Cost-effectiveness of multi-component interventions to prevent delirium in older people admitted to medical wards

Nutrition care for older adults with delirium: A scoping review

AIMS

This scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group.

DESIGN

Scoping review.

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered.

DATA SOURCES

Databases searched were CINAHL, Medline, Embase, JBI Evidence-based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023.

RESULTS

The database search identified 1561 articles, 186 underwent full-text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group.

CONCLUSION

This scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Providing nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families.

IMPACT

This scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes.

REPORTING METHOD

This scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).

PATIENT OF PUBLIC CONTRIBUTION

No patient or public contribution.

The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review

INTRODUCTION

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

METHODS

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

RESULTS

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively.

CONCLUSION

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings

BACKGROUND

Delirium is an underdiagnosed clinical syndrome typified by an acute alteration of mental state. It is an important problem in critical care and intensive care units (ICU) due to its high prevalence and its association with adverse outcomes. Delirium is a very distressing condition for patients, with a huge impact on their well-being. Diagnosis of delirium in the critical care setting is challenging. This is especially true for patients who are mechanically ventilated and are therefore unable to engage in a verbal interview. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a tool specifically designed to assess for delirium in the context of ICU patients, including those on mechanical ventilation. CAM-ICU can be administered by non-specialists to give a dichotomous delirium present/absent result.

OBJECTIVES

To determine the diagnostic accuracy of the CAM-ICU for the diagnosis of delirium in adult patients in critical care units.

SEARCH METHODS

We searched MEDLINE (Ovid SP, 1946 to 8 July 2022), Embase (Ovid SP, 1982 to 8 July 2022), Web of Science Core Collection (ISI Web of Knowledge, 1945 to 8 July 2022), PsycINFO (Ovid SP, 1806 to 8 July 2022), and LILACS (BIREME, 1982 to 8 July 2022). We checked the reference lists of included studies and other resources for additional potentially relevant studies. We also searched the Health Technology Assessment database, the Cochrane Library, Aggressive Research Intelligence Facility database, WHO ICTRP, ClinicalTrials.gov, and websites of scientific associations to access any annual meetings and abstracts of conference proceedings in the field.

SELECTION CRITERIA

We included diagnostic studies enrolling adult ICU patients assessed using the CAM-ICU tool, regardless of language or publication status and reporting sufficient data on delirium diagnosis for the construction of 2 x 2 tables. Eligible studies evaluated the diagnostic performance of the CAM-ICU versus a clinical reference standard based on any iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria applied by a clinical expert.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and collated study data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used two univariate fixed-effect or random-effects models to determine summary estimates of sensitivity and specificity. We performed sensitivity analyses that excluded studies considered to be at high risk of bias and high concerns in applicability, due mainly to the target population included (e.g. patients with traumatic brain injury). We also investigated potential sources of heterogeneity, assessing the effect of reference standard diagnosis and proportion of patients ventilated.

MAIN RESULTS

We included 25 studies (2817 participants). The mean age of participants ranged from 48 to 69 years; 15 of the studies included critical care units admitting mixed populations (e.g. medical, trauma, surgery patients). The percentage of patients receiving mechanical ventilation ranged from 11.8% to 100%. The prevalence of delirium in the studies included ranged from 12.5% to 83.9%. Presence of delirium was determined by the application of DSM-IV criteria in 13 out of 25 included studies. We assessed 13 studies as at low risk of bias and low applicability concerns for all QUADAS-2 domains. The most common issue of concern was flow and timing of the tests, followed by patient selection. Overall, we estimated a pooled sensitivity of 0.78 (95% confidence interval (CI) 0.72 to 0.83) and a pooled specificity of 0.95 (95% CI 0.92 to 0.97). Sensitivity analysis restricted to studies at low risk of bias and without any applicability concerns (n = 13 studies) gave similar summary accuracy indices (sensitivity 0.80 (95% CI 0.72 to 0.86), specificity 0.95 (95% CI 0.93 to 0.97)). Subgroup analyses based on diagnostic assessment found summary estimates of sensitivity and specificity for studies using DSM-IV of 0.79 (95% CI 0.72 to 0.85) and 0.94 (95% CI 0.90 to 0.96). For studies that used DSM-5 criteria, summary estimates of sensitivity and specificity were 0.75 (95% CI 0.67 to 0.82) and 0.98 (95% CI 0.95 to 0.99). DSM criteria had no significant effect on sensitivity (P = 0.421), but the specificity for detection of delirium was higher when DSM-5 criteria were used (P = 0.024). The relative specificity comparing DSM-5 versus DSM-IV criteria was 1.05 (95% CI 1.02 to 1.08). Summary estimates of sensitivity and specificity for studies recruiting < 100% of patients with mechanical ventilation were 0.81 (95% CI 0.75 to 0.85) and 0.95 (95% CI 0.91 to 0.98). For studies that exclusively recruited patients with mechanical ventilation, summary estimates of sensitivity and specificity were 0.91 (95% CI 0.76 to 0.97) and 0.98 (95% CI 0.92 to 0.99). Although there was a suggestion of differential performance of CAM-ICU in ventilated patients, the differences were not significant in sensitivity (P = 0.316) or in specificity (P = 0.493).

