Delirium in Intensive Care

Common molecular and pathophysiological underpinnings of delirium and Alzheimer's disease: molecular signatures and therapeutic indications

BACKGROUND

Delirium and Alzheimer's disease (AD) are common causes of cognitive dysfunction among older adults. These neurodegenerative diseases share a common and complex relationship, and can occur individually or concurrently, increasing the chance of permanent mental dysfunction. However, the common molecular pathophysiology, key proteomic biomarkers, and functional pathways are largely unknown, whereby delirium is superimposed on AD and dementia.

METHODS

We employed an integrated bioinformatics and system biology analysis approach to decipher such common key proteomic signatures, pathophysiological links between delirium and AD by analyzing the gene expression data of AD-affected human brain samples and comparing them with delirium-associated proteins. The present study identified the common drug target hub-proteins examining the protein-protein interaction (PPI) and gene regulatory network analysis. The functional enrichment and pathway analysis was conducted to reveal the common pathophysiological relationship. Finally, the molecular docking and dynamic simulation was used to computationally identify and validate the potential drug target and repurposable drugs for delirium and AD.

RESULTS

We detected 99 shared differentially expressed genes (sDEGs) associated with AD and delirium. The sDEGs-set enrichment analysis detected the transmission across chemical synapses, neurodegeneration pathways, neuroinflammation and glutamatergic signaling pathway, oxidative stress, and BDNF signaling pathway as the most significant signaling pathways shared by delirium and AD. The disease-sDEGs interaction analysis highlighted the other disease risk factors with delirium and AD development and progression. Among the sDEGs of delirium and AD, the top 10 hub-proteins including ALB, APP, BDNF, CREB1, DLG4, GAD1, GAD2, GFAP, GRIN2B and GRIN2A were found by the PPI network analysis. Based on the maximum molecular docking binding affinities and molecular dynamic simulation (100 ns) results, the ALB and GAD2 were found as prominent drug target proteins when tacrine and donepezil were identified as potential drug candidates for delirium and AD.

CONCLUSION

The study outlined the common key biomolecules and biological pathways shared by delirium and AD. The computationally reported potential drug molecules need a deeper investigation including clinical trials to validate their effectiveness. The outcomes from this study will help to understand the typical pathophysiological relationship between delirium and AD and flag future therapeutic development research for delirium.

The development of a family-led novel intervention for delirium prevention and management in the adult intensive care unit: A co-design qualitative study

AIM

The aim of this study was to codesign a Family Members' Voice Reorientation Intervention (FAMVR) for delirium prevention and management in critically ill adult patients through collaborative process with previous patients, families, and clinical staff.

BACKGROUND

Delirium is a common consequence of intensive care admission, and there is limited evidence to support family-led interventions to prevent or minimise delirium in intensive care. People with lived experience of intensive care are seldom involved in codesigning delirium prevention and management interventions despite the identified benefits of their involvement in delirium care.

DESIGN

Codesign qualitative study.

METHODS

The process of co-designing was undertaken using the four stages of the Double Diamond model. Participants included people with lived experience of the intensive care unit, family members, and intensive care clinicians. The codesign approach was utilised, and data were gathered from a series of focus groups and individual interviews. Data were digitally recorded, transcribed verbatim, and analysed using thematic analysis.

FINDINGS

Of the 26 people who indicated their interest in participating, 12 (46%) completed the first and second stages, and nine (35%) completed the third and fourth stages of the Family Members' Voice Reorientation Intervention development. All participant groups were represented in the fourth stage: patients (n = 4), family members (n = 1), nurses (n = 2), and medical staff (n = 2). Four themes were identified: message content, wording, reactions, and tone, all of which informed the prototype of the intervention and its associated domains.

CONCLUSION

A codesign approach was important for developing a delirium management intervention. This process enabled participants to provide their feedback in the context of their unique experiences, which in turn enhanced the authenticity and appropriateness of this unique intervention.

