Acute delirium and functional decline in the hospitalized elderly patient

COVID-19 vaccination may prevent postoperative delirium in elderly patients undergoing elective non-cardiac surgery: The PNDRFAP and PNDABLE studies

Background

Postoperative delirium (POD) often occurs in elderly patients after surgery. We conducted two clinical studies to determine whether COVID-19 vaccination has a protective effect on POD and to explore the role of CSF biomarkers in this process.

Methods

We conducted two clinical studies, Perioperative Neurocognitive Disorder Risk Factor and Prognosis (PNDRFAP) and Perioperative Neurocognitive Disorder and Biomarker Lifestyle (PNDABLE), in which patients more than or equal to 65 years old who have had elective non-cardiac surgery were enrolled. The preoperative cognitive status of patients were evaluated by Mini-Mental State Examination (MMSE) one day preoperatively. Confusion Assessment Method (CAM) was used to diagnose POD. We used the mediation model to analyze the relationship between CSF biomarkers, COVID-19 vaccination and POD, as well as Dynamic Nomogram to calculate the incidence of Non-Postoperative Delirium (NPOD). The main outcome of these studies was the incidence of POD during seven days postoperatively or before discharge, which was assessed by CAM.

Results

In the final, 705 participants were enrolled in the PNDRFAP study, and 638 patients in the PNDABLE. In both studies, we found that the occurrence of POD was lower in patients who had injected COVID-19 vaccination before surgery compared with those without vaccination (PNDRFAP: 10.20 % [21/205] vs 25.80 % [129/500], P < 0.001; PNDABLE: 2.40 % [4/164] vs 34.60 % [164/474], P < 0.001). Mediation analysis showed that the protective effect of preoperative COVID-19 vaccine on POD was significantly mediated by CSF Aβ42 (proportion = 17.56 %), T-tau (proportion = 19.64 %), Aβ42/T-tau (proportion = 29.67 %), and Aβ42/P-tau (proportion = 12.26 %).

Conclusions

COVID-19 vaccine is a protective factor for POD in old patients, which is associated with CSF biomarkers.

Post-Acute Care in China: Development, Challenges, and Path Forward

OBJECTIVES

To evaluate the evolution and challenges of China's post-acute care (PAC) system over the past 20 years and suggest actionable policy recommendations for its improvement.

DESIGN

A retrospective review of policies and initiatives aimed at PAC system development, analyzed alongside unsolved challenges in light of global PAC practices, informed by literature reviews and collaborative discussion.

SETTING AND PARTICIPANTS

PAC in China involves diverse settings such as general hospitals, inpatient rehabilitation centers, skilled nursing facilities, community health centers, and homes. The patients are mainly those discharged from acute hospitals with functional impairment and in need of continuous care.

METHOD

An extensive search of government policy documents, statistical sources, peer-reviewed studies, and the gray literature. The research team conducted literature reviews and discussions regularly to shape the findings.

RESULTS

China has strengthened its PAC system through improved rehabilitation and nursing infrastructure, establishment of tiered rehabilitation networks, and adoption of innovative payment methods. However, challenges persist, including a lack of clinical consensus, resource constraints in PAC facilities and among professionals, the need for integrated care coordination, and the unification of PAC assessment tools and payment mechanisms.

CONCLUSIONS AND IMPLICATIONS

Although China has made substantial progress in its PAC system over 2 decades, continued efforts are needed to address its lingering challenges. Elevating awareness of PAC's significance and instituting policy adjustments targeting these challenges are essential for the system's optimization.

Unveiling the nexus of postoperative fever and delirium in cardiac surgery: identifying predictors for enhanced patient care

Background

Postoperative delirium (POD) is a significant complication observed in cardiac surgery patients, characterized by acute cognitive decline, fluctuating mental status, consciousness impairment, and confusion. Despite its impact, POD often goes undiagnosed. Postoperative fever, a common occurrence after cardiac surgery, has not been comprehensively studied in relation to delirium. This study aims to identify perioperative period factors associated with POD in patients undergoing cardiopulmonary bypass, with the potential for implementing preventive interventions.

Methods

In a prospective observational study conducted between February 2023 and April 2023 at the Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, a total of 232 patients who underwent cardiac surgery were enrolled. POD assessment utilized the Confusion Assessment Method for the ICU (CAM-ICU), while high fever was defined as a bladder temperature exceeding 39°C. Statistical analysis included univariate and multivariate analyses, logistic regression, nomogram development, and internal validation.

Result

The overall incidence of postoperative delirium was found to be 12.1%. Multivariate analysis revealed that postoperative lactate levels [odds ratio (OR) = 1.787], maximum temperature (OR = 11.290), and cardiopulmonary bypass time (OR = 1.015) were independent predictors of POD. A predictive nomogram for POD was developed based on these three factors, demonstrating good discrimination and calibration. The prediction model exhibited a C-statistic value of 0.852 (95% CI, 0.763-0.941), demonstrating excellent discriminatory power. Sensitivity and specificity, based on the area under the receiver operating characteristic (AUROC) curve, were 91.2% and 67.9%, respectively.

