performed by physicians and nurses, and certified nursing assistants (CNA). The cohort included 535 hospitalized patients aged 79.7 (SD = 6.6) years enrolled at 2 different sites. Each patient was assessed on 2 consecutive days by the research associate who performed the reference delirium assessment. Thereafter, physicians, nurses, and CNAs performed adaptive delirium assessments using the app. Qualitative data to assess the experience of administering the 2-step protocol, and the app usability were also collected and analyzed from 50 physicians, 189 nurses, and 83 CNAs. We used extensible hypertext markup language (XHTML) and JavaScript to develop the app for the iOS-based iPad. The App was linked to Research Electronic Data Capture (REDCap), a relational database system, via a REDCap application programming interface (API) that sent and received data from/to the app. The data from REDCap were sent to the Statistical Analysis System for statistical analysis.

RESULTS

The app graphical interface was successfully implemented by XHTML and JavaScript. The API facilitated the instant updating and retrieval of delirium status data between REDCap and the app. Clinicians performed 881 delirium assessments using the app for 535 patients. The transmission of data between the app and the REDCap system showed no errors. Qualitative data indicated that the users were enthusiastic about using the app with no negative comments, 82% positive comments, and 18% suggestions of improvement. Delirium administration time for the 2-step protocol showed similar total time between nurses and physicians (103.9 vs 106.5 seconds). Weekly enrollment reports of the app data were generated for study tracking purposes, and the data are being used for statistical analyses for publications.

DISCUSSION

The app developed using iOS could be easily converted to other operating systems such as Android and could be linked to other relational databases beside REDCap, such as electronic health records to facilitate better data retrieval and updating of patient's delirium status.

CONCLUSION

Our app operationalizes an adaptive 2-step delirium screening protocol. Its algorithm and cross-plat formed code of XHTML and JavaScript can be easily exported to other operating systems and hardware platforms, thus enabling wider use of the efficient delirium screening protocol that we have developed. The app is currently implemented as a research tool, but with adaptation could be implemented in the clinical setting to facilitate widespread delirium screening in hospitalized older adults.

Case of hypoactive delirium precipitated by thiamine deficiency

Thiamine is an essential cofactor in the process of nucleic acid synthesis. Neuronal tissues are especially sensitive to thiamine deficiency, manifesting as Wernicke's encephalopathy (WE). The typical triad of WE, encephalopathy, oculomotor dysfunction and gait ataxia, is only present in less than one-third of the cases. We present the case of a middle-aged man with hypoactive delirium due to presumed thiamine deficiency, who had a prolonged hospital course and a delayed diagnosis of the cause of altered mental status. The presentation of this disorder solely as a decreased level of consciousness is uncommon but has been reported in the literature. It is essential to recognise WE as a treatable condition that may manifest only as a hypoactive delirium. The delay in the diagnosis and treatment may lead to coma and death.

Delirium after Deep Brain Stimulation in Parkinson's Disease

Deep brain stimulation is a primary treatment method that improves motor and motor complications in patients with advanced Parkinson's disease. Delirium is a common and serious complication following deep brain stimulation. However, the clinical attention toward this complication remains insufficient. Advanced age, cognitive decline, and the severity of the disease may all be risk factors for delirium. The presence of delirium may also affect cognitive function and disease prognosis. Neurotransmitters such as acetylcholine and dopamine may be involved in the occurrence of delirium. Furthermore, inflammation, the effects of microlesioning of local nuclei, and brain atrophy may also play roles in the onset of delirium. Nonpharmacological therapy appears to be the primary treatment for postoperative delirium in Parkinson's disease. The current article reviews the pathogenesis, epidemiology, prognosis, and treatment of delirium following deep brain stimulation in Parkinson's disease to help clinicians better understand this common complication and to prevent, identify, and treat it as soon as possible, as well as to provide more accurate treatment for patients.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care

Background

Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death.

Methods

This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017.

Results

In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% ‐ 6.3%) vs. 1.4% (0.7% ‐ 2.3%) on admission (p < 0.001) and 7.6% (6.4% ‐ 8.9%) vs. 5.4% (4.0% ‐ 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms.

Conclusions

There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

The Effect of Multiple Assessments on Delirium Detection: a Pilot Study

Background

Delirium is characterized by fluctuating attention or arousal, with high prevalence in the orthopaedic ward. Our aim was to: 1) establish the prevalence of delirium on an orthopaedic ward, and 2) compare delirium prevalence using a single geriatrician assessment vs. multiple 3D-CAM (3-Minute Diagnostic Interview for Confusion Assessment Method) assessments during the day. We hypothesized that multiple assessments would increase the detection rate due to the fluctuating nature of delirium.

Methods

Comparative study conducted at an academic hospital in Hamilton, Ontario. Participants included patients 65 years and older admitted to the orthopaedic ward (n=55). After a geriatrician made the first assessment of delirium by 3D-CAM on each patient, teams with specialized geriatrics training re-assessed participants up to four times. Delirium rates based on first assessment were compared to cumulative end-of-day rates to determine if detection increased with multiple assessments.

Results

The prevalence of delirium was 30.9% (17 participants) using multiple assessments. Of these cases, 13 (76.4%) were detected in the initial geriatrician assessment. In patients with hip fractures, 70.6% (12 of 17) were identified as delirious by multiple assessments.

Conclusion

As symptoms fluctuate, multiple daily CAM assessments may increase the identification of delirium in orthopaedic inpatients.

Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings

BACKGROUND/OBJECTIVES

Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research.

DESIGN

We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments.

MEASUREMENTS

Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework.

RESULTS

Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale.

CONCLUSION

Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.