AUTHORS' CONCLUSIONS

The CAM-ICU tool may have a role in the early identification of delirium, in adult patients hospitalized in intensive care units, including those on mechanical ventilation, when non-specialized, properly trained clinical personnel apply the CAM-ICU. The test is most useful for exclusion of delirium. The test may miss a proportion of patients with incident delirium, therefore in situations where detection of all delirium cases is desirable, it may be best to repeat the test or combine CAM-ICU with another assessment. Future studies should compare different screening tests proposed for bedside assessment of delirium, as this approach will reveal which tool yields superior accuracy. In addition, future studies should consider and report the flow and timing of the tests and clearly report key characteristics related to patient selection. Finally, future research should focus on the impact of CAM-ICU screening on patient outcomes.

Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium

Background: Delirium can occur in cancer patients during an acute hospitalization or in the terminal stages of cancer. Iatrogenic delirium can complicate hospital stays for over 2.6 million older persons by increasing fall risk, restraint use, length of stay, postacute placement, and costs. The purpose of this evidence-based quality improvement project was to implement routine screening for delirium with a consistent instrument and adopt an interprofessional plan of care for delirium. Methods: This project was identified as an interprofessional improvement initiative. The project leader identified a deficiency in the screening for delirium, convened stakeholders, evaluated evidence, reviewed screening instruments, and developed a plan of care for delirium management. Practice changes incorporated routine delirium screening across the inpatient units. A delirium interprofessional plan of care was integrated into the electronic health record for ease of adoption and workflow modification. Results: Routine screening for delirium and early interprofessional interventions reduced length of stay by 2.27 days for patients screening positive for delirium. The percentage of inpatient falls that were linked to an episode of delirium during hospitalization reduced from 23.4% to 17%. Discussions: Routine screening and targeted interventions are a first step in prevention and identification of those inpatients at risk of developing delirium. Delirium prevention is the goal for potential associated iatrogenic conditions.

Validation and Recalibration of Modified Mayo Delirium Prediction (MDP) Tool in a Hospitalized Cohort

BACKGROUND

Delirium prediction can augment and optimize care of older adults. Mayo delirium prediction (MDP) tool is a robust tool, developed from a large retrospective data set. MDP tool predicts delirium risk for hospitalized older adults, within 24 hours of hospital admission, based on risk factor information available from electronic health record. We intend to validate the prediction performance of this tool and optimize the tool for clinical use.

DESIGN

Observational cohort study SETTINGS: Mayo Clinic Hospitals, Rochester, MN PARTICIPANTS: All Hospitalized older adults (age >50 years) from December 2019 to June 2020. Patients with an admitting diagnosis of substance use disorder were excluded.

INTERVENTION

Original MDP tool was modified to adjust for the fall risk variable as a binary variable that will facilitate broader applicability across different fall risk tools. The modified MDP tool was validated in the retrospective derivation and validation data set which yielded similar prediction capability (AUROC = 0.85, 0.83 respectively).

MEASUREMENTS

Diagnosis of delirium was captured by flowsheet diagnosis of delirium documented by nursing staff in medical record. Predictive variable data were collected daily.

RESULTS

8055 patients were included in the study (median age 71 years). The modified MDP tool delirium prediction compared to delirium occurrence was 4% in the low-risk group, 17.8% in the medium-risk group, and 45.3% in the high-risk group (AUROC of 0.80). Recalibration of the tool was attempted to further optimize the tool that resulted in both simplification and increased performance (AUROC 0.82). The simplified tool was able to predict delirium in hospitalized patients admitted to both medical and surgical services.

CONCLUSIONS

Validation of modified MDP tool revealed good prediction capabilities. Recalibration resulted in simplification with increased performance of the tool in both medical and surgical hospitalized patients.

Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations

OBJECTIVE

Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium.

METHODS

Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%).

CONCLUSION

Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.

Identification through the Manchester Triage System of the older population at risk of delirium: A case-control study

OBJECTIVE

To identify the flow charts and discriminators of the Manchester Triage System that are most likely to identify the onset of delirium in older people.

BACKGROUND

Delirium is an underdiagnosed geriatric syndrome, and up to 80% of all cases of delirium go undetected in emergency departments. Patient triage seeks to manage clinical risk with a view to safely and appropriately managing patient flows.

DESIGN

A case-control study was performed according to the STROBE checklist.

SETTING

The emergency department of a secondary hospital.

PARTICIPANTS

Older adults aged ≥65 years and admitted from 1 January to 31 December 2020.

METHODS

Older patients were identified from the emergency department research database. Cases were defined as patients diagnosed with delirium (n = 128), excluding cases of delirium due to alcohol or substance abuse. Controls were randomised from the remaining patients (n = 128).

RESULTS

A total of 29.35% of the subjects admitted to the emergency department were older adults with an incidence of delirium of 0.7%. The flow charts with the highest probability of delirium were 'unwell adult' [OR = 3.04 (95%CI:1.82-5.1)] and 'behaving strangely' [OR = 16.06 (95%CI:3.72-69.29)], and the discriminators were 'rapid onset' [OR = 3.3 (95%CI:1.85-5.88)] and 'new neurological deficit less than 24 h old' [OR = 4.76 (95%%CI:1.01-22.5). The area under the curve for 'unwell adult' in the presence of dementia, previous stroke and fall in the previous 30 days was 0.73 (95%CI: 0.67-0.79), and that for 'behaving strangely' in the presence of diabetes was 0.75 (95%CI: 0.69-0.81).

CONCLUSIONS

Knowing which flow charts, discriminators and risk factors are most likely to predict delirium allows the identification of the older population at risk for triage screening in emergency departments.

RELEVANCE TO CLINICAL PRACTICE

Risk factors such as diabetes, dementia, previous stroke and recent fall among 'unwell adult' or 'behaving strangely' triaged older persons should be assessed for the probable presence of delirium.

Structured delirium management in the hospital—a randomized controlled trial

BACKGROUND

Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients.

METHODS

The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]).

RESULTS

The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02).

CONCLUSION

Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.

Effectiveness of Interprofessional Consultation-Based Interventions for Delirium: A Scoping Review

BACKGROUND

Interprofessional geriatric consultation teams and multicomponent interventions are established models for delirium care. They are combined in interprofessional consultative delirium team interventions; however, insight into this novel approach is lacking.

OBJECTIVE

To describe the effectiveness and core components of consultation-based interventions for delirium.

METHOD

Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, and ProQuest. Data on core intervention components, outcomes, facilitators, and barriers were extracted.

RESULTS

10 studies were included. Core intervention components were systematic delirium screening, ongoing consultation, implementation of non-pharmacologic and pharmacological interventions, and staff education. Of the included studies, 1/6 found a significant reduction in delirium incidence, 1/2 a reduction in delirium duration, and 2/3 found a reduction in falls. Facilitators and barriers to implementation were discussed.

CONCLUSION

There was consistency in team structure and core components, however intervention operationalization and effectiveness varied widely. There is some evidence that this model is effective for reducing delirium and its sequelae.

Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson's Disease, Dementia, and Older Adults

BACKGROUND

Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal.

OBJECTIVE

To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson's disease (PD) and dementia.

METHODS

Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria.

RESULTS

On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS (AUC=0.90 and 0.84, respectively, p < 0.001 for both).

CONCLUSION

Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Predicting Delirium Risk Using an Automated Mayo Delirium Prediction Tool: Development and Validation of a Risk-Stratification Model

OBJECTIVE

To develop a delirium risk-prediction tool that is applicable across different clinical patient populations and can predict the risk of delirium at admission to hospital.

METHODS

This retrospective study included 120,764 patients admitted to Mayo Clinic between January 1, 2012, and December 31, 2017, with age 50 and greater. The study group was randomized into a derivation cohort (n=80,000) and a validation cohort (n=40,764). Different risk factors were extracted and analyzed using least absolute shrinkage and selection operator (LASSO) penalized logistic regression.

RESULTS

The area under the receiver operating characteristic curve (AUROC) for Mayo Delirium Prediction (MDP) tool using derivation cohort was 0.85 (95% confidence interval [CI], .846 to .855). Using the regression coefficients obtained from the derivation cohort, predicted probability of delirium was calculated for each patient in the validation cohort. For the validation cohort, AUROC was 0.84 (95% CI, .834 to .847). Patients were classified into 1 of the 3 risk groups, based on their predicted probability of delirium: low (≤5%), moderate (6% to 29%), and high (≥30%). In the derivation cohort, observed incidence of delirium was 1.7%, 12.8%, and 44.8% (low, moderate, and high risk, respectively), which is similar to the incidence rates in the validation cohort of 1.9%, 12.7%, and 46.3%.

CONCLUSION

The Mayo Delirium Prediction tool was developed from a large heterogeneous patient population with good validation results and appears to be a reliable automated tool for delirium risk prediction with hospitalization. Further prospective validation studies are required.

Play attention! Therapeutic aspects to play in delirium prevention and management

It is recognised that delirium is common among older adult inpatients and correlated with negative outcomes. The gold standard care for delirium management is achieved using multicomponent interventions. Which components work best is not yet well defined. During the COVID-19 outbreak, a paediatric ward was repurposed to treat adult patients. Paediatric nurses and play specialists remained on the ward. It was observed that the paediatric ward aesthetic and the team's dedicated approach to cognitive stimulation and sleep promotion improved well-being among older adult patients. We propose that elements of paediatric care, primarily deployment of a play specialist, could be incorporated into a multicomponent intervention for delirium prevention and management.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

Risk factors for postoperative delirium after spinal surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative delirium is common in older patients after spinal surgery. Many reports investigating the risk factors for delirium after spinal surgery have been published recently.

METHODS

A literature search was performed using the Cochrane Library, Web of Science, PubMed, Embase, and Springer databases from inception to February 2019. Relevant studies involving patients with delirium who underwent spinal surgery were included if the studies contained data about blood transfusion or other related factors, such as haemoglobin, haematocrit, and blood loss levels. The Newcastle-Ottawa Scale was used for the study-quality evaluation. The pooled odds ratios or (standard) mean differences of the individual risk factors were estimated using the Mantel-Haenszel or inverse-variance methods.