Patient Outcomes and Management Strategies for Intensive Care Unit (ICU)-Associated Delirium: A Literature Review

Delirium is a significant public health concern, with tremendous implications for patient outcomes. Intensive care unit (ICU)-related delirium is gaining attention due to the higher prevalence of delirium in ICU-admitted patients. The most common negative outcomes of ICU delirium include cognitive impairments, functional dependence, high incidence of mortality, extended stay in the ICU, and high costs. So far, no single etiological factor has been identified as the sole cause of delirium. Several functional, neurotransmitter, or injury-causing hypotheses have been proposed for ICU delirium. Several risk factors contribute to the development of delirium in patients admitted to the ICU. These are age, gender, types of sedation, physical restraints, medical and surgical interventions, pain, and extended stay in the ICU. The most commonly used assessment modules for ICU delirium are the PREdiction of DELIRium in ICu patients (PRE-DELIRIC), Early PREdiction model for DELIRium in ICu patients (E-PRE-DELERIC), and Lanzhou Model, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), and Delirium Rating Scale (DRS). There is no proper treatment for ICU delirium; however, it can be managed through various pharmacological and non-pharmacological interventions. Healthcare providers should receive constant education and training on delirium recognition, prevention, and management to enhance patient care and outcomes in the ICU. Further research is needed on the effective prevention and management of ICU delirium.

Long-term outcomes with haloperidol versus placebo in acutely admitted adult ICU patients with delirium

PURPOSE

We assessed long-term outcomes in acutely admitted adult patients with delirium treated in intensive care unit (ICU) with haloperidol versus placebo.

METHODS

We conducted pre-planned analyses of 1-year outcomes in the Agents Intervening against Delirium in the ICU (AID-ICU) trial, including mortality and health-related quality of life (HRQoL) assessed by Euroqol (EQ) 5-dimension 5-level questionnaire (EQ-5D-5L) index values and EQ visual analogue scale (EQ VAS) (deceased patients were assigned the numeric value zero). Outcomes were analysed using logistic and linear regressions with bootstrapping and G-computation, all with adjustment for the stratification variables (site and delirium motor subtype) and multiple imputations for missing HRQoL values.

RESULTS

At 1-year follow-up, we obtained vital status for 96.2% and HRQoL data for 83.3% of the 1000 randomised patients. One-year mortality was 224/501 (44.7%) in the haloperidol group versus 251/486 (51.6%) in the placebo group, with an adjusted absolute risk difference of - 6.4%-points (95% confidence interval [CI] - 12.8%-points to - 0.2%-points; P = 0.045). These results were largely consistent across the secondary analyses. For HRQoL, the adjusted mean differences were 0.04 (95% CI - 0.03 to 0.11; P = 0.091) for EQ-5D-5L-5L index values, and 3.3 (95% CI - 9.3 to 17.5; P = 0.142) for EQ VAS.

CONCLUSIONS

In acutely admitted adult ICU patients with delirium, haloperidol treatment reduced mortality at 1-year follow-up, but did not statistically significantly improve HRQoL.

Exploration of key drug target proteins highlighting their related regulatory molecules, functional pathways and drug candidates associated with delirium: evidence from meta-data analyses

BACKGROUND

Delirium is a prevalent neuropsychiatric medical phenomenon that causes serious emergency outcomes, including mortality and morbidity. It also increases the suffering and the economic burden for families and carers. Unfortunately, the pathophysiology of delirium is still unknown, which is a major obstacle to therapeutic development. The modern network-based system biology and multi-omics analysis approach has been widely used to recover the key drug target biomolecules and signaling pathways associated with disease pathophysiology. This study aimed to identify the major drug target hub-proteins associated with delirium, their regulatory molecules with functional pathways, and repurposable drug candidates for delirium treatment.

