A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis

Comparative effect of nonpharmacological interventions on emergence delirium prevention in children following sevoflurane general anesthesia: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Children receiving general anesthesia while undergoing surgery have a significantly high incidence of emergence delirium (ED). Nonpharmacological interventions yield beneficial effects on preventing pediatric ED. However, the relative effects of nonpharmacological interventions on pediatric ED prevention based on various perioperative phases remain unknown.

OBJECTIVE

To compare the effects of nonpharmacological interventions on pediatric ED prevention at different surgical phases.

DESIGN

A systematic review and network meta-analysis.

DATA SOURCES

A comprehensive search of five electronic databases (PubMed, CINAHL via EBSCOhost, Embase via Elsevier, Cochrane Trials, and ProQuest Dissertations and theses) for identifying randomized control trials published from inception to October 15, 2023.

METHODS

Two reviewers independently screened, assessed, and extracted data from the eligible studies. A random-effects network meta-analysis was used to determine the comparative effect of nonpharmacological interventions on preventing pediatric ED.

RESULTS

A total of 19 studies involving 2522 children were included in this network meta-analysis. Thirteen studies reported on the prevention of pediatric ED in the preoperative phase, and six studies reported on the prevention of pediatric ED in the intraoperative phases. Multimedia devices (OR 0.39, 95 % CIs 0.20-0.74), a multicomponent program (OR 0.20, 95 % CI 0.14-0.28) significantly reduced the incidence of pediatric ED during the preoperative phase compared with usual care. During the intraoperative phase, listening to regular heartbeat sounds significantly reduced the risk of pediatric ED compared with usual care (OR 0.06, 95 % CI 0.02-0.22), placebo (OR 0.11, 95 % CI 0.03-0.36), acupuncture (OR 0.17, 95 % CI 0.03-0.88), acupuncture with electrical stimulus (OR 0.16, 95 % CI 0.04-0.68), and acupuncture with midazolam (OR 0.04, 95 % CI 0.00-0.41).

CONCLUSIONS

Our study results suggest that the multicomponent program and listening to heartbeat sounds are relatively effective nonpharmacological interventions for preventing pediatric ED during the perioperative phase. This study compared the effectiveness and ranking of various interventions, and the findings can serve as a guide to assist health professionals in choosing the optimal strategy for preventing ED.

REGISTRATION

The study protocol was registered at PROSPERO (CRD42023459541).

TWEETABLE ABSTRACT

Nonpharmacological interventions can reduce the high incidence of pediatric emergence delirium after surgery. Our systematic review highlights the efficacy of multicomponent programs and listening to heartbeat sounds intraoperatively in reducing ED risk. The findings aid health professionals in selecting optimal strategies for pediatric perioperative care.

A bibliometric analysis on delirium in intensive care unit from 2013-2023

Background

Delirium is a common manifestation of acute brain dysfunction among patients in the Intensive Care Unit (ICU), afflicting an estimated 30-35% of this vulnerable population. The prevalence of delirium in ICU settings has catalyzed a surge in academic interest, as evidenced by a growing body of literature on the subject. This study seeks to synthesize the progress in understanding ICU delirium through a bibliometric analysis.

Methods

We conducted a comprehensive search of the Web of Science Core (WOS) Collection database for literature on ICU delirium, focusing on studies published between 2013 and 2023. Our analysis utilized two bibliometric software tools, Citespace and VOSviewer, to scrutinize the data across various dimensions, including country contributions, authorship patterns, publishing journals, key thematic terms, and other pertinent metrics, with the aim of identifying emerging trends in the field.

Results

Our search yielded a total of 1,178 publications on ICU delirium within the WOS database from January 2013 to June 2023. The United States emerged as the leading contributor in terms of published articles, with Ely, E. Wesley being the most prolific author, having published 85 articles, and "Critical Care Medicine" as the journal with the highest number of publications, totaling 105. The application of literature clustering and keyword analysis revealed that future research is poised to delve deeper into areas such as pediatric delirium, risk factors, and the development of preventive and therapeutic strategies.

Conclusion

This study employs bibliometric analysis to provide a multifaceted overview of the ICU delirium research landscape over the past decade. By examining the topic from various perspectives, we have not only mapped the current state of ICU delirium research but also illuminated potential avenues for future inquiry and areas of emphasis.

Delirium in psychiatric settings: risk factors and assessment tools in patients with psychiatric illness: a scoping review

BACKGROUND

Delirium is a common disorder affecting patients' psychiatric illness, characterized by a high rate of underdiagnosis, misdiagnosis, and high risks. However, previous studies frequently excluded patients with psychiatric illness, leading to limited knowledge about risk factors and optimal assessment tools for delirium in psychiatric settings.

OBJECTIVES

The scoping review was carried out to (1) identify the risk factors associated with delirium in patients with psychiatric illness; (2) synthesize the performance of assessment tools for detecting delirium in patients with psychiatric illness in psychiatric settings.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science, and Embase were searched to identify primary studies on delirium in psychiatric settings from inception to Dec 2023 inclusive. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted.

RESULTS

A final set of 36 articles meeting the inclusion criteria, two main themes were extracted: risk factors associated with delirium in patients with psychiatric illness and assessment tools for detecting delirium in psychiatric settings. The risk factors associated with delirium primarily included advanced age, physical comorbid, types of psychiatric illness, antipsychotics, anticholinergic drug, Electroconvulsive therapy, and the combination of lithium and Electroconvulsive therapy. Delirium Rating Scale-Revised-98, Memorial Delirium Assessment Scale, and Delirium Diagnostic Tool-Provisional might be valuable for delirium assessment in patients with psychiatric illness in psychiatric settings.

CONCLUSIONS

Delirium diagnosis in psychiatric settings is complex due to the overlapping clinical manifestations between psychiatric illness and delirium, as well as their potential co-occurrence. It is imperative to understand the risk factors and assessment methods related to delirium in this population to address diagnostic delays, establish effective prevention and screening strategies. Future research should focus on designing, implementing, and evaluating interventions that target modifiable risk factors, to prevent and manage delirium in patients with psychiatric illness.

The Validity and Applicability of the Revised Delirium Rating Scale (DRS-R98) for Delirium Severity Assessment in a Critical Care Setting

BACKGROUND

Delirium is a neuropsychiatric syndrome common in critical illness. Worsening delirium severity is associated with poorer clinical outcomes, yet its assessment remains under-reported with most severity assessment tools not validated for critical care. The DRS-R98 is a widely applied and validated tool. The aim of this project is to report the validation and utility of the DRS-R98 in critical illness.

METHODS

This prospective, cohort study was conducted in adults with delirium admitted to a critical care unit and predicted to stay for ≥ 24 h. We excluded patients with severe neurological or communication barriers that would have interfered with the DRS-R98 assessment. Patients were screened using a delirium detection algorithm and the Confusion Assessment Method for the Intensive Care Unit. Eligible patient informations were collected and reported to qualified assessor/s before visiting clinical areas, confirming delirium presence and undertaking DRS- R98 assessments. To assess the tool's construct validity, an intensivist completed the Clinical Global Impression-Scale (CGI-S). To calculate the inter-rater reliability (IRR) a subset of patients were simultaneously evaluated by two assessors.

