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Chotai S, Chen JW, Turer R, Smith C, Kelly PD, Bhamidipati A, Davis P, McCarthy JT, Bendfeldt GA, Peyton MB, Dennis BM, Terry DP, Guillamondegui O, Yengo-Kahn AM. Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury. Neurosurgery 2023; 93:1425-1431. [PMID: 37326424 DOI: 10.1227/neu.0000000000002562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.
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Affiliation(s)
- Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Robert Turer
- Department of Emergency Medicine, University of Texas Southwestern, Dallas , Texas , USA
| | - Candice Smith
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | | | - Philip Davis
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Jack T McCarthy
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | | | - Mary B Peyton
- Vanderbilt University School of Medicine, Nashville , Tennessee , USA
| | - Bradley M Dennis
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Douglas P Terry
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Oscar Guillamondegui
- Division of Trauma and Surgicaxzl Critical Care, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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Kappen PR, Mos MI, Jeekel J, Dirven CMF, Kushner SA, Osse RJ, Coesmans M, Poley MJ, van Schie MS, van der Holt B, Klimek M, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC): a single-centre, prospective randomised controlled trial. BMJ Open 2023; 13:e069957. [PMID: 37369412 PMCID: PMC10410844 DOI: 10.1136/bmjopen-2022-069957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/11/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. DESIGN Prospective randomised controlled trial. SETTING Single centre, conducted at the neurosurgical department of the Erasmus Medical Center, Rotterdam, the Netherlands. PARTICIPANTS Adult patients undergoing craniotomy were eligible. INTERVENTIONS Patients in the intervention group received preferred recorded music before, during and after the operation until day 3 after surgery. Patients in the control group were treated according to standard of clinical care. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was presence or absence of postoperative delirium within the first 5 postoperative days measured with the Delirium Observation Screening Scale (DOSS) and, in case of a daily mean score of 3 or higher, a psychiatric evaluation with the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Secondary outcomes included anxiety, heart rate variability (HRV), depth of anaesthesia, delirium severity and duration, postoperative complications, length of stay and location of discharge. RESULTS We enrolled 189 patients (music=95, control=94) from July 2020 through September 2021. Delirium, as assessed by the DOSS, was less common in the music (n=11, 11.6%) than in the control group (n=21, 22.3%, OR:0.49, p=0.048). However, after DSM-5 confirmation, differences in delirium were not significant (4.2% vs 7.4%, OR:0.47, p=0.342). Moreover, music increased the HRV (root mean square of successive differences between normal heartbeats, p=0.012). All other secondary outcomes were not different between groups. CONCLUSION Our results support the efficacy of music in reducing the incidence of delirium after craniotomy, as found with DOSS but not after DSM-5 confirmation, substantiated by the effect of music on preoperative autonomic tone. Delirium screening tools should be validated and the long-term implications should be evaluated after craniotomy. TRIAL REGISTRATION NUMBER Trialregister.nl: NL8503 and ClinicalTrials.gov: NCT04649450.
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Affiliation(s)
- Pablo R Kappen
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M I Mos
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment (iMTA), Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatric Surgery and Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bronno van der Holt
- Department of Haematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
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3
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Ceppi MG, Rauch MS, Spöndlin J, Gantenbein AR, Meier CR, Sándor PS. Potential Risk Factors for, and Clinical Implications of, Delirium during Inpatient Rehabilitation: A Matched Case-Control Study. J Am Med Dir Assoc 2023; 24:519-525.e6. [PMID: 36828136 DOI: 10.1016/j.jamda.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES To investigate the association between a wide set of baseline characteristics (age, sex, rehabilitation discipline), functional scores [Functional Independence Measure (FIM), cumulative Illness Rating Scale (CIRS)], diseases, and administered drugs and incident delirium in rehabilitation inpatients and, furthermore, to assess clinical implications of developing delirium during rehabilitation. DESIGN Matched case-control study based on electronic health record data. SETTING AND PARTICIPANTS We studied rehabilitation stays of inpatients admitted between January 1, 2015, and December 31, 2018, to ZURZACH Care, Rehaklinik Bad Zurzach, an inpatient rehabilitation clinic in Switzerland. METHODS We conducted unconditional logistic regression analyses to estimate adjusted odds ratios (AORs) with 95% CIs of exposures that were recorded in ≥5 cases and controls. RESULTS Among a total of 10,503 rehabilitation stays, we identified 125 validated cases. Older age, undergoing neurologic rehabilitation, a low FIM, and a high CIRS were associated with an increased risk of incident delirium. Being diagnosed with a bacterial infection (AOR 2.62, 95% CI 1.06-6.49), a disorder of fluid, electrolyte, or acid-base balance (AOR 2.76, 95% CI 1.19-6.38), Parkinson's disease (AOR 5.68, 95% CI 2.54-12.68), and administration of antipsychotic drugs (AOR 8.06, 95% CI 4.26-15.22), antiparkinson drugs (AOR 2.86, 95% CI 1.42-5.77), drugs for constipation (AOR 2.11, 95% CI 1.25-3.58), heparins (AOR 2.04, 95% CI 1.29-3.24), or antidepressant drugs (AOR 1.88, 95% CI 1.14-3.10) during rehabilitation, or an increased anticholinergic burden (ACB ≥ 3) (AOR 2.59, 95% CI 1.41-4.73) were also associated with an increased risk of incident delirium. CONCLUSIONS AND IMPLICATIONS We identified a set of factors associated with an increased risk of incident delirium during inpatient rehabilitation. Our findings contribute to detect patients at risk of delirium during inpatient rehabilitation.
