The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients

Delirium in acute stroke is associated with increased cognitive and psychiatric symptoms over time: The Nor-COAST study

BACKGROUND

Delirium, an acute and fluctuating mental disturbance of attention, cognition, and consciousness, commonly occurs in acute stroke. Research on long-term outcomes of stroke patients experiencing delirium is limited, especially regarding cognitive and psychiatric symptoms.

METHODS

As part of the Nor-COAST study, 373 patients were screened for delirium using the Confusion Assessment Method (CAM) in the acute phase of stroke. Patients were included in the mixed-model linear regression analyses if they had available data from the follow-ups at three, 18 or 36 months, totaling 334 (44.6 % women, mean (SD) age: 72.1 (12.5) years, 17 (5.1 %) diagnosed with delirium). Global cognition was measured using the Montreal Cognitive Assessment (MoCA). Psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q).

RESULTS

At three months, delirium was associated with a higher NPI-Q score (Mean (SD) 2.9 (3.6) vs 1.4 (2.2)). At 18 and 36 months, delirium was associated with a lower MoCA score (Mean (SD) 19.7 (6.6) vs 24.3 (5.0), and 20.6 (7.6) vs 24.6 (4.8)), higher HADS anxiety symptoms (5.0 (4.3) vs 3.3 (3.3), and 5.9 (4.1) vs 3.4 (3.6)), higher HADS depression symptoms (7.2 (4.7) vs 3.4 (3.3), and 6.6 (5.1) vs 3.7 (3.7)), and higher NPI-Q score (2.4 (4.4) vs 1.7 (2.3), 2.6 (4.5) vs 1.0 (1.9)). Delirium significantly predicted the psychiatric symptoms hallucinations and agitation.

CONCLUSIONS

Patients with delirium in the acute phase of stroke may be particularly vulnerable to developing cognitive and psychiatric symptoms in the chronic phase.

Risk of drug-induced delirium in older patients- a pharmacovigilance study of FDA adverse event reporting system database

BACKGROUND

Drug-induced delirium is known risk factors associated with increased morbidity and mortality in older patients. The objective was to evaluate the risk of drug-related delirium in older patients based on the FDA Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

Delirium reports in older patients (age ≥65) extracted from the FAERS database using Open Vigil 2.1. The reported odds ratio and the proportional reported ratio were calculated to detect the adverse reaction signal of delirium. Combined with published evidence, suspected drugs were categorized as known, possible, or new potential delirium-risk-increasing drugs.

RESULTS

Of the 130,885 reports (including 28,850 delirium events and 1,857 drugs) analyzed for this study, 314 positive signal drugs were detected. Positive signal drugs are mainly concentrated on the drug of nervous system, cardiovascular system , alimentary tract and metabolism and anti-infectives for systemic use. Of the positive signal drugs, 26.11% (82/314) were known delirium-risk increasing drugs, 44.90% (141/314) were possible and 28.98% (91/314) were new potential.

CONCLUSION

Drug-induced delirium risk is prevalent in older patients, according to the FAERS. The risk level of drug-induced delirium should be taken into account to optimize drug therapy in clinical practice.

Introducing a machine learning algorithm for delirium prediction-the Supporting SURgery with GEriatric Co-Management and AI project (SURGE-Ahead)

INTRODUCTION

Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14-56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project.

METHODS

The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC).

RESULTS

The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78-0.85] in the training set, 0.81 [95% CI 0.71-0.88] in the test set and 0.76 [95% CI 0.71-0.79] in a cross-centre validation.

CONCLUSION

We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project.

Electroencephalographic monitoring of anesthesia during surgical procedures in mice using a modified clinical monitoring system

Monitoring brain activity and associated physiology during the administration of general anesthesia (GA) in mice is pivotal to guarantee postanesthetic health. Clinically, electroencephalogram (EEG) monitoring is a well-established method to guide GA. There are no established methods available for monitoring EEG in mice (Mus musculus) during surgery. In this study, a minimally invasive rodent intraoperative EEG monitoring system was implemented using subdermal needle electrodes and a modified EEG-based commercial patient monitor. EEG recordings were acquired at three different isoflurane concentrations revealing that surgical concentrations of isoflurane anesthesia predominantly contained burst suppression patterns in mice. EEG suppression ratios and suppression durations showed strong positive correlations with the isoflurane concentrations. The electroencephalographic indices provided by the monitor did not support online monitoring of the anesthetic status. The online available suppression duration in the raw EEG signals during isoflurane anesthesia is a straight forward and reliable marker to assure safe, adequate and reproducible anesthesia protocols.

Reduction of Postoperative Delirium and Opioid Use in Hip Fracture Patients Through Utilization of Emergency Department Physician Administered Regional Nerve Blocks

Introduction

The complication of delirium for hip fracture patients is a predictor of mortality. Use of opioid medication increases the incidence of delirium in the pre- and postoperative periods. Regional nerve blocks are effective in managing acute pain for acute hip fractures. This study aims to evaluate the utilization of ED physicians to perform fascia iliaca nerve blocks on hip fracture patients to decrease the incidence of delirium by decreasing usage of opioid medication.

Methods

A quality improvement project for performing regional nerve blocks on patients with femoral neck fractures was implemented during fiscal year 2019. Data was collected retrospectively for frequency of ED nerve block procedures, amount of opioid medication use, and incidence of delirium in patients diagnosed with hip fracture. This data was compared to baseline data to determine success of the intervention.

Results

Utilization of regional nerve blocks in the ED increased from 2% in 2018 to 96% in 2021 and 89% in 2022. Preoperative opioid usage decreased from 38 MMEs to 16.9 and 18 MMEs respectively. Daily average MMEs decreased from 34 to 12.1 and 14 respectively. Postoperative delirium decreased from 6% in 2018 to 0% from 2020 to 2022.

