Understanding terminology of delirium and long-term cognitive impairment in critically ill patients

Cognitive impairment in critically ill patients and former critically ill patients: A concept analysis

OBJECTIVES

This concept analysis aimed to clarify the meaning of the concept of cognitive impairment in critically ill patients throughout the trajectory of their rehabilitation during and after an intensive care unit admission.

REVIEW METHODS USED

This study used concept analysis based on Rodgers' evolutionary method.

DATA SOURCES

A systematic search was conducted in Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, and American Psychological Associations PsycINFO. The web was searched for grey literature.

REVIEW METHODS

Overall search terms used were "patients with cognitive impairments" AND "intensive care unit". Literature published between 2008 and 2022 was included and screened by title and abstract using systematic review software. The descriptive analysis focussed on surrogate terms/related concepts, attributes, and contextual basis.

RESULTS

Thirty studies were included, representing variability in study design and country of origin. The analysis uncovered descriptions of the general terminology and the temporal trajectory of the concept, spanning from the acute phase to a long-term perspective. Attributes of the concept were described as delirium and domains of cognition. Antecedents were juxtaposed to risk factors, which were multifactorial. Consequences of cognitive impairment related to patients' quality of life, such as a decline in their ability to function independently, return to work, and manage everyday life. Also, cognitive impairment was identified as a significant public health problem.

CONCLUSION

Cognitive impairment is a complex concept with many surrogate and related terms. Furthermore, the concept is inextricably intertwined with the concepts of delirium and post-intensive care syndrome. Cognitive impairment may manifest as symptoms that can be challenging to identify and assess due to limitations in current screening tools and the absence of a consensus on timing. In relation to assessment and preventive strategies, the findings underline the need to distinguish between acute and long-term cognitive impairment.

REGISTRATION

There is no study registration number.

Nurses' experiences of managing cognitive problems in intensive care unit patients: A qualitative study

OBJECTIVES

Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit.

RESEARCH METHODOLOGY

A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation.

FINDINGS

Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment.

CONCLUSIONS

The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment.

IMPLICATIONS FOR CLINICAL PRACTICE

Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

Morning Chronotype Is Associated with Improved Adherence to Continuous Positive Airway Pressure among Individuals with Obstructive Sleep Apnea

Rationale: Poor adherence limits the effectiveness of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). A better understanding of CPAP adherence is needed to develop novel strategies to improve it. Objectives: To determine if the chronotype (morning, evening, or intermediate) of patients with OSA is associated with differences in CPAP adherence. If such an association exists, determine the mechanisms underlying this association. Methods: We performed a secondary analysis of the APPLES (Apnea Positive Pressure Long-term Efficacy Study) clinical trial. We assessed chronotype using the Morningness-Eveningness Questionnaire (MEQ) among participants randomized to the CPAP arm with daily adherence data (n = 469). Evening (MEQ ⩽ 41), intermediate (41 < MEQ < 59), and morning type (MEQ ⩾ 59) categories were the exposures. We modeled daily CPAP use (hours per night) over a 6-month period, using a linear mixed model, adjusted for covariates (e.g., age, sex, marital status). To assess mechanisms of the association, we performed mediation analyses using sleep duration, weekend catch-up sleep, depression, and other factors. Results: Most participants were obese men with severe OSA (body mass index of 32.3 ± 7.3 kg/m2, 65% male, and apnea-hypopnea index 39.8 ± 24.6/h). Participants were 44% morning, 47% intermediate, and 8% evening chronotype. Participants with the morning chronotype reported the shortest sleep duration on weekends (7.3 vs. 7.6 and 7.9 h/night) compared with the intermediate and evening types. Participants with the morning chronotype exhibited a 40-min/night higher CPAP use (P = 0.001) than persons with the intermediate chronotype. This relationship was mildly attenuated (32.8 min/night; P = 0.011) after adjustment for covariates. None of the selected factors (e.g., sleep duration, weekend catch-up sleep) exhibited a significant mediation effect. Conclusions: Morning chronotype is associated with a clinically meaningful increase in CPAP adherence compared with other chronotypes. Mechanisms of this association require further study. Chronotype may be a novel predictor of CPAP adherence. Clinical trial registered with www.clinicaltrials.gov (NCT00051363).

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses

BACKGROUND

Improving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lacking OBJECTIVES: The objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties.