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Affiliation(s)
- Marco G Ceppi
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland
| | - Marlene S Rauch
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Julia Spöndlin
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Andreas R Gantenbein
- Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland; Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph R Meier
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland; Boston Collaborative Drug Surveillance Program, Lexington, MA, USA
| | - Peter S Sándor
- Neurorehabilitation and Research Department, ZURZACH Care, Bad Zurzach, Switzerland; Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
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Li S, Li R, Li M, Cui Q, Zhang X, Ma T, Wang D, Zeng M, Li H, Bao Z, Peng Y, Sessler DI. Dexmedetomidine administration during brain tumour resection for prevention of postoperative delirium: a randomised trial. Br J Anaesth 2023; 130:e307-e316. [PMID: 36517290 DOI: 10.1016/j.bja.2022.10.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/05/2022] [Accepted: 10/19/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Delirium is common, especially after neurosurgery. Dexmedetomidine might reduce delirium by improving postoperative analgesia and sleep quality. We tested the primary hypothesis that dexmedetomidine administration during intracerebral tumour resection reduces the incidence of postoperative delirium. METHODS This randomised, double-blind, placebo-controlled trial was conducted in two tertiary-care hospitals in Beijing. We randomised 260 qualifying patients to either dexmedetomidine (n=130) or placebo (n=130). Subjects assigned to dexmedetomidine were given a loading dose of 0.6 μg kg-1 followed by continuous infusion at 0.4 μg kg-1 h-1 until dural closure; subjects in the placebo group were given comparable volumes of normal saline. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method twice daily during the initial 5 postoperative days. RESULTS The average (standard deviation) age of participating patients was 45 (12) yr, duration of surgery was 4.2 (1.5) h, and patients assigned to dexmedetomidine were given an average of 126 (45) μg of dexmedetomidine. There was less delirium during the initial 5 postoperative days in patients assigned to dexmedetomidine (22%, 28 of 130 patients) than in those given placebo (46%, 60 of 130 patients) with a risk ratio of 0.51 (95% confidence interval: 0.36-0.74, P<0.001). Postoperative pain scores with movement, and recovery and sleep quality were improved by dexmedetomidine (P<0.001). The incidence of safety outcomes was similar in each group. CONCLUSIONS Prophylactic intraoperative dexmedetomidine infusion reduced by half the incidence of delirium during the initial 5 postoperative days in patients recovering from elective brain tumour resection. CLINICAL TRIAL REGISTRATION NCT04674241.
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Affiliation(s)
- Shu Li
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Ruowen Li
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Muhan Li
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Qianyu Cui
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xingyue Zhang
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Tingting Ma
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Dexiang Wang
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Hao Li
- Department of Anaesthesiology, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, PR China
| | - Zhaoshi Bao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yuming Peng
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Hildenbrand FF, Murray FR, von Känel R, Deibel AR, Schreiner P, Ernst J, Zipser CM, Böettger S. Predisposing and precipitating risk factors for delirium in gastroenterology and hepatology: Subgroup analysis of 718 patients from a hospital-wide prospective cohort study. Front Med (Lausanne) 2022; 9:1004407. [PMID: 36530904 PMCID: PMC9747774 DOI: 10.3389/fmed.2022.1004407] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/15/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS Delirium is the most common acute neuropsychiatric syndrome in hospitalized patients. Higher age and cognitive impairment are known predisposing risk factors in general hospital populations. However, the interrelation with precipitating gastrointestinal (GI) and hepato-pancreato-biliary (HPB) diseases remains to be determined. PATIENTS AND METHODS Prospective 1-year hospital-wide cohort study in 29'278 adults, subgroup analysis in 718 patients hospitalized with GI/HPB disease. Delirium based on routine admission screening and a DSM-5 based construct. Regression analyses used to evaluate clinical characteristics of delirious patients. RESULTS Delirium was detected in 24.8% (178/718). Age in delirious patients (median 62 years [IQR 21]) was not different to non-delirious (median 60 years [IQR 22]), p = 0.45). Dementia was the strongest predisposing factor for delirium (OR 66.16 [6.31-693.83], p < 0.001). Functional impairment, and at most, immobility increased odds for delirium (OR 7.78 [3.84-15.77], p < 0.001). Patients with delirium had higher in-hospital mortality rates (18%; OR 39.23 [11.85-129.93], p < 0.001). From GI and HPB conditions, cirrhosis predisposed to delirium (OR 2.11 [1.11-4.03], p = 0.023), while acute renal failure (OR 4.45 [1.61-12.26], p = 0.004) and liver disease (OR 2.22 [1.12-4.42], p = 0.023) were precipitators. Total costs were higher in patients with delirium (USD 30003 vs. 10977; p < 0.001). CONCLUSION Delirium in GI- and HPB-disease was not associated with higher age per se, but with cognitive and functional impairment. Delirium needs to be considered in younger adults with acute renal failure and/or liver disease. Clinicians should be aware about individual risk profiles, apply preventive and supportive strategies early, which may improve outcomes and lower costs.
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Affiliation(s)
- Florian F. Hildenbrand
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Fritz R. Murray
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
| | - Ansgar R. Deibel
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Science, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Carl M. Zipser
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
- Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Soenke Böettger
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
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Song Y, Yang X, Luo Y, Ouyang C, Yu Y, Ma Y, Li H, Lou J, Liu Y, Chen Y, Cao J, Mi W. Comparison of logistic regression and machine learning methods for predicting postoperative delirium in elderly patients: A retrospective study. CNS Neurosci Ther 2022; 29:158-167. [PMID: 36217732 PMCID: PMC9804041 DOI: 10.1111/cns.13991] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/16/2022] [Accepted: 09/23/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS To compare the performance of logistic regression and machine learning methods in predicting postoperative delirium (POD) in elderly patients. METHOD This was a retrospective study of perioperative medical data from patients undergoing non-cardiac and non-neurology surgery over 65 years old from January 2014 to August 2019. Forty-six perioperative variables were used to predict POD. A traditional logistic regression and five machine learning models (Random Forest, GBM, AdaBoost, XGBoost, and a stacking ensemble model) were compared by the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and precision. RESULTS In total, 29,756 patients were enrolled, and the incidence of POD was 3.22% after variable screening. AUCs were 0.783 (0.765-0.8) for the logistic regression method, 0.78 for random forest, 0.76 for GBM, 0.74 for AdaBoost, 0.73 for XGBoost, and 0.77 for the stacking ensemble model. The respective sensitivities for the 6 aforementioned models were 74.2%, 72.2%, 76.8%, 63.6%, 71.6%, and 67.4%. The respective specificities for the 6 aforementioned models were 70.7%, 99.8%, 96.5%, 98.8%, 96.5%, and 96.1%. The respective precision values for the 6 aforementioned models were 7.8%, 52.3%, 55.6%, 57%, 54.5%, and 56.4%. CONCLUSIONS The optimal application of the logistic regression model could provide quick and convenient POD risk identification to help improve the perioperative management of surgical patients because of its better sensitivity, fewer variables, and easier interpretability than the machine learning model.