RESULTS

We assessed 22 patients, 73% were male, with a median age of 65 years (IQR14). The DRS -R98 mean (SD) severity score was 24 (+/-7.7), total scale was 29 (+/18.0), and CGI-S 3.5 (+/11.5). Assessment duration was 90 min (+/-55) and 15 min (+/-5) for record data extraction and clinical assessment respectively. The CGI-S significantly correlated with DRS-R98 severity (r = 0.626) and total (r = 0.628) scales. The DRS-R98 Cronbach's alpha was 0.896 for severity scale and 0.886 for total scale. The inter-rater reliability (IRR) was assessed in six patients and reported an inter-correlation coefficient of 0.505 (p = 0.124) and 0.565 (p = 0.93) for the severity and total scale respectively.

CONCLUSIONS

In critical care, the Delirium Rating Scale R98 had good construct validity, excellent internal consistency, and moderate inter-rater reliability.

Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study

OBJECTIVES

To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia.

METHODS

A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4).

RESULTS

Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group.

CONCLUSION

The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Delirium is associated with low levels of upright activity in geriatric inpatients-results from a prospective observational study

BACKGROUND

Delirium is common in geriatric inpatients and associated with poor outcomes. Hospitalization is associated with low levels of physical activity. Motor symptoms are common in delirium, but how delirium affects physical activity remains unknown.

AIMS

To investigate differences in physical activity between geriatric inpatients with and without delirium.

METHODS

We included acutely admitted patients ≥ 75 years in a prospective observational study at a medical geriatric ward at a Norwegian University Hospital. Delirium was diagnosed according to the DSM-5 criteria. Physical activity was measured by an accelerometer-based device worn on the right thigh. The main outcome was time in upright position (upright time) per 24 h (00.00 to 23.59) on the first day of hospitalization with verified delirium status. Group differences were analysed using t test.

RESULTS

We included 237 patients, mean age 86.1 years (Standard Deviation (SD) 5.1), and 73 patients (30.8%) had delirium. Mean upright time day 1 for the entire group was 92.2 min (SD 84.3), with 50.9 min (SD 50.7) in the delirium group and 110.6 min (SD 89.7) in the no-delirium group, mean difference 59.7 minutes, 95% Confidence Interval 41.6 to 77.8, p value < 0.001.

DISCUSSION

Low levels of physical activity in patients with delirium raise the question if immobilization may contribute to poor outcomes in delirium. Future studies should investigate if mobilization interventions could improve outcomes of delirium.

CONCLUSIONS

In this sample of geriatric inpatients, the group with delirium had lower levels of physical activity than the group without delirium.

Development and validation of nurse's assessment ability questionnaire in delirium subtypes: Based on Delphi expert consensus

BACKGROUND

Delirium, a common occurrence in clinical work, can be divided into three subtypes according to Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5). Each subtype has its special significance and focus. As the primary caregivers and observer of delirious patients, nurses should be able to quickly and accurately indentify each subtype. Therefore, it is necessary to clarify nurses' assessment ability of delirium subtypes. However, there is currently no suitable questionnaire available for investigating nurses' assessment ability of delirium subtypes.

OBJECTIVE

To develop a scientifically validated questionnaire for assessing nursing assessment ability of delirium subtypes based on Knowledge-Attitude-Practice(KAP) Model.

METHODS

The questionnaire was conducted from October 2021 to February 2022 to assess the KAP status of nurses the regarding delirium subtype. A two-round Delphi Method was employed to revise the draft questionnaire, ensuring the importance and rationality of each item. Ten experts specializing in critically ill patients, clinical nursing, and nursing management were invited from seven provinces in China for the Delphi process. Additionally, we validated the reliability and validity of the questionnaire.

RESULTS

The return rate in the first and second rounds were 83% and 100%, respectively. The individual authority coefficients for the two rounds of correspondence ranged from 0.787 to 0.987, while the overall authority coefficient of experts was 0.866. Kendall's coefficient of coordination for the importance scores were found to be 0.192 and 0.156, respectively, whereas those for rationality scores were calculated as 0.149 and 0.141, respectively. Notably, all mean values of importance and rationality scores in the two rounds were exceeded a threshold of 4.10 across both rounds of assessment with coefficient variations (CV) ranging from 0.00 to 0.19 for importance ratings and 0.00 to 0.16 for rationality ratings, both of which were <0.25. Experts proposed modifications to eleven items while introducing four new ones into consideration during this process; thus ensuring that reliability and validity standards were met by the final questionnaire design which consists of a total of thirty-seven items distributed across four dimensions: delirium subtype-related knowledge, assessment attitude, assessment practice, and knowledge source-thereby establishing its clinical relevance as a reliable scientific instrument.

CONCLUSION

The development process is both scientific and theoretical, encompassing reliable expert correspondence results and a diverse range of question formats. As thus, effectively captures the current landscape of delirium subtypes assessment among clinical nurses from multiple perspectives, including knowledge level and source, attitude, assessment behavior, and assessment barriers. It offers comprehensive and detailed insights.

Online interpretable dynamic prediction models for postoperative delirium after cardiac surgery under cardiopulmonary bypass developed based on machine learning algorithms: A retrospective cohort study

OBJECTIVE

Postoperative delirium (POD) is strongly associated with poor early and long-term prognosis in cardiac surgery patients with cardiopulmonary bypass (CPB). This study aimed to develop dynamic prediction models for POD after cardiac surgery under CPB using machine learning (ML) algorithms.

METHODS

From July 2021 to June 2022, clinical data were collected from patients undergoing cardiac surgery under CPB at Nanjing First Hospital. A dataset from the same center (October 2022 to November 2022) was also used for temporal external validation. We used ML and deep learning to build models in the training set, optimized parameters in the test set, and finally validated the best model in the validation set. The SHapley Additive exPlanations (SHAP) method was introduced to explain the best models.

RESULTS

Of the 885 patients enrolled, 221 (25.0%) developed POD. 22 (22.0%) of 100 validation cohort patients developed POD. The preoperative and postoperative artificial neural network (ANN) models exhibited optimal performance. The validation results demonstrated satisfactory predictive performance of the ANN model, with area under the receiver operator characteristic curve (AUROC) values of 0.776 and 0.684 for the preoperative and postoperative models, respectively. Based on the ANN algorithm, we constructed dynamic, highly accurate, and interpretable web risk calculators for POD.

CONCLUSIONS

We successfully developed online interpretable dynamic ANN models as clinical decision aids to identify patients at high risk of POD before and after cardiac surgery to facilitate early intervention or care.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis

BACKGROUND

No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population.

OBJECTIVE

To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI.

METHODS

In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention.

RESULTS

Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%).