METHODS

Draft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021.

RESULTS

Content validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47-19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test-retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools.

CONCLUSIONS

The newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.

Novel Bedside Dynamic Nomograms to Predict the Probability of Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Noncardiac Surgery: A Retrospective Study

Purpose

Early and accurate prediction of elderly patients at high risk of postoperative cognitive dysfunction (POCD) after non-cardiac surgery will provide favorable evidence for rational perioperative management and long-term postoperative recovery. This study aimed to develop bedside dynamic nomograms to provide accurately an individualized prediction of the risk of POCD at 6-month postoperatively with patients undergoing non-cardiac surgery and to guide clinical decision-making and postoperative management.

Patients and Methods

We retrospectively collected patients undergoing surgical treatment at the Nanjing First Hospital between May 2020 and May 2021. We collected the data on preoperative, intraoperative, and postoperative variables. Clinical and laboratory data on admission and intraoperative variables and postoperative variables were used. We measured the performances of the nomograms using sensitivity, specificity of the receiver operating characteristic (ROC), the area under the ROC curves (AUC), the 10-fold cross-validation, and decision curve analysis (DCA).

Results

POCD was observed in 23 of 415 patients (5.6%) at 6-month postoperatively. The preoperative and postoperative models obtained 91.6% and 94.0% accuracy rates on the data. Compared to the preoperative model, the postoperative model had an area under the receiver characteristic curve (AUC) of 0.973 vs 0.947, corresponding to a specificity of 0.941 vs 0.918 and a sensitivity of 0.913 vs 0.870. The overall performance of the postoperative model was better than the preoperative model.

Conclusion

In this study, we developed novel bedside dynamic nomograms with reasonable clinical utility that can provide individualized prediction of POCD risk at 6-month postoperatively in elderly patients undergoing non-cardiac surgery at different time points based on patient admission and postoperative data. External validations are needed to ensure their value in predicting POCD in elderly patients.

Association between delirium and cognitive impairment: there is a link?

BACKGROUND

Delirium and dementia are both disorders involving global cognitive impairment that can occur separately or at the same time in the elderly.

OBJECTIVE

The aim of this study was to examine the frequency, correlation and relative risk between delirium and cognitive impairment in a prospective population study starting at basal line (onset of delirium) over a period of five years. The secondary aim was to determine any possible correlation between the kind of delirium and a specific type of dementia.

MATERIAL AND METHODS

We studied 325 patients, diagnosed according to the DSM-IV. The neuropsychological, moods and delirium disorders were evaluated with Hamilton Depression Rating Scale, Delirium Rating Scale-Revised-98, MMSE, Rey auditory-verbal learning test, Digit Span, Symbol Digit Modalities Test, Raven Progressive Matrices, ADL and IADL.

RESULTS

The prevalence of delirium in our population was 89 cases (27.4%): 78 patients (48 women and 30 men) showed evolution toward dementia (mean age was 67.9 ± 6.1 years for men and 68.4 ± 9.1 for women), and 11 patients (5 men and 6 women) presented only isolated delirium without evolution toward cognitive impairment (mean age of men was 68.1 ± 5.1 years and of women 66.4 ± 7.1). The neuropsychological study of the patients with delirium with dementia evolution revealed statistically significant differences over time with statistically significant intergroup difference and predisposition toward depression.

CONCLUSION

The association between delirium and cognitive impairment and the possible role of delirium as an early marker of neurodegenerative diseases need to be future investigated.

A retrospective multicentre cohort study of the performances on attention tests in outpatients with cognitive dysfunctions without delirium

OBJECTIVE

Attention is the cardinal feature of delirium, but attentional domains may also be affected by dementia and its severity. It is, therefore, of interest to study the correlation between the severity of cognitive impairment in non-delirious patients and different measurements of attentional performance, to identify attention subdomains less affected by severity of cognitive impairment.

METHODS

Neuropsychological data from non-delirious outpatients (age ≥ 65 years), presenting at two memory clinics were analysed retrospectively. Scores for selective, divided, and sustained attention were correlated with cognitive impairment as defined by the score of the Mini-Mental State Examination.

RESULTS

A total of 1658 outpatients were included. The mean age was 77.15 (± 8.17) years, with a mean MMSE score of 22.67 (± 4.91). Compared to the type of attention, the tests that are less influenced by the severity of cognitive impairment are those of selective attention, in particular the Digit Span Forward (DSF).