Discussion

ED provider administration of fascia iliaca blocks and follow-up is a novel practice in our region to decrease the adverse effects of opiate use and decrease delirium rates. There was a reduction in length of stay and increased discharge home rate despite the Covid-19 pandemic.

Conclusion

Administration of regional nerve blocks by ED physicians to hip fracture patients presenting to the ED results in a decrease in opioid medication usage. This also results in a decreased delirium rates in the hip fracture patient population.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]

The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

The effects of environmental interventions for delirium in critically ill surgical patients

BACKGROUND

Delirium occurs at high rates among patients in intensive care units and increases the risk of morbidity and mortality. The purpose of this study was to investigate the effects of environmental interventions on delirium.

METHODS

This prospective cohort study enrolled 192 patients admitted to the surgical intensive care unit (SICU) during the pre-intervention (June 2013 to October 2013) and post-intervention (June 2014 to October 2014) periods. Environmental interventions involved a cognitive assessment, an orientation, and a comfortable environment including proper sleep conditions. The primary outcomes were the prevalence, duration, and onset of delirium.

RESULTS

There were no statistically significant differences in incidence rate, time of delirium onset, general characteristics, and mortality between the pre-intervention and post-intervention groups. The durations of delirium were 14.4±19.1 and 7.7±7.3 days in the pre-intervention and post-intervention groups, respectively, a significant reduction (P=0.027). The lengths of SICU stay were 20.0±22.9 and 12.6±8.7 days for the pre-intervention and post-intervention groups, respectively, also a significant reduction (P=0.030).

CONCLUSIONS

The implementation of an environmental intervention program reduced the duration of delirium and length of stay in the SICU for critically ill surgical patients.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Presence of Preoperative Neurodegeneration Biofluid Markers in Patients with Postoperative Delirium

BACKGROUND

The pathophysiology of delirium is incompletely understood, including what molecular pathways are involved in brain vulnerability to delirium. This study examined whether preoperative plasma neurodegeneration markers were elevated in patients who subsequently developed postoperative delirium through a retrospective case-control study.

METHODS

Inclusion criteria were patients of 65 yr of age or older, undergoing elective noncardiac surgery with a hospital stay of 2 days or more. Concentrations of preoperative plasma P-Tau181, neurofilament light chain, amyloid β1-42 (Aβ42), and glial fibrillary acidic protein were measured with a digital immunoassay platform. The primary outcome was postoperative delirium measured by the Confusion Assessment Method. The study included propensity score matching by age and sex with nearest neighbor, such that each patient in the delirium group was matched by age and sex with a patient in the no-delirium group.

RESULTS

The initial cohort consists of 189 patients with no delirium and 102 patients who developed postoperative delirium. Of 291 patients aged 72.5 ± 5.8 yr, 50.5% were women, and 102 (35%) developed postoperative delirium. The final cohort in the analysis consisted of a no-delirium group (n = 102) and a delirium group (n = 102) matched by age and sex using the propensity score method. Of the four biomarkers assayed, the median value for neurofilament light chain was 32.05 pg/ml for the delirium group versus 23.7 pg/ml in the no-delirium group. The distribution of biomarker values significantly differed between the delirium and no-delirium groups (P = 0.02 by the Kolmogorov-Smirnov test) with the largest cumulative probability difference appearing at the biomarker value of 32.05 pg/ml.

CONCLUSIONS

These results suggest that patients who subsequently developed delirium are more likely to be experiencing clinically silent neurodegenerative changes before surgery, reflected by changes in plasma neurofilament light chain biomarker concentrations, which may identify individuals with a preoperative vulnerability to subsequent cognitive decline.

EDITOR’S PERSPECTIVE

Bispectral EEG (BSEEG) Algorithm Captures High Mortality Risk Among 1,077 Patients: Its Relationship to Delirium Motor Subtype

OBJECTIVE

Delirium is dangerous and a predictor of poor patient outcomes. We have previously reported the utility of the bispectral EEG (BSEEG) with a novel algorithm for the detection of delirium and prediction of patient outcomes including mortality. The present study employed a normalized BSEEG (nBSEEG) score to integrate the previous cohorts to combine their data to investigate the prediction of patient outcomes. We also aimed to test if the BSEEG method can be applicable regardless of age, and independent of delirium motor subtypes.

METHODS

We calculated nBSEEG score from raw BSEEG data in each cohort and classified patients into BSEEG-positive and BSEEG-negative groups. We used log-rank test and Cox proportional hazards models to predict 90-day and 1-year outcomes for the BSEEG-positive and -negative groups in all subjects and motor subgroups.

RESULTS

A total of 1,077 subjects, the BSEEG-positive group showed significantly higher 90-day (hazard ratio 1.33 [95% CI 1.16-1.52] and 1-year (hazard ratio 1.22 [95% CI 1.06-1.40] mortality rates than the negative group after adjustment for covariates such as age, sex, CCI, and delirium status. Among patients with different motor subtypes of delirium, the hypoactive group showed significantly higher 90-day (hazard ratio 1.41 [95% CI 1.12-1.76] and 1-year mortality rates (hazard ratio 1.32 [95% CI 1.05-1.67], which remained significant after adjustment for the same covariates.

CONCLUSION

We found that the BSEEG method is capable of capturing patients at high mortality risk.

Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure

BACKGROUND

Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden.

METHODS

We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors.

RESULTS

Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14).

CONCLUSIONS

FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.

Thinking Clearly: The History of Brain Dysfunction in Critical Illness

Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.

Comment on Yang et al., 2020: Melatonergic agents in the prevention of delirium: A network meta-analysis of randomized controlled trials

An analysis of delirium prevention considering only older adults is essential. Delirium markedly impacts the older adult population, as it is associated with inpatient occurrence rates from 14% to 56% and hospital mortality rates from 25% to 33% [2]. Ageing comes with a cumulative decline in physiological systems and is a relevant risk factor for chronic diseases [3,4]. Delirium causes in older adults can be multifactorial, including underlying medical conditions, medications, and environmental factors. Therefore, it is vital for healthcare providers to monitor for delirium symptoms in older adults and to implement appropriate interventions, such as addressing underlying medical conditions and addressing possible triggers [5]. Likewise, it is reasonable to think that eventual delirium preventive solutions for older patients would differentiate from the general population.