CONCLUSIONS

Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

Prevalence of delirium among critically ill patients who received extracorporeal membrane oxygenation therapy: A systematic review and proportional meta-analysis

OBJECTIVES

To pool the overall prevalence of delirium among critically ill patients who received extracorporeal membrane oxygenation (ECMO) support.

METHODOLOGY

This systematic review and proportional meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Six electronic databases including PubMed, Cochrane Library, Web of Science, EMBASE, CINAHL, and PsycINFO were searched from inception to March 2023. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. A random effects model was used to pool the summary prevalence estimates and 95% CIs using the score statistic and the exact binomial method and incorporates the Freeman-Tukey double arcsine transformation of proportions. Sensitivity analyses including subgroup analysis, meta-regression, and outlier detection were carried out.

SETTING

Intensive care units.

MAIN OUTCOME MEASURES

Prevalence of delirium.

RESULTS

A total of 10 studies involving 8,580 patients were included for meta-analysis. All studies had a low risk of bias in methodological quality. The pooled prevalence rate of 40.79% [95% CI, 17.58%-66.25%] was observed. The between-study heterogeneity (I2) was 98.28%. The subgroup analysis reveals the pooled prevalence of delirium for veno-arterial (V-A) ECMO, veno-venous (V-V) ECMO, and mixed sample of V-A and V-V ECMO were 63.57% [95% CI, 55.77%-71.04%], 51.84% [95% CI, 37.43%-66.12%] and 35.23% [95% CI, 11.84%-62.95%], respectively. Sample size (p = 0.024) was a significant factor associated with the heterogeneity. No evidence for small-study effects was observed (Egger's test: p = 0.5664).

CONCLUSION

This systematic review and proportional meta-analysis reveals a high prevalence of delirium among critically ill patients who received ECMO support.

IMPLICATIONS FOR CLINICAL PRACTICE

The results of this meta-analysis can be epidemiological evidence to inform the awareness of clinicians and researchers in critical care clinical practice and research.

The phenotype of delirium based on a close reading of diagnostic criteria

OBJECTIVE

Although delirium is well known to acute care clinicians, the features required for its diagnosis and how to understand and operationalize them remain sticking points in the field. To clarify the delirium phenotype, we present a close reading of past and current sets of delirium diagnostic criteria.

METHODS

We first differentiate the delirium syndrome (i.e., features evaluated at bedside) from additional criteria required for diagnosis. Next, we align related features across diagnostic systems and examine them in context to determine intent. Where criteria are ambiguous, we review common delirium instruments to illustrate how they have been interpreted.

RESULTS

An acute disturbance in attention is universally attested across diagnostic systems. A second core feature denotes confusion and has been included across systems as disturbance in awareness, impaired consciousness, and thought disorganization. This feature may be better understood as a disturbance in thought clarity and operationalized in terms of neuropsychological domains thereby clearly linking it to global neurocognitive disturbance. Altered level of activity describes a third core feature, including motor and sleep/wake cycle disturbances. Excluding stupor (wherein mental content cannot be assessed due to reduced arousal) from delirium, as in DSM-5-TR, is appropriate for a psychiatric diagnosis, but the brain injury exclusion in ICD-11 is unjustified.

CONCLUSIONS

The delirium phenotype involves a disturbance in attention, qualitative thought clarity, and quantitative activity level, including in relation to expected sleep/wake cycles. Future diagnostic systems should include a severity threshold and specify that delirium diagnosis refers to a 24-h period.

Natural language processing diagnosed behavioural disturbance phenotypes in the intensive care unit: characteristics, prevalence, trajectory, treatment, and outcomes

BACKGROUND

Natural language processing (NLP) may help evaluate the characteristics, prevalence, trajectory, treatment, and outcomes of behavioural disturbance phenotypes in critically ill patients.

METHODS

We obtained electronic clinical notes, demographic information, outcomes, and treatment data from three medical-surgical ICUs. Using NLP, we screened for behavioural disturbance phenotypes based on words suggestive of an agitated state, a non-agitated state, or a combination of both.

RESULTS

We studied 2931 patients. Of these, 225 (7.7%) were NLP-Dx-BD positive for the agitated phenotype, 544 (18.6%) for the non-agitated phenotype and 667 (22.7%) for the combined phenotype. Patients with these phenotypes carried multiple clinical baseline differences. On time-dependent multivariable analysis to compensate for immortal time bias and after adjustment for key outcome predictors, agitated phenotype patients were more likely to receive antipsychotic medications (odds ratio [OR] 1.84, 1.35-2.51, p < 0.001) compared to non-agitated phenotype patients but not compared to combined phenotype patients (OR 1.27, 0.86-1.89, p = 0.229). Moreover, agitated phenotype patients were more likely to die than other phenotypes patients (OR 1.57, 1.10-2.25, p = 0.012 vs non-agitated phenotype; OR 4.61, 2.14-9.90, p < 0.001 vs. combined phenotype). This association was strongest in patients receiving mechanical ventilation when compared with the combined phenotype (OR 7.03, 2.07-23.79, p = 0.002). A similar increased risk was also seen for patients with the non-agitated phenotype compared with the combined phenotype (OR 6.10, 1.80-20.64, p = 0.004).

CONCLUSIONS

NLP-Dx-BD screening enabled identification of three behavioural disturbance phenotypes with different characteristics, prevalence, trajectory, treatment, and outcome. Such phenotype identification appears relevant to prognostication and trial design.

Delirium and Delirium Prevention in the Emergency Department

This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.

Knowledge, attitude and practice regarding hypoactive delirium among ICU nurses: A nationwide cross-sectional study

AIMS AND OBJECTIVES

This study aimed to assess the knowledge, attitude and practice (KAP) of intensive care unit (ICU) nurses in patients with hypoactive delirium in China.

BACKGROUND

The presentation of hypoactive delirium is not obvious and tends to be ignored. However, it has a high incidence and can cause critical impairment. Although nurses are the primary caregivers of patients, the evidence of the current status of KAP of hypoactive delirium among ICU nurses is insufficient in China.

DESIGN

The study participants were 2835 ICU nurses from 201 hospitals in 69 cities from 31 provinces in China.

METHODS

The current status of KAP of hypoactive delirium among ICU nurses was determined using a self-reported structured questionnaire, including 52 questions covering general personal information; three dimensions of KAP; and relevant issues. Descriptive analyses of the sample distribution were reported as percentages and medians. The factors were detected using univariate and multivariate analyses. To guide the reporting of the research, a STROBE checklist of cross-sectional studies was used.

RESULTS

Of the 3101 returned questionnaires, 2835 were analyzed. Approximately 64. 94 % and 53. 30 % of them were identified with a positive attitude and appropriate practice, respectively, whereas only 1. 48 % showed a good level of knowledge. The regression analysis showed that age, years of working in the ICU, educational background, professional title, caring for patients with delirium, attending training on hypoactive delirium and hospital grading were significantly associated with their KAP status(P＜005).