CONCLUSIONS

This is the first study to correlate deficits in attention subdomains with the degree of cognitive impairment in non-delirious patients. The results suggest that measurements of selective attention (i.e. DSF) might be better suited to discriminate delirium from dementia. Indeed, a lower score on these tests might be indicative of an acute change and worsening of the baseline inattention and a longitudinal monitoring of these changes might be used to determine the delirium resolution.

Delirium in Intensive Care

Purpose of Review

Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge.

Recent Findings

This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged.

Summary

With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.

Does cognitive decline/dementia increase Delirium risk after stroke?

BACKGROUND

Delirium is a common contributor to mortality and hospital costs in stroke patients. Different observational studies have showed inconsistent results regarding the association between cognitive decline/dementia and delirium after acute stroke. Therefore, we performed this meta-analysis with the aim of determining whether cognitive decline/dementia is related to the risk of delirium after acute stroke.

METHODS

We systematically searched PubMed, Embase, Google Scholar, and Web of Science for relevant studies from inception to September 2020. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) by using fixed or random effects models based on heterogeneity measured by the I² index.

RESULTS

The association between cognitive decline/dementia and post-stroke delirium was examined in 13 studies with 3183 participants. After pooled analysis, we found that cognitive decline/dementia was significantly associated with susceptibility to delirium in post-stroke patients (OR = 3.70, 95%CI: 2.90-4.71, P < 0.001). Subgroup analysis suggested that cognitive decline/dementia was associated with an increased risk of delirium in Caucasians (OR = 3.73, 95%CI: 2.73-5.11, P < 0.001), non-Caucasians (OR = 3.65, 95%CI: 2.50-5.33, P < 0.001), samples with <200 subjects (OR = 3.70, 95%CI: 2.17-6.31, P < 0.001), samples with ≥200 subjects (OR = 3.70, 95%CI: 2.82-4.85, P < 0.001), studies published in 1990-2009 (OR = 3.17, 95%CI: 1.48-6.77, P = 0.003), and studies published in 2010-2020 (OR = 3.76, 95%CI: 2.92-4.86, P < 0.001).

CONCLUSIONS

We identified an association between cognitive decline/dementia and the risk of developing delirium. Cognitive decline/dementia may be a promising predictor for delirium in post-stroke patients.

Identifying and Responding to Delirium in Acute Stroke: Clinical Team Members' Understandings

Delirium is associated with increased mortality, morbidity, and length of hospital stay. In the acute stroke setting, delirium identification is challenging due to the complexity of cognitive screening in this patient group. The aim of this study was to explore how members of interprofessional stroke-unit teams identified and responded to a potential delirium in a patient. Online focus groups and interviews utilizing case vignettes were conducted with 15 participants: nurses, occupational therapists, speech and language therapists, and physiotherapists working in acute stroke services. Participants' understandings of delirium varied, most participants did not identify the symptoms of a possible hypoactive delirium, and nearly all participants discussed delirium symptoms in tentative terms. Aspects of interprofessional working were discussed through the expression of distinct roles around delirium identification. Although participants demonstrated an ethos of person-focused care, there are ongoing challenges involved in early identification and management of delirium in stroke survivors.

Long-term patient-important outcomes after septic shock: A protocol for 1-year follow-up of the CLASSIC trial

BACKGROUND

In patients with septic shock, mortality is high, and survivors experience long-term physical, mental and social impairments. The ongoing Conservative vs Liberal Approach to fluid therapy of Septic Shock in Intensive Care (CLASSIC) trial assesses the benefits and harms of a restrictive vs standard-care intravenous (IV) fluid therapy. The hypothesis is that IV fluid restriction improves patient-important long-term outcomes.

AIM

To assess the predefined patient-important long-term outcomes in patients randomised into the CLASSIC trial.

METHODS

In this pre-planned follow-up study of the CLASSIC trial, we will assess all-cause mortality, health-related quality of life (HRQoL) and cognitive function 1 year after randomisation in the two intervention groups. The 1-year mortality will be collected from electronic patient records or central national registries in most participating countries. We will contact survivors and assess EuroQol 5-Dimension, -5-Level (EQ-5D-5L) and EuroQol-Visual Analogue Scale and Montreal Cognitive Assessment 5-minute protocol score. We will analyse mortality by logistic regression and use general linear models to assess HRQoL and cognitive function.