Understanding the association between admission source and in-hospital delirium: A cross-sectional study

Patients admitted via interhospital transfer (IHT) experience increased risk-adjusted mortality, adverse events, length of stay, and discharge to facility; however, the etiology is not well understood. We hypothesize that IHTs are more likely to experience in-hospital delirium as compared with admissions to the hospital via the emergency department (ED) and clinic. This is a cross-sectional study of all adult admissions to medical, surgical, neurological, and obstetrics and gynecology services at an academic medical center who were screened for delirium between August 2018 and January 2020. Unit of analysis was admission source (IHT vs ED vs clinic) as the independent variable and the primary outcome was in-hospital delirium, assessed with initial brief confusion assessment method (bCAM) screening. 30,100 hospitalizations were included in this study with 3925 admissions (13.0%) screening positive for delirium at the initial bCAM assessment. The prevalence of delirium was much higher in IHTs at 22.3% (1334/5971) when compared with clinic at 5.8% (244/4214) and ED at 11.8% (2347/19,915) admissions. Multivariable logistic regression adjusting for demographics and comorbidities showed that IHT admissions had higher odds (OR 1.91, 95% CI 1.74 to 2.10) and clinic admissions had lower odds (OR 0.56, 95% CI 0.48 to 0.64) of in-hospital delirium compared with ED admissions. Increased odds of delirium in IHT admissions may contribute to the observed increased length of stay, discharge to facility, and mortality. These results emphasize the importance of routine screening and possible intervention prior to patient transfer.

New onset delirium prediction using machine learning and long short-term memory (LSTM) in electronic health record

OBJECTIVE

To develop and test an accurate deep learning model for predicting new onset delirium in hospitalized adult patients.

METHODS

Using electronic health record (EHR) data extracted from a large academic medical center, we developed a model combining long short-term memory (LSTM) and machine learning to predict new onset delirium and compared its performance with machine-learning-only models (logistic regression, random forest, support vector machine, neural network, and LightGBM). The labels of models were confusion assessment method (CAM) assessments. We evaluated models on a hold-out dataset. We calculated Shapley additive explanations (SHAP) measures to gauge the feature impact on the model.

RESULTS

A total of 331 489 CAM assessments with 896 features from 34 035 patients were included. The LightGBM model achieved the best performance (AUC 0.927 [0.924, 0.929] and F1 0.626 [0.618, 0.634]) among the machine learning models. When combined with the LSTM model, the final model's performance improved significantly (P = .001) with AUC 0.952 [0.950, 0.955] and F1 0.759 [0.755, 0.765]. The precision value of the combined model improved from 0.497 to 0.751 with a fixed recall of 0.8. Using the mean absolute SHAP values, we identified the top 20 features, including age, heart rate, Richmond Agitation-Sedation Scale score, Morse fall risk score, pulse, respiratory rate, and level of care.

CONCLUSION

Leveraging LSTM to capture temporal trends and combining it with the LightGBM model can significantly improve the prediction of new onset delirium, providing an algorithmic basis for the subsequent development of clinical decision support tools for proactive delirium interventions.

A novel semiautomatic Chinese keywords instrument screening delirium based on electronic medical records

BACKGROUND

Delirium is frequently unrecognized due to the absence of regular screening. In addition to validated bedside tools, the computer-assisted instrument based on clinical notes from electronic medical records may be useful.

AIMS

To assess the psychometric properties of a Chinese-chart-based keyword instrument for semiautomatically screening delirium using Natural language processing (NLP) based on clinical notes from electronic medical records.

METHODS

The patients were admitted to West China Hospital from January 2015 to December 2017. Grouping patients based on the medical notes, those with accessible physician documents but no nurse documents were classified as the physician & no-nurse (PNN) group, while those with accessible physician and nurse documents were classified as the physician & nurse (PN) group. The psychometric properties, test-retest reliability, internal consistency reliability (Cronbach's α), and criterion validity were calculated. Using receiver operating characteristic (ROC) analysis, the criterion validity of delirium was evaluated in comparison to the results of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

RESULTS

A total of 779 patients were enrolled in the study. Their ages ranged from 65 to 103 years (82.5 ± 6.5), with men accounting for 71.9% of the total. A total of 312 patients had access to only physician documents in the physician & no-nurse (PNN) group, whereas 467 patients had access to both physician and nurse documents in the physician & nurse (PN) group. All 779 patients had a Cronbach's alpha of 0.728 in terms of reliability, with 100% test-retest reliability. The area under the ROC curve (AUC) values of the delirium screening instrument for criterion validity were 0.76 (all patients, n = 779), 0.72 (PNN, n = 312), and 0.79 (PN, n = 467), respectively.

CONCLUSION

A delirium screening instrument composed of Chinese keywords that can be easily and quickly obtained from electronic medical records was developed, which improved delirium detection in older people.

TRIAL REGISTRATION

Not applicable.

Developing the Patient Falls Risk Report: A Mixed-Methods Study on Sharing Falls-Related Clinical Information from Home Care with Primary Care Providers

If interRAI home care information were shared with primary care providers, care provision and integration could be enhanced. The objective of this study was to co-develop an interRAI-based clinical information sharing tool (i.e., the Patient Falls Risk Report) with a sample of primary care providers. This mixed-methods study employed semi-structured interviews to inform the development of the Patient Falls Risk Report and online surveys based on the System Usability Scale instrument to test its usability. Most of the interview sample (n = 9) believed that the report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified, including insufficient detail, clarity, and support for shared care planning. After incorporating suggestions for improvement, the survey sample (n = 27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7-88.2). By prioritizing the needs of end-users, sustainable interRAI interventions can be developed to support primary care.