METHODS

We used a comprehensive proteomic seed dataset derived from a systematic literature review and the Comparative Toxicogenomics Database (CTD). An integrated multi-omics network-based bioinformatics approach was utilized in this study. The STRING database was used to construct the protein-protein interaction (PPI) network. The gene set enrichment and signaling pathways analysis, the regulatory transcription factors and microRNAs were conducted using delirium-associated genes. Finally, hub-proteins associated repurposable drugs were retrieved from CMap database.

RESULTS

We have distinguished 11 drug targeted hub-proteins (MAPK1, MAPK3, TP53, JUN, STAT3, SRC, RELA, AKT1, MAPK14, HSP90AA1 and DLG4), 5 transcription factors (FOXC1, GATA2, YY1, TFAP2A and SREBF1) and 6 microRNA (miR-375, miR-17-5, miR-17-5p, miR-106a-5p, miR-125b-5p, and miR-125a-5p) associated with delirium. The functional enrichment and pathway analysis revealed the cytokines, inflammation, postoperative pain, oxidative stress-associated pathways, developmental biology, shigellosis and cellular senescence which are closely connected with delirium development and the hallmarks of aging. The hub-proteins associated computationally identified repurposable drugs were retrieved from database. The predicted drug molecules including aspirin, irbesartan, ephedrine-(racemic), nedocromil, and guanidine were characterized as anti-inflammatory, stimulating the central nervous system, neuroprotective medication based on the existing literatures. The drug molecules may play an important role for therapeutic development against delirium if they are investigated more extensively through clinical trials and various wet lab experiments.

CONCLUSION

This study could possibly help future research on investigating the delirium-associated therapeutic target biomarker hub-proteins and repurposed drug compounds. These results will also aid understanding of the molecular mechanisms that underlie the pathophysiology of delirium onset and molecular function.

Orexin receptor antagonists versus antipsychotics for the management of delirium in intensive care unit patients with cardiovascular disease: A retrospective observational study

OBJECTIVE

Although antipsychotics are often used in the pharmacological treatment of delirium, recent reports suggest the efficacy of orexin receptor antagonists. This study investigated whether orexin receptor antagonists could be a possible treatment option for delirium.

METHOD

A nonblinded nonrandomized routine clinical treatment was performed. Patients treated in intensive care units (ICU) for cardiovascular disease and receiving psychiatric intervention were studied retrospectively. The scores from the Intensive Care Delirium Screening Checklist (ICDSC) were compared between patients treated with orexin receptor antagonists and those treated with antipsychotics.

RESULTS

The mean (standard deviation) ICDSC scores were 4.5 (1.8) at day -1 and 2.6 (2.6) at day 7 for orexin receptor antagonist group (n = 25) and 4.6 (2.4) at day -1 and 4.1 (2.2) at day 7 for antipsychotic group (n = 28). The orexin receptor antagonist group showed significantly lower ICDSC scores than the antipsychotic group (p = 0.021).

CONCLUSION

While precise efficacy cannot be determined from our retrospective, observational, and uncontrolled pilot study, this analysis encourages a future double-blind randomized placebo-controlled trial of orexin-antagonists for delirium treatment.

Struggling to return to everyday life-The experiences of quality of life 1 year after delirium in the intensive care unit

BACKGROUND

Many critically ill patients report a change in their health-related quality of life after intensive care unit (ICU) discharge. Patients who experience delirium during their ICU stay are perceived as a fragile group of ICU survivors, and the 'quality of life' phenomenon needs to be studied among these patients.

AIM

To explore everyday life experiences of critically ill patients with delirium during the ICU stay, from ICU discharge until 1-year follow-up, focusing on their health-related quality of life and cognitive function.

STUDY DESIGN

We used a descriptive qualitative research design and interviewed patients 1 year after ICU admission. The participants were recruited from a pre-planned one-year follow-up study of 'Agents Intervening against Delirium for patients in the Intensive Care Unit trial'. Data were analysed using Framework Analysis Method and content analysis.