DISCUSSION

With this pre-planned follow-up study of the CLASSIC trial, we will provide patient-important data on long-term survival, HRQoL and cognitive function of restrictive vs standard-care IV fluid therapy in patients with septic shock.

Risk factors for early postoperative cognitive dysfunction after colorectal surgery

Background

It has been reported that postoperative cognitive dysfunction (POCD) is correlated with the degeneration of the central nervous system, oxidative stress, inflammation, and endocrine and immune dysfunction. Increased age, predisposed comorbidity, long surgery time, and prolonged stay in the intensive care unit have been reported to be risk factors for developing POCD for cardiac surgery. In the present study, the risk factors of early POCD after colorectal surgery were investigated.

Methods

Eighty patients, who provided informed consents for their participation in this study, were enrolled and received colorectal surgery under general anesthesia. Neuropsychological tests were performed preoperatively and on postoperative day seven. The risk factors for POCD were analyzed using a multivariate logistic regression model.

Results

Nineteen patients were diagnosed with POCD (24.7%). Diabetes history (OR = 8.391 [2.208–31.882], P = 0.012), fasting over 3 days after surgery (OR = 5.236 [1.998–13.721], P = 0.001) and an SIRS score of > 3 on the second day after surgery (OR = 6.995 [1.948–25.111], P = 0.003) were risk factors for early POCD in colorectal cancer patients.

Conclusion

The risk factors for early POCD after colorectal surgery included diabetes history, fasting over 3 days, and an SIRS score of > 3 on the second day.

Preliminary study of the reliability and validity of the Johns Hopkins Adapted Cognitive Exam (Chinese version) in neurological intensive care unit patients

OBJECTIVE

To evaluate the reliability and validity of the Chinese version of the Johns Hopkins Adapted Cognitive Exam (ACE) in neurological intensive care unit patients.

DESIGN

The English version of the ACE was translated and adapted into Chinese. The cognitive function of 40 critically ill NICU patients was assessed using the Chinese version of the ACE and the Mini-mental state examination (MMSE) battery. Scores on the ACE and MMSE were analyzed, and the scale's content validity, construct validity, concurrent validity, internal consistency, inter-rater reliability, and test-retest reliability metrics were determined.

RESULT

The coefficients for the Pearson correlations between individual item scores and total score ranged from 0.617 to 0.938, and content validity was good. ACE scores were significantly correlated with MMSE scores(r = 0.822, p<0.05). Five factors were extracted during the principal component analysis, the cumulative contribution of which was 85.90%. Overall, the factor loading of each item was 0.5, and the scale had good construct validity. The Chinese version of the ACE demonstrated good internal consistency (Cronbach'α = 0.756), inter-rater reliability (ICC>0.95), and test-retest reliability (ICC = 0.652-0.979).

CONCLUSIONS

The results of this study suggest that the Chinese version of the ACE was a reliable and valid screening tool for cognitive impairment in NICU patients. List of abbreviations: ACE: (Johns Hopkins Adapted Cognitive Exam); NICU : (neurological intensive care unit); MMSE: (Mini-Mental State Examination); SPSS: (the Statistical package for the Social Sciences); ICC: (Intra-class Correlation Coefficients); SCCM: (Society of Critical Care Medicine); PICS: (post-intensive care syndrome); ARDS:(acute respiratory distress syndrome); MoCA; (Montreal Cognitive Assessment); EFA: (exploratory factor analysis).

A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness

OBJECTIVES

To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.

DATA SOURCES

For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017.

STUDY SELECTION

Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment.

DATA EXTRACTION

Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale.

DATA SYNTHESIS

Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications.

CONCLUSIONS

Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.

Barriers to delirium assessment in the intensive care unit: A literature review

BACKGROUND

Delirium is a common syndrome that has both short and long-term negative outcomes for critically ill patients. Many studies over several years have found a knowledge gap and lack of evidence-based practice from critical care personnel, but there has been little exploration of the reasons for this.

AIM

To identify the perceived barriers to delirium assessment and management among critical care nurses.

METHOD

A literature review of published studies to examine barriers to effective delirium assessment using a comprehensive search strategy. Five relevant studies identified for review.