CONCLUSIONS

Hypoactive delirium is an ignored entity by nursing professionals, with no definite nursing procedure. This study shows that receiving relevant training is a factor affecting KAP status, indicating that training should be strengthened. Additionally, appropriate screening and nursing procedures should be developed to standardize the behavior of ICU nurses and improve the quality of care.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses have poor knowledge of hypoactive delirium and related training should be strengthened, especially for middle-aged nurses. Screening and nursing procedures should be set up, which is critical to promote nursing practice.

NO PATIENT OR PUBLIC CONTRIBUTION

None.

ICU Delirium in Cardiac Patients

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

Data-driven categorization of postoperative delirium symptoms using unsupervised machine learning

Background

Phenotyping analysis that includes time course is useful for understanding the mechanisms and clinical management of postoperative delirium. However, postoperative delirium has not been fully phenotyped. Hypothesis-free categorization of heterogeneous symptoms may be useful for understanding the mechanisms underlying delirium, although evidence is currently lacking. Therefore, we aimed to explore the phenotypes of postoperative delirium following invasive cancer surgery using a data-driven approach with minimal prior knowledge.

Methods

We recruited patients who underwent elective invasive cancer resection. After surgery, participants completed 5 consecutive days of delirium assessments using the Delirium Rating Scale-Revised-98 (DRS-R-98) severity scale. We categorized 65 (13 questionnaire items/day × 5 days) dimensional DRS-R-98 scores using unsupervised machine learning (K-means clustering) to derive a small set of grouped features representing distinct symptoms across all participants. We then reapplied K-means clustering to this set of grouped features to delineate multiple clusters of delirium symptoms.

Results

Participants were 286 patients, of whom 91 developed delirium defined according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria. Following the first K-means clustering, we derived four grouped symptom features: (1) mixed motor, (2) cognitive and higher-order thinking domain with perceptual disturbance and thought content abnormalities, (3) acute and temporal response, and (4) sleep-wake cycle disturbance. Subsequent K-means clustering permitted classification of participants into seven subgroups: (i) cognitive and higher-order thinking domain dominant delirium, (ii) prolonged delirium, (iii) acute and brief delirium, (iv) subsyndromal delirium-enriched, (v) subsyndromal delirium-enriched with insomnia, (vi) insomnia, and (vii) fit.

Conclusion

We found that patients who have undergone invasive cancer resection can be delineated using unsupervised machine learning into three delirium clusters, two subsyndromal delirium clusters, and an insomnia cluster. Validation of clusters and research into the pathophysiology underlying each cluster will help to elucidate the mechanisms of postoperative delirium after invasive cancer surgery.

Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study

Background

Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear.

Objectives

This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources.

Methods

This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation.

Results

A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores.

Conclusion

Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery

Importance

Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain.

Objective

To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery.

Design, Setting, and Participants

This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022.

Exposures

Gabapentin use within 2 days after surgery.

Main Outcomes and Measures

The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated.

Results

Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons).

Conclusion and Relevance

In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.

How do predisposing factors differ between delirium motor subtypes? A systematic review and meta-analysis

BACKGROUND

Delirium is a common neurocognitive disorder in hospitalised older adults with vast negative consequences. The predominant method of subtyping delirium is by motor activity profile into hypoactive, hyperactive and mixed groups.

OBJECTIVE

This systematic review and meta-analysis investigated how predisposing factors differ between delirium motor subtypes.

METHODS

Databases (Medline, PsycINFO, Embase) were systematically searched for studies reporting predisposing factors (prior to delirium) for delirium motor subtypes. A total of 61 studies met inclusion criteria (N = 14,407, mean age 73.63 years). Random-effects meta-analyses synthesised differences between delirium motor subtypes relative to 22 factors.

RESULTS

Hypoactive cases were older, had poorer cognition and higher physical risk scores than hyperactive cases and were more likely to be women, living in care homes, taking more medications, with worse functional performance and history of cerebrovascular disease than all remaining subtypes. Hyperactive cases were younger than hypoactive and mixed subtypes and were more likely to be men, with better cognition and lower physical risk scores than all other subtypes. Those with no motor subtype (unable to be classified) were more likely to be women and have better functional performance. Effect sizes were small.

CONCLUSIONS

Important differences in those who develop motor subtypes of delirium were shown prior to delirium occurrence. We provide robust quantitative evidence for a common clinical assumption that indices of frailty (institutional living, cognitive and functional impairment) are seen more in hypoactive patients. Motor subtypes should be measured across delirium research. Motor subtyping has great potential to improve the clinical risk assessment and management of delirium.

Potential Usefulness of Blood Urea Nitrogen to Creatinine Ratio in the Prediction and Early Detection of Delirium Motor Subtype in the Intensive Care Unit

Prediction and early detection of delirium can improve patient outcomes. A high blood urea nitrogen to creatinine ratio (BCR), which reflects dehydration, has been reported as a risk factor for delirium. Additionally, BCR represents skeletal muscle loss in intensive care unit (ICU) patients, which can have critical implications for clinical outcomes. We investigated whether BCR could be used to predict the occurrence and motor subtype of delirium in ICU patients through a retrospective cohort study that included 7167 patients (50 years or older) admitted to the ICU. Patients were assessed daily using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for ICU and categorized according to the delirium subtype. Participants were split into 10 groups according to BCR at ICU admission and the prevalence of each delirium subtype was compared. Multivariable logistic regression was then used for analysis. A higher BCR at ICU admission was associated with the development of hypoactive delirium. Moreover, BCR > 24.9 was associated with higher rates of hypoactive delirium. Our findings showed that a high BCR at ICU admission was associated with the development of hypoactive delirium, which suggested that BCR could be a potential biomarker for hypoactive delirium in ICU patients.

Structural integrity of the anterior mid-cingulate cortex contributes to resilience to delirium in SuperAging

Despite its devastating clinical and societal impact, approaches to treat delirium in older adults remain elusive, making it important to identify factors that may confer resilience to this syndrome. Here, we investigated a cohort of 93 cognitively normal older patients undergoing elective surgery recruited as part of the Successful Aging after Elective Surgery study. Each participant was classified either as a SuperAger (n = 19) or typically aging older adult (n = 74) based on neuropsychological criteria, where the former was defined as those older adults whose memory function rivals that of young adults. We compared these subgroups to examine the role of preoperative memory function in the incidence and severity of postoperative delirium. We additionally investigated the association between indices of postoperative delirium symptoms and cortical thickness in functional networks implicated in SuperAging based on structural magnetic resonance imaging data that were collected preoperatively. We found that SuperAging confers the real-world benefit of resilience to delirium, as shown by lower (i.e. zero) incidence of postoperative delirium and decreased severity scores compared with typical older adults. Furthermore, greater baseline cortical thickness of the anterior mid-cingulate cortex-a key node of the brain's salience network that is also consistently implicated in SuperAging-predicted lower postoperative delirium severity scores in all patients. Taken together, these findings suggest that baseline memory function in older adults may be a useful predictor of postoperative delirium risk and severity and that superior memory function may contribute to resilience to delirium. In particular, the integrity of the anterior mid-cingulate cortex may be a potential biomarker of resilience to delirium, pointing to this region as a potential target for preventive or therapeutic interventions designed to mitigate the risk or consequences of developing this prevalent clinical syndrome.