RESULTS

Nine women and eight men participated and reported a struggle when returning to everyday life or adapting to a new normality from hospital discharge to 1 year later. None of the participants had been aware of the challenges they would face after hospital discharge. They described a need for more information about these challenges to themselves and about primary care to better understand their situation and the struggles they experience during recovery. One overall theme emerged from the analysis 'From enduring to adapting' with three subthemes: 'Struggling to regain a functional life', 'Struggling to regain normal cognition' and 'Distressing manifestations from the ICU'.

CONCLUSIONS

To improve recovery and the quality of rehabilitation for critically ill patients suffering from delirium, it is essential to understand the phenomenon of ICU survivorship and what this fragile group of patients is going through. It is necessary to bridge the gap between secondary and primary care so patients can receive optimal training and support when needed.

RELEVANCE TO CLINICAL PRACTICE

Bridging the gap between primary and secondary healthcare services is urgently needed to improve rehabilitation for ICU survivors after critical illness.

Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue?

How to cite this article: Sinha S, Bhattacharjee S. Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue? Indian J Crit Care Med 2023;27(5):301-302.

Delirium in trauma ICUs: a review of incidence, risk factors, outcomes, and management

PURPOSE OF REVIEW

This article reviews the impact and importance of delirium on patients admitted to the ICU after trauma, including the latest work on prevention and treatment of this condition. As the population ages, the incidence of geriatric trauma will continue to increase with a concomitant rise in the patient and healthcare costs of delirium in this population.

RECENT FINDINGS

Recent studies have further defined the risk factors for delirium in the trauma ICU patient population, as well as better demonstrated the poor outcomes associated with the diagnosis of delirium in these patients. Recent trials and meta-analysis offer some new evidence for the use of dexmedetomidine and quetiapine as preferred agents for prevention and treatment of delirium and add music interventions as a promising part of nonpharmacologic bundles.

SUMMARY

Trauma patients requiring admission to the ICU are at significant risk of developing delirium, an acute neuropsychiatric disorder associated with increased healthcare costs and worse outcomes including increased mortality. Ideal methods for prevention and treatment of delirium are not well established, especially in this population, but recent research helps to clarify optimal prevention and treatment strategies.

Investigating the molecular mechanisms of delirium-like neuropsychiatric disorder induced by electromagnetic pulse based on bioinformatics analysis

Electromagnetic pulse (EMP), a unique type of electromagnetic radiation, may induce diverse neuropsychiatric disorders, such as irritability, hyperkinesis, retardation of learning and memory. However, the underlying mechanism of EMP exposure on neuronal injury has not been elucidated. Here, we aimed to delineate the regulatory expression networks based on high-throughput sequencing data to explore the possible molecular mechanisms related to EMP-induced delirium-like neuropsychiatric disorder in rats. It's shown that EMP exposure induced anxiety, cognitive decline and short-term memory impairment. The expression profiles of the long noncoding RNAs (lncRNAs) and mRNAs, along with their biological function and regulatory network, were explored in rats after EMP exposure. We identified 41 differentially expressed lncRNAs (DELs) and 266 differentially expressed mRNAs (DEMs) between EMP and sham groups. Sixty-one co-expression relationships between 18 DELs and 56 DEMs were mostly associated with synapse- and metabolic-related pathways. We predicted 51 DEL-miRNA pairs and 290 miRNA-mRNA pairs using the miRanda database to constructed a DEL-miRNA-DEM network. LncRNA AABR07042999.1 and mRNA Tph2, Slc6a4, Dbh and Th were upregulated, and the contents of serotonin, dopamine and norepinephrine were increased in both PFC and HIP after EMP exposure. The current study provided a better understanding of the ceRNA network, which might reveal the pathological mechanism and provide more treatment options for the EMP-induced neurobehavioral disorder.

Nurses' knowledge, barriers and practice in the care of patients with delirium in the intensive care unit in Poland-A cross-sectional study

Background

Delirium is a cognitive disorder that occurs with high frequency in patients in intensive care units and affects patient outcomes. Despite recommendations for monitoring and assessing delirium in the ICU, studies show that it is still not routinely assessed and often remains undiagnosed or misinterpreted as dementia or depression.