A Quality Improvement Study on Delirium Awareness Day: In Pursuit of Missed Delirium Diagnoses

The current study aimed to screen for delirium in hospitalized older adults and assess the validity of the Turkish version of the 4A's Test (4AT-TR) as a feasible tool to integrate in routine patient care. The point prevalence of delirium according to clinical evaluation in routine practice was detected among all patients aged ≥60 years in 12 pilot wards. Delirium screening was then conducted by two arms: (a) nurses using the 4AT-TR and (b) geriatricians according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Prevalence of delirium according to clinical impression was 3.3% (n = 4), whereas prevalence was 12.4% (n = 17) according to DSM-5 criteria and 13.8% (n = 17) according to the 4AT-TR. The 4AT-TR performed by nurses had a sensitivity of 66.6% and specificity of 93.5%. Area under the receiver operating characteristic curve for delirium diagnosis was 0.819 (p < 0.001). Most delirium cases remain undetected unless a routine and formal delirium assessment is integrated in hospital care of high-risk patients. The 4AT-TR performed by nurses seems to be a valid tool for determining delirium in hospitalized older adults. [Journal of Gerontological Nursing, 48(8), 43-51.].

Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials

Objective

Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD.

Methods

Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model.

Results

Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63).

Conclusions

There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

Objective

Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.

Method

As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.

Results

Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).

Conclusions

Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02756-5.

The crucial factors influencing the development and outcomes of postoperative delirium in proximal femur fractures

Objective

The aim of this study is to find the incidence, risks, and reasons for prolonged length of hospital stay, short, long‐term mortality, and the factors contributing to mortality of postoperative delirium in proximal femoral fractures.

Methods

The data for the study was obtained from National Hip Fracture Database (NHFD) and internal hospital computer systems (Medway, ICE, Clinic letters) between January 2018 and December 2019. One hundred seventy‐five patients were found have developed postoperative delirium. The outcomes measured were postoperative anemia, lower respiratory tract infection, urinary tract infection, acute kidney injury, urinary retention, cardiac event and stroke, alcohol or drug withdrawal, length of hospital stay, and 30 day and 1 year mortality.

Results

The patients who developed delirium were 68 (38.9%) with American Society of Anesthesiologists (ASA) grade 4 and 94 (22.3%) without delirium (p < 0.05). The average length of stay after developing postoperative delirium was 19.69 days compared to 17.4 days for patients without delirium. The mortality at 30 days and 1 year was 10.9% and 37% in patients who had postoperative delirium compared to 2.1% and 2.8% to those without delirium, respectively.

Conclusion

Postoperative delirium is three times more common in hip fractures. Early detection and timely management are crucial in the improvement of functional outcomes and mortality.

Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis

BACKGROUND

Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.

AIM

To determine the effect of melatonin on the prevention of delirium in hospitalized patients.

METHODS

A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.

RESULTS

A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I² = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].

CONCLUSION

Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.

Delirium Among Adults Undergoing Solid Organ Transplantation

Purpose of Review

To summarize the research on post-operative delirium among patients undergoing solid organ transplantation in efforts to improve recognition, evaluation, and management, as well as highlight areas for future research.

Recent Findings

Delirium is a common complication in patients with organ failure before and after undergoing solid organ transplant (range: 4.7-47%). However, it is frequently unrecognized and underdiagnosed-even among those closely monitored after major surgery-given that its manifestation is often variable and inconsistent. Delirium has multifactorial etiologies comprising of a complex mix of predisposing recipient, donor, and transplant factors, as well as intraoperative and perioperative factors. Evidence suggests that delirium risk increases with presence of a greater number of such risk factors, and can lead to adverse outcomes such as increased hospital length of stay, time in the ICU, time on mechanical ventilators, graft dysfunction, graft loss, and mortality. Though no trials have been conducted among transplant populations specifically, delirium has been shown to be preventable among hospitalized older adults generally. Multicomponent, primary prevention strategies designed to target multiple risk factors of delirium, such as cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration, have been identified as most effective. Whether these approaches translate to improvements in quality of life and long-term health outcomes among patients with organ failure before and after transplantation is yet to be determined.

Summary

Delirium is an important, common, yet potentially preventable complication among patients with organ failure. Future studies are needed to test the efficacy of multicomponent, primary prevention strategies on long-term health outcomes among these vulnerable populations.

Association of preoperative frailty with postoperative delirium in elderly orthopedic trauma patients

BACKGROUND

Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients.

AIM

Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients.

METHODS

We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders.

RESULTS

Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02-1.72, p = 0.03).

CONCLUSIONS

Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial

PURPOSE

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients.

METHODS

We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression.

RESULTS

A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively.

CONCLUSIONS

Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Evaluation and Management of Delirium

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.

Machine Learning to Identify Psychomotor Behaviors of Delirium for Patients in Long-Term Care Facility

This study aimed to develop accurate and explainable machine learning models for three psychomotor behaviors of delirium for hospitalized adult patients. A prospective pilot study was conducted with 33 participants admitted to a long-term care facility between August 10 and 25, 2020. During the pilot study, we collected 560 cases that included 33 clinical variables and the survey items from the short confusion assessment method (S-CAM), and developed a mobile-based application. Multiple machine learning algorithms, including four rule-mining algorithms (C4.5, CBA, MCAR, and LEM2) and four other statistical learning algorithms (LR, ANNs, SVMs with three kernel functions, and random forest), were validated by paired Wilcoxon signed-rank tests on both macro-averaged F1 and weighted average F1-measures during the 10-times stratified 2-fold cross-validation. The LEM2 algorithm achieved the best prediction performance (macro-averaged F1-measure of 49.35%; weighted average F1-measure of 96.55%), correctly identifying adult patients at delirium risk. In the pairwise comparison between predictive powers observed from independent models, the LEM2 model showed a medium or large effect size between 0.4925 and 0.8766 when compared with LR, ANN, SVM with RBF, and MCAR models. We have confirmed that acute consciousness in S-CAM assessment is closely associated with different predictors for screening three psychomotor behaviors of delirium: 1) education level, dementia type or its level, sleep disorder, dehydration, and infection in mixed-type delirium; 2) gender, education level, dementia type, dehydration, bedsores, and foley catheter in hyperactive delirium; and 3) pain, sleep disorder, and haloperidol use in hypoactive delirium.