Gabapentinoid Use Is Associated With Reduced Occurrence of Hyperactive Delirium in Older Cancer Patients Undergoing Chemotherapy: A Nationwide Retrospective Cohort Study in Japan

BACKGROUND

It is unclear whether gabapentinoids affect the development of delirium. We aimed to determine the association between gabapentinoid use and hyperactive delirium in older cancer patients undergoing chemotherapy.

METHODS

We conducted propensity score-matched analyses using data from a nationwide inpatient database in Japan. We included cancer patients with pain ≥70 years of age undergoing chemotherapy between April 2016 and March 2018. Patients receiving gabapentinoids were matched with control patients using propensity scores. The primary outcome was occurrence of hyperactive delirium during hospitalization, and the secondary outcomes were length of hospital stay, in-hospital fractures, and in-hospital mortality. Hyperactive delirium was identified by antipsychotic use or discharge diagnoses from the International Classification of Diseases, 10th Revision.

RESULTS

Among 143,132 identified patients (59% men; mean age, 76.3 years), 14,174 (9.9%) received gabapentinoids and 128,958 (90.1%) did not (control group). After one-to-one propensity score matching, 14,173 patients were included in each group. The occurrence of hyperactive delirium was significantly lower (5.2% vs 8.5%; difference in percent, -3.2% [95% confidence interval, -3.8 to -2.6]; odds ratio, 0.60 [0.54-0.66]; P < .001), the median length of hospital stay was significantly shorter (6 days [interquartile range, 3-15] vs 9 days [4-17]; subdistribution hazard ratio, 1.22 [1.19-1.25]; P < .001), and the occurrence of in-hospital mortality was significantly lower in the gabapentinoid group than in the control group (1.3% vs 1.8%; difference in percent, -0.6% [-0.9 to -0.3]; odds ratio, 0.69 [0.57-0.83]; P < .001). Gabapentinoid use was not significantly associated with the occurrence of in-hospital fractures (0.2% vs 0.2%; difference in percent, 0.0% [-0.1 to 0.1]; odds ratio, 1.07 [0.65-1.76]; P = .799). The results of sensitivity analyses using stabilized inverse probability of treatment weighting were consistent with the results of the propensity score-matched analyses.

CONCLUSIONS

Our findings suggest that gabapentinoid use is associated with reduced hyperactive delirium in older cancer patients undergoing chemotherapy, with no evidence of an increase in the fracture rate, length of hospital stay, or in-hospital death.

Effect of midazolam on delirium in critically ill patients: a propensity score analysis

Objective

To observe the association between exposure to midazolam within 24 hours prior to delirium assessment and the risk of delirium.

Methods

We performed a systematic cohort study with two sets of cohorts to estimate the relative risks of outcomes among patients administered midazolam within 24 hours prior to delirium assessment. Propensity score matching was performed to generate a balanced 1:1 matched cohort and identify potential prognostic factors. The outcomes included the odds of delirium, mortality, length of intensive care unit stay, length of hospitalization, and odds of being discharged home.

Results

A total of 78,364 patients were included in this study, of whom 22,159 (28.28%) had positive records. Propensity matching successfully balanced covariates for 9348 patients (4674 per group). Compared with no administration of midazolam, midazolam administration was associated with a significantly higher risk of delirium, higher mortality, and a longer intensive care unit stay. Patients treated with midazolam were relatively less likely to be discharged home. There was no significant difference in hospitalization duration.

Conclusions

Midazolam may be an independent risk factor for delirium in critically ill patients.

Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment

Introduction

Postoperative delirium (POD) is a serious complication occurring in 4–53.3% of geriatric patients undergoing surgeries for hip fracture. Incidence of hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in 2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected to increase, POD is also anticipated to increase.

Signficance

Postoperative delirium remains the most common complication of emergency hip fracture surgery leading to high morbidity and mortality rates despite significant research conducted regarding this topic. This study reviews literature from 1990 to 2021 regarding POD in geriatric hip fracture management.

Results

Potentially modifiable and non-modifiable risk factors for developing POD include, but are not limited to, male gender, older age, multiple comorbidities, specific comorbidities (dementia, cognitive impairment, diabetes, vision impairment, and abnormal blood pressure), low BMI, preoperative malnutrition, low albumin, low hematocrit, blunted preoperative cytokines, emergency surgery, time to admission and surgery, preoperative medical treatment, polypharmacy, delirium-inducing medications, fever, anesthesia time, and sedation depth and type. Although the pathophysiology remains unclear, the leading theories suggest neurotransmitter imbalance, inflammation, and electrolyte or metabolic derangements as the underlying cause of POD. POD is associated with increased length of hospital stay, cost, morbidity, and mortality. Prevention and early recognition are key factors in managing POD. Methods to reduce POD include utilizing interdisciplinary teams, educational programs for healthcare professionals, reducing narcotic use, avoiding delirium-inducing medications, and multimodal pain control.

Conclusion

While POD is a known complication after hip fracture surgery, further exploration in prevention is needed. Early identification of risk factors is imperative to prevent POD in geriatric patients. Early prevention will enhance delivery of health care both pre- and post-operatively leading to the best possible surgical outcome and better quality of life after hip fracture treatment.

Distribution of delirium motor subtypes in the intensive care unit: a systematic scoping review

BACKGROUND

Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.

METHODS

This systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model.

RESULTS

We included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0-54.7]), followed by mixed delirium (27.7% [95% CI 24.1-31.3]) and hyperactive delirium (22.7% [95% CI 19.0-26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium.

CONCLUSIONS

Hypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted.

Depressed mood, associated factors, and understanding of delirium among caregivers of patients with delirium

OBJECTIVE

Delirium is stressful for both the patient and caregiver. However, caregivers have attracted minimal attention. We here identify depressed moods and associated factors among caregivers and caregiver knowledge of the delirium and non-pharmacological management.

METHODS

This was a cross-sectional study. Caregiver and patient demographic characteristics, and patient clinical data, were collected. Caregiver depressed mood was analysed using the Hospital Anxiety and Depression Scale-depression subscale (HADS-D). We explored caregiver understanding of delirium and knowledge of non-pharmacological management. We used a multivariate linear regression model to identify factors associated with caregiver depressed mood.

RESULTS

For 224 caregivers, the median (interquartile range) HADS-D score was 8.0 (4.0-11.8). More than half (54.9%) had scores ≥8. Answers to multiple choice questions revealed that delirium was frequently misinterpreted as "anxiety" (25.9%) or "dementia" (25.4%). Of all caregivers, 74% had received no information on non-pharmacological delirium management. Younger age of patient, a longer time from delirium detection to consultation, a patient past history of depression, a spousal relation with the patient, and misinterpretation of delirium as dementia were associated with the depressed mood of caregivers.

CONCLUSIONS

The mental health of caregivers of patients with delirium requires more attention; they should be recommended to be informed and educated about delirium. Also, the clinicians need to find an easier term for the delirium to help caregivers understand.

Individual Pharmacotherapy Management (IPM) - I: a group-matched retrospective controlled clinical study on prevention of complicating delirium in the elderly trauma patients and identification of associated factors

Background

Delirium is one of the most frequent complications in hospitalized elderly patients with additional costs such as prolongation of hospital stays and institutionalization, with risk of reduced functional recovery, long-term cognitive impairment, and increased morbidity and mortality. We analyzed the effect of individual pharmacotherapy management (IPM) in the University Hospital Halle in geriatric trauma patients on complicating delirium and aimed to identify associated factors.

Methods

In a retrospective controlled clinical study of 404 hospitalized trauma patients ≥70 years we compared the IPM intervention group (IG) with a control group (CG) before IPM implementation. Delirium was recorded from the hospital discharge letter. The medication review and data records included baseline data, all medications, diagnoses, electrocardiogram (ECG), laboratory and vital parameters during hospitalization. The IPM internist and the senior trauma physician guaranteed personnel and structural continuity in the implementation of the interdisciplinary patient rounds.

Results

There was a highly matched congruence between CG and IG in terms of age, gender, residency, BMI, most diagnoses, and injury patterns to compare the two groups. The total number of medications per patient was 11.1 ± 4.9 (CG) versus 10.4 ± 3.6 (IG). Our targeted IPM focus on 6 frontline aspects with reduction of antipsychotics, anticholinergic burden, benzodiazepines, serotonergic opioids, elimination of pharmacokinetic and pharmacodynamic drug interactions and overdosage reduced complicating delirium from 5% to almost zero at 0.5%. The association of IPM with a significant 10-fold reduction, OR = 0.09 [95% CI 0.01–0.7], in univariable regression, maintained of clinical relevance in multivariable regression OR = 0.1 [95% CI 0.01–1.1]. Factors most strongly associated with complicating delirium in univariable regression were cognitive dysfunction, nursing home residency, muscle relaxants, antiparkinsonian agents, xanthines, transient disorientation documented in the fall risk scale, antibiotic-requiring infections, antifungals, antipsychotics, and intensive care stay, the two latter maintaining significance in multivariable regression.

Conclusions

IPM is associated with a highly effective prevention of complicating delirium in the elderly trauma patients. For patient safety it should be integrated as an essential preventative contribution. The associated factors help identify patients at risk.

[Predictors of severe lesions of the central nervous system in the treatment of blood system diseases]

OBJECTIVE

To determine the types, frequency and key symptoms of severe lesions of the central nervous system (SLCNS) that occurred in patients with hematological malignancies (HM).

MATERIALS AND METHODS

The authors conducted a retrospective exploratory study by analyzing the data of 3.620 patients with HM during the period from 01.01.18 to 31.12.19. Thirty-four patients (14 men and 20 women, median age 39 years), who developed SLCNS during treatment, were selected. For comparison with the main group of patients and exclusion of predictors associated with the development of SLCNS, a comparison group was added (by Kernel matching method). A comparison group consisted of 137 patients (59 men and 78 women, median age - 36 years) and was similar to the main group by clinical and laboratory characteristics. A neurological complication was marked as SLCNS if it was an indication for transfer to the intensive care unit (ICU). Statistical analysis included multivariate analysis - multiple binary logistic regression with stepwise inclusion of variables (that were found in the preliminary contingency table analysis) in the model, with control false results (by the false discovery rate method) and estimating the odds ratio, OR (95% CI).

RESULTS

SLCNS in patients with HM developed in 0.94% of cases. The main SLCNS in patients with HM were: epileptic seizure (50.0%, n=17), ischemic stroke (20.6%, n=7), hemorrhagic stroke (17.6%, n=6) and meningoencephalitis (11.8%, n=4). The following independent significant (Wald test p≤0.05) predictors associated with the development of SLCNS in patients with HM during inpatient treatment were identified: antibiotic therapy (when more than 5 drugs are prescribed), OR=2.9 (1.2-7, four); polychemotherapy (if more than 4 drugs are prescribed), OR=2.9 (1.1-7.8); thrombocytopenia (with a platelet count less than 50·10⁹ g/l), OR=2.3 (1.0-5.2) and delirium, OR=3.7 (1.3-10.8), and also the presence of neurological disorders in the patient's history, OR=2.6 (1.1-6.3).

CONCLUSION

The main types of SLCNS in patients with HM were: epileptic seizure, ischemic and hemorrhagic strokes, and meningoencephalitis. Four predictors associated with the development of SLCNS in the course of HM treatment were identified: massive antibacterial (with more than 5 drugs) and chemotherapeutic (with more than 4 drugs) effects, thrombocytopenia and manifestation of delirium, as well as one risk factor: a history of neurological disorder. These factors need to be considered and monitored during treatment, because each of them increases the risk of developing SLCNS.

The neuropsychological profile of delirium vulnerability: A systematic review and meta-analysis

Delirium is a common neurocognitive disorder in hospitalised older adults with substantial negative consequences. Impaired global cognition is a well-established delirium risk factor. However, poor performance on attention tests and higher intra-subject variability may be more sensitive delirium risk factors, given the disorder is characterised by a fluctuating course and attentional deficits. We systematically searched databases (Embase, PsycINFO, MEDLINE) and 44 studies satisfied inclusion criteria. Random-effects meta-analysis models showed poor performance in all cognitive domains except perception was significantly associated with incident delirium. Largest effects were for orientation (g=-1.20) and construction and motor performance (g=-0.60). These effects were no longer significant in the subgroup without pre-existing cognitive impairment, where executive functions and verbal functions and language skills were associated with incident delirium. A small, non-significant association between intra-subject variability and incident delirium was found (g=0.42). Cognitive domain specific tests may be quicker and more sensitive predictors of incident delirium. This pattern of neuropsychological findings supports the proposition that vulnerability for delirium manifests as a dysfunction of whole-brain information integration.

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.

Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression

Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.

Delirium in Frail Older Adults

Delirium and frailty are prevalent geriatric syndromes and important public health issues among older adults. The prevalence of delirium among hospitalized older adults ranges from 15% to 75%, while that of frailty ranges from 12% to 24%. The exact pathophysiology of these two conditions has not been clearly identified, although several hypotheses have been proposed. However, these conditions are considered to be multifactorial in etiology and are associated with inflammation related to aging, alterations in vascular systems, genetics, and nutritional deficiency. Furthermore, clinically, they are significantly associated with frailty, which increases the risk of delirium by almost two- to three-fold among hospitalized older adults. With their multifactorial etiology and unknown pathophysiology, current evidence supports more practical multicomponent patient-centered approaches to prevent and manage delirium with frailty among hospitalized older adults. These comprehensive and organized bundled approaches can identify high-risk patients with frailty and more effectively manage their delirium.