RESULTS

Few studies have investigated barriers to delirium assessment and management, but several themes reoccur throughout the literature. The perceived time consuming nature of the assessment tools is cited by many, as is the lack of medical prioritisation of results. Lack of education on delirium appears to be a significant factor and reinforces some of the stated misconceptions.

CONCLUSION

Many barriers exist to prevent effective assessment and management of delirium, but several of these are due to a lack of understanding or unfamiliarity with the condition and the assessment tools as well as lack of medical prioritisation of the results. Further research is needed on this topic.

Critical care nursing: caring for patients who are agitated

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Critical care nurses' knowledge and practice of delirium assessment

AIMS

The aim of this study was to examine perceived barriers to assessment of delirium for critical care nurses, and the impact of education on their knowledge and practice.

BACKGROUND

Delirium is a significant problem in critical care, leading to increased morbidity and mortality. Many authors have found variations in assessment by critical care nurses, but there has been limited analysis of the reasons for this. Education on the topic improves knowledge and practice, but the best approach has not been examined.

DESIGN

A questionnaire survey design.

METHODS

A self-reported questionnaire was distributed to critical care nurses (n=31) at a district general hospital. Data were analysed with descriptive statistics.

RESULTS

Knowledge and practice were variable, but correlation was seen between nursing band and years of experience with better scores. Any type of education led to significantly improved scores. Several barriers to assessment were found, with the most common being lack of knowledge and difficulty in assessing intubated patients.

CONCLUSION

It is essential to improve practice in delirium assessment and management. Education is vital to improve the knowledge and practice of critical care nurses regarding delirium.

Dose-dependent effects of intravenous methoxamine infusion during hip-joint replacement surgery on postoperative cognitive dysfunction and blood TNF-α level in elderly patients: a randomized controlled trial

Background

Postoperative cognitive dysfunction (POCD), common in elderly patients, is thought to be closely associated with intraoperative instability of hemodynamics and excessive excretion of tumor necrosis factor-α (TNF-α). Methoxamine is a blood-pressure increasing drug commonly used for maintaining intraoperative hemodynamics. Methoxamine potentially promotes TNF-α expression, leading to an increased risk of POCD. This study aimed to investigate the dose-dependent effect of methoxamine on the incidence of early POCD and blood TNF-α level.

Methods

This single-center prospective double-blind controlled clinical trial included a total of 300 adult patients (75–90 years old, American Society of Anesthesiologists class II–III) who underwent unilateral hip-joint replacement surgery under epidural anesthesia. Patients were randomly divided into three methoxamine groups (M1, M2, and M3), and one control group (n = 75 per group). During surgery, M1, M2, and M3 patients received intravenous infusion of methoxamine at 2, 3, or 4 μg·kg⁻¹·min⁻¹, respectively; the control group received saline of same volume at the same infusion rate. All patients received standard transfusion to maintain stable circulation. Hemodynamics, cardiovascular events, and serum TNF-α levels were monitored. Mini Mental State Examination was performed both before and after surgery to diagnose POCD.

Results

The primary outcome of this study was the incidence of POCD, which was higher in the M3 group (18.7%) than in the control group (5.3%), the M1 group (6.7%), or the M2 group (6.7%) (all P < 0.05). The secondary outcomes were the postoperative blood TNF-α level and intraoperative hemodynamic parameters. The postoperative TNF-α level was found to be higher than baseline in all groups and was highest in M3 patients (P < 0.05). The intraoperative hemodynamic parameters showed improved stability in the M1 and M2 groups compared with the control group. However, in the M3 group, abnormally increased intraoperative blood pressure, cardiac output, and systolic stroke volume were observed.

Conclusions

Intravenous infusion of methoxamine at 2–3 μg·kg⁻¹·min⁻¹ can maintain stable hemodynamics in elderly patients during epidural anesthesia for hip-joint replacement surgery, without increasing the incidence of POCD. Increasing the dose to 4 μg·kg⁻¹·min⁻¹ provided no further advantages but induced adverse effects on the intraoperative hemodynamics.

Trial registration

Chinese Clinical Trial Register (Unique identifier: ChiCTR-INR-15007607, retrospectively registered 18 Dec 2015).