Aim

The aim of this study was (1) to assess nurses' knowledge and clinical practices regarding delirium, (2) to identify the factors associated with nurses' knowledge, and (3) to define barriers to effective control of delirium.

Methods

A cross-sectional study was conducted among 371 ICU nurses in Poland.

Results

53.1% of nurses had never been educated on delirium control resulting in a deficit in knowledge of delirium symptoms, risk factors and complications associated with delirium in ICU patients. Master's degree in nursing (vs. Registered nurses + Bachelor's), female gender, and working in university hospital (vs. other) were positively correlated with nurse's knowledge, while age had a negative impact on knowledge. Delirium is a marginalized state in ICU patients, only 16.4% of nurses assessed delirium routinely and 35.8% assessed delirium occasionally, rarely using validated scales. Barriers to effective delirium control were primarily the lack of a requirement to assess delirium, the difficulty of assessing delirium in intubated patients and nurses' lack of confidence in their ability to use delirium assessment tools.

Conclusions

There is an urgent need to educate nurses about delirium and to make delirium assessment obligatory in clinical practice. The area of change should also include a hospital policy on delirium monitoring and management. The study was registered on ClinicalTrials.gov (NCT05384964).

[Weaning from invasive ventilation : Challenges in the clinical routine]

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.

Assessing Discomfort in Critically Ill Patients: A Narrative Review of the Literature

BACKGROUND

The intensive care unit environment exposes patients to stressful conditions contributing to distressing symptoms. Discomfort is an infrequently and inconsistently described symptom experienced by intensive care unit patients.

OBJECTIVE

To complete a narrative literature review to summarize the currently available literature on discomfort assessment in critical care practice and identify knowledge gaps to direct future intervention research.

METHODS

A review of the currently available literature was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. No parameters were set for publication years or specific study designs. Inclusion criteria were patients aged at least 18 years, description of patient reports of discomfort in the intensive care unit, and English language.

RESULTS

This narrative review includes 10 studies that used 4 distinct self-reported, discomfort-related symptom assessment instruments. Two studies assessed overall discomfort. Only 1 assessment instrument, Inconforts des Patients de Reanimation, is validated for use in the intensive care unit.

CONCLUSION

The reviewed literature highlights the current gap in discomfort symptom assessment during the intensive care unit stay. An assessment instrument specific for intensive care unit-related discomfort, such as the Inconforts des Patients de Reanimation, would allow for prompt recognition and mitigation of intensive care unit-related patient discomfort.

Implementation of a Follow-Up Program for Intensive Care Unit Survivors

In Intensive Care Unit (ICU) survivors, critical illness has an impact on an individual’s long-term health status and quality of life. Adults who have recovered from intensive care management could develop muscle weakness, neurocognitive impairment, difficulties in managing activities of daily living and to returning to work, and psychological problems such as depression and anxiety. A prospective, observational study was designed. Data were collected from January to December 2018 from a structured follow-up program, at 3 time points after ICU discharge: at seven days, a visit in the general ward, a phone interview at three months and an ambulatory visit at six months. A total of 95 patients were enrolled, 36% female, with a median age of 65 (55–73) years and a median ICU length of stay of 13 (8–20) days. At the seven days follow-up, patients who had a positive Hospital Anxiety and Depression Scale showed a significantly longer time of intubation (p = 0.048) and length of ICU stay (p = 0.023). At three months, we observed a significant relationship between a positive Hospital Anxiety and Depression Scale and a median value of EuroQol-5D (p = 0.048). At six months, we observed that patients who had a positive Post-Traumatic Symptom Scale were significantly younger than the other group. Findings from the present study suggest that a longer time of intubation and length of ICU stay are associated with a higher level of anxiety and depression immediately after ICU discharge. Follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge.