The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study

Novel drug targets for delirium based on genetic causality

BACKGROUND

Effective treatment and prevention of delirium remain challenging, largely due to the limited efficiency in identifying and validating drug targets. To address this gap, we performed a systematic Mendelian Randomization (MR) study of the druggable genome to identify potential therapeutic targets for delirium.

METHODS

To identify therapeutic targets for delirium, we conducted MR and colocalization analyses using cis-eQTL data (31,684 blood samples and 1387 brain samples) and genome-wide association study (GWAS) data for delirium (discovery cohort N = 431,880; validation cohort N = 403,037). This approach enabled us to identify annotated druggable gene targets with significant associations with delirium. Additional analyses included phenome-wide association studies (PheWAS), enrichment analyses, protein network construction, drug prediction, molecular docking, and mediation analyses to assess the therapeutic and clinical relevance of these targets.

RESULTS

Five genes were identified as significant therapeutic targets for delirium: C4BPA, A2M, GRIK4, and C1R from blood samples, and SUMF1 from both blood and brain tissues. These genes are biologically significant for their strong association with immune function. At the gene level, PheWAS identified associations between C4BPA and other traits. Molecular docking demonstrated strong binding between drugs and proteins with available structural data. Mediation analysis revealed that C4BPA explained 16.7 % of the aging-related risk for delirium.

CONCLUSION

Our MR analysis identifies 5 potential druggable targets for the treatment of delirium. Drugs targeting these genes are more likely to succeed in clinical trials and are expected to prioritize the development of delirium treatments while reducing drug development costs.

Delirium prevalence and management in general wards, emergency departments, rehabilitation centres and nursing homes in Germany, Austria and Switzerland (DACH countries): A secondary analysis of a worldwide point prevalence study

Background

Delirium is a common neuropsychiatric syndrome associated with an increased risk of mortality and length of stay. Current delirium prevalence, assessments and management practices of delirium in DACH countries are unknown.

Objective

To examine the delirium point prevalence, assessment, management practices in general wards, emergency departments, rehabilitation centres and nursing homes in DACH countries.

Design

Secondary data analysis from a prospective, cross-sectional, worldwide one-day point delirium prevalence study (registered in the German Registry for Clinical Trials, DRKS00030002).

Settings

General hospital wards, emergency departments, rehabilitation centres and nursing homes excluding operating rooms, ambulatory, high acuity, intermediate care and intensive care units.

Participants

In total, 172 wards (majority were general wards; 91.3 %, n = 157) from Germany, Austria and Switzerland participated.

Methods

Descriptive analysis of a 39-questions online survey with aggregated routine patient and facility data completed by healthcare professionals, administrators, and researchers on World Delirium Awareness Day, March 15th, 2023. Data on delirium prevalence were collected at 8:00 A.M. and P.M. (± 4 h). Use of delirium assessments, delirium awareness structures, presence of care protocols, and barriers to delirium management structures were reported.

Results

Overall delirium prevalence was 7.1 % (n = 143/2,028) at 8:00 A.M. and 7.2 % (n = 133/1,842) at 8:00 P.M. There was no statistically significant difference between the delirium prevalence assessed with valid (p = .770) or non-valid assessment (p = .643). The most frequent delirium assessments were the Nursing Delirium Screening Scale (16.3 %, n = 28/172), the Confusion Assessment Method (15.7 %, n = 27/172) and the Delirium Observation Screening Scale (9.3 %, n = 16/172). The most reported interventions to provide delirium awareness and education were "delirium is mentioned in handovers" (53.5 %, n = 92/172), "availability of delirium experts" (51.2 %, n = 88/172) and "delirium education during the last year" (48.3 %, n = 83/172). An existing delirium management protocol was present in 76.7 % (n = 132/172) of participating wards. The most frequently reported barriers to delirium care were "shortage of staff" (45.3 %, n = 78/172), "patients who are difficult to assess" (32.6 %, n = 56/172), and "communication gaps between professions" (29.1 %, n = 50/172). As non-pharmacological interventions, "mobilization" (92.4 %, n = 159/172), "pain management" (87.8 %, n = 151/172), and "adequate fluids" (83.7 %, n = 144/172) were mostly reported.

Conclusions

Delirium is a frequent complication in patients in DACH countries. More than three quarter of participating wards reported a delirium management protocol suggesting awareness of published guidelines and best practice recommendations. Improved staffing, education on delirium assessment, and interprofessional communication could be helpful to improve the usage of valid delirium assessments and addressing barriers to delirium management.

Outcomes associated with older patients who present or develop delirium in the emergency department: protocol for a systematic review and meta-analysis

INTRODUCTION

Delirium is commonly observed in older patients who are admitted to the emergency department (ED). Previous systematic reviews have identified poor outcomes associated with delirium in surgical, intensive care and other hospital settings, yet none have specifically considered the ED. This systematic review aims to examine associations between older patients who present or develop delirium in the ED and adverse outcomes within the hospital and after discharge.

METHODS AND ANALYSIS

Searches will be conducted in MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. There will be no date or language restrictions. Key terms will include concepts related to delirium, the ED and older adults. Observational studies or non-intervention clinical studies will be included that compare outcomes in older patients (ie, ≥65 years) with and without delirium. Outcomes of interest will include length of hospital stay, non-home discharge (eg, nursing home/residential aged care facility), cognitive impairment, decreased physical function, mortality, readmission to hospital and quality of life measures. Two reviewers will independently screen the studies. Data extraction and quality assessment will be extracted by one reviewer and checked by a second reviewer, with any disagreements resolved by discussion or by a third reviewer. Where appropriate, data will be combined in a meta-analysis and a GRADE assessment will be made for each outcome. All methods will be guided by the Cochrane Handbook and the Centre for Reviews and Dissemination and reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis statement as well as the recommendations set out by the Meta-analysis Of Observational Studies in Epidemiology group.

ETHICS AND DISSEMINATION

As this systematic review will use published data, ethical approval is not required. The results will be disseminated through a peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42024594975.

Neurological Orientation and Verbal Assessment of Delirium-Hospital Clinical Decision Support Tool

IMPORTANCE

Delirium is a complex medical condition that is underdiagnosed. We present findings of a novel electronic medical record (EMR) clinical decision support tool called the Neurologic, Orientation and Verbal Assessment of Delirium (NOVAD) that can optimize delirium identification and management. In this retrospective observational study, we report the performance of NOVAD as a clinical decision support tool for delirium.

OBJECTIVE

We present an innovative EMR based clinical decision support tool for delirium called NOVAD. NOVAD utilizes variables from nursing assessments that are documented in EMR consistently and accurately. We aim to study the NOVAD (sensitivity, specificity, and predictive value) ability in detecting delirium among hospitalized adults and assess its potential as a clinical decision support tool for delirium.

DESIGN

A retrospective observational study of consecutive hospital admissions to Banner Health System between January 1, 2020, and December 31, 2020. 464,395 participants were included in this study. The mean age of study participants was 56.18 years (SD 20.82), with 56.2% women (n = 260,856).

RESULTS

NOVAD was 86.6% sensitive (95% CI 86.5, 86.7) and 78.1% specific (95% CI: 77.9, 78.2) based on ICD-10 diagnosis codes for delirium. The positive predictive value for NOVAD was 33.5% (95% CI 33.3, 33.6) and the negative predictive value was 97.8% (95% CI 97.8, 97.9).

CONCLUSIONS AND RELEVANCE

We demonstrate that an innovative EMR tool that leverages nursing assessments, NOVAD, has the potential to be used as a clinical tool to predict and screen for delirium in hospitalized adults.

Lipid dysregulation and delirium in older adults: A review of the current evidence and future directions

Delirium is a complex medical condition marked by acute episodes of cognitive dysfunction and behavioral disturbances, with a multifaceted etiology and challenging management across various clinical settings. Older adults, particularly in postoperative contexts, are at increased risk of developing delirium. Despite extensive research, a single underlying pathophysiological mechanism for delirium remains elusive. However, emerging evidence suggests a correlation between lipid dysregulation and delirium development in elderly patients, especially in postoperative settings. This connection has led to proposed treatments targeting dyslipidemia and associated neuroinflammatory effects in acute-phase delirium. This review aims to synthesize current literature on the relationship between lipid dysregulation and delirium in older adults, highlighting the need for further research into specific neurolipidome constituents and age-related lipid profile changes, potentially uncovering novel therapeutic strategies for delirium.

The Therapeutic Hub: A Person-Centered Approach to Age-Friendly Care

ABSTRACT

Providing age-friendly care to hospitalized older adults is critical to achieving favorable outcomes. The Therapeutic Hub is a space at an acute care level 1 trauma center in which nurses and other staff utilize the 4Ms of an Age-Friendly Health System framework to offer multisensory stimulation and comfort to older patients, with the aim of preventing cognitive and functional decline, agitation, and delirium. Individualized nonpharmacological therapeutic interventions are delivered through relationship-centered care. This article outlines the 4Ms (Mobility, Mentation, Medication, and What Matters), addresses barriers to implementing age-friendly care, and describes the Therapeutic Hub and its positive impact on patient outcomes.

Development of a checklist for systematic screening of precipitating factors in older patients admitted to hospital with delirium

OBJECTIVES

Causes of delirium are often multiple in older people and a significant number of them are missed at the initial assessment. We wanted to develop a checklist to help clinicians to systematically screen for the most frequent and important causes of delirium in this population.

METHODS

Three investigators, based on previous studies, drafted three possible checklist base models, comprising 18-29 items. A panel of 12 experts voted to choose one of the models, and then followed a modified Delphi consensus method to review each item and further develop the checklist. The consensus checklist was then tested in a small group of patients. The target population was older patients with delirium arriving to the emergency department or to a medical hospital ward.

RESULTS

The longest of the three drafts was unanimously chosen by the panel. After three rounds, a consensus was reached and a final checklist agreed. It is composed by 27 items organized in five groups of causes: infections, hydro-electrolytic disturbances, drugs, acute neurological conditions, and other acute diseases. A pilot study conducted by 15 physicians in 21 consecutive patients showed that the checklist was easy to complete, quick (mean 4 min) and most clinicians, though it helped them through the initial diagnostic work.

CONCLUSIONS

We have developed and pilot tested a checklist for screening for acute precipitants of delirium in older patients, aimed to facilitate early recognition and treatment of the multiple causes that often coexists in this population.

Comparison of the efficacy of pharmacological interventions for the prevention of delirium: A systematic review and network meta-analysis

BACKGROUND

In recent years, many pharmacological agents for the prevention of delirium have emerged; however, the efficacy of these agents in preventing delirium remains unclear.

OBJECTIVE

To compare and rank the efficacy of different pharmacological interventions for the prevention of delirium.

DESIGN

A systematic review and network meta-analysis.

METHODS

Relevant randomized controlled trials on drug prevention of delirium were extracted from three electronic databases. A network meta-analysis was then conducted to assess the relative efficacy of drug interventions in preventing delirium. The quality of the data was evaluated using the Cochrane Risk of Bias tool.

RESULTS

A total of 80 randomized controlled trials on drug interventions were included in the final analysis. Treatment with dexmedetomidine can prevent delirium.

CONCLUSION

Dexmedetomidine treatment can prevent delirium and reduce patient suffering. Healthcare professionals should be encouraged to use dexmedetomidine for delirium prevention.

Psychometric properties of the Chinese version of difficulty scale for nurses who care for patients with delirium in the intensive care unit

BACKGROUND

Intensive Care Unit (ICU) nurses experience many difficulties and challenges in caring for delirium patients. Identifying and measuring these difficulties experienced by nurses is critical for implementing precise interventions. We currently lack a standard tool for assessing the level of difficulty faced by ICU nurses in caring for delirium patients that fits the nursing context in China. This study aimed to translate the Difficulty Scale for Nurses who Care for Patients with Delirium in the Intensive Care Unit (DSNCPD-ICU) into Chinese (C-DSNCPD-ICU) and psychometrically validate the translated scale.

METHODS

The English version of DSNCPD-ICU consisted of a main scale with eight factors and an additional scale of one factor. It was translated in strict accordance with Brislin's translation model to yield the Chinese versions. Using a convenience sampling method, 477 ICU nurses from ten general hospitals were recruited for online survey, which collected sociodemographic information, scores on C-DSNCPD-ICU and the Strain of Care for Delirium Index. Subsequent psychometric attributes of the C-DSNCPD-ICU were also tested by the validity and reliability.

RESULTS

There were 437 valid responses. The content validity index was calculated as 0.96. Cronbach's alpha for the total scale and each factor were 0.919 and 0.705-0.878, respectively. Exploratory factor analysis verified an eight-factor scale and an additional scale structure with cumulative variance contributions of the factors of 63.78% and 57.62%, respectively. Confirmatory factor analysis showed that all data-model fits were acceptable.

CONCLUSIONS

The C-DSNCPD-ICU validated in this study showed satisfactory psychometric properties. This will help Chinese nurse managers to accurately assess the degree of difficulty and identify the causes of precise barriers in caring for patients with delirium. Using the scale, nurse managers can determine what kind of measures should be taken, including formulating effective and tailored educational programs and providing more resources to support nurses.

The effect of dexamethasone on the prevalence of delirium in older COVID-19 patients: a retrospective cohort study

PURPOSE

Corticosteroids decrease mortality in patients with COVID-19 in need of oxygen therapy. However, corticosteroids are known to increase the risk of delirium in older patients. We studied whether dexamethasone increased the risk of delirium in older patients hospitalized with COVID-19.

METHODS

Single centre, retrospective cohort study including patients ≥ 70 years hospitalized in a large teaching hospital with COVID-19 during the first (control group) and second wave (dexamethasone group, receiving dexamethasone) of the COVID-19 pandemic. Only patients on regular (non-ICU) wards were included. Delirium was defined as having a mean delirium observation screening (DOS)-score of ≥ 3 or having an altered mental state on day 3 of admission.

RESULTS

We included 233 patients. The mean age in the dexamethasone group was 78.83 years [SD 6.5] compared to 79.43 years [SD 6.3] in the control group. In the dexamethasone group (n = 114), less patients developed delirium compared to the control group (n = 119) on day 3 of admission (5.3% vs 15.1%; p = 0.01). The Odds ratio of dexamethasone use for delirium was 0.23 (95% CI 0.08-0.64).

CONCLUSION

In this study, dexamethasone did not increase the risk of delirium in older patients with COVID-19.

Prediction of postoperative delirium by blood metabolome analysis

No established blood markers can preoperatively predict postoperative delirium. Blood concentrations of amino acid catabolites and dipeptides, including those secreted extracellularly during T-lymphocyte activation, were investigated as predictors of postoperative delirium using metabolomic analyses to ascertain whether preoperative blood metabolites could predict postoperative delirium. Eighteen and 24 participants were included in the delirium and non-delirium groups, respectively. Higher preoperative levels of amino acid (tryptophan) catabolites, via the indoleamine 2,3-dioxygenase pathway, were observed in the delirium group and identified as potential predictors of postoperative delirium in this study. The delirium group had preoperatively elevated levels of tryptophan catabolites and only a limited increase postoperatively, suggesting that the tryptophan catabolic pathway may be activated preoperatively in patients at high risk of delirium. Non-targeted metabolomic analysis found a set of preoperatively elevated γ-glutamyl dipeptides as potential predictors of postoperative delirium. In vitro experiments showed that T-cell-receptor stimulation increases tryptophan metabolism and specific γ-glutamyl dipeptide secretion, offering a possible explanation for the increased levels of metabolites in postoperative delirium. This study showed that levels of amino acid metabolites associated with blood immune activity may have the potential to predict postoperative delirium.

Small vessel disease contributions to acute delirium: a pilot feasibility MRI study

BACKGROUND AND AIMS

Delirium carries an eight-fold risk of future dementia. Small vessel disease (SVD), best seen on magnetic resonance imaging (MRI), increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability and prevalence of SVD lesions in delirium.

METHODS

This case-control feasibility study performed MRI (3D T1/T2-weighted), fluid-attenuated inversion recovery, susceptibility-weighted and diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS) and cognition. We excluded acute stroke, agitation necessitating sedation, mobility assistance of >2 and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts and SVD features. Six months later, we recorded CFS and cognitive diagnoses.

RESULTS

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 min. MRI was well tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). Also, 4/20 had early scan termination, but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (30%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (30%) without delirium (2/10 small subcortical; 1/10 cortical). Mean white matter hyperintensity Fazekas score was 6 in delirium versus 4.5 without.

CONCLUSIONS

MRI is feasible, usable and tolerable in delirium, and we detected DWI-hyperintense lesions in one-third of all study participants, regardless of delirium status. This study indicates acute vascular contributions, including SVD, to both delirium- and non-delirium-related presentations, supporting the need for larger studies.

Delirium is a Potential Predictor of Unfavorable Long-term Functional Outcomes in Patients with Acute Ischemic Stroke: A Prospective Observational Study

Purpose

Delirium is an acute fluctuating impairment of attention and awareness, common in acute ischemic stroke (AIS). This study aimed to evaluate the prognostic significance of delirium for neurological function at 3 months post-stroke, and develop a predictive model integrating delirium and biomarkers to enhance prognostic accuracy.

Methods

We conducted a prospective cohort study of patients admitted to the stroke unit (n=722). All patients were screened for daily delirium during clinical care. Plasma biomarkers were measured within 24 hours after admission. The main outcomes were evaluated with the 3-months modified Rankin Scale (mRS).

Results

Delirium developed in 10.2% of patients during the acute phase of stroke. Patients with post-stroke delirium (PSD) was significantly older (median age 74 vs 68 years, P<0.001), more likely to have pre-stroke cognitive impairment (14.9% vs 4.8%, P=0.001), a higher prevalence of cardiovascular history (35.1% vs 16.2%, P<0.001). PSD was also associated with higher scores of NIHSS (14.3 vs 9.1, P<0.001) and greater scores of mRS (3.0 vs 1.5, P<0.001) at admission. PSD patients showed worse outcomes, with elevated NIHSS and mRS scores at discharge and 3-month follow-up, as well as higher mortality rates (5.4% vs 1.4%, P=0.025). Biomarker analysis revealed increased plasma levels of inflammatory (white blood cells, neutrophils, C-reactive protein) and coagulation biomarkers (fibrinogen, D-dimer) in PSD patients, particularly those with poorer outcomes (P<0.01). Our model, which incorporated delirium and biomarkers of inflammation and coagulation dysfunction, demonstrated strong predictive accuracy for adverse outcomes at 3 months with an AUC of 0.779 (95% CI=0.736-0.822), with clinical utility confirmed by decision curve analysis.

Conclusion

PSD is a strong independent predictor of poor 3-month outcomes in AIS, including higher mortality and disability. Our findings highlight the critical role of inflammation and coagulation dysfunction in the pathogenesis of PSD. Furthermore, we present the clinical utility of a predictive model integrating delirium and relevant biomarkers to assess the risk of adverse outcomes at 3 months, suggesting potential targets for intervention.

A Cross-Sectional Study of Online Survey Respondents' Knowledge and Attitudes Toward Delirium

BACKGROUND

Delirium affects approximately a quarter of hospitalized adults and is associated with higher mortality, cognitive decline, and prolonged hospitalizations. Patient and caregiver education may improve outcomes. However, limited literature exists on the general public's current understanding of this condition.

OBJECTIVE

To assess knowledge and attitudes toward delirium via an online convenience sample.

DESIGN

Cross-sectional survey using Amazon's Mechanical Turk between October 2023 and January 2024.

PARTICIPANTS

Adults 18 years old and older, living in the USA, and fluent in English.

MAIN MEASURES

We assessed delirium knowledge using a 15-question knowledge assessment covering three categories (risk factors, symptoms, and management). We compared mean scores between knowledge categories using one-way analysis of variance (ANOVA). We used univariate and multivariate logistic regression models to identify demographics associated with low delirium knowledge scores.

KEY RESULTS

Among 397 respondents, 52% were male, 67% were White, and the median age was 44.6 (IQR 36-52). Participants reported living in 43 states. Participants answered 59% (SD 14.8) of knowledge questions correctly; respondents performed highest within the risk factor category (74%, SD 19.6) and lowest in management (47%, SD 21.1), p = <0.01. Few knew that bedrest is not recommended for delirium and that symptoms do not develop gradually (18% and 25%, respectively). Most (83%) agreed that more patient and caregiver education on delirium is needed. In multivariate analysis, individuals with higher incomes were less likely to score in the lowest quartile compared to those earning under $50K (e.g., OR 0.60 for persons earning $50-100K, 95% CI 0.29-0.91). Finally, low self-confidence in delirium knowledge was not associated with low knowledge scores.

CONCLUSIONS

Respondents had misconceptions about delirium that could be addressed in future educational initiatives, including the importance of early mobilization. Further work is needed to characterize what types of knowledge are valued by patients and caregivers and are critical to facilitating engagement.

Application of machine learning for delirium prediction and analysis of associated factors in hospitalized COVID-19 patients: A comparative study using the Korean Multidisciplinary cohort for delirium prevention (KoMCoDe)

BACKGROUND

The incidence of delirium in hospitalized coronavirus disease 2019 (COVID-19) patients is linked to adverse health outcomes. Predicting the occurrence and risk factors of delirium is key to preventing its sudden onset.

AIMS

To explore the factors associated with delirium in hospitalized COVID-19 patients and to compare the performance of various machine learning (ML) techniques for future use in predicting delirium.

METHODS

We analyzed a dataset of 1,031 cases from two healthcare centers, which included 178 variables such as demographics, clinical data, and medication information. The ML techniques used in this study were extreme gradient boosting (XGB), light gradient boosting machine (LGBM), logistic regression (LR), random forest (RF), and support vector machine (SVM).

RESULTS

The RF model emerged as the most effective for predicting delirium, achieving an area under the curve (AUC) of 0.923. It showed a sensitivity of 0.639, accuracy of 0.900, specificity of 0.934, positive predictive value (PPV) of 0.561, negative predictive value (NPV) of 0.952, and an F1 score of 0.597. The RF model identified key variables related to delirium, including medication type (antipsychotic, sedative, opioid), duration of hospital stay, remdesivir usage, and patient age. The reliability of the model was affirmed through calibration plots and Brier score evaluations.

CONCLUSIONS

This research developed and validated an RF-based ML model for predicting delirium in hospitalized COVID-19 patients. The model demonstrates superior accuracy and reliability compared to other ML methods and would possibly serve as a valuable tool for managing and anticipating delirium in COVID-19 patients, with the potential to enhance patient outcomes.

Delirium assessment, management and barriers to effective care across Scotland: A secondary analysis of survey data from World Delirium Awareness Day 2023

INTRODUCTION

Delirium is a common, severe neuropsychiatric syndrome in hospitalised older adults. We evaluated use of validated delirium assessment tools, adherence to national guidelines and prevalence and management of delirium across Scotland, identifying barriers to effective care.

METHODS

Secondary analysis of national survey data, collected by participating clinicians on World Delirium Awareness Day (15 March 2023).

RESULTS

Among 120 responses (3,257 patients), the 4AT was the most frequently used assessment tool (75%), while 14% of units reported using clinical judgement alone. The delirium assessment rate was 74%, with a prevalence of 22% at 8 am. Management protocols varied, with frequent routine non-pharmacological interventions including pain management (88%), hydration (87%) and open family visiting (80%). Barriers to delirium care included insufficient staffing and training.

CONCLUSION

While many hospital settings follow national delirium guidelines, some still rely on clinical judgement for assessment, with variability in management protocols and practices. We have highlighted key barriers to effective delirium care in Scotland.

Prevalence, risk factors and impact of delirium in adult inpatients in a tertiary care hospital: A point prevalence study

AIMS

To describe the point prevalence, risk factors and possible outcomes of delirium in inpatients.

DESIGN

A cross-sectional point prevalence study.

BACKGROUND

Delirium is an acute brain syndrome that negatively affects patients, healthcare professionals and institutions alike; it is common in inpatient settings and is preventable in about one third of cases. Although guidelines recommend systematic screening and assessment, delirium is often unrecognised, undiagnosed and uncoded. There is a lack of valid data on this patient safety indicator in German-speaking countries.

METHODS

The study was conducted in a tertiary care hospital in Switzerland on 5 July 2022. Specially trained registered nurses collected data from all patients meeting the inclusion criteria using CAM, ICDSC or mCAM-ED. Data were analysed descriptively with stratification by delirium status, setting and surgery.

RESULTS

The point prevalence across all settings was 6.9% (27/390), with large variation between settings: ICU 28.6% (4/14), IMC 28.0% (7/25), wards 4.6% (15/326) and ED 4% (1/25). Surgical patients were almost twice as likely to be affected as medical patients (8.9% vs. 4.8%). Patients with delirium differed most clearly from those without by having a larger number of ICD-10 F-diagnoses, a larger number of medications and higher age, which are known risk factors. Moreover, those with delirium had more missed diagnoses, increased mortality, more adverse events and higher costs.

CONCLUSIONS

A significant number of patients experienced delirium and adverse clinical outcomes. Missed delirium diagnoses may further jeopardise patient safety and result in lost revenue. It remains unclear to what extent the risk factors and effects of delirium are causal and what determinants underlie missed diagnoses.

RELEVANCE TO CLINICAL PRACTICE

Consistent identification of high-risk patients and treatment settings with elevated risk, accompanied by the implementation of effective preventive and management strategies, is critical to addressing delirium.

Evaluation of the Quality of Delirium Website Content for Patient and Family Education: Cross-Sectional Study

BACKGROUND

Patients and families who have experienced delirium may seek information about delirium online, but the quality and reliability of online delirium-related websites are unknown.

OBJECTIVE

This study aimed to identify and evaluate online delirium-related websites that could be used for patient and family education.

METHODS

We searched Microsoft Bing, Google, and Yahoo using the keywords "delirium" and the misspelled "delerium" to identify delirium-related websites created to inform patients, families, and members of the public about delirium. The quality of identified delirium-related website content was evaluated by 2 authors using the validated DISCERN tool and the JAMA (Journal of the American Medical Association) benchmark criteria. Readability was assessed with the Simple Measure of Gobbledygook, the Flesch Reading Ease score, and the Flesch Kincaid grade level. Each piece of website content was assessed for its delirium-related information using a checklist of items co-designed by a working group, which included patients, families, researchers, and clinicians.

RESULTS

We identified 106 websites targeted toward patients and families, with most hospital-affiliated (21/106, 20%) from commercial websites (20/106, 19%), government-affiliated organizations (19/106, 18%), or from a foundation or advocacy group (16/106, 15%). The median time since the last content update was 3 (IQR 2-5) years. Most websites' content (101/106, 95%) was written at a reading level higher than the recommended grade 6 level. The median DISCERN total score was 42 (IQR 33-50), with scores ranging from 20 (very poor quality) to 78 (excellent quality). The median delirium-related content score was 8 (IQR 6-9), with scores ranging from 1 to 12. Many websites lacked information on the short- and long-term outcomes of delirium as well as how common it is. The median JAMA benchmark score was 1 (IQR 1-3), indicating the quality of the websites' content had poor transparency.

CONCLUSIONS

We identified high-quality websites that could be used to educate patients, families, or the public about delirium. While most delirium-related website content generally meets quality standards based on DISCERN and JAMA benchmark criteria, high scores do not always ensure patient and family-friendliness. Many of the top-rated delirium content were text-heavy and complex in layout, which could be overwhelming for users seeking clear, concise information. Future efforts should prioritize the development of websites with patients and families, considering usability, accessibility, and cultural relevance to ensure they are truly effective for delirium education.

Predictive Validity of Hospital-Associated Complications of Older People Identified Using Diagnosis Procedure Combination Data From an Acute Care Hospital in Japan: Observational Study

BACKGROUND

A composite outcome of hospital-associated complications of older people (HAC-OP; comprising functional decline, delirium, incontinence, falls, and pressure injuries) has been proposed as an outcome measure reflecting quality of acute hospital care. Estimating HAC-OP from routinely collected administrative data could facilitate the rapid and standardized evaluation of interventions in the clinical setting, thereby supporting the development, improvement, and wider implementation of effective interventions.

OBJECTIVE

This study aimed to create a Diagnosis Procedure Combination (DPC) data version of the HAC-OP measure (HAC-OP-DPC) and demonstrate its predictive validity by assessing its associations with hospital length of stay (LOS) and discharge destination.

METHODS

This retrospective cohort study acquired DPC data (routinely collected administrative data) from a general acute care hospital in Tokyo, Japan. We included data from index hospitalizations for patients aged ≥65 years hospitalized for ≥3 days and discharged between July 2016 and March 2021. HAC-OP-DPC were identified using diagnostic codes for functional decline, incontinence, delirium, pressure injury, and falls occurring during the index hospitalization. Generalized linear regression models were used to examine the associations between HAC-OP-DPC and LOS, and logistic regression models were used to examine the associations between HAC-OP-DPC and discharge to other hospitals and long-term care facilities (LTCFs).

RESULTS

Among 15,278 patients, 3610 (23.6%) patients had coding evidence of one or more HAC-OP-DPC (1: 18.8% and ≥2: 4.8%). Using "no HAC-OP-DPC" as the reference category, the analysis showed a significant and graded association with longer LOS (adjusted risk ratio for patients with one HAC-OP-DPC 1.29, 95% CI 1.25-1.33; adjusted risk ratio for ≥2 HAC-OP-DPC 1.97, 95% CI 1.87-2.08), discharge to another hospital (adjusted odds ratio [AOR] for one HAC-OP-DPC 2.36, 95% CI 2.10-2.65; AOR for ≥2 HAC-OP-DPC 6.96, 95% CI 5.81-8.35), and discharge to LTCFs (AOR for one HAC-OP-DPC 1.35, 95% CI 1.09-1.67; AOR for ≥2 HAC-OP-DPC 1.68, 95% CI 1.18-2.39). Each individual HAC-OP was also significantly associated with longer LOS and discharge to another hospital, but only delirium was associated with discharge to LTCF.

CONCLUSIONS

This study demonstrated the predictive validity of the HAC-OP-DPC measure for longer LOS and discharge to other hospitals and LTCFs. To attain a more robust understanding of these relationships, additional studies are needed to verify our findings in other hospitals and regions. The clinical implementation of HAC-OP-DPC, which is identified using routinely collected administrative data, could support the evaluation of integrated interventions aimed at optimizing inpatient care for older adults.

Long-Term Impact of Delirium on the Risk of Dementia in Hospitalized Older Patients: A Real-World Multicenter Study

BACKGROUND

The association between delirium and dementia has been suggested, but mostly in the postoperative setting. This study aims to explore this relationship in a broader inpatient population, leveraging extensive real-world data to provide a more generalized understanding.

METHODS

In this retrospective cohort study, electronic health records of 11,970,475 hospitalized patients aged over 60 from nine institutions in South Korea were analyzed. Patients with and without delirium were identified, and propensity score matching (PSM) was used to create comparable groups. A 10-year longitudinal analysis was conducted using the Cox proportional hazards model, which calculated the hazard ratio (HR) and 95% confidence interval (CI). Additionally, a meta-analysis was performed, aggregating results from all nine medical institutions. Lastly, we conducted various subgroup and sensitivity analyses to demonstrate the consistency of our study results across diverse conditions.

RESULTS

After 1:1 PSM, a total of 47,306 patients were matched in both the delirium and nondelirium groups. Both groups had a median age group of 75-79 years, with 43.1% being female. The delirium group showed a significantly higher risk of all dementia compared with the nondelirium group (HR: 2.70 [95% CI: 2.27-3.20]). The incidence risk for different types of dementia was also notably higher in the delirium group (all dementia or mild cognitive impairment, HR: 2.46 [95% CI: 2.10-2.88]; Alzheimer's disease, HR: 2.74 [95% CI: 2.40-3.13]; vascular dementia, HR: 2.55 [95% CI: 2.07-3.13]). This pattern was consistent across all subgroup and sensitivity analyses.

CONCLUSIONS

Delirium significantly increases the risk of onset for all types of dementia. These findings highlight the importance of early detection of delirium and prompt intervention. Further research studies are warranted to investigate the mechanisms linking delirium and dementia.

Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study

INTRODUCTION

The purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients.

METHODS

We conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed.

RESULTS

In total, 162 patients were included and divided into delirium (n=54) and nondelirium (n=108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients.

CONCLUSION

The incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.

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

BACKGROUND

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

Association between alcohol use disorder and the incidence of delirium in the intensive care unit: a retrospective cohort study using propensity score matching

BACKGROUND

Although alcohol consumption is considered one of the risk factors for delirium in intensive care unit (ICU) patients, quantitative research on the association between alcohol use disorder (AUD) and the development of delirium in the ICU remains relatively scarce.

METHODS

This retrospective cohort study was conducted using the Medical Information Mart for Intensive Care-IV database, including all patients admitted to the ICU for the first time and underwent delirium assessment. Patients were divided into AUD and non-AUD groups, with the primary outcome being the occurrence of ICU delirium. Propensity score matching (PSM) was used to balance baseline characteristics between the two groups. The association between AUD and the occurrence of ICU delirium was evaluated using Cox proportional hazards and competing risk models, with sensitivity and subgroup analyses to assess the stability of the results.

RESULTS

A total of 35,053 patients were included, with 3,455 (9.9%) in the AUD group. The incidence of ICU delirium and ICU mortality were significantly higher in the AUD group compared to the non-AUD group, with a longer median ICU stay. Multivariable Cox regression analysis, adjusting for all covariates, revealed a significant association between AUD and increased risk of ICU delirium (HR 1.59, 95% CI 1.50-1.69, P < 0.01). After PSM, multivariable Cox regression analysis showed consistent results (HR 1.52, 95% CI 1.41-1.65, P < 0.01), and these results remained consistent after performing competitive risk analysis.

CONCLUSIONS

We found a significant correlation between AUD and the incidence of delirium in the ICU, highlighting the importance of assessing and managing the risk of delirium in patients with AUD in the ICU.

CLINICAL TRIAL NUMBER

Not applicable.

Increased cell-free DNA in CSF and serum of hip fracture patients with delirium

Delirium is a neuropsychiatric syndrome commonly presenting during acute illness. The pathophysiology of delirium is unknown, but neuroinflammation is suggested to play a role. In this cross-sectional study, we aimed to investigate whether cell-free DNA and markers of neutrophil extracellular traps in serum and CSF were associated with delirium and neuronal damage, assessed by neurofilament light chain. Hip fracture patients (n = 491) with a median (25, 75 percentiles) age of 83 (74, 88) years and 69% females were enrolled at Oslo University Hospital, Diakonhjemmet Hospital, Akershus University Hospital and Bærum Hospital. Delirium was assessed daily, pre- and postoperatively. Cognitively healthy adults (n = 32) with a median (25, 75 percentiles) age of 75 (70, 77) years and 53% females were included as controls. Cell-free DNA was measured by using the fluorescent nucleic acid stain Quant-iT PicoGreen® in serum and CSF. Myeloperoxidase-DNA and citrullinated histone H3 were analysed by enzyme-linked immunosorbent assay in serum. Hip fracture patients have significantly higher levels of cell-free DNA and neutrophil extracellular traps in blood than cognitively healthy controls. In hip fracture patients without dementia, cell-free DNA in CSF and serum was significantly higher in patients with (n = 68) versus without (n = 221) delirium after adjusting for age and sex (70 (59, 84) versus 62 (53, 77) ng/ml, P = 0.037) and 601 (504, 684) versus 508 (458, 572) ng/ml, P = 0.007, respectively). In the total hip fracture cohort, CSF levels of cell-free DNA and neurofilament light chain were significantly correlated after adjusting for age and sex (r = 0.441, P < 0.001). The correlation was stronger in those with delirium (r = 0.468, P < 0.001) and strongest in delirious patients without dementia (r = 0.765, P = 0.045). In delirious patients without dementia, significantly higher levels of cell-free DNA in CSF and serum were shown. The association between cell-free DNA and neurofilament light chain suggest simultaneous release of cell-free DNA and neuronal damage during delirium.

Factors Affecting Delirium Care Core Competency Among Nurses: A Descriptive Correlational Study

Nurses require optimal competency to deliver safe and high-quality care to patients with delirium. However, the factors influencing delirium care core competency remain unclear. This study aims to investigate the factors influencing core competency in delirium care among nurses. This study was conducted as a descriptive correlational study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A convenience sample of 202 Korean nurses from 15 hospitals completed a structured, web-based, self-administered questionnaire. The survey covered general characteristics, delirium care knowledge, moral sensitivity, barriers to delirium care, and core competency in delirium care. Multiple regression analysis identified the factors affecting core competency in delirium care. Results showed that barriers to delirium care, moral sensitivity, academic qualifications, and clinical ladder level were significant factors, accounting for 18.1% of the variance in delirium care core competency. To improve delirium care among nurses, using individual, team, and organizational approaches to address perceived barriers and moral sensitivity is crucial. Competency-based training programs and administrative support are crucial for enhancing the competency of nurses who are novices and those with associate degrees.

The Relationship between Delirium and Dementia

Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes.

Pharmacologic Treatment Strategies for Delirium in Hospitalized Adults: Past, Present, and Future

Despite the use of multidomain prevention strategies, delirium still frequently occurs in hospitalized adults. With delirium often associated with undesirable symptoms and deleterious outcomes, including cognitive decline, treatment is important. Risk-factor reduction and the protocolized use of multidomain, nonpharmacologic bundles remain the mainstay of delirium treatment. There is a current lack of strong evidence to suggest any pharmacologic intervention to treat delirium will help resolve it faster, reduce its symptoms (other than agitation), facilitate hospital throughput, or improve post-hospital outcomes including long-term cognitive function. With the exception of dexmedetomidine as a treatment of severe delirium-associated agitation in the ICU, current practice guidelines do not recommend the routine use of any pharmacologic intervention to treat delirium in any hospital population. Future research should focus on identifying and evaluating new pharmacologic delirium treatment interventions and addressing key challenges and gaps surrounding delirium treatment research.

The possible interaction between tryptophan and its metabolites with delirium in older patients with critical illnesses

AIM

The present study aimed to investigate the relationship between delirium and tryptophan and its metabolites in critically ill older patients.

METHODS

This prospective and observational study was conducted on patients who were > 60 years of age and hospitalized for at least 24 h at the internal medicine ICU in the tertiary health care unit (n = 120). All consecutively selected patients were evaluated for delirium at the baseline and follow-up period at the bedside by an intensive care specialist. At the end of the 24 h follow up, the patients were divided into two groups (with and without delirium). Clinical properties and tryptophan (TRP) and its metabolites [kynurenine (KYN), kynurenic acid (KYNA), quinolinic acid (QA), 3-hydroxykynurenine (3-HK), 3-hydroxyanthranilic acid (3HAA)] were compared between groups.

RESULTS

The median age of the patients was 79.5 (62-95) years and 53.3% were female. The median age and CCI score were significantly higher among patients with delirium than in those without delirium (P = 0.001 and 0.031, respectively). The level of TRP was significantly (borderline) decreased among patients with delirium (P = 0.056). The KYN/TRP and QA/TRP ratios were statistically and significantly higher in patients with delirium than those without (P < 0.001 and P = 0.016, respectively). The best predictive values for detecting delirium were calculated as ≤ 14,100 ng/mL for TRP (AUC: 0.601, P = 0.052), > 1.12 for KYN/TRP ratio (AUC: 0.704, P < 0.001), and > 0.75 for QA/TRP ratio (AUC: 0.627, P = 0.013). The QA/TRP ratio showed independent and borderline significant association with being delirium in multivariable regression analysis (Odds ratio: 2.007, P = 0.066).

CONCLUSION

This study demonstrated that tryptophan and its metabolites obtained within the first 24 h of ICU admission might have predictive value for determining high-risk older patients for delirium.

The causal effects of dietary component intake and blood metabolites on risk of delirium: a Mendelian randomization study

Backgrounds

Growing evidence has indicated that the nutritional quality of dietary intake and alterations in blood metabolites were related to human brain activity. This study aims to investigate the causal relationship between dietary component intake, blood metabolites, and delirium risks.

Methods

We performed Mendelian randomization (MR) analysis using genetic variants as instrumental variables for dietary component intake, blood metabolites, and delirium. Inverse variance weighting, maximum likelihood, weighted median, weighted mode, and MR-Egger methods were used for statistical analyses.

Results

We found that genetic prediction of salt added to food (odds ratio [OR] 1.715, 95% confidence interval [CI] 1.239-2.374, p = 0.001) significantly increased the risks of delirium, while low-fat polyunsaturated margarine used in cooking (OR 0.044, 95%CI 0.004-0.432, p = 0.007), cheese intake (OR 0.691, 95%CI 0.500-0.955, p = 0.025) and coffee intake (OR 0.595, 95%CI 0.370-0.956, p = 0.032) was suggestively associated with decreased risks of delirium. Moreover, increased blood 1-stearoylglycerol levels (OR 0.187, 95%CI 0.080-0.435, p = 9.97E-05) significantly contributed to reducing the risks of delirium. 3-methoxytyrosine (OR 0.359, 95%CI 0.154-0.841, p = 0.018) also has the potential to decrease the risk of delirium.

Conclusion

Our study highlights the potential causal effect relationships of dietary component intake and blood metabolites on the risk of delirium, which potentially provides novel insights into targeted dietary prevention strategies or biomarkers for delirium.

Delirium and frailty in older adults: Clinical overlap and biological underpinnings

Frailty and delirium are two common geriatric syndromes sharing several clinical characteristics, risk factors, and negative outcomes. Understanding their interdependency is crucial to identify shared mechanisms and implement initiatives to reduce the associated burden. This literature review summarizes scientific evidence on the complex interplay between frailty and delirium; clinical, epidemiological, and pathophysiological commonalities; and current knowledge gaps. We conducted a PubMed systematic search in June 2023, which yielded 118 eligible articles out of 991. The synthesis of the results-carried out by content experts-highlights overlapping risk factors, clinical phenotypes, and outcomes and explores the influence of one syndrome on the onset of the other. Common pathophysiological mechanisms identified include inflammation, neurodegeneration, metabolic insufficiency, and vascular burden. The review suggests that frailty is a risk factor for delirium, with some support for delirium associated with accelerated frailty. The proposed unifying framework supports the integration and measurement of both constructs in research and clinical practice, identifying the geroscience approach as a potential avenue to develop strategies for both conditions. In conclusion, we suggest that frailty and delirium might be alternative-sometimes coexisting-manifestations of accelerated biological aging. Clinically, the concepts addressed in this review can help approach older adults with either frailty or delirium from a different perspective. From a research standpoint, longitudinal studies are needed to explore the hypothesis that specific pathways within the biology of aging may underlie the clinical manifestations of frailty and delirium. Such research will pave the way for future understanding of other geriatric syndromes as well.

Effects of E-Learning Materials on Caregivers' Knowledge about the 3Ds of Geriatric Psychiatry

Background

E-learning has emerged as a crucial technique that educators embrace and apply. Two effective e-learning materials are video-based learning (VBL) and e-book-based remote learning (EBRL). While several studies have proven their effectiveness, none have compared these e-learning materials, especially regarding caregivers' knowledge of delirium, dementia, and depression (3Ds). Based on the extant literature, many caregivers are untrained and often lack the knowledge and skills to lessen the burden on delirious, demented, and depressed older adults. Hence, there is a growing need to explore how e-learning materials will address caregivers' lack of knowledge about the 3Ds of geriatric psychiatry.

Objectives

This study ascertained the effects of e-learning materials on caregivers' knowledge about the 3Ds of geriatric psychiatry and determined significant differences within and between groups.

Methods

A three-arm, quasi-experimental study, which included 63 informal caregivers in Baguio City who met the inclusion criteria and were chosen through purposive sampling, was conducted. Data were gathered using the Delirium-related knowledge tool, the Bangladesh version of the Depression Literacy Questionnaire, and the Dementia Knowledge Assessment Tool version 2. Data collection was done face-to-face and was conducted from March to April 2023. Data were treated with descriptive and inferential statistics using means, paired t-test, one-way omnibus ANOVA, and the post hoc Scheffé's test. Ethics approval was provided by the Saint Louis University Research Ethics Committee (SLU-REC-UG 2023-004).

Results

All the pretest mean scores of respondents in the VBL, EBRL, and control groups increased in the posttest. Additionally, the paired t-test revealed that the VBL and EBRL materials significantly affected the caregivers' knowledge about the 3Ds of geriatric psychiatry, evidenced by a t-statistic of -5.80 (p=0.00001) and -4.48 (p= 0.00023), respectively. Lastly, one-way ANOVA revealed that there was a statistically significant difference in mean scores between at least two groups (F(2,60) = [7.060], p=0.002). Post hoc analysis using Scheffé's test for multiple comparisons found that the mean values significantly differed between the VBL and the waitlist control group (Scheffé=10.589), and between the EBRL and the waitlist control group (Scheffé=10.589). There was no statistically significant difference between the VBL and the EBRL groups (Scheffé=0).

Conclusions

This study suggests that informal caregivers in Baguio City are moderately knowledgeable about the 3Ds of geriatric psychiatry. Moreover, both VBL and EBRL materials showed effectiveness in improving caregivers' knowledge about the 3Ds of geriatric psychiatry, highlighting the substantial equivalence of both materials. Lastly, caregivers' knowledge about the 3Ds of geriatric psychiatry increases as they engage in e-learning materials. Thus, it is acknowledged that VBL and EBRL materials are valuable, cost-effective, and practical interventions in improving caregivers' knowledge about the 3Ds of geriatric psychiatry.

Delirium prevalence and delirium literacy across Italian hospital wards: a secondary analysis of data from the World Delirium Awareness Day 2023

PURPOSE

Delirium, a common medical emergency among hospitalized patients, requires effective detection and management protocols. This study aims to evaluate the delirium point prevalence and its management across Italian hospitals, categorized by delirium literacy levels. Additionally, it seeks to identify prevailing barriers and future priorities in delirium practice and research.

METHODS

We analyzed data from World Delirium Awareness Day (WDAD) on March 15th, 2023, collected by participating clinicians in Italian hospitals. High delirium literacy (HL) was determined based on the use of validated delirium assessment tools and the presence of a written protocol for delirium management. Conversely, low delirium literacy (LL) was determined by meeting only one or neither of these criteria.

RESULTS

Fifty-eight hospital wards participated in the survey, with 25 (43.1%) classified as HL. The overall reported point prevalence of delirium was found to be approximately 10%. Notably, the reported prevalence was twice as high in the HL group compared to the LL group. Despite minimal differences compared to the other group, the HL group demonstrated greater adherence to appropriate delirium management strategies, encompassing both non-pharmacological and pharmacological strategies. Critical gaps in delirium care emerged, including suboptimal management practices, barriers to implementing evidence-based strategies, and insufficient awareness and training among professionals.

CONCLUSION

The study highlights the suboptimal identification and management of delirium among Italian hospitals, emphasizing the necessity of enhancing awareness and implementing evidence-based strategies. Addressing these shortcomings is crucial for optimizing delirium care, improving patient outcomes, and mitigating the burden of delirium in hospital settings.

Substance use problems and disorders among adults 50 years and older receiving mental health treatment for a primary neurocognitive disorder

OBJECTIVES

This study sought to (1) identify the percentage of high-risk substance use or substance use disorder (SUD) and (2) examine the factors associated with high-risk substance use or SUD in adults aged 50 years and older receiving mental health treatment with a primary delirium or dementia diagnosis.

METHOD

This study used 7 years (2013-2019) of national administrative data on community mental health center patients aged 50 years and older with a primary delirium or dementia diagnosis receiving treatment in the United States (U.S.). To examine factors associated with the dependent variable (high-risk substance use or SUD), a multivariable binary logistic regression model was utilized.

RESULTS

The sample included 77,509 individuals who were mostly aged 65 years and older (69.7%), and did not have co-occurring high-risk substance use or SUD (90.1%). Receiving treatment in a U.S. region other than the Northeast, being younger, male, not non-Hispanic White, and having multiple mental health diagnoses had greater odds of co-occurring high-risk substance use or SUD.

CONCLUSION

One in ten persons in this sample having high-risk substance use or SUD highlights the clinical necessity for screening and subsequent treatment for co-occurring high-risk substance use among persons receiving treatment for a neurocognitive disorder.

Non-pharmacological delirium detection and management interventions for informal caregivers of older people at home: A scoping review protocol

OBJECTIVE

The objective of this proposed scoping review is to identify and map the available evidence on interventions that aim to help informal caregivers identify and/or manage delirium in an older person at home.

INTRODUCTION

Delirium is a neurocognitive condition characterized by acute confusion and is associated with increased risk of morbidity and mortality. Research estimates delirium to be present in 17% of community-dwellers aged 85 and older, increasing proportionally with age to 45% in those aged 90 and older. Delirium often occurs at the onset of an older person's acute illness or exacerbation of a chronic illness (sometimes while at home) and, because of its protracted nature, usually continues after a hospital stay. Even when an older person's delirium resolves during hospitalization, they remain at risk of its recurrence after discharge home. Consequently, knowing how to detect and manage delirium is critical for informal caregivers of older people at home. However, there are no reviews focused exclusively on this topic in this setting.

INCLUSION CRITERIA

The population of interest includes informal caregivers of a person aged 65+. Concepts of interest include delirium detection and/or management interventions. The context of interest is any setting where informal care is delivered, including the transition from hospital to home, in any geographical area.

MATERIALS AND METHODS

The review will be conducted according to the JBI guidelines for scoping reviews. A three-step search strategy will be used to locate both published and unpublished papers in MEDLINE, Embase, CINAHL, PsycINFO, Web of Science Core Collection, ProQuest Nursing & Allied Health, SCOPUS, LILACS, and SciELO, PQD&T, NDLTD, Google Scholar and Google. No language restrictions will be placed on the review. Papers will be screened for eligibility at the title, abstract, and full text level by two independent reviewers. Data will be extracted by two independent reviewers and managed in Covidence. Any disagreements in screening or data extraction will be resolved by consensus or a third reviewer. Results will be summarised in narrative and tabular formats.

How much risk does delirium represent for the development of dementia?: Retrospective cohort study from over 260,000 patients record in a solitary institution

Background

Delirium frequently affects the consciousness of the elderly, particularly those in hospitals. Evidence increasingly associates linking delirium history to an increased risk of dementia. However, most studies are limited in scope, focusing mainly on postoperative or intensive care units with small patient samples, which affects the broader applicability of their findings.

Aims

To elucidate the precise incidence of delirium and the subsequent onset of dementia within whole inpatients. Additionally, we aimed to explore the correlation between the emergence of delirium during hospitalization and the subsequent manifestation of dementia.

Design setting and participants

We conducted a retrospective cohort analysis employing a decade-long electronic medical record dataset consisted of 261,123 patients in Osaka Medical and Pharmaceutical University Hospital. Key analyses were performed October 2022 to January 2023.

Main outcomes and measures

The primary outcome, dementia onset, was determined by prescriptions for the anti-dementia drugs donepezil, galantamine, memantine, or rivastigmine, which are approved for use in Japan.

Results

10,781 patients met the inclusion criteria. The median interval between the onset of dementia was 972.5 days for individuals without a history of delirium, whereas for those with a history of delirium, it was notably shorter at 592.5 days. This disparity culminated in a hazard ratio of 5.29 (95% confidence interval: 1.35-20.75) for subsequent dementia onset.

Conclusions and relevance

This investigation underscores the imperative significance of directing attention toward preventive measures against delirium during hospitalization, alongside the necessity of diligent monitoring and intervention for cognitive decline in patients who encounter delirium.

DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study

OBJECTIVES

To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs).

DESIGN

Prospective cross-sectional study.

SETTING

Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals.

PARTICIPANTS

494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious.

MEASUREMENTS

DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets.

METHODS

Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus.

RESULTS

DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity.

CONCLUSIONS

DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.

Effects of Exercise Intervention for the Management of Delirium in Hospitalized Older Adults: A Randomized Clinical Trial

OBJECTIVE

Delirium is a serious neuropsychiatric syndrome frequently occurring in hospitalized older adults, for which pharmacological treatments have shown limited effectiveness. Multicomponent physical exercise programs have demonstrated functional benefits; however, the impact of exercise on the course of delirium remains unexplored. The aim of this study was to investigate the effect of an individualized, multicomponent exercise intervention on the evolution of delirium and patient outcomes.

DESIGN

A single-center, single-blind randomized controlled trial.

SETTING AND PARTICIPANTS

Medical inpatients with delirium in an acute geriatric unit of a tertiary public hospital.

METHODS

Thirty-six patients (mean age 87 years) were recruited and randomized into 2 groups. The control group received usual care and the intervention group received individualized physical exercise (1 daily session) for 3 consecutive days. Primary endpoints were the duration and severity of delirium (4-AT, Memorial Delirium Assessment Scale) and change in functional status [Barthel Index, Short Physical Performance Battery, Hierarchical Assessment of Balance and Mobility (HABAM), and handgrip strength]. Secondary endpoints included length of stay, falls, and health outcomes at 1- and 3-month follow-up.

RESULTS

The intervention group showed more functional improvement at discharge (HABAM, P = .015) and follow-up (Barthel, P = .041; Lawton P = .027). Less cognitive decline was observed at 1 and 3 months (Informant Questionnaire on Cognitive Decline in the Elderly, P = .017). Exercise seemed to reduce delirium duration by 1 day and contribute to delirium resolution at discharge, although findings did not reach statistical significance. No exercise-related adverse events occurred.

CONCLUSION AND IMPLICATIONS

Findings suggest that individualized exercise in acutely hospitalized older patients with delirium is safe, may improve delirium course and help preserve post-hospitalization function and cognition.

Association of triglyceride-glucose index and delirium in patients with sepsis: a retrospective study

OBJECTIVE

It is well known that glucose and lipid metabolism disorders and insulin resistance are common in sepsis, which affect the occurrence and prognosis of multiple organ dysfunction in septic patients. Previous study reported the predictive value of triglyceride-glucose index (TyG), a clinical indicator for insulin resistance, in postoperative delirium patients. However, it remains unclear whether the TyG index is a novel predictive biomarker for sepsis-associated delirium. The aim of this study is to explore the relationship between TyG index and the risk of delirium in patients with sepsis.

METHODS

Adult septic patients were identified from the MIMIC-IV database and divided into four groups based on the mean value of TyG. The primary outcome was the incidence of delirium. The association between TyG and the risk of developing delirium was evaluated by restricted cubic spline (RCS), multivariate logistic regression and subgroup analysis. Propensity Score Matching (PSM) method was used to balance the baseline data.

RESULTS

A total of 3,331 septic patients were included in the analysis, and further divided into four groups: Q1 (TyG ≤ 8.67), Q2 (8.67 < TyG ≤ 9.08), Q3 (9.08 < TyG ≤ 9.61), and Q4 (TyG > 9.61). The RCS curves demonstrated a non-linear positive relationship between TyG index and the risk of developing delirium, and an optimal cut-of value 9.09 was recommended. After balancing the baseline information by PSM, patients in the TyG > 9.09 group had a significant higher incidence of delirium compared with those in the TyG ≤ 9.09 group. In logistic regression analysis, TyG > 9.09 was significantly associated with lower risk of developing delirium in both original cohort (OR 1.54-1.78, all P < 0.001) and the PSM cohort (OR 1.41-1.48, all P < 0.001). No association was found between the TyG index and mortality (all P > 0.05). In subgroup analysis, our findings were consistent (all OR > 1 in all subgroups).

CONCLUSION

Our study demonstrated an independent association between TyG index and increased risk of delirium in septic patients, indicating that TyG index can serve as a biomarker for delirium in sepsis.

Blowing the whistle on mixed gender hospital rooms in Australia and New Zealand: a human rights issue

The practice of placing men and women in the same hospital room (mixed gender rooms) has been prohibited in the UK National Health Service for over a decade. However, recent research demonstrates that the practice is common and increasing in a major New Zealand public hospital. Reports and complaints show that the practice also occurs in Australia. We argue that mixed gender rooms violate the fundamental human rights of personal security and dignity. The high rates of cognitive impairment, sensory impairment and frailty in hospital wards exacerbates the risk for these violations and subsequent harm. We argue for the adoption of specific national policies prohibiting mixed gender rooms and public reporting of breaches. Importantly, these guidelines can be adopted without compromising the rights of gender minorities. In the long term, hospitals should be built with single occupancy rooms.

Sex-stratified analyses of comorbidities associated with an inpatient delirium diagnosis using real world data

Delirium is a detrimental mental condition often seen in older, hospitalized patients and is currently hard to predict. In this study, we leverage electronic health records (EHR) to identify 7,492 UCSF patients and 19,417 UC health system patients with an inpatient delirium diagnosis and the same number of control patients without delirium. We found significant associations between comorbidities or laboratory values and an inpatient delirium diagnosis, including metabolic abnormalities and psychiatric diagnoses. Some associations were sex-specific, including dementia subtypes and infections. We further explored the associations with anemia and bipolar disorder by conducting longitudinal analyses from the time of first diagnosis to development of delirium, demonstrating a significant relationship across time. Finally, we show that an inpatient delirium diagnosis leads to increased risk of mortality. These results demonstrate the powerful application of the EHR to shed insights into prior diagnoses and laboratory values that could help predict development of inpatient delirium and the importance of sex when making these assessments.

The genetic relationship between hypotension and delirium: a Mendelian randomization study

Background

Observational research suggests that hypotension is a potential hazard factor of delirium. Nevertheless, previous observational articles are limited in their ability to establish causality between hypotension and delirium. The present study was sought to explore the genetic causal relationship between these two conditions using two-sample Mendelian randomization (MR).

Methods

Genome-wide association study (GWAS) summarized data for hypotension and delirium were obtained from the FinnGen Consortium. The researchers utilized several statistical methods, such as inverse-variance weighted (IVW), weighted median, MR Egger, weighted mode, and simple mode in conducting the MR statistical analysis. In order to identify heterogeneity among the MR outcomes, we employed the Cochrane's Q test. Furthermore, we used the MR-Egger intercept test and MR pleiotropy residual sum and outliers (MR-PRESSO) test to examine horizontal pleiotropy.

Results

The findings revealed that hypotension was identified as an independent hazard variable for delirium (p = 0.010, odds ratio [OR] [95% confidence interval (CI)] = 1.302 [1.066-1.592]) using the IVW method. The presence of horizontal pleiotropy was found to have minimal impact on establishing causal relationship (p = 0.999), and there was no evidence to suggest heterogeneity between genetic variations (p = 0.379). Additionally, the leave-one-out method demonstrated the stability and robustness of this association.

Conclusion

We performed two-sample MR analyses and found evidence of a genetic causal relationship between hypotension and delirium. Our findings suggest that individuals with a genetic predisposition for hypotension may have a higher risk of developing delirium. This suggests that interventions aimed at improving perioperative hypotension could aid in limiting the incidence of delirium.

Barriers to healthcare professionals recognizing and managing delirium in older adults during a hospital stay: A mixed-methods systematic review

AIM

To investigate barriers to healthcare professionals recognizing and managing delirium in hospitalized older people.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42020187932.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO and CINAHL were searched (2007 to February 2023).

REVIEW METHODS

Included studies focused on healthcare professionals' recognition and management of delirium for patients aged 65 years and over in a hospital ward or emergency department. Enhancing rigour, screening of results was conducted independently by two researchers. Qualitative and quantitative data were tabulated separately and grouped. Data were compared to identify similarities and differences. All studies were quality appraised.

RESULTS

43 studies were included; 24 quantitative, 16 qualitative and three mixed-methods. Data synthesis highlighted synergy between qualitative and quantitative findings. Barriers were reflected in six themes: (1) healthcare professionals' knowledge and understanding; (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints.

CONCLUSIONS

Of significance, for older adults in hospital experiencing delirium, there is variability in whether and how well it is recognized and managed. To prevent adverse outcomes best practice guidance for screening, recognizing, diagnosing and managing delirium in older people needs to be agreed and disseminated widely. Supporting healthcare professionals to care for this patient population using an integrated approach is essential, how to involve and communicate with patients and their family and friends, how to recognize and manage delirium for patients with additional needs, e.g., those living with dementia and/or a learning disability. Hospitals need to have policy and guidance in place for the recognition and management of delirium in older adults presenting to a ward or to an emergency department. An IT infrastructure is needed that integrates assessments and care management plans in patient electronic records and makes them accessible within and across teams in hospital, primary and community care settings.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this systematic review.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Healthcare professionals can be better supported to be able to recognize and manage delirium during an acute hospital stay for older adults. This includes maximizing best care for those patients living with dementia, involving families and friends to help understand patients' baseline status and changes and supporting families and friends during this process. Of significance, attention to hospital IT infrastructures is warranted, integrating screening, assessment and care management plans in patients' electronic records and making these accessible to healthcare professionals caring for this patient population across care settings.

IMPACT

What problem did the study address? Delirium is a common condition experienced by older hospitalized patients, but it is consistently under-recognized which has implications for patient and organization outcomes. To help address this, understanding barriers to healthcare professionals recognizing and managing delirium for this patient population is paramount. What were the main findings? Barriers to healthcare professionals recognizing and managing delirium for this patient population were synthesized in six themes: (1) healthcare professionals' knowledge and understanding, (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. Where and on whom will the research have an impact? The findings of this original systematic review can contribute to hospital policy and protocol for the recognition and management of delirium in older patients. The findings can meaningfully contribute to workforce professional development for practitioners caring for older people during an acute hospital stay and for practitioners in primary and community settings involved in the follow-up of patients post hospital discharge. For researchers, the findings indicate several research recommendations including investigating the impact of an education programme for nurses and other healthcare professionals on the recognition and management of the condition and understanding and investigating how best to support delirium-related distress experienced by patients and their families and practitioners.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study

Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.

Interventions to prevent and treat delirium: An umbrella review of randomized controlled trials

Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.

Identifying Symptoms of Delirium from Clinical Narratives Using Natural Language Processing

Delirium is an acute decline or fluctuation in attention, awareness, or other cognitive function that can lead to serious adverse outcomes. Despite the severe outcomes, delirium is frequently unrecognized and uncoded in patients' electronic health records (EHRs) due to its transient and diverse nature. Natural language processing (NLP), a key technology that extracts medical concepts from clinical narratives, has shown great potential in studies of delirium outcomes and symptoms. To assist in the diagnosis and phenotyping of delirium, we formed an expert panel to categorize diverse delirium symptoms, composed annotation guidelines, created a delirium corpus with diverse delirium symptoms, and developed NLP methods to extract delirium symptoms from clinical notes. We compared 5 state-of-the-art transformer models including 2 models (BERT and RoBERTa) from the general domain and 3 models (BERT_MIMIC, RoBERTa_MIMIC, and GatorTron) from the clinical domain. GatorTron achieved the best strict and lenient F1 scores of 0.8055 and 0.8759, respectively. We conducted an error analysis to identify challenges in annotating delirium symptoms and developing NLP systems. To the best of our knowledge, this is the first large language model-based delirium symptom extraction system. Our study lays the foundation for the future development of computable phenotypes and diagnosis methods for delirium.

Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review

BACKGROUND

Multiple short delirium detection tools have been validated in research studies and implemented in routine care, but there has been little study of these tools in real-world conditions. This systematic review synthesized literature reporting completion rates and/or delirium positive score rates of detection tools in large clinical populations in general hospital settings.

METHODS

PROSPERO (CRD42022385166). Medline, Embase, PsycINFO, CINAHL, and gray literature were searched from 1980 to December 31, 2022. Included studies or audit reports used a validated delirium detection tool performed directly with the patient as part of routine care in large clinical populations (n ≥ 1000) within a general acute hospital setting. Narrative synthesis was performed.

RESULTS

Twenty-two research studies and four audit reports were included. Tools used alone or in combination were the Confusion Assessment Method (CAM), 4 'A's Test (4AT), Delirium Observation Screening Scale (DOSS), Brief CAM (bCAM), Nursing Delirium Screening Scale (NuDESC), and Intensive Care Delirium Screening Checklist (ICDSC). Populations and settings varied and tools were used at different stages and frequencies in the patient journey, including on admission only; inpatient, daily or more frequently; on admission and as inpatient; inpatient post-operatively. Tool completion rates ranged from 19% to 100%. Admission positive score rates ranged from: CAM 8%-51%; 4AT 13%-20%. Inpatient positive score rates ranged from: CAM 2%-20%, DOSS 6%-42%, and NuDESC 5-13%. Postoperative positive score rates were 21% and 28% (4AT). All but two studies had moderate-high risk of bias.

CONCLUSIONS

This systematic review of delirium detection tool implementation in large acute patient populations found clinically important variability in tool completion rates, and in delirium positive score rates relative to expected delirium prevalence. This study highlights a need for greater reporting and analysis of relevant healthcare systems data. This is vital to advance understanding of effective delirium detection in routine care.

Single-channel qEEG characteristics distinguish delirium from no delirium, but not postoperative from non-postoperative delirium

OBJECTIVE

This exploratory study examined quantitative electroencephalography (qEEG) changes in delirium and the use of qEEG features to distinguish postoperative from non-postoperative delirium.

METHODS

This project was part of the DeltaStudy, a cross-sectional,multicenterstudy in Intensive Care Units (ICUs) and non-ICU wards. Single-channel (Fp2-Pz) four-minutes resting-state EEG was analyzed in 456 patients. After calculating 98 qEEG features per epoch, random forest (RF) classification was used to analyze qEEG changes in delirium and to test whether postoperative and non-postoperative delirium could be distinguished.

RESULTS

An area under the receiver operatingcharacteristic curve (AUC) of 0.76 (95% Confidence Interval (CI) 0.71-0.80) was found when classifying delirium with a sensitivity of 0.77 and a specificity of 0.63 at the optimal operating point. The classification of postoperative versus non-postoperative delirium resulted in an AUC of 0.50 (95%CI 0.38-0.61).

CONCLUSIONS

RF classification was able to discriminate delirium from no delirium with reasonable accuracy, while also identifying new delirium qEEG markers like autocorrelation and theta peak frequency. RF classification could not distinguish postoperative from non-postoperative delirium.

SIGNIFICANCE

Single-channel EEG differentiates between delirium and no delirium with reasonable accuracy. We found no distinct EEG profile for postoperative delirium, which may suggest that delirium is one entity, whether it develops postoperatively or not.

Mitochondrial dysfunction precedes hippocampal IL-1β transcription and cognitive impairments after low-dose lipopolysaccharide injection in aged mice

Acute cognitive impairments termed delirium often occur after inflammatory insults in elderly patients. While previous preclinical studies suggest mitochondria as a target for reducing neuroinflammation and cognitive impairments after LPS injection, fewer studies have evaluated the effects of a low-grade systemic inflammation in the aged brain. Thus, to identify the significance of mitochondrial dysfunction after a clinically relevant systemic inflammatory stimulus, we injected old-aged mice (18-20 months) with low-dose lipopolysaccharide (LPS, 0.04 mg/kg). LPS injection reduced mitochondrial respiration in the hippocampus 24 h after injection (respiratory control ratio [RCR], state3u/state4o; control = 2.82 ± 0.19, LPS = 2.57 ± 0.08). However, gene expression of the pro-inflammatory cytokine IL-1β was increased (RT-PCR, control = 1.00 ± 0.30; LPS = 2.01 ± 0.67) at a more delayed time point, 48 h after LPS injection. Such changes were associated with cognitive impairments in the Barnes maze and fear chamber tests. Notably, young mice were unaffected by low-dose LPS, suggesting that mitochondrial dysfunction precedes neuroinflammation and cognitive decline in elderly patients following a low-grade systemic insult. Our findings highlight mitochondria as a potential therapeutic target for reducing delirium in elderly patients.

Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study

OBJECTIVES

To determine the strength and nature of the association between delirium and incident dementia in a population of older adult patients without dementia at baseline.

DESIGN

Retrospective cohort study using large scale hospital administrative data.

SETTING

Public and private hospitals in New South Wales, Australia between July 2001 and March 2020.

PARTICIPANTS

Data were extracted for 650 590 hospital patients aged ≥65 years. Diagnoses of dementia and delirium were identified from ICD-10 (international classification of diseases, 10th revision) codes. Patients with dementia at baseline were excluded. Delirium-no delirium pairs were identified by matching personal and clinical characteristics, and were followed for more than five years.

MAIN OUTCOME MEASURES

Cox proportional hazards models and Fine-Gray hazard models were used to estimate the associations of delirium with death and incident dementia, respectively. Delirium-outcome dose-response associations were quantified, all analyses were performed in men and women separately, and sensitivity analyses were conducted.

RESULTS

The study included 55 211 matched pairs (48% men, mean age 83.4 years, standard deviation 6.5 years). Collectively, 58% (n=63 929) of patients died and 17% (n=19 117) had a newly reported dementia diagnosis during 5.25 years of follow-up. Patients with delirium had 39% higher risk of death (hazard ratio 1.39, 95% confidence interval 1.37 to 1.41) and three times higher risk of incident dementia (subdistribution hazard ratio 3.00, 95% confidence interval 2.91 to 3.10) than patients without delirium. The association with dementia was stronger in men (P=0.004). Each additional episode of delirium was associated with a 20% increased risk of dementia (subdistribution hazard ratio 1.20, 95% confidence interval 1.18 to 1.23).

CONCLUSIONS

The study findings suggest delirium was a strong risk factor for death and incident dementia among older adult patients. The data support a causal interpretation of the association between delirium and dementia. The clinical implications of delirium as a potentially modifiable risk factor for dementia are substantial.