Effects of vasodilator and esmolol-induced hemodynamic stability on early post-operative cognitive dysfunction in elderly patients: a randomized trial

OBJECTIVE

To investigate the effect of continuous intravenous injection of nicardipine and/or nitroglycerin with or without esmolol on the occurrence of early post-operative cognitive dysfunction (POCD) in elderly patients.

METHODS

Elderly patients (n=340) who underwent radiofrequency ablation for atrial fibrillation were randomized into five groups: A, nicardipine; B nicardipine+esmolol; C, (nitroglycerin) group; D nitroglycerin+esmolol; E (control) groups. The hemodynamic parameters were recorded, and Mini Mental State Examination was used to assess cognitive function.

RESULTS

At 30 min and 60 minutes after anesthesia and at the conclusion of surgery, the rate pressure product value was significantly lower in Groups B (10621.1±321.7, 10544.2±321.8, and 10701.3±325.5, respectively) and D (10807.4±351.1, 10784.3±360.3, and 10771.7±345.7, respectively) than in Group E (13217.1±377.6, 13203.5±357.3, and 13119.2±379.5, respectively). The heart rate was significantly higher in Groups A (104.1±10.3, 104.9±11.1, and 103.9±11.8, respectively) and C (103.7±11.3, 105.5±10.5, and 107.7±11.7, respectively) than in Group E (89.3±12.0, 88.5±11.5, and 85.5±11.6, respectively). The incidence of POCD was significantly lower in Groups A and B than in Groups C, D, and E. Univariate regression analysis showed that regimens in Groups A, B, and E and doses of propofol and fentanyl were risk factors for POCD. Multivariate logistic regression analysis revealed significant associations between the incidence of POCD and interventions in Groups A and B.

CONCLUSION

Maintenance of stable intraoperative hemodynamics using nicardipine and nitroglycerin or their combinations with esmolol, especially nicardipine with esmolol, reduced the incidence of POCD in the elderly with potential cardiovascular diseases.

The Impact of Plasma Cholinergic Enzyme Activity and Other Risk Factors for the Development of Delirium in Patients Receiving Palliative Care

CONTEXT

Delirium is an important complication in palliative care patients. One of the potential risk factors for cognitive disorders is deterioration in cholinergic neurotransmission. Anticholinergic medications are known to be important owing to the association of their metabolites with significant morbidity, which is often the result of cumulative effects of medications (anticholinergic burden). Additionally, cholinergic enzymes are possible candidates reflecting the cholinergic situation in patients. However, the role of cholinesterases (CHE) for delirium in palliative care patients is unknown.

OBJECTIVES

Following local Ethics Board approval and written informed consent, we recruited a cohort of patients who had been admitted to the Heidelberg University Palliative Care Unit related to CHE and other factors at risk for delirium.

METHODS

Delirium was assessed using the Nursing Delirium Screening Scale once daily in all cancer patients (N = 100) during their stay on the palliative care unit. In a subgroup of 69 probes, blood samples were analyzed for acetyl- and butyrylcholinesterase activity spectrophotometrically. Furthermore, patients' medications were recorded. Logistic regression analysis was used to evaluate potential predictors of delirium.

RESULTS

Delirium was identified in 29% of patients. Karnofsky Performance Status Scale score was significantly lower (P = 0.021) and mortality higher (P = 0.018) in patients with delirium. Plasma CHE activity was not associated with delirium. However, a significant effect of anticholinergic medication on plasma CHE activity was detected; so far midazolam (P = 0.01) seems to play an important role in that process.

CONCLUSION

Special care might be necessary with anticholinergic medication to minimize risk for delirium in palliative cancer patients.

Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards

BACKGROUND

Delirium is a neuropsychiatric disorder, triggered by medical precipitants causes. Study aims were to describe the prevalence and impact on in-hospital mortality of delirium identified through ICD-9 codes as well as evidence of neurocognitive deficits demonstrated in a population of older patients admitted to acute medical wards.

METHODS

This was a prospective cohort multicenter study of 2521 older patients enrolled in the "Registro Politerapie SIMI (REPOSI)" during the years 2010 and 2012. The diagnosis of delirium was obtained by ICD-9 codes. Cognitive function was evaluated with the Short Blessed Test (SBT) and single SBT items were used as measures of deficits in attention, orientation and memory. Combination of deficits in SBT items was used as a proxy for delirium. Logistic regression was used to evaluate the association with in-hospital mortality of delirium and combined deficits in SBT items.