Biomarkers in delirium: A systematic review

BACKGROUND

Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies.

METHOD

Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles.

RESULTS

2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions.

CONCLUSION

Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.

The complex interaction of genetics and delirium: a systematic review and meta-analysis

The objective is to understand genetic predisposition to delirium. Following PRISMA guidelines, we undertook a systematic review of studies involving delirium and genetics in the databases of Pubmed, Scopus, Cochrane Library and PsycINFO, and performed a meta-analysis when appropriate. We evaluated 111 articles, of which 25 were finally included in the analysis. The studies were assessed by two independent researchers for methodological quality using the Downs and Black Tool and for genetic analysis quality. We performed a meta-analysis of 10 studies of the Apolipoprotein E (APOE) gene, obtaining no association with the presence of delirium (LOR 0.18, 95% CI - 0.10-0.47, p = 0.21). Notably, only 5 out of 25 articles met established criteria for genetic studies (good quality) and 6 were of moderate quality. Seven studies found an association with APOE4, the dopamine transporter gene SCL6A3, dopamine receptor 2 gene, glucocorticoid receptor, melatonin receptor and mitochondrial DNA haplotypes. One genome-wide association study found two suggestive long intergenic non-coding RNA genes. Five studies found no association with catechol-o-methyltransferase, melatonin receptor or several interleukins genes. The studies were heterogenous in establishing the presence of delirium. Future studies with large samples should further specify the delirium phenotype and deepen our understanding of interactions between genes and other biological factors.

Symptom trajectories for palliative care inpatients with and without hyperactive delirium in the last week of life

AIMS

Hyperactive delirium (HD) is a common and distressing symptom among palliative care patients. This study aimed to describe the characteristics of HD and associated symptoms among palliative care inpatients and evaluate relationships between HD development and symptom trajectories in this population.

DESIGN

A retrospective study was conducted.

METHODS

A retrospective review of medical records was conducted for all patients who died in a large Australian specialist palliative care unit between 1 January and 31 December 2019. Patients were assessed daily using the Symptoms Assessment Scale (SAS) and Palliative Care Problem Severity Scale (PCPSS). Multilevel models were used to estimate the differences in symptoms trajectories in the last 7 days of life between the two groups.

RESULTS

Of the 501 included patients, 64.5% (323) had an episode of HD. For 30% (95) of patients, HD occurred prior to admission. Compared with patients without HD, those with HD had significantly higher odds ratios (ORs) for four of the seven SAS symptoms (sleep problems, appetite, fatigue and pain; OR range: 1.94-4.48, p < .05), and all four PCPSS items (OR range: 2.00-3.00, p < .05) in the last week of life.

CONCLUSIONS

Palliative care inpatients commonly experience HD in their last week of life. There are higher levels of symptom distress, complexity, psychological concerns and family/carer concerns among patients with HD compared with those without HD.

IMPACT

The high prevalence of HD, and its association with higher levels of symptom distress, highlights the importance of routine screening and optimal management for HD among palliative care patients. Given the widely recognized challenges facing palliative care professionals in assessment and management of delirium, provision of relevant training among these professionals is recommended.

Association of Hypoactive and Hyperactive Delirium With Cognitive Function After Critical Illness

OBJECTIVES

Delirium, a heterogenous syndrome, is associated with worse long-term cognition after critical illness. We sought to determine if duration of motoric subtypes of delirium are associated with worse cognition.

DESIGN

Secondary analysis of prospective multicenter cohort study.

SETTING

Academic, community, and Veteran Affairs hospitals.

PATIENTS

Five-hundred eighty-two survivors of respiratory failure or shock.

INTERVENTIONS

We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale daily during hospitalization. We defined a day with hypoactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score less than or equal to 0 and a day with hyperactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score greater than 0. At 3 and 12 months, we assessed global cognition with the Repeatable Battery for the Assessment of Neurologic Status and executive function with the Trail Making Test Part B. We used multivariable regression to examine the associations between days of hypoactive and hyperactive delirium with cognition outcomes. We allowed for interaction between days of hypoactive and hyperactive delirium and adjusted for baseline and in-hospital covariates.

MEASUREMENTS AND RESULTS

Hypoactive delirium was more common and persistent than hyperactive delirium (71% vs 17%; median 3 vs 1 d). Longer duration of hypoactive delirium was associated with worse global cognition at 3 (-5.13 [-8.75 to -1.51]; p = 0.03) but not 12 (-5.76 [-9.99 to -1.53]; p = 0.08) months and with worse executive functioning at 3 (-3.61 [-7.48 to 0.26]; p = 0.03) and 12 (-6.22 [-10.12 to -2.33]; p = 0.004) months; these associations were not modified by hyperactive delirium. Hyperactive delirium was not associated with global cognition or executive function in this cohort.

CONCLUSIONS

Longer duration of hypoactive delirium was independently associated with worse long-term cognition. Assessing motoric subtypes of delirium in the ICU might aid in prognosis and intervention allocation. Future studies should consider delineating motoric subtypes of delirium.

Motoric Subtypes of Delirium and Long-Term Functional and Mental Health Outcomes in Adults After Critical Illness

OBJECTIVES

Adult ICU survivors that experience delirium are at high risk for developing new functional disabilities and mental health disorders. We sought to determine if individual motoric subtypes of delirium are associated with worse disability, depression, and/or post-traumatic stress disorder in ICU survivors.

DESIGN

Secondary analysis of a prospective multicenter cohort study.

SETTING

Academic, community, and Veteran Affairs hospitals.

PATIENTS

Adult ICU survivors of respiratory failure and/or shock.

INTERVENTIONS

We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation and Sedation Scale daily during hospitalization. We classified delirium as hypoactive (Richmond Agitation and Sedation Scale ≤ 0) or hyperactive (Richmond Agitation and Sedation Scale > 0). At 3- and 12-month postdischarge, we assessed for dependence in activities of daily living and instrumental activities of daily living, symptoms of depression, and symptoms of post-traumatic stress disorder. Adjusting for baseline and inhospital covariates, multivariable regression examined the association of exposure to delirium motoric subtype and long-term outcomes.

MEASUREMENTS AND MAIN RESULTS

In our cohort of 556 adults with a median age of 62 years, hypoactive delirium was more common than hyperactive (68.9% vs 16.8%). Dependence on the activities of daily living was present in 37% at 3 months and 31% at 12 months, whereas dependence on instrumental activities of daily living was present in 63% at 3 months and 56% at 12 months. At both time points, depression and post-traumatic stress disorder rates were constant at 36% and 5%, respectively. Each additional day of hypoactive delirium was associated with higher instrumental activities of daily living dependence at 3 months only (0.24 points [95% CI, 0.07-0.41; p = 0.006]). There were no associations between the motoric delirium subtype and activities of daily living dependence, depression, or post-traumatic stress disorder.

