The Diagnostic Sensitivity of the Memorial Delirium Assessment Scale-Spanish Version

The role of C-reactive protein as a risk marker of postoperative delirium in older hip fracture patients: a prospective cohort study

PURPOSE

Postoperative delirium (POD) is a common and serious neuropsychiatric syndrome that leads to higher morbidity and mortality. We investigated the association between serum C-reactive protein (CRP) and the occurrence of POD in older hip fracture patients, and whether CRP predicted POD better than a clinical model.

METHODS

Patients aged ≥ 75 years admitted for surgical repair of an acute hip fracture were recruited. We compared serum CRP levels between patients with and without POD.

RESULTS

Sixty patients were included, of whom 21 (35%) developed POD. Serum CRP levels were significantly higher in patients who developed delirium (p = 0.011). In a multiple regression model including clinical variables and CRP, cognitive impairment (p = 0.003) and infection (p = 0.001) were the best predictors of POD.

CONCLUSIONS

Although higher levels of serum CRP were significantly associated with POD in older hip fracture patients, pre-existing cognitive impairment and infections were the most important risk factors for POD.

Severity of Symptoms as an Independent Predictor of Poor Outcomes in Patients with Advanced Cancer Presenting to the Emergency Department: Secondary Analysis of a Prospective Randomized Study

Background/Objectives: Patients with advanced cancer often present to the emergency department (ED) with pain and distressing symptoms that are not systematically evaluated. The current study investigated the association of symptom severity with the diagnosis of delirium and short-term survival. Methods: In this secondary analysis of a prospective randomized study of delirium among advanced cancer patients in the ED, in which symptoms were assessed by the MD Anderson Symptom Inventory (MDASI), we analyzed the distribution of MDASI item scores by 90-day mortality (Kolmogorov-Smirnov), the association of MDASI item scores with short-term mortality (logistic regression models), and the symptoms in those with or without delirium (Mann-Whitney U test or chi-square test). Results: Of the 243 patients included, 222 (91.4%) had complete MDASI scores. The MDASI median symptom scores for pain, fatigue, and interference with work were the highest. A significant difference in MDASI item score distribution with 90-day mortality was observed for fatigue (p = 0.018), shortness of breath (p < 0.001), difficulty remembering (p = 0.038), lack of appetite (p = 0.035), drowsiness (p < 0.001), feeling sad (p = 0.031), and interference with walking (p < 0.001). In multivariable logistic regression models, shortness of breath (adjusted OR 1.15, 95% CI 1.04-1.26, p = 0.005) and drowsiness (adjusted OR 1.17, 95% CI 1.05-1.33, p = 0.008) were associated with 90-day mortality, adjusting for age, race, performance status, and cancer type. The median total MDASI score was significantly higher in patients with delirium than in those without (88, IQR 83-118 vs. 80, IQR 55-104; p < 0.001). Conclusions: Patients with advanced cancer presenting to the ED had severe symptoms, some of which were associated with shorter survival. These findings underscore the necessity of systematic symptom assessment, focusing on shortness of breath, drowsiness, fatigue, difficulty remembering, lack of appetite, feeling sad, and feeling distressed, to enhance clinical decision-making and improve the care of patients with advanced cancer. Additional longitudinal studies are needed to evaluate the improvement in symptoms and quality of life for these patients.

Association of postoperative delirium with serum and cerebrospinal fluid proteomic profiles: a prospective cohort study in older hip fracture patients

Postoperative delirium (POD) is a common neuropsychiatric complication in geriatric inpatients after hip fracture surgery and its occurrence is associated with poor outcomes. The purpose of this study was to investigate the relationship between preoperative biomarkers in serum and cerebrospinal fluid (CSF) and the development of POD in older hip fracture patients, exploring the possibility of integrating objective methods into future predictive models of delirium. Sixty hip fracture patients were recruited. Blood and CSF samples were collected at the time of spinal anesthesia when none of the subjects had delirium. Patients were assessed daily using the 4AT scale, and based on these results, they were divided into POD and non-POD groups. The Olink® platform was used to analyze 45 cytokines. Twenty-one patients (35%) developed POD. In the subsample of 30 patients on whom proteomic analyses were performed, a proteomic profile was associated with the incidence of POD. Chemokine (C-X-C motif) ligand 9 (CXCL9) had the strongest correlation between serum and CSF samples in patients with POD (rho = 0.663; p < 0.05). Although several cytokines in serum and CSF were associated with POD after hip fracture surgery in older adults, there was a significant association with lower preoperative levels of CXCL9 in CSF and serum. Despite the small sample size, this study provides preliminary evidence of the potential role of molecular biomarkers in POD, which may provide a basis for the development of new delirium predictive models.