High proportion of thiamine deficiency in referred cancer patients with delirium: a retrospective descriptive study

BACKGROUND/OBJECTIVES

Recent studies have revealed thiamine deficiency (TD) as a cause of delirium in cancer patients. However, the extent to which Wernicke encephalopathy is present and in what patients is not well understood.

SUBJECTS/METHODS

In this retrospective descriptive study, we investigated referred cancer patients who were diagnosed with delirium by a psycho-oncologist to clarify the proportion of TD, the therapeutic effect of thiamine administration, and the factors involved in its onset.

RESULTS

Among 71 patients diagnosed with delirium by a psycho-oncologist, TD was found in 45% of the patients. Intravenous administration of thiamine led to a recovery in about 60% of these patients. We explored the factors associated with TD using a multivariable regression model with a Markov chain Monte Carlo imputation procedure. We found an association between TD and chemotherapy (adjusted odds ratio, 1.98 [95% confidence interval, 1.04-3.77]); however, there were no significant associations between TD and the other factors we considered.

CONCLUSIONS

TD is not particularly rare in delirium patients undergoing psychiatric consultation. The delirium was resolved in more than half of these patients by intravenous administration of thiamine. Oncologists should consider TD as a cause of delirium in cancer patients. Further prospective study is needed to clarify the relationship between TD and delirium in cancer patients.

The Polish Version of the Nursing Delirium Screening Scale (NuDESC PL)-Experience of Using in Nursing Practice in Cardiac Surgery Intensive Care Unit

Introduction: Delirium is a common complication of patients hospitalized in Intensive care units (ICU). The risk of delirium is estimated at approximately 80% in intensive care units. In the case of cardiac surgery ICU, the risk of delirium increases due to the type of procedures performed with the use of extracorporeal circulation. The aim of this study was to provide an official translation and evaluation of Nursing Delirium Screening Scale (NuDESC) into Polish. The NuDESC scale is a scale used by nurses around the world to detect delirium at an early stage in treatment. Methods: The method used in the study was the NuDESC tool, which was translated into Polish. The study was conducted by Cardiac ICU nurses during day shift (at 8 a.m.), night shift (at 8 p.m.) and in other situations where the patients showed delirium-like symptoms. Results: Statistically significant differences were observed between the first and second day in the studied group of patients in the case of illusions/hallucinations. Delirium occurred more frequently during the night, but statistical significance was demonstrated for both daytime and nighttime shifts. It was not demonstrated in relation to the NuDESC scale in the case of insomnia disorders. The diagnosis of delirium and disorientation was the most common diagnosis observed in patients on the first day of their stay in the ICU, followed by problems with communication. Delirium occurred on the first day, mainly at night. On the second day, delirium was much less frequent during the night; the biggest problem was disorientation and problems with communication. Conclusion: This study contributed to the development of the Polish version of the scale (NuDESC PL) which is now used as the Polish screening tool for delirium detection. The availability of an easy-to-use nurse-based delirium instrument is a prerequisite for widespread implementation.

A Preliminary Scoring Model to Predict In-hospital Mortality Risk for Geriatric Patients with Delirium

BACKGROUND: Elderly patients are at an increased risk of death, particularly those with altered mental status. AIM: We aimed to develop a scoring model from simple clinical data and routine laboratory testing to aid in predicting in-hospital mortality risk for geriatric patients with delirium. METHODS: A total of 73 hospitalized geriatric patients with delirium were included in the study. A multivariate regression analysis employed to obtain independent risk factors to predict in-hospital mortality. All patients were followed until dead or discharged from hospital. The formula of (B/SE)/lowest B/SE was used to calculate the scores for each variable with strong discrimination power to be included in scoring system. RESULTS: A total of 25 (34.2%) of patients were death when being hospitalized. The mean age of the patients was 73.27 ± 7.8. From a total of 20 probable variables, three variables were then included in constructing the scoring model; no caregiver (p < 0.012), abnormal diastolic blood pressure (p < 0.05), and abnormal serum SGOT levels (p < 0.03). Each variable was scored as 1, following the use of formula. Total score ranges from 0 to maximum of 3. The cutoff score of ≥ 2 provided the best accuracy with sensitivity of 40% and specificity of 89.6% (p < 0.001). The probability of in-hospital mortality was 8.8%, 32.6%, 70.8%, and 92.4% for the total score of 0, 1, 2, and 3, respectively. CONCLUSION: This novel scoring system with simple examination may aid to identify geriatric patients with delirium which possess higher risk for in-hospital mortality.

Wernicke encephalopathy in a lung cancer patient receiving home medical care

OBJECTIVE

Cancer patients often want to spend their final days at home, and it is essential that general practitioners have knowledge of and technical skills related to cancer medicine and symptom relief. Recent clinical studies have revealed that Wernicke encephalopathy (WE) is quite common in cancer patients. However, there have been no reports to date on WE in cancer patients undergoing home medical care.

METHODS

From a series of cancer patient undergoing home medical care, we reported a patient with lung cancer who developed WE.

RESULTS

An 84-year-old female with lung cancer undergoing home medical care developed an impaired mental state and an attention deficit. Her symptoms fulfilled the diagnostic criteria for delirium. WE was suspected as the patient's food intake had fallen from normal a month previously to somewhere between 50% or just a few mouthfuls. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after thiamine administration.

SIGNIFICANCE OF THE RESULTS

When delirium occurs in cancer patients undergoing home treatment, it is necessary to suspect thiamine deficiency as a potential cause, as appropriate diagnosis and treatment can prevent irreversible brain-related sequelae.

Processed Multiparameter Electroencephalogram-Guided General Anesthesia Management Can Reduce Postoperative Delirium Following Carotid Endarterectomy: A Randomized Clinical Trial

Background: Patients undergoing carotid endarterectomy (CEA) for severe carotid stenosis are vulnerable to postoperative delirium, a complication frequently associated with poor outcome. This study investigated the impact of processed electroencephalogram (EEG)-guided anesthesia management on the incidence of postoperative delirium in patients undergoing CEA.

Methods: This single-center, prospective, randomized clinical trial on 255 patients receiving CEA under general anesthesia compared the outcomes of patient state index (PSI) monitoring [SEDLine Brain Function Monitor (Masimo, Inc, Irvine, CA)] (standard group, n = 128) with PSI combined with density spectral array(DSA) -guided monitoring (intervention group, n = 127) to reduce the risk of intraoperative EEG burst suppression. All patients were monitored by continuous transcranial Doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) to avoid perioperative cerebral hypoperfusion or hyperperfusion. According to the surgical process, EEG suppression time was calculated separately for three stages: S₁ (from anesthesia induction to carotid artery clamping), S₂ (from clamping to declamping), and S₃ (from declamping to the end of surgery). The primary outcome was incidence of postoperative delirium according to the Confusion Assessment Method algorithm during the first 3 days post-surgery, and secondary outcomes were other neurologic complications and length of hospital stay.

Results: There were no episodes of cerebral hypoperfusion or hyperperfusion according to TCD and NIRS monitoring in either group during surgery. The incidence of postoperative delirium within 3 days post-surgery was significantly lower in the intervention group than the standard group (7.87 vs. 28.91%, P < 0.01). In the intervention group, the total EEG suppression time and the EEG suppression time during S2 and S3 were shorter (Total, 0 “0” vs. 0 “1.17” min, P = 0.04; S₂, 0 “0” vs. 0 “0.1” min, P < 0.01; S₃, 0 “0” vs. 0 “0” min, P = 0.02). There were no group differences in incidence of neurologic complications and length of postoperative hospital stay.

Conclusion: Processed electroencephalogram-guided general anesthesia management, consisting of PSI combined with DSA monitoring, can significantly reduce the risk of postoperative delirium in patients undergoing CEA. Patients, especially those exhibiting hemodynamic fluctuations or receiving surgical procedures that disrupt cerebral perfusion, may benefit from the monitoring of multiple EEG parameters during surgery.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03622515.

Assessment and Management of Delirium in Critically Ill Veterans

BACKGROUND

Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality.

OBJECTIVE

To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility.

METHODS

Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions.

RESULTS

Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008).

CONCLUSIONS

The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

Identifying frequent drug combinations associated with delirium in older adults: Application of association rules method to a case-time-control design

BACKGROUND

Older adults are at an increased risk of delirium because of age, polypharmacy, multiple comorbidities, frailty, and acute illness. Although medication-induced delirium in older adults is well understood, limited population-level evidence is available, particularly on combinations of medications associated with delirium in older adults.

OBJECTIVES

We aimed to apply association rule analysis to identify drug combinations contributing to delirium risk in adults aged 65 and older using a case-time-control design.

METHOD

We sourced a nationwide representative sample of New Zealander's aged ≥65 years from the pharmaceutical collections and hospital discharge information. Prescription records (2005-2015) were obtained from New Zealand pharmaceutical collections (Pharms). Medication exposures were coded as binary variables (exposed vs. not exposed) at the individual drug level. All medications, including antimicrobials, antihistamines, diuretics, opioids, and nonsteroidal anti-inflammatory medications, were considered drugs of interest. The first-time coded diagnosis of delirium was extracted from the National Minimal Dataset (NMDS). A unique patient identifier linked the prescription dataset to the event dataset to set up a case-time-control cohort, indexed at the first delirium event. Association rules were then applied to identify frequent drug combinations in the case and the control periods (l-day with a 35-day washout period) that are statistically associated with delirium, and the association was tested by computing a time-trend adjusted matched odds-ratio (MOR) and its 95% confidence interval (CI).

RESULTS

We identified 28 503 individuals (mean age 84.1 years) from 2005 to 2015 with delirium. Our combined association rule and case-time-control analysis identified several drug classes, including antipsychotics, benzodiazepines, opioids, and diuretics associated with delirium. Our analysis also identified frequently used drug combinations that are associated with delirium. Examples include combined exposures to quetiapine and furosemide (MOR = 6.17; 95%CI = [2.05-18.54]), haloperidol (MOR = 4.81; 95%CI = [3.16-6.69]), combined exposures to furosemide, omeprazole, and lorazepam (MOR = 3.94; 95%CI = [3.03-5.10]), and fentanyl exposure (MOR = 3.46; 95%CI [2.05-9.21]).

CONCLUSION

The association rule method applied to a case-time-control design is a novel approach to identifying drug combinations contributing to delirium with adjustment for any temporal trends in exposures. The study provides new insight into the combination of medicines linked to delirium.

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit

AIM

(a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge.

DESIGN

A mixed-methods approach will be applied.

METHODS

In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

Associations between caregiver-detected delirium and symptoms of depression and anxiety in family caregivers of critically ill patients: a cross-sectional study

BACKGROUND

Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers.

METHODS

Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed.

RESULTS

One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3).

CONCLUSIONS

Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.

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

Background

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

Objective

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

Design

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

Data sources

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

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

The Montreal Cognitive Test Intervention: The Relationship Between Cognitive-Impaired Patients and Readmissions

BACKGROUND

The purpose of this study is to determine whether there is a relationship between cognitive impairment among Medicare patients and hospital readmissions. Although there has been research on cognitive impairment and readmissions, seldom action has been done in regard to economic costs with hospitals. The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program in 2012. Hospitals may not be fully reimbursed for Medicare patient readmissions within 30 days ().

STUDY DESIGN

An ethnographic approach was utilized with purposive sampling.This was a nonrandomized purposive sampling intervention study using data from Epic health systems database.

METHODS

The intervention spanned over 5 months and the MoCA (Montreal Cognitive Assessment) intervention was conducted in the hospital in a 3-phase study. The purpose of the study was for quality improvement and to detect cognitive impairment among Medicare readmitted patients.

RESULTS

The result shows cognitive impairment is prevalent among the Medicare population. Seventy-one (61%) had evidence of cognitive impairment (i.e., obtained a score below 25). The mean MoCA score for the 71 patients identified as having evidence of cognitive impairment was 17.84 (SD, ±5.06; range, 5-24). MoCA is useful in the acute care setting for identifying patients who are at increased risk for readmission. A randomly assigned controlled clinical trial test is warranted to further validate the association between cognitive impairment and readmissions.

IMPLICATIONS FOR CASE MANAGEMENT

The ACA aims to improve case management by improving effective outcomes for individuals, care coordination among hospital professionals, economic efficiency, cost-effectiveness, and the collaborative process that services the patient. Hospitals across the country are implementing polices that adhere to patient-centered care. Before the ACA was passed, health care services were value metric. The ACA regulates hospitals toward holistic care or quality metrics. Case management will be critical, as hospitals look toward innovative methods to evaluate their patients.

A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons

BACKGROUND/OBJECTIVES

The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium.

DESIGN

Hypothesis testing was carried out using a pretest-posttest design on program administrative data.

SETTING

Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium.

INTERVENTION

A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system.

MEASUREMENTS

Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units.

RESULTS

There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units.

CONCLUSION

Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.

ADAPT-2: A Randomized Clinical Trial to Reduce Intraoperative EEG Suppression in Older Surgical Patients Undergoing Major Noncardiac Surgery

BACKGROUND

Recent limited evidence suggests that the use of a processed electroencephalographic (EEG) monitor to guide anesthetic management may influence postoperative cognitive outcomes; however, the mechanism is unclear.

METHODS

This exploratory, single-center, randomized clinical trial included patients who were ≥65 years of age undergoing elective noncardiac surgery. The study aimed to determine whether monitoring the brain using a processed EEG monitor reduced EEG suppression and subsequent postoperative delirium. The interventional group received processed EEG-guided anesthetic management to keep the Patient State Index (PSI) above 35 computed by the SEDline Brain Function Monitor (Masimo, Inc, Irvine, CA), while the standard care group was also monitored, but the EEG data were blinded from the clinicians. The primary outcome was intraoperative EEG suppression. A secondary outcome was incident postoperative delirium during the first 3 days after surgery.

RESULTS

All outcomes were analyzed using the intention-to-treat paradigm. Two hundred and four patients with a mean age of 72 ± 5 years were studied. Minutes of EEG suppression adjusted by the length of surgery was found to be less for the interventional group than the standard care group (median [interquartile range], 1.4% [5.0%] and 2.5% [10.4%]; Hodges-Lehmann estimated median difference [95% confidence interval {CI}] of -0.8% [-2.1 to -0.000009]). The effect of the intervention on EEG suppression differed for those with and without preoperative cognitive impairment (interaction P = .01), with the estimated incidence rate ratio (95% CI) of 0.39 (0.33-0.44) for those with preoperative cognitive impairment and 0.48 (0.44-0.51) for those without preoperative cognitive impairment. The incidence of delirium was not found to be different between the interventional (17%) and the standard care groups (20%), risk ratio = 0.85 (95% CI, 0.47-1.5).

CONCLUSIONS

The use of processed EEG to maintain the PSI >35 was associated with less time spent in intraoperative EEG suppression. Preoperative cognitive impairment was associated with a greater percent of surgical time spent in EEG suppression. A larger prospective cohort study to include more cognitively vulnerable patients is necessary to show whether an intervention to reduce EEG suppression is efficacious in reducing postoperative delirium.

How long are mechanically ventilated patients fasted prior to surgery? An exploratory study examining preoperative fasting practices across trauma centres

For mechanically ventilated patients undergoing surgery, interrupting enteral feeding to prevent pulmonary aspiration is common; however, there are no published preoperative fasting guidelines for these patients, resulting in fasting practices that often vary greatly between hospitals. This retrospective study described fasting practices and surgical outcomes of mechanically ventilated patients across five trauma centres. The primary exposure was hours nil per os before surgery and was stratified into short (<6h) and moderate (≥6h) fasting duration. Shared frailty models assessed the relationship between time to perioperative complication and nil per os category. Three of the five hospitals had preoperative fasting guidelines, and those most compliant required patients to be fed up until surgery. Most patients were fasted ≥6h prior to surgery and no increased risk of complication was found for patients who were fasted <6h. Future studies are needed to establish appropriate preoperative fasting thresholds for mechanically ventilated patients.

Prevalence and risk factors of delirium in the intensive care unit: An observational study

BACKGROUND

Several risk factors, such as age, alcohol abuse, dementia, and severe illness, can contribute to the development of delirium. However, limited information is available in the literature regarding the risk of delirium among surgical, trauma, neurological, and medical intensive care patients.

AIM

To describe the prevalence of risk factors associated with delirium in intensive care units.

DESIGN

This study used an observational design.

METHODS

We enrolled 165 patients hospitalized in two intensive care units in Italy. Patients were first evaluated using the Prediction of Delirium model and were subsequently evaluated using the Intensive Care Delirium Screening Checklist; evaluation lasted a maximum of 5 days for each admitted patient after sedation. A logistic regression model was used to identify the prevalence and risk factors of delirium.

RESULTS

The average age of the patients was 57.6 (SD = 18.3) years, and the patients were predominantly male (65.0%). The majority of patients had been subjected to trauma (38.8%); 37.6% had undergone general surgical interventions, and 23.6% had undergone medical interventions. Delirium occurred in 55.8% of the 165 patients. The risk of delirium was independently associated with coma (odds ratio = 10.6; 95% confidence interval, 3.08-39.9) and the Acute Physiology and Chronic Health Evaluation II score (odds ratio = 4.27; 95% confidence interval, 1.58-11.53).

CONCLUSIONS

This study confirmed that coma and the Acute Physiology and Chronic Health Evaluation II score were non-modifiable risk factors for delirium. Further studies could categorize the different types of coma. Proper delirium management could limit the impact on the recovery of these patients, their autonomy, and their reintegration into the social and professional world.

RELEVANCE TO CLINICAL PRACTICE

Delirium increases intensive care unit and hospital length of stay. Early identification and risk factor assessment by critical care nurses are considered the key factors in the treatment of delirium.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Family caregiver's experience of caring for an older adult with delirium: A systematic review

AIM

To enhance understanding of how family caregivers perceive the experience of caring for an older adult with delirium across care settings and to identify the challenges in recognising and managing delirium to inform future research and best practices.

METHOD

A systematic literature review was conducted in five databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Primary or secondary peer-reviewed articles published between 1987 and October 2018 describing the experiences of family caregivers caring for older adults with delirium or delirium superimposed on dementia were included in the review. Mixed Method Appraisal Tool (MMAT) was used to evaluate the methodological quality. A thematic synthesis of results was conducted to extract relevant data as per the aims of the study.

RESULTS

Eighteen articles met the eligibility criteria, which were reviewed and analysed in regard to purpose, sample, research design, variables and results. Seven themes emerged in the process. The current challenges and gaps in our knowledge of this phenomenon have also been highlighted, which should be helpful to inform best practices, and finally, an agenda for future research is proposed.

CONCLUSION

Family caregivers are an important partner in the detection and management of delirium. The impact of caring for an older adult with delirium on the family caregivers should not be overlooked. This paper highlights the dearth of research on family caregiver's experience of caring for older adults with delirium and even less in the context of delirium superimposed on dementia. More research is required to further understand the family caregiver's experience and their challenges in order to support them in their caregiving role and to determine their needs and preferences of being involved in the plan of care.

IMPLICATIONS FOR PRACTICE

These findings suggest that family caregivers are a valuable resource in the recognition and management of delirium and should be included as care partners in the health care team, while also catering to their health and well-being in the process.

Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study

OBJECTIVES

Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium.

DESIGN

Prospective observational study.

SETTING

Single-centre at a European academic hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD.

RESULTS

A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD.

CONCLUSIONS

We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.

Utilization of Medications With Cognitive Impairment Side Effects and the Implications for Older Adults' Cognitive Function

Objectives: Many medications have cognitive impairment, memory loss, amnesia, or dementia as side effects ("cognitive side effects" hereafter), but little is known about trends in the prevalence of these medications or their implications for population-level cognitive impairment. Method: We use data from the National Health and Nutrition Examination Survey (1999-2016) to describe trends in the use of medications with cognitive side effects among adults aged 60+ (N = 16,937) and their implications for cognitive functioning (measured using word learning and recall, animal fluency, and digit symbol substitution assessments). Results: Between 1999 to 2000 and 2015 to 2016, the prevalence of older adults taking one, two, and at least three medications with cognitive side effects increased by 10.2%, 57.3%, and 298.7%, respectively. Compared to non-users, respondents who simultaneously used three or more medications with cognitive side effects scored 0.22 to 0.27 standard deviations lower in word learning and recall (p = .02), digit symbol substitution (p < .01), and the average standardized score of the three assessments (p < .001). Limitation: Dosage of medications associated with cognitive side effects was not measured. Discussion: Concurrent use of medications with cognitive side effects among older adults has increased dramatically over the past two decades. The use of such medications is associated with cognitive impairment and may explain for disparities in cognitive function across subgroups. These findings highlight the need for cognitive screenings among patients who consume medications with cognitive side effects. They also highlight the synergic effects of polypharmacy and potential drug-drug interactions that result in cognitive deficits.

A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): A New Screening Tool for the Detection of Delirium

BACKGROUND

Delirium is a prevalent neuropsychiatric disorder associated with increased morbidity and mortality. Half the cases remain misdiagnosed.

OBJECTIVE

Assess the effectiveness of the Stanford Proxy Test for Delirium (S-PTD) in detecting delirium in an inpatient setting.

METHODS

This is a comparison study. Daily assessment with S-PTD, by the patient's nurse, and a neuropsychiatric assessment by a psychiatrist. Assessments were blinded. Inclusion criteria included 18 years or older. Exclusion criteria included patient's or surrogate's unwillingness to participate, inability to consent if a surrogate was not available, and inability to communicate in English or Spanish. A total of 309 patients were approached: 27 declined participation, 4 were excluded, and 278 subjects were followed up throughout their hospital stay. In the end, 78 were excluded for lack of neuropsychiatric assessment, S-PTD, or both. One was excluded for lack of demographic data. The sensitivity and specificity of the S-PTD in detecting delirium when compared with a neuropsychiatric assessment.

RESULTS

Participants were on average 60.8 years old and 54.3% were male. Patients who developed delirium were, on average, older (15.12 y, confidence interval: 8.94-21.32). A total of 199 patients were analyzed; 43 patients (21.6%) met criteria for delirium. S-PTD detected 67 days with delirium (16.5%) of 405 hospital days, while neuropsychiatric evaluation identified 83 (20.5%). S-PTD had a sensitivity of 80.72% and a specificity of 90.37%.

CONCLUSION

S-PTD is an effective, comprehensive, and simple screening tool for delirium, which is robust despite fluctuating symptoms and lack of cooperation. The use of S-PTD may enhance early diagnosis of delirium.

Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study

AIM

To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS).

DESIGN

This is a retrospective study.

METHODS

We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014).

RESULTS

In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle.

CONCLUSION

The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness.

IMPACT

The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.