CONCLUSIONS

Longer duration of hypoactive delirium, but not hyperactive, was associated with a minimal increase in early instrumental activities of daily living dependence scores in adult survivors of critical illness. Motoric delirium subtype was neither associated with early or late activities of daily living functional dependence or mental health outcomes, nor late instrumental activities of daily living functional dependence.

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]

BACKGROUND

Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients.

METHODS

240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium.

DISCUSSION

The findings will inform clinical practice regarding delirium assessment in palliative care settings.

TRIAL REGISTRATION

ISRCTN ISRCTN97417474 (21/02/2020).

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients

OBJECTIVES

To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology.

DESIGN

Cross-sectional study.

SETTING

International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings.

PARTICIPANTS

1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV).

PRIMARY AND SECONDARY OUTCOME MEASURES

Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory.

RESULTS

Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001).

CONCLUSIONS

This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

Delirium in the acute hospital setting: the role of psychiatry

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Association of neurogranin with delirium among critically ill patients

Background: Neurogranin (Ng) concentrates at dendritic spines. In patients with Alzheimer disease Ng levels are elevated. The role of Ng in delirium development has not been assessed, therefore we hypothesized that Ng levels are associated with delirium in critically ill patients. Materials & methods: From 94 critically ill patients, 47 developed delirium and 47 controls were included. Blood was collected during the first 24 h of intensive care unit (ICU) admission, and on the day of delirium diagnoses. Ng and IL-1β were determined. Results: Ng and IL-1β levels were higher in the delirium group at ICU admission and on the day of delirium diagnoses. IL-1β and Ng were independently associated with delirium occurrence. Conclusion: Ng levels are associated with delirium development in ICU patients.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients

Emergence from anesthesia can be associated with a wide spectrum of cognitive and behavioral dysregulation in children, including delirium or acute brain dysfunction. This period of neurobehavioral recovery can be further confounded by pain, anxiety, and fear. The implementation of monitoring for level of consciousness, pain, and delirium using valid pediatric tools is necessary to avoid misdiagnosis due to overlapping symptomatology and support appropriate management. Understanding the epidemiology of delirium in the postoperative setting will require consistent use of accurate terminology in the medical literature. The current interchangeable use of the terms “emergence agitation” and “emergence delirium” needs to be highlighted and awareness of differences in patient conditions and assessment tools is essential. We discuss epidemiology of emergence agitation and delirium in the pediatric population, and the challenges for future delineation of monitoring and management. Furthermore, we describe the possible impact of long-term consequences of emergence delirium among infants and children, and the necessary areas of future research.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses

Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.

Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients

BACKGROUND

Delirium is common in hospitalised patients but its epidemiology remains poorly characterised.

AIMS

To test the hypothesis that patient demographics, clinical phenotype, management and outcomes of patient with delirium in hospital ward patients differ from intensive care unit (ICU) patients.

METHODS

Retrospective cohort of patients admitted to an Australian university-affiliated hospital between March 2013 and April 2017 and coded for delirium at discharge using the International Classification of Diseases System, 10th revision, criteria.

RESULTS

Among 61 032 hospitalised patients, 2864 (4.7%) were coded for delirium. From these, we studied a random sample of 100 ward patients and 100 ICU patients. Ward patients were older (median age: 84 vs 65 years; P < 0.0001), more likely to have dementia (38% vs 2% for ICU patients; P < 0.0001) and less likely to have had surgery (24% vs 62%; P < 0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P < 0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, P < 0.0001). On multivariable analysis, age and dementia predicted persistent delirium, while surgery predicted recovery.

CONCLUSIONS

Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by dementia and is less likely to recover at hospital discharge. Therefore, delirium prevention, detection and goals of care should be adapted to the environment in which it occurs.

Benzodiazepines for treatment of patients with delirium excluding those who are cared for in an intensive care unit

BACKGROUND

Delirium is a very common condition associated with significant morbidity, mortality, and costs. Current critical care guidelines recommend first and foremost the use of nonpharmacological strategies in both the prevention and treatment of delirium. Pharmacological interventions may augment these approaches and they are currently used widely in clinical practice to manage the symptoms of delirium. Benzodiazepines are currently used in clinical practice to treat behavioural disturbances associated with delirium but current guidelines do not recommend their use for this indication. The use of these medicines is controversial because there is uncertainty about whether they are effective for patients or have the potential to harm them.

OBJECTIVES

To assess the effectiveness and safety of benzodiazepines in the treatment of delirium (excluding delirium related to withdrawal from alcohol or benzodiazepines) in any healthcare settings other than intensive care units (ICU).

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register up to 10 April 2019. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, Embase, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmaceutical registries), and grey literature sources.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) conducted in healthcare settings that ranged from nursing homes and long-term care facilities to any hospital setting except for ICUs, involving adult patients with delirium excluding those with delirium related to alcohol or benzodiazepine withdrawal. Included RCTs had to assess the effect of benzodiazepines, at any dose and given by any route, compared with placebo or another drug intended to treat delirium.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We decided whether or not to pool data on the basis of clinical heterogeneity between studies. We used GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods to assess the quality of evidence.

MAIN RESULTS

We identified only two trials that satisfied the selection criteria. We did not pool the data because of the substantial clinical differences between the trials. In one trial, participants (n = 58) were patients in an acute palliative care unit with advanced cancer who had a mean age of 64 years. All of the participants had delirium, were treated with haloperidol, and were randomised to receive either lorazepam or placebo in combination with it. Due to very serious imprecision, all evidence was of low certainty. We were unable to determine whether there were clinically important differences in the severity of delirium (mean difference (MD) 2.10, 95% CI -0.96 to 5.16; n = 50), length of hospital admission (MD 0.00, 95% CI -3.45 to 3.45; n = 58), mortality from all causes (risk ratio (RR) 0.33, 95% CI 0.04 to 3.02; participants = 58) or any of a number of adverse events. Important effects could not be confirmed or excluded. The study authors did not report the length of the delirium episode. In the other trial, participants (n = 30) were patients in general medical wards with acquired immune deficiency syndrome (AIDS) who had a mean age of 39.2 years. Investigators compared three drug treatments: all participants had delirium, and were randomised to receive lorazepam, chlorpromazine, or haloperidol. Very low-certainty evidence was identified, and we could not determine whether lorazepam differed from either of the other treatments in the effect on severity of delirium, any adverse event, or mortality from all causes. The study authors did not report the length of the delirium episode or the length of hospital admission.

AUTHORS' CONCLUSIONS

There is no enough evidence to determine whether benzodiazepines are effective when used to treat patients with delirium who are cared for in non-ICU settings. The available evidence does not support their routine use for this indication. Because of the scarcity of data from randomised controlled trials, further research is required to determine whether or not there is a role for benzodiazepines in the treatment of delirium in non-ICU settings.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.