The Confusion Assessment Method Could Be More Accurate than the Memorial Delirium Assessment Scale for Diagnosing Delirium in Older Cancer Patients: An Exploratory Study

BACKGROUND

Older people with cancer carry a high risk of delirium, an underdiagnosed syndrome due to its diagnostic complexity and often subtle presentation. Tools based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) are available to different health professionals. Our aim is to assess the prevalence of delirium in older people with cancer in an inpatient unit and the accuracy of the Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS).

METHODS

This exploratory, cross-sectional study included people aged 65 years or older with a diagnosis of cancer and admitted to the medical oncology unit from June 2021 to December 2022. The diagnostic accuracy of CAM and MDAS was analyzed against the gold standard medical diagnosis based on DSM-5 criteria by two medical oncologists. The cutoff point for the MDAS was determined using a receiver-operating characteristics (ROC) curve.

RESULTS

Among the 75 included patients (mean age 71.6 years, standard deviation 4.1; 52% males), the prevalence of delirium was 62.7%. The most prevalent types of cancer in patients with delirium were hematological and lung cancer. The scale with the highest diagnostic accuracy was the CAM, with a sensitivity of 100% and specificity of 86%, followed by the MDAS, with a sensitivity of 88% and specificity of 30%. The presence of cognitive impairment hindered the detection of delirium.

CONCLUSIONS

The CAM scale was more accurate than the MDAS pre-existing cognitive impairment in our sample. Further studies are needed to analyze the diagnostic accuracy of delirium tools in older populations with cancer and in the presence of cognitive impairment.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

OBJECTIVE

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements.

RESULTS

This article provides a compendium of the recommendations along with their rationales, as well as a short summary.

CONCLUSIONS

These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Accuracy of Delirium Screening Tools in Older People with Cancer-A Systematic Review

BACKGROUND

The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages.

OBJECTIVE

To determine which delirium screening instrument is the most accurate in older people with cancer.

METHODS

A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded.

RESULTS

From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group.

CONCLUSIONS

Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.

Effectiveness of a multicomponent exercise training program for the management of delirium in hospitalized older adults using near-infrared spectroscopy as a biomarker of brain perfusion: Study protocol for a randomized controlled trial

Delirium is an important cause of morbidity and mortality in older adults admitted to hospital. Multicomponent interventions targeting delirium risk factors, including physical exercise and mobilization, have been shown to reduce delirium incidence by 30-40% in acute care settings. However, little is known about its role in the evolution of delirium, once established. This study is a randomized clinical trial conducted in the Acute Geriatric Unit of Hospital Universitario de Navarra (Pamplona, Spain). Hospitalized patients with delirium who meet the inclusion criteria will be randomly assigned to the intervention or the control group. The intervention will consist of a multicomponent exercise training program, which will be composed of supervised progressive resistance and strength exercise over 3 consecutive days. Functional Near-Infrared Spectroscopy (NIRS) will be used for assessing cerebral and muscle tissue blood flow. The objective is to assess the effectiveness of this intervention in modifying the following primary outcomes: duration and severity of delirium and functional status. This study will contribute to determine the effectiveness of physical exercise in the management of delirium. It will be the first study to evaluate the impact of a multicomponent intervention based on physical exercise in the evolution of delirium.

Clinical trial registration

ClinicalTrials.gov. identifier: NCT05442892 (date of registration June 26, 2022).

Association between Baseline Cognitive Score and Postoperative Delirium in Parkinson’s Disease Patients following Deep Brain Stimulation Surgery

Background

Deep brain stimulation of the subthalamic nuclei (STN-DBS) is a standard treatment option for advanced Parkinson's disease (PD) patients. Delirium following DBS electrode implantation is common, by several studies, and cognitive impairment is a risk factor for developing postoperative delirium (POD). This prospective observational study was conducted to identify whether preoperative baseline cognitive status has an association with POD in PD patients undergoing DBS surgery.

Methods

Preoperatively, neuropsychiatric and neuropsychological assessments of the patients were performed including clinical dementia rating (CDR) score, instrumental activities of daily living (IADL) score, mini-mental state exam (MMSE) score, Montreal cognitive assessment (MoCA) score, Hamilton anxiety (HAMA) and Hamilton depression (HAMD) scores, and numerical cancellation test. POD was identified by the confusion assessment method (CAM) twice per day on postoperative day 1 until discharge.

Results

Twenty-seven (21.6%) of 125 patients developed POD. Among the variables screened, age, CDR score, MMSE score, and HAMA score were indicated to be independent influence factors of POD. The cutoff score, AUC, sensitivity, and specificity of age, CDR score, MMSE score, and HAMA score associated with POD was 58.5, 0.751, 92.6%, 52.0%; 0.5, 0.848, 77.8%, 91.8%; 27.5, 0.827, 88.9%, 62.2%; and 12.5, 0.706, 85.2%, 54.1%, respectively.