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Affiliation(s)
- Yu‐xiang Song
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina
| | - Xiao‐dong Yang
- Institute of Computing TechnologyChinese Academy of SciencesBeijingChina
| | - Yun‐gen Luo
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina
| | - Chun‐lei Ouyang
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yao Yu
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yu‐long Ma
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Hao Li
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Jing‐sheng Lou
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yan‐hong Liu
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yi‐qiang Chen
- Institute of Computing TechnologyChinese Academy of SciencesBeijingChina
| | - Jiang‐bei Cao
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Wei‐dong Mi
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
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Huang HW, Zhang XK, Li HY, Wang YG, Jing B, Chen Y, Patel MB, Ely EW, Liu YO, Zhou JX, Lin S, Zhang GB. Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium. Front Aging Neurosci 2022; 14:822984. [PMID: 35493935 PMCID: PMC9045131 DOI: 10.3389/fnagi.2022.822984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The brain compensation mechanism in postoperative delirium (POD) has not been reported. We uncovered the mechanism by exploring the association between POD and glioma grades, and the relationship between preoperative brain structural and functional compensation with POD in patients with frontal glioma. Methods A total of 335 adult patients with glioma were included. The multivariable analysis examined the association between tumor grade and POD. Then, 20 patients with left frontal lobe glioma who had presurgical structural and functional MRI data and Montreal Cognitive Assessment (MoCA) in this cohort were analyzed. We measured the gray matter volume (GMV) and functional connectivity (FC) in patients with (n = 8) and without (n = 12) POD and healthy controls (HCs, n = 29) to detect the correlation between the structural and functional alteration and POD. Results The incidence of POD was 37.3%. Multivariable regression revealed that high-grade glioma had approximately six times the odds of POD. Neuroimaging data showed that compared with HC, the patients with left frontal lobe glioma showed significantly increased GMV of the right dorsal lateral prefrontal cortex (DLPFC) in the non-POD group and decreased GMV of right DLPFC in the POD group, and the POD group exhibited significantly decreased FC of right DLPFC, and the non-POD group showed the increasing tendency. Partial correlation analysis showed that GMV in contralesional DLPFC were positively correlated with preoperative neurocognition, and the GMV and FC in contralesional DLPFC were negatively correlated with POD. Conclusions Our findings suggested that insufficient compensation for injured brain regions involving cognition might be more vulnerable to suffering from POD.
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Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Kang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Hao-Yi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yong-Gang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Bin Jing
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - You Chen
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, United States
- Department of Electrical Engineering & Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Mayur B. Patel
- Section of Surgical Sciences, Department of Surgery and Neurosurgery, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ya-Ou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
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Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System. J Am Med Dir Assoc 2022; 23:1322-1327.e2. [PMID: 35172165 PMCID: PMC9359928 DOI: 10.1016/j.jamda.2022.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services. DESIGN Pragmatic prospective cohort study of consecutive admissions to a large health care system. SETTING AND PARTICIPANTS A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014. METHODS Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI). RESULTS Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001). CONCLUSIONS AND IMPLICATIONS This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.
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Wang D, Li R, Li S, Wang J, Zeng M, Dong J, Liu X, Lin N, Peng Y. Effect of dexmedetomidine on postoperative delirium in patients undergoing brain tumour resections: study protocol of a randomised controlled trial. BMJ Open 2021; 11:e051584. [PMID: 34758995 PMCID: PMC8587577 DOI: 10.1136/bmjopen-2021-051584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication. The incidence of POD is about 25% in non-cardiac surgery and ranges from 10% to 30% in neurological procedures. A lot of trials show that dexmedetomidine might help to reduce the incidence of delirium in patients undergoing non-cardiac surgery. However, the impact of dexmedetomidine on POD for patients undergoing craniotomy and tumour resections remains unclear. METHODS AND ANALYSIS The study is a prospective, single-centre, randomised, double-blinded, paralleled-group controlled trial. Patients undergoing elective frontotemporal tumour resections will be randomly assigned to the dexmedetomidine group and the control group. After endotracheal intubation, patients in the dexmedetomidine group will be administered with a loading dose of dexmedetomidine 0.6 µg/kg in 10 min followed by continuous infusion at a rate of 0.4 µg/kg/hour until the start of dural closure. In the control group, patients will receive the identical volume of normal saline in the same setting. The primary outcome will be the cumulative incidence of POD within 5 days. The delirium assessment will be performed by using the confusion assessment method in the first 5 consecutive days after surgery. Secondary outcomes include the pain severity assessed by Numerical Rating Scale pain score, quality of postoperative sleep assessed by the Richards Campbell sleep questionnaire and postoperative quality of recovery from anaesthesia by the Postoperative Quality Recovery Scale. ETHICS AND DISSEMINATION The protocol (V.1.0, 10 November 2020) has been approved by the Ethics Review Committee of the Chinese Clinical Trial Registry (number ChiECRCT-20200436). The findings of the study will be disseminated in a peer-reviewed journal and at a scientific conference. TRIAL REGISTRATION NUMBER NCT04674241.
