[3D-CAM Guideline-Conform Translation for German-Speaking Countries]

[Delirium superimposed on dementia : Early detection and treatment]

BACKGROUND

Delirium superimposed on dementia (DSD) is a widespread but often undetected problem. Additional delirium significantly reduces the quality of life in patients with dementia. Awareness of this condition must be increased among professionals to recognize its development at an early stage, distinguish it from dementia and treat it accordingly.

OBJECTIVE

This review describes the current state of diagnostic, preventive, and therapeutic methods in dealing with DSD.

MATERIAL AND METHODS

A comprehensive literature search was conducted in the PubMed database using the terms "dementia", "delirium", "delirium superimposed on dementia" and "DSD". An additional literature search was performed via Google Scholar.

RESULTS

The diagnostic techniques for detecting DSD are currently limited to delirium-only diagnostic tools, such as the confusion assessment method. A multiprofessional screening of high-risk patients on a regular basis is essential for the early detection and prevention of this disease. An interdisciplinary approach is also required for treatment. Pharmacological therapy is indicated when nonpharmacological measures are insufficient or to treat delirium-inducing causes. The focus lies on the mental and physical care of the patient and on the elimination of risk factors for developing DSD.

CONCLUSION

DSD is a serious syndrome, however, there is still no gold standard for diagnosis and treatment. Multicomponent nonpharmacological intervention programs have been shown to reduce the incidence of delirium. Their benefit in DSD must be verified in large multicenter studies.

Increasing preoperative cognitive reserve to prevent postoperative delirium and postoperative cognitive decline in cardiac surgical patients (INCORE): Study protocol for a randomized clinical trial on cognitive training

Introduction

Postoperative delirium (POD) and postoperative cognitive decline (POCD) can be observed after cardiosurgical interventions. Taken together, these postoperative neurocognitive disorders (PNCDs) contribute to increased morbidity and mortality. Preoperative risk factors of PNCD, such as decreased neuropsychometric performance or decreased cognitive daily activities, can be interpreted as reduced cognitive reserve. This study aims to build up cognitive reserves to protect against the development of PNCD through preoperative, home-based, cognitive training.

Methods

The planned research project is a monocentric, two-arm randomized controlled intervention study involving 100 patients undergoing elective cardiac surgery with extracorporeal circulation. Patients will be assigned to a training group or control group. The intervention involves a standardized, paper-and-pencil-based cognitive training that will be performed by the patients at home for ~40 min per day over a preoperative period of 2-3 weeks. The control group will receive neither cognitive training nor a placebo intervention. A detailed assessment of psychological functions will be performed ~2-3 weeks before the start of training, at the end of the training, during hospitalization, at discharge from the acute clinic, and 3 months after surgery. The primary objective of this study is to investigate the interventional effect of preoperative cognitive training on the incidence of POD during the stay in the acute clinic, the incidence of POCD at the time of discharge from the acute clinic, and 3 months after surgery. Secondary objectives are to determine the training effect on objective cognitive functions before the surgery and subjective cognitive functions, as well as health-related quality of life 3 months after surgery.

Discussion

Should it become evident that the use of our cognitive training can both reduce the incidence of POCD and POD and improve health-related quality of life, this intervention may be integrated into a standardized prehabilitation program.

Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design

BACKGROUND

Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment.

METHODS

Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3).

DISCUSSION

Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.

Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis

BACKGROUND

Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU.

AIM

To examine the diagnostic accuracy of delirium screening tools used in the PACU.

METHODS

A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool.

RESULTS

A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU.

CONCLUSION

Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.