RESULTS

Fifteen observational studies met the inclusion criteria; the studies included a total of 583,290 patients (5431 patients with delirium and 577,859 patients without delirium). In addition to an advanced age, the results of the meta-analyses showed that living in an institution, diabetes, cerebral vascular diseases, pulmonary diseases, opioid use, length of surgery, intraoperative blood loss, blood transfusions, intraoperative infusion, preoperative albumin, postoperative albumin, preoperative haematocrit, postoperative haematocrit, preoperative haemoglobin, postoperative haemoglobin, preoperative sodium, postoperative sodium, Mini-Mental State Examination score, inability to ambulate, depression, number of medications, and treatment with multiple drugs (> three types) were significantly associated with delirium.

CONCLUSION

The above-mentioned risk factors can be used to identify high-risk patients, and the appropriate prophylaxis strategies should be implemented to prevent delirium after spinal surgery.

Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital

BACKGROUND

delirium is a common condition associated with hospital admission. Detection and diagnosis is important to identify the underlying precipitating cause and implement effective management and treatment. Quality improvement (QI) methodology has been applied in limited publications. There are even fewer publications of the role of development of the electronic health record (EHR) to enhance implementation.

METHODS

we used QI methodology to improve delirium detection in the emergency department (ED). Plan Do Study Act (PDSA) cycles could be broadly categorised into technology, training and education and leadership. As part of the technology PDSA an electronic delirium pathway was developed as part of an NHS England digital systems improvement initiative (NHS England Global Digital Exemplar). The electronic pathway incorporated the 4AT screening tool, the Confusion Assessment Method, the TIME delirium management bundle, investigation order sets and automated coding of delirium as a health issue.

RESULTS

development of the EHR combined with education initiatives had benefit in terms of the number of people assessed for delirium on admission to the ED and the total number of people diagnosed with delirium across the organisation. The implementation of a delirium pathway as part of the EHR improved the use of 4AT in those 65 years and over from baseline of 3% completion in October 2017 to 43% in January 2018.

CONCLUSION

we showed that enhancement of the digital record can improve delirium assessment and diagnosis. Furthermore, the implementation of a delirium pathway is enhanced by staff education.

Predicting incident delirium diagnoses using data from primary-care electronic health records

IMPORTANCE

risk factors for delirium in hospital inpatients are well established, but less is known about whether delirium occurring in the community or during an emergency admission to hospital care might be predicted from routine primary-care records.

OBJECTIVES

identify risk factors in primary-care electronic health records (PC-EHR) predictive of delirium occurring in the community or recorded in the initial episode in emergency hospitalisation. Test predictive performance against the cumulative frailty index.

DESIGN

Stage 1: case-control; Stages 2 and 3: retrospective cohort.

SETTING

clinical practice research datalink: PC-EHR linked to hospital discharge data from England.

SUBJECTS

Stage 1: 17,286 patients with delirium aged ≥60 years plus 85,607 controls. Stages 2 and 3: patients ≥ 60 years (n = 429,548 in 2015), split into calibration and validation groups.

METHODS

Stage 1: logistic regression to identify associations of 110 candidate risk measures with delirium. Stage 2: calibrating risk factor weights. Stage 3: validation in independent sample using area under the curve (AUC) receiver operating characteristic.

RESULTS

fifty-five risk factors were predictive, in domains including: cognitive impairment or mental illness, psychoactive drugs, frailty, infection, hyponatraemia and anticholinergic drugs. The derived model predicted 1-year incident delirium (AUC = 0.867, 0.852:0.881) and mortality (AUC = 0.846, 0.842:0.853), outperforming the frailty index (AUC = 0.761, 0.740:0.782). Individuals with the highest 10% of predicted delirium risk accounted for 55% of incident delirium over 1 year.

CONCLUSIONS

a risk factor model for delirium using data in PC-EHR performed well, identifying individuals at risk of new onsets of delirium. This model has potential for supporting preventive interventions.

Delirium in hospitalized older adults

Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.

Delirium research, education and practice

Delirium research and clinical care have seen great strides in the last decade. Age and Ageing is making freely available an online collection of 15 papers published since 2012 which provides an overview of the range of research in delirium. It covers prevention and prediction, interventions and their health economic evaluations, outcomes following delirium, and clinical application in a review of the recent SIGN guidelines. The majority of studies took place in hospitals, but we also introduce some important research about another group at high risk of delirium: care home residents. We highlight the importance of delirium education. The studies comprised a range of methodologies (systematic reviews/meta-analysis, observational studies, trials and qualitative research). The selected papers are exemplars of work that has clear clinical implications. Given that delirium affects 15-20% of hospital patients, studies or analysis of existing data with clinical relevance have the potential for enormous impact on practice and on more efficient use of healthcare resources. There is, however, still a great deal of work to be done to implement what is known to be effective, and so reduce the incidence of this distressing condition, and to support those affected: not only patients, but also families and carers, as well as staff in secondary and primary care, including care homes.

Nomogram for Predicting Postoperative Delirium After Deep Brain Stimulation Surgery for Parkinson's Disease

OBJECTIVE

The purpose of the present study was to construct a nomogram for postoperative delirium (POD) after deep brain stimulation (DBS) surgery in patients with Parkinson's disease (PD).

METHODS

The present study retrospectively enrolled 165 patients with PD who had undergone DBS surgery. The patients were assessed using the Confusion Assessment Method for the Intensive Care Unit and were divided into 2 groups: the delirium group and nondelirium group. The nomogram for POD after DBS surgery was constructed from the results of univariate analysis and multivariate logistic analysis of the influencing factors for POD after DBS surgery.

RESULTS

Univariate analysis revealed that the preoperative length of stay and the presence of preoperative brain atrophy, preoperative pulmonary inflammation, and postoperative cerebral edema were statistically significant. The results from the nonmotor symptoms scale for PD, mini-mental state examination, PD sleep scale, and unified PD rating scale III were also statistically significant (P < 0.05). Multivariate logistic regression analysis showed that the unified PD rating scale III (odds ratio [OR], 2.284; 95% confidence interval [CI], 1.614-3.232), nonmotor symptoms scale for PD (OR, 8.191; 95% CI, 5.629-11.917), PD sleep scale (OR, 0.058; 95% CI, 0.05-0.067), preoperative length of stay (OR, 1.230; 95% CI, 1.053-1.437), and preoperative brain atrophy (OR, 3.912; 95% CI, 3.5-4.255) were independent factors that influenced the occurrence of POD after DBS surgery. A nomogram model was constructed using these indicators. The model predicted an area under the receiver operating characteristic curve after DBS surgery of 0.870 (95% CI, 0.808-0.918), sensitivity of 74.19%, and specificity of 91.54%.

CONCLUSIONS

The present study has presented a reliable and useful nomogram that can accurately predict the occurrence of POD after DBS surgery in patients with PD. This tool is easy to use and could assist physicians during the therapeutic decision-making process.

Reflections on delirium - A patient's perspective

Delirium, and its importance, is briefly discussed to contextualise the intricate story of one patient's experience of the condition. This recounting of the main episodes of delirium shows how its nature and severity changed with time and location, from ICU to the surgical ward. Reflection on these experiences provides insights and conclusions for consideration by the medical profession. Discussion of the nature of delirium, and the sort of interventions that helped, or might be provided, for recovery from, or reduction of, the condition are considered. Thought is given to what might be done to aid recovery and reduce severity. Some suggestions are made as to what education might be provided and the research required to better detect the condition and understand its nature and prevention.

An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study

Background

Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium.

Methods

Using a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation.

Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests.

Focus groups were conducted to explore clinicians’ experiences of the OPTA role.

Results

Three thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9.

The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group.

Focus group interviews described mixed responses and support for the OPTA role.

Conclusions

An assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED.

Trial registration

Australian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.

Development of an international undergraduate curriculum for delirium using a modified delphi process

Background

delirium is a medical emergency affecting approximately 30% of hospitalised older patients. Recent work examining UK undergraduate medical curricula highlighted inconsistencies in the delivery of teaching on delirium. The aim of this project was to develop consensus agreement on a delirium curriculum for medical undergraduates.

Methods

a modified Delphi process was used to determine consensus amongst experts in an iterative manner. Experts at the European Delirium Association Conference (London, 2015) were invited to participate. Participants were asked to consider: (i) What should be taught? (ii) How should teaching be delivered? (iii) Who should deliver the teaching? (iv) Where should the teaching be delivered? (v) When should the teaching be delivered? Delphi rounds continued until consensus on curriculum content (defined as 80% agreement) was achieved.

Results

consensus was reached after three rounds. A recurrent theme was the need to involve patients, families and carers to help drive attitudinal change. The final curriculum, along with data pertaining to agreement with each curriculum item during the Delphi process, is presented.

Conclusion

this Delphi process enabled an international group of experts from a broad range of specialties, to reach consensus agreement on the components of an undergraduate curriculum for delirium. The curriculum represents an important step in the development of delirium education within medical training. Despite competing demands of increasingly crowded undergraduate curricula, delirium, given its relevance to 21st century healthcare, must be prioritised. We call on Medical Schools to consider integrating this delirium curriculum into their degree programmes.

Protocol for the Delirium and Cognitive Impact in Dementia (DECIDE) study: A nested prospective longitudinal cohort study

BACKGROUND

Delirium is common, affecting at least 20% of older hospital inpatients. It is widely accepted that delirium is associated with dementia but the degree of causation within this relationship is unclear. Previous studies have been limited by incomplete ascertainment of baseline cognition or a lack of prospective delirium assessments. There is an urgent need for an improved understanding of the relationship between delirium and dementia given that delirium prevention may plausibly impact upon dementia prevention. A well-designed, observational study could also answer fundamental questions of major importance to patients and their families regarding outcomes after delirium. The Delirium and Cognitive Impact in Dementia (DECIDE) study aims to explore the association between delirium and cognitive function over time in older participants. In an existing population based cohort aged 65 years and older, the effect on cognition of an episode of delirium will be measured, independent of baseline cognition and illness severity. The predictive value of clinical parameters including delirium severity, baseline cognition and delirium subtype on cognitive outcomes following an episode of delirium will also be explored.

METHODS

Over a 12 month period, surviving participants from the Cognitive Function and Ageing Study II-Newcastle will be screened for delirium on admission to hospital. At the point of presentation, baseline characteristics along with a number of disease relevant clinical parameters will be recorded. The progression/resolution of delirium will be monitored. In those with and without delirium, cognitive decline and dementia will be assessed at one year follow-up. We will evaluate the effect of delirium on cognitive function over time along with the predictive value of clinical parameters.

DISCUSSION

This study will be the first to prospectively elucidate the size of the effect of delirium upon cognitive decline and incident dementia. The results will be used to inform future dementia prevention trials that focus on delirium intervention.

Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery

STUDY DESIGN

This study is a systematic review.

OBJECTIVE

Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery.

SUMMARY OF BACKGROUND DATA

Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available.

METHODS

A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015.

RESULTS

Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05).

CONCLUSIONS

An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed.

LEVEL OF EVIDENCE

Level II.

Delirium in the elderly: Current problems with increasing geriatric age

Delirium is an acute disorder of attention and cognition seen relatively commonly in people aged 65 yr or older. The prevalence is estimated to be between 11 and 42 per cent for elderly patients on medical wards. The prevalence is also high in nursing homes and long term care (LTC) facilities. The consequences of delirium could be significant such as an increase in mortality in the hospital, long-term cognitive decline, loss of autonomy and increased risk to be institutionalized. Despite being a common condition, it remains under-recognised, poorly understood and not adequately managed. Advanced age and dementia are the most important risk factors. Pain, dehydration, infections, stroke and metabolic disturbances, and surgery are the most common triggering factors. Delirium is preventable in a large proportion of cases and therefore, it is also important from a public health perspective for interventions to reduce further complications and the substantial costs associated with these. Since the aetiology is, in most cases, multfactorial, it is important to consider a multi-component approach to management, both pharmacological and non-pharmacological. Detection and treatment of triggering causes must have high priority in case of delirium. The aim of this review is to highlight the importance of delirium in the elderly population, given the increasing numbers of ageing people as well as increasing geriatric age.

The Future Hospital: a blueprint for effective delirium care

Delirium remains the most common hospital complication. Occurrence rates are set to rise as the population ages and, despite being preventable and treatable, delirium continues to be under-recognised. Given the adverse outcomes associated with delirium and the considerable financial burden, patients with delirium must be considered 'core business' for 21st century hospitals. We propose that the principles of care outlined by the Future Hospital Commission report provide an ideal blueprint for effective, evidence-based delirium prevention and management. In this context, we outline practical advice for clinicians to improve standards of care for patients with delirium in hospitals. Because negative cultural attitudes, coupled with a lack of ownership towards this highly complex group, remain a major challenge, we consider novel educational interventions that empower the multidisciplinary team. Further, improved outcomes for patients with delirium are likely to translate to wider benefits for the hospital population at large.

Predicting outcome in older hospital patients with delirium: a systematic literature review

OBJECTIVE

Delirium is a serious neuropsychiatric syndrome common in older hospitalised adults. It is associated with poor outcomes, however not all people with delirium have poor outcomes and the risk factors for adverse outcomes within this group are not well described. The objective was to report which predictors of outcome had been reported in the literature.

METHODS

We performed a systematic review by an initial electronic database search of MEDLINE, Embase and PsycINFO using four key search criteria. These were: (1) participants with a diagnosis of delirium, (2) clearly defined outcome measures, (3) a clearly defined variable as predictor of outcomes and (4) participants in the general hospital, rehabilitation and care home settings, excluding intensive care. Studies were then selected in a systematic fashion using specific predetermined criteria by three reviewers.

RESULTS

A total of 559 articles were screened, and 57 full text articles were assessed for eligibility. Twenty seven studies describing 18 different predictors of poor outcome were reported. The studies were rated by the Newcastle-Ottawa Score and were generally at low risk of bias. Four broad themes of predictor were identified; five delirium related predictors, two co-morbid psychiatric illness related predictors, eight patient related predictors and three biomarker related predictors. The most numerously described and clinically important appear to be the duration of the delirium episode, a hypoactive motor subtype, delirium severity and pre-existing psychiatric morbidity with dementia or depression. These are all associated with poorer delirium outcomes.

CONCLUSION

Important predictors of poor outcomes in patients with delirium have been demonstrated. These could be used in clinical practice to focus direct management and guide discussions regarding prognosis. These results also demonstrate a number of key unknowns, where further research to explore delirium prognosis is recommended and is vital to improve understanding and management of this condition.

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

BACKGROUND

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

AIM

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

DESIGN AND METHODS

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

SETTINGS

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Prevention of delirium (POD) for older people in hospital: study protocol for a randomised controlled feasibility trial

BACKGROUND

Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme.

METHODS/DESIGN

The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; in-hospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience.

DISCUSSION

This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial.

TRIAL REGISTRATION

ISRCTN01187372 . Registered 13 March 2014.

Review of delirium in patients with Parkinson's disease

Parkinson's disease (PD) is common and has a number of associated neuropsychiatric disturbances. Of these, delirium has historically been under-recognised. Delirium is an acute disturbance of attention and awareness that fluctuates, and is accompanied by an additional disturbance of cognition. As delirium is known to carry a particularly poor prognosis in terms of morbidity and mortality, and the relationship between delirium and dementia is becoming better defined, we completed a literature review of delirium in the context of PD. A literature search was completed using the databases PubMed, Embase and Ovid Medline. PubMed (1945-2014) was searched in September 2014; Embase (1974-2014); and Ovid Medline (1946-2014) in October 2014. The search terms 'delirium' and 'Parkinsons' in combination were used. Large studies using a robust definition of delirium were lacking in PD. There is the suggestion that PD is a risk factor for delirium and that delirium negatively impacts upon the motor symptom trajectory. Deficits in the neurotransmitters dopamine and acetylcholine are implicated in the pathophysiology of delirium in PD. Systemic inflammation also appears to have a role. Treatment of delirium in PD should include medication review and cautious use of atypical antipsychotics where pharmacological treatment is indicated. Of the atypical antipsychotics studied, quetiapine has the least extrapyramidal side effects. Evidence suggests a specific link between delirium and PD but well-designed clinical studies to evaluate the prevalence, impact and treatment of delirium in PD are required. Given the potential to improve outcomes through delirium prevention we conclude that delirium in PD is an area worthy of further study.

Towards an understanding of why undergraduate teaching about delirium does not guarantee gold-standard practice--results from a UK national survey

BACKGROUND

delirium is common and serious, yet frequently missed by medical staff. It is known that delirium is widely taught and examined in UK medical schools; however, what is taught, and how such teaching is delivered, remains unknown. The primary aim of this study was to determine the content of UK undergraduate medical education about delirium and establish how it is delivered. A secondary aim was to highlight and share examples of gold-standard teaching on delirium.

METHODS

all UK undergraduate medical schools were invited to complete a survey. Schools were asked to describe how delirium was taught and to provide delirium-related learning outcomes. Learning outcomes were mapped to the three overarching themes outlined in Tomorrow's Doctors (knowledge, skills and attitudes).

RESULTS

24/31 schools (77%) provided responses. In line with previous work, delirium was widely taught and examined. 18/24 schools reported at least one learning outcome that mapped to the knowledge domain, 19/24 for the skills domain and 2/24 for the attitudes domain. 4/24 evaluated the impact of sessions and 3/24 involved patients and the public in teaching. 13/24 schools were confident that exposure to delirium was guaranteed. Innovative teaching methods were reported by a number of schools; weblinks to examples are provided.

DISCUSSION

there was widespread failure to address attitudes on delirium within teaching, to evaluate the impact of sessions, to involve patients and the public in teaching and to guarantee exposure to delirium. Future teaching interventions should be directed at attitudinal outcomes, using a synthesis of clinical experience with multidisciplinary interaction and supportive technologies.

Validation of a consensus method for identifying delirium from hospital records

Background

Delirium is increasingly considered to be an important determinant of trajectories of cognitive decline. Therefore, analyses of existing cohort studies measuring cognitive outcomes could benefit from methods to ascertain a retrospective delirium diagnosis. This study aimed to develop and validate such a method for delirium detection using routine medical records in UK and Ireland.

Methods

A point prevalence study of delirium provided the reference-standard ratings for delirium diagnosis. Blinded to study results, clinical vignettes were compiled from participants' medical records in a standardised manner, describing any relevant delirium symptoms recorded in the whole case record for the period leading up to case-ascertainment. An expert panel rated each vignette as unlikely, possible, or probable delirium and disagreements were resolved by consensus.

Results

From 95 case records, 424 vignettes were abstracted by 5 trained clinicians. There were 29 delirium cases according to the reference standard. Median age of subjects was 76.6 years (interquartile range 54.6 to 82.5). Against the original study DSM-IV diagnosis, the chart abstraction method gave a positive likelihood ratio (LR) of 7.8 (95% CI 5.7–12.0) and the negative LR of 0.45 (95% CI 0.40–0.47) for probable delirium (sensitivity 0.58 (95% CI 0.53–0.62); specificity 0.93 (95% CI 0.90–0.95); AUC 0.86 (95% CI 0.82–0.89)). The method diagnosed possible delirium with positive LR 3.5 (95% CI 2.9–4.3) and negative LR 0.15 (95% CI 0.11–0.21) (sensitivity 0.89 (95% CI 0.85–0.91); specificity 0.75 (95% CI 0.71–0.79); AUC 0.86 (95% CI 0.80–0.89)).

Conclusions

This chart abstraction method can retrospectively diagnose delirium in hospitalised patients with good accuracy. This has potential for retrospectively identifying delirium in cohort studies where routine medical records are available. This example of record linkage between hospitalisations and epidemiological data may lead to further insights into the inter-relationship between acute illness, as an exposure, for a range of chronic health outcomes.

Cost-benefit analysis of a delirium prevention strategy in the intensive care unit

AIMS

The aim of this study was to evaluate the effect of a delirium prevention strategy.

BACKGROUND

A high prevalence has been reported for delirium after liver transplantation surgery in the intensive care unit (ICU). Delirium increases treatment costs because of treatment delays, prolonged hospital stays and other associated complications. Despite all those problems associated with delirium, a systemic prevention strategy does not exist yet.

DESIGN

This study used an economic evaluation design by reviewing relevant medical records.

METHODS

Study objects were 130 patients who were admitted to the ICU after liver transplantation surgery. After looking at the medical records of these patients, we divided them into two groups according to the application of the prevention strategy. This study analysed the costs and benefits of the prevention strategy between the groups.

RESULTS

The prevalence rate of delirium was 35·3% in the prevention-care group and 51·6% in the usual-care group. A sum of $38·4 was invested for the prevention strategy in opposite to the expected total costs of $5578 for a probable treatment. Thus, the net benefit was $5539·6 with a benefit ratio of 145·3 CONCLUSIONS: A strategy is necessary for the delirium prevention of patients in the ICU to decrease the economic burden.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrated that a prevention strategy was cost-effective because of its low input costs. With low additional investment, it is expected that this prevention strategy will be more available to other patients in the future.

Prevention of post-operative delirium in older patients with cancer undergoing surgery

Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.

Feasibility of a nursing intervention to prepare frail older patients for cardiac surgery: a mixed-methods study

BACKGROUND

Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery.

AIM

The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings.

METHODS

In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI).

RESULTS

Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4-8.7) and 7.6 (6.6-8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.

CONCLUSIONS

The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital's cardiac surgery pathway or applied in home care.

A standardized, bundled approach to providing geriatric-focused acute care

OBJECTIVES

To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications.

DESIGN

Pre-post interventional trial.

SETTING

Large academic medical center.

PARTICIPANTS

Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls.

INTERVENTION

The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults.

MEASUREMENTS

Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous (IV) morphine in excess of 2 mg, and discharge disposition.

RESULTS

Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio (OR) for the difference of differences = 1.23 (95% confidence interval (CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol (OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine (OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities (OR = 1.18, 95% CI = 1.04-1.35, P = .01).

CONCLUSION

An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care.

A neurologist's approach to delirium: diagnosis and management of toxic metabolic encephalopathies

Toxic metabolic encephalopathies (TMEs) present as an acute derangement in consciousness, cognition and behavior, and can be brought about by various triggers, including endocrine and metabolic disturbances, exogenous toxins, pain and infection. Also referred to as "delirium" or "acute confusional states," TMEs are characterized by (1) an altered level of consciousness and activity, (2) global changes in cognition with inattention, (3) a fluctuating course with disturbances in the sleep-wake cycle, and (4) asterixis and myoclonus. The pathophysiology of this syndrome is poorly understood. Imbalanced neurotransmitter signaling and pathologically heightened brain inflammatory cytokine signaling have been proposed as candidate mechanisms. Focal brain lesions can also occasionally mimic TMEs. A neurological examination is required to identify the presence of focal findings, which when present, identify a new focal lesion or the recrudescence of prior ischemic, inflammatory or neoplastic insults. Diagnostic testing must include a search for metabolic and infectious derangements. Offending medications should be withdrawn. Magnetic resonance imaging, cerebrospinal fluid analysis and electroencephalography should be considered in select clinical situations. In addition to being an unpleasant experience for the patient and family, this condition is associated with extended hospital stays, increased mortality and high costs. In individuals with diminished cognitive reserve, episodes of TME lead to an accelerated decline in cognitive functioning. Starting with an illustrative case, this paper provides a neurologist's approach to the diagnosis, differential diagnosis and management of toxic metabolic encephalopathies.

Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards

OBJECTIVE

to examine the effect of a multi-component, delirium prevention intervention on rates of incident delirium for patients admitted to specialist elderly care wards.

DESIGN

'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted as emergencies.

METHODS

a multi-component delirium prevention intervention that targeted delirium risk factors was implemented by clinical staff. Demographic information and assessments for delirium risk factors were recorded by research staff within 24 h of admission to the ward. New onset (incident) delirium was diagnosed by daily research staff assessments using the Confusion Assessment Method and Delirium Rating Scale-Revised-98.

RESULTS

a total of 436 patients were recruited (249 in the 'before' and 187 in the 'after' group). Incident delirium was significantly reduced ('before' = 13.3%; 'after' = 4.6%; P = 0.006). Delirium severity and duration were significantly reduced in the 'after' group. Mortality, length of stay, activities of daily living score at discharge and new discharge to residential or nursing home rates were similar for both groups.

CONCLUSIONS

a multi-component, delirium prevention intervention directed at delirium risk factors and implemented by local clinical staff can reduce incident delirium on specialist elderly care wards.

New horizons in the pathogenesis, assessment and management of delirium

Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.

Prevention and treatment options for postoperative delirium in the elderly

PURPOSE OF REVIEW

To review recent findings and developments in strategies for prevention and treatment of postoperative delirium.

RECENT FINDINGS

Current advances in the field include improved knowledge about predisposing and precipitating factors, evidence for efficacy of multicomponent prevention programmes, refinement of perioperative procedures, and promising pharmacological approaches for prophylaxis and management of postoperative delirium.

SUMMARY

Postoperative delirium is a common and serious complication in elderly patients. Preoperative assessment of risk profiles and tailored multimodal prevention approaches proved effective and should be integrated into clinical practice. Despite promising recent findings, at present, the routine use of pharmacological prophylaxis cannot be recommended. Validated and easy-to-use bedside diagnostic tools are available and should be regularly applied for delirium screening in the first days after surgery. In patients developing delirium, causal conditions and contributing factors need to be identified and addressed. Whereas administration of antipsychotics may represent an option for symptomatic treatment, further studies are needed to evaluate the effects of pharmacological approaches on long-term outcomes in elderly patients with delirium.