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Affiliation(s)
- Dexiang Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Ruowen Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Nan Lin
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Beijing, China
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Abstract
Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Mount Sinai Medical Center, New York, New York
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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Kappen P, Jeekel J, Dirven CMF, Klimek M, Kushner SA, Osse RJ, Coesmans M, Poley MJ, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial. BMJ Open 2021; 11:e048270. [PMID: 34598983 PMCID: PMC8488750 DOI: 10.1136/bmjopen-2020-048270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Delirium is a neurocognitive disorder characterised by an acute and temporary decline of mental status affecting attention, awareness, cognition, language and visuospatial ability. The underlying pathophysiology is driven by neuroinflammation and cellular oxidative stress.Delirium is a serious complication following neurosurgical procedures with a reported incidence varying between 4% and 44% and has been associated with increased length of hospital stay, increased amount of reoperations, increased costs and mortality.Perioperative music has been reported to reduce preoperative anxiety, postoperative pain and opioid usage, and attenuates stress response caused by surgery. We hypothesize that this beneficial effect of music on a combination of delirium eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. METHODS This protocol concerns a single-centred prospective randomised controlled trial with 6 months follow-up. All adult patients undergoing a craniotomy at the Erasmus Medical Center in Rotterdam are eligible. The music group will receive recorded music through an overear headphone before, during and after surgery until postoperative day 3. Patients can choose from music playlists, offered based on music importance questionnaires administered at baseline. The control group will receive standard of clinical careDelirium is assessed by the Delirium Observation Scale and confirmed by a delirium-expert psychiatrist according to the DSM-5 criteria. Risk factors correlated with the onset of delirium, such as cognitive function at baseline, preoperative anxiety, perioperative medication use, depth of anaesthesia and postoperative pain, and delirium-related health outcomes such as length of stay, daily function, quality of life (ie, EQ-5D, EORTC questionnaires), costs and cost-effectiveness are collected. ETHICS AND DISSEMINATION This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Center Rotterdam, The Netherlands, approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBERS NL8503 and NCT04649450.
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Affiliation(s)
- Pablo Kappen
- Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Neuroscience, Erasmus MC, Rotterdam, The Netherlands
- Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Klimek
- Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
- Medical Technology Assessment (iMTA), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
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Zhou H, Gu Y, Guan Y, Liu F. Reflections on dexmedetomidine as an optimum therapy for emergence delirium in the elderly with emergency abdominal surgery. IBRAIN 2021; 7:257-262. [PMID: 37786795 PMCID: PMC10528764 DOI: 10.1002/j.2769-2795.2021.tb00089.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/15/2021] [Accepted: 08/09/2021] [Indexed: 10/04/2023]
Abstract
Emergence delirium (ED) is a common complication in elderly patients in post post-anesthesia care units (PACU), To our knowledge, there is currently no specific treatment for ED in the elderly, especially for patients combined with vital organs dysfunction. This article described an elderly patient with ED was successfully treated with dexmedetomidine. Although dexmedetomidine has been widely used in recent years, there are few articles on the administration of dexmedetomidine in PACU. The purpose of this paper is to review the literature and analyze related hazardous factors for ED in the elderly with complications of emergency abdominal surgery and angiocardiopathy, and to further confirm and explain the effectiveness and validation of dexmedetomidine as a rescue therapy in PACU. Finally, we look forward to more samples being collected to persuasively prove our opinion in this case.
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Affiliation(s)
- Hong‐Su Zhou
- Department of AnesthesiaWest China Hospital, Sichuan UniversityChengduChina
- Department of AnesthesiaZunyi Medical UniversityZunyiGuizhouChina
| | - Yue Gu
- Department of AnesthesiaWest China Hospital, Sichuan UniversityChengduChina
| | - Yi‐Huan Guan
- Department of AnesthesiaZunyi Medical UniversityZunyiGuizhouChina
| | - Fei Liu
- Department of AnesthesiaWest China Hospital, Sichuan UniversityChengduChina
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Kappen PR, Kakar E, Dirven CMF, van der Jagt M, Klimek M, Osse RJ, Vincent APJE. Delirium in neurosurgery: a systematic review and meta-analysis. Neurosurg Rev 2021; 45:329-341. [PMID: 34396454 PMCID: PMC8827408 DOI: 10.1007/s10143-021-01619-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/08/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022]
Abstract
Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.