Conclusions

We observed age, CDR score, MMSE score, and HAMA score were independent influence factors of POD in PD patients who received DBS. It is necessary to assess the cognitive status of PD patients before surgery to identify high-risk patients.

The Effect of Propofol versus Sevoflurane on Postoperative Delirium in Parkinson's Disease Patients Undergoing Deep Brain Stimulation Surgery: An Observational Study

BACKGROUND

The selection of the maintenance of general anesthesia may affect the development of postoperative delirium (POD), notably for Parkinson's disease (PD) patients, due to their lower cognitive reserve. The present study was designed to compare the potential impact of propofol vs. sevoflurane based general anesthesia maintenance methods on the development of POD in PD patients following deep brain stimulation (DBS) surgery.

METHODS

A total of 125 PD patients who were scheduled to undergo DBS surgery were randomly divided into the propofol (n = 63) and the sevoflurane groups (n = 62). The patients in the two groups randomly received propofol- or sevoflurane-based general anesthesia. The Confusion Assessment Method (CAM) was employed by an investigator who was blinded to the anesthesia regimen and was administered twice per day from postoperative day 1 until discharge.

RESULTS

The incidence of POD was 22.22% (14/63) with propofol anesthesia and 20.97% (13/62) with sevoflurane anesthesia (p = 0.865). In addition, no difference was noted in the duration and severity of delirium between the propofol and sevoflurane groups.

CONCLUSIONS

In the present study, propofol- and sevoflurane-based general anesthesia exhibited comparable results with regard to the POD incidence in PD patients undergoing deep brain stimulation surgery.

Risk factors for delirium in adult patients receiving specialist palliative care: A systematic review and meta-analysis

BACKGROUND

Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.

AIM

To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.

DESIGN

Systematic review and meta-analysis (PROSPERO CRD42019157168).

DATA SOURCES

CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.

RESULTS

Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.

POTENTIALLY MODIFIABLE RISK FACTORS

Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).

NON-MODIFIABLE RISK FACTORS

Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.

CONCLUSIONS

Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

First-line methadone for cancer pain: titration time analysis

BACKGROUND

Methadone is a low-cost, strong opioid that is increasingly used as a first-line treatment for pain in palliative care (PC). Its long and unpredictable half-life and slow elimination phase can make titration challenging. Evidence for titration modalities is scarce.

OBJECTIVE

To describe the titration phase of the treatment with low-dose first-line methadone and the use of methadone for breakthrough pain.

METHODS

Prospective study with strong opioid-naïve patients with moderate to severe cancer pain followed at a tertiary PC unit in Argentina. Starting methadone dose was 2.5-5 mg/day every 8, 12, or 24 h. Titration allowed daily dose increases from day 1, and prescription of oral methadone 2.5 mg every 2 h with a maximum of 3 rescue doses/day for breakthrough pain. Pain control, methadone stabilization dose, and adverse effects, among other variables, were daily assessed over the first 7 days (T0-T7).

RESULTS

Sixty-two patients were included. Initial median (IQR) methadone dose was 5 (2.5) mg/day. Pain intensity decreased from a median (IQR) of 8 (2.3) at T0 to 4 (2.3) at T1 and remained ≤ 4 until T7 (all p < 0.0001 compared to T0). Similar results were obtained through the categorical and tolerability scales for pain. Fifty patients (81%) reached pain control, 66% in the first 48 h. Methadone daily doses at T2 and T7 were higher than that at T0: 7.5 (3) and 6.7 (5.5) versus 5 (2.5), respectively (all p < 0.05). The opioid escalation index at T7 was 1.7%. The median (IQR) number of rescues, stabilization dose, and time for stabilization was 0 (1), 5(4.5) mg, and 3(2) days, respectively. Two patients were discontinued due to delirium. All other side effects were mild.

CONCLUSIONS

First-line, low-dose methadone using rescue methadone resulted in a pronounced and rapid decrease in pain, with minimal need for titration and for breakthrough doses, and no evidence of accumulation or sedation by the end of the week.

Delirium screening tools validated in the context of palliative care: A systematic review

BACKGROUND

Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review.

AIM

To systematically review studies that validate delirium screening tools conducted in palliative care settings.

DESIGN

Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed.

DATA SOURCES

Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded.

RESULTS

Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias.

CONCLUSIONS

The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.

A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care

CONTEXT

Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps.

OBJECTIVES

To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes.

METHODS

A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent.

RESULTS

Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature.

CONCLUSION

Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.