Delirium screening in older patients

Evaluation and Management of Delirium

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

Occurrence Rate of Delirium in Acute Stroke Settings

Background and Purpose—

Delirium is associated with increased mortality, length of stay, and poor functional outcome following critical illness. The epidemiology of delirium in stroke is poorly described. We sought to collate evidence around occurrence (incidence or prevalence) of delirium in acute stroke.

Methods—

We searched multiple cross-disciplinary electronic databases using a prespecified search strategy, complemented by hand searching. Eligible studies described delirium in acute (first 6 weeks) stroke. We compared delirium occurrence using random-effects models to describe summary estimates. We assessed risk of bias using the Newcastle-Ottawa tool, incorporating this in sensitivity analyses. We performed subgroup analyses for delirium diagnostic method (confusion assessment method scoring, clinical diagnosis, other), duration and timing of delirium assessment (>1 or <1 week), and performed meta-regression based on the year of publication.

Results—

Of 8822 titles, we included 32 papers (6718 participants) in the quantitative analysis. Summary estimate for occurrence of delirium was 25% (95% CI, 20%–30%; moderate quality evidence). Limiting to studies at low risk of bias (22 studies, 4422 participants), the occurrence rate was 23% (95% CI, 17%–28%). Subgroup summary estimates suggest that delirium occurrence may vary with assessment method: confusion assessment method, 21% (95% CI, 16%–27%); clinical diagnosis, 27% (95% CI, 19%–38%); other, 32% (95% CI, 22%–43%) but not with duration and timing of assessment. Meta-regression suggested decline in occurrence of delirium comparing historical to more recent studies (slope, 0.03 [SE, 0.004]; P <0.0001).

Conclusions—

Delirium is common, affecting 1 in 4 acute stroke patients. Reported rates of delirium may be dependent on assessment method. Our estimate of delirium occurrence could be used for audit, to plan intervention studies, and inform clinical practice.

Clinical Trial Registration—

URL: http://www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD42015029251.

Delirium in an Acute Stroke Setting, Occurrence, and Risk Factors

Background and Purpose—

Delirium is a common and serious complication of acute illness. We describe delirium occurrence in an unselected, acute stroke population.

Methods—

We collected data from consecutive stroke admissions. We performed comprehensive cognitive assessment within the first week including Diagnostic Statistical Manual-5–based delirium diagnosis. We reported proportion with delirium and the clinical and demographic associations with delirium using multiple logistic regression.

Results—

Of 708 patients, median age of 71 years (interquartile range, 59–80), we recorded delirium in 187 of 708 (26.4%; 95% CI, 23.0–30.0). Across 395 patients with complete risk factor data (105 delirium), factors independently associated with delirium were: age (odds ratio, 1.05; 95% CI, 1.03–1.08), drug/alcohol misuse (odds ratio, 2.64; 95% CI, 1.10–6.26), and stroke severity (odds ratio, 1.22; 95% CI, 1.14–1.31).

Conclusions—

Delirium is common in acute stroke, affecting 1 in 4. It may be possible to predict those at risk using prestroke and stroke-specific factors.

Clinical Trial Registration—

URL: researchregistry.com . Protocol: 1147.