RESULTS

Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates.

CONCLUSIONS

The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.

Biomarkers of Brain Damage and Postoperative Cognitive Disorders in Orthopedic Patients: An Update

The incidence of postoperative cognitive dysfunction (POCD) in orthopedic patients varies from 16% to 45%, although it can be as high as 72%. As a consequence, the hospitalization time of patients who developed POCD was longer, the outcome and quality of life were worsened, and prolonged medical and social assistance were necessary. In this review the short description of such biomarkers of brain damage as the S100B protein, NSE, GFAP, Tau protein, metalloproteinases, ubiquitin C terminal hydrolase, microtubule-associated protein, myelin basic protein, α-II spectrin breakdown products, and microRNA was made. The role of thromboembolic material in the development of cognitive decline was also discussed. Special attention was paid to optimization of surgical and anesthetic procedures in the prevention of postoperative cognitive decline.

A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment

BACKGROUND

Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear.

AIM

To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment.

DESIGN AND METHODS

This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication.

SETTINGS

The study was conducted within four medical wards of an acute care university hospital in urban Switzerland.

PARTICIPANTS

A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively.

RESULTS

Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units.

CONCLUSIONS

The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.

Intranasal administration of butorphanol benefits old patients undergoing H-uvulopalatopharyngoplasty: a randomized trial

BACKGROUND

To evaluate intranasal administration of butorphanol on postoperative pain and early postoperative cognitive dysfunction in old patients undergoing H-uvulopalatopharyngoplasty (H-UPPP).

METHODS

A total of 260 male patients (65 to 77 years old) with obstructive sleep apnea hypopnea syndrome and scheduled for H-UPPP were divided randomly to receive intranasal butorphanol, intravenous butorphanol, intranasal fentanyl, or intravenous saline (controls). The definition of preemptive analgesia is that the tested drugs are given before anesthesia induction. Visual analog scale (VAS) and Bruggrmann comfort scale (BCS) scores were recorded at postoperative 1, 6, 12, 18, 24, 36, and 48 h. Postoperative cognitive dysfunction (POCD) was evaluated by Mini-Mental State Examination (MMSE) scores assessed one day before, and 1, 3, and 7 days postsurgery.

RESULTS

Compared with control group, those given preemptive analgesia required significantly less sufentanil during surgery, had less pain at postoperative 6-12 h; those given butorphanol experienced less nausea and vomiting, less pain at postoperative 6-24 h, and less POCD. Compared with patients given fentanyl, those given butorphanol required significantly less postoperative fentanyl, had less pain at postoperative 18-24 h, less nausea and vomiting, and less POCD. Compared with patients given intravenous butorphanol, those who received butorphanol by nasal route required significantly less postoperative fentanyl, had less pain at 36 and 48 h, and less POCD.

CONCLUSION

Intranasal administration of butorphanol is safe and effective, reducing postoperative usage of analgesics and the incidence of POCD in old patients undergoing H-UPPP.

TRIAL REGISTRATION

ChiCTR-TRC-14004121.

Delirium and cognitive decline: more than a coincidence

PURPOSE OF REVIEW

To review the recent findings on the relationships between delirium and cognitive decline in the elderly.

RECENT FINDINGS

Current advances in the field include substantial new evidence that delirium increases the risk of dementia in patients without previous cognitive impairment and accelerates cognitive decline in patients with Alzheimer's disease. Findings on cognitive trajectories and domains affected contribute to better understanding of the clinical nature of cognitive impairment after delirium. Volume loss and disruption of white matter integrity may represent early MRI markers for long-term cognitive impairment. Neurodegenerative and low-level chronic inflammatory processes predispose to exaggerated response to incident stimuli that may precipitate both acute brain dysfunction and persisting cerebral damage.

SUMMARY

Still little is known about the relationship between delirium and cognitive trajectories in the elderly, and the underlying pathophysiological mechanisms. The association of neurodegenerative and inflammatory processes appears to play an important role in the pathogenesis and the clinical course of cognitive impairment after delirium. The hypothetical role of several other factors remains to be clarified. Further clinical studies are needed to evaluate whether prevention and treatment approaches that proved to be useful to reduce delirium incidence and severity may also improve long-term outcomes, and prevent cognitive decline.