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Affiliation(s)
- P R Kappen
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.
| | - E Kakar
- Department of Neuroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - C M F Dirven
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - R J Osse
- Department of Psychiatry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A P J E Vincent
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Belanger K, Grassia F, Kortz MW, Thompson JA, DeStefano S, Ojemann S. Management of post-operative delirium following stereoelectroencephalography electrode placement for drug resistant epilepsy: Lessons learned from two case reports. Epilepsy Behav Rep 2021; 16:100438. [PMID: 33997756 PMCID: PMC8093411 DOI: 10.1016/j.ebr.2021.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 12/02/2022] Open
Abstract
Post-operative delirium poses unique challenges in neurosurgical patients. Substance use is a modifiable risk factor for post-operative delirium after SEEG. SEEG patients have increased risk of harm when experiencing post-operative delirium.
Post-operative delirium (POD) represents a unique challenge in the care of any surgical patient but is especially challenging in neurosurgical inpatient management due to a host of potentially significant predisposing factors. Patients undergoing stereoencephalography (SEEG) for diagnosis of drug resistant epilepsy are at unique risk due to safety concerns, yet POD has been underdiscussed in this population. Patients should be counseled pre-operatively about their risk and subsequent steps be taken post-operatively. We present two cases of POD status-post SEEG and propose a mechanism by which future post-operative care be coordinated by the physician, patient, and patient’s family.
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Affiliation(s)
- Katherine Belanger
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
| | - Fabio Grassia
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
| | - John A Thompson
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
| | - Sam DeStefano
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
| | - Steven Ojemann
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO 80217, USA
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Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients. Palliat Support Care 2020; 19:274-282. [DOI: 10.1017/s1478951520000887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectivesPatients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.MethodsIn this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.ResultsIn 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).Significance of resultsThe results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.
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Predisposing and precipitating risk factors for delirium in palliative care patients. Palliat Support Care 2019; 18:437-446. [DOI: 10.1017/s1478951519000919] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractObjectiveDelirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.MethodIn this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.ResultsThe prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).Significance of resultsOur study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.
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Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients. J Neurol 2019; 266:3065-3075. [PMID: 31520105 DOI: 10.1007/s00415-019-09533-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Predisposing and precipitating factors for delirium are well known; however, their interaction and impact on delirium in neurological patients remains largely unknown. Therefore, those factors were evaluated in hospitalized patients with neurological disorders. METHODS In this prospective cohort study, 1487 neurological patients were included, 356 patients with delirium and 1131 without delirium. Relevant neurological- and medical-related clusters were assessed with multiple regression analyses, prediction models, and cluster analysis evaluating their association with delirium. RESULTS The 1-year incidence of delirium in this cohort was 23.9%. Delirium developed in 31% of patients with stroke, in 39.5% with epilepsy, and in 58.4% with ICH. The most relevant predisposing factors were substance-use disorders (OR 4.24, 2.28-7.78, p < 0.001), advanced age (OR 3.44, CI 2.40-4.92, p < 0.001), and neurodegenerative disorders (OR 2.58, CI 1.47-4.54, p = 0.001). The most relevant precipitating factors were meningitis (OR 21.52, CI 1.22-379.83, p = 0.036), acute renal failure (OR 10.01, CI 1.13-88.73, p = 0.039), and intracranial hemorrhage (OR 3.62, CI 2.08-6.30, p < 0.001). Delirious patients were hospitalized 6 days longer, had higher in-hospital mortality, and were discharged more often to nursing homes and rehabilitation. Best predictor for delirium was the coexistence of advanced age with epilepsy (58.3%, p < 0.001), while patients aged < 65 years without epilepsy and stroke rarely developed delirium (5.1%, p < 0.001). CONCLUSIONS Delirium is common in elder neurological patients and associated with worse outcome. Primary cerebral conditions most frequently precipitate delirium in neurology. Neurologists are advised to monitor symptoms of delirium in the presence of risk factors to enable both timely diagnostic work-up and management of delirium.
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Stienen MN. Delirium in neurosurgery. Acta Neurochir (Wien) 2019; 161:1305-1306. [PMID: 31062179 DOI: 10.1007/s00701-019-03928-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Martin N Stienen
- Department of Neurosurgery, Stanford University Hospital and Clinics, Stanford, CA, USA.
- Department of Neurosurgery & Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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