Conclusion

This study underscores the high prevalence of POD in cardiac surgery patients and identifies postoperative lactate levels, cardiopulmonary bypass duration, and postoperative fever as independent predictors of delirium. The association between postoperative fever and POD warrants further investigation. These findings have implications for implementing preventive strategies in high-risk patients, aiming to mitigate postoperative complications and improve patient outcomes.

Assessment tools and incidence of hospital-associated disability in older adults: a rapid systematic review

Background

During hospitalization older adults have a high risk of developing functional impairments unrelated to the reasons for their admission. This is termed hospital-associated disability (HAD). This systematic review aimed to assess the incidence of HAD in older adults admitted to acute care with two outcomes: firstly in at least one activity of daily living from a set of functional tasks (e.g., Katz Index) and secondly the incidence of functional decline in an individual functional task (e.g., bathing), and to identify any tools or functional tasks used to assess activities of daily living (ADL) in hospitalized older patients.

Methods

A rapid systematic review was performed according to the recommendations of the Cochrane Rapid Reviews Methods Group and reported the data according the PRISMA statement. A literature search was performed in Medline (via Ovid), EMBASE, and Cochrane Central Register of Controlled Trials databases on 26 August 2021. Inclusion criteria: older adults (≥65 years), assessment of individual items of activities of daily living at baseline and discharge. Exclusion criterion: studies investigating a specific condition that could affect functional decline and studies that primarily examined a population with cognitive impairment. The protocol was registered on OSF registries (https://osf.io/9jez4/) identifier: DOI 10.17605/OSF.IO/9JEZ4.

Results

Ten studies were included in the final review. Incidence of HAD (overall score) was 37% (95% CI 0.30-0.43). Insufficient data prevented meta-analysis of the individual items. One study provided sufficient data to calculate incidence, with the following values for patients' self-reported dependencies: 32% for bathing, 27% for dressing, 27% for toileting, 30% for eating and 27% for transferring. The proxy reported the following values for patients' dependencies: 70% for bathing, 66% for dressing, 70% for toileting, 61% for eating and 59% for transferring. The review identified four assessment tools, two sets of tasks, and individual items assessing activities of daily living in such patients.

Conclusions

Incidence of hospital-associated disability in older patients might be overestimated, due to the combination of disease-related disability and hospital-associated disability. The tools used to assess these patients presented some limitations. These results should be interpreted with caution as only one study reported adequate information to assess the HAD incidence. At the item level, the latter was higher when disability was reported by the proxies than when it was reported by patients. This review highlights the lack of systematic reporting of data used to calculate HAD incidence. The methodological quality and the risk of bias in the included studies raised some concerns.

Current Trends for Delirium Screening within the Emergency Department

Delirium is an acute neurological disorder that involves attention and cognition. It is associated with a high risk of morbidity and mortality among older people (>65 years old). In the context of the Emergency Department (ED), it is frequently experienced by patients but often not recognized. Literature studies have identified some screening instruments for an initial evaluation of delirium. Most of these tools have not been validated yet in the context of emergencies, but, in other settings, they were very useful for assessing and maximizing the recognition of this condition among older patients. We conducted a review of the literature, including randomized control trials, clinical and observational studies, and research studies published in recent years, confirming that most of the screening tools for delirium used in the intensive care unit (ICU) or the geriatric department have not been tested in the ED, and the ideal timing and form of the delirium assessment process for older adults have not been defined yet. The aim of our review is to summarize the updated evidence about the screening tools for delirium in the context of the ED, due to the fact that overcrowding of the ED and the stressful condition of emergency situations (that contribute to the onset of delirium) could expose older patients to a high risk of complications and mortality if delirium is not promptly recognized. In conclusion, we support the evidence that delirium is a current and real condition that emergency physicians have to face daily, and we are aware that more research is needed to explore this field in order to improve the overall outcomes of older patients admitted to the ED.

Health Literacy and Exercise to Treat Frailty in Community-Dwelling Older Adults: A National Survey Study

Aging is a major challenge facing modern society and has attracted global attention. Studies have provided some initial evidence that health literacy plays a role in determining frailty; however, most of these studies have used small convenience samples of individuals recruited from geographically limited areas, thus limiting the generalizability of their findings. The present study explored the relationships among health literacy, exercise, and frailty in Taiwanese older adults by using the data of a national population-based survey. We retrieved data from the Taiwan Longitudinal Study on Aging, a population-based survey. We gathered the 2015 data on the age, sex, education level, marital status, exercise habits, and activities of daily living (ADLs) of each eligible respondent. We evaluated the respondents’ health literacy by using a nine-item health literacy scale and categorized their health literacy level as low, medium, or high. Frailty was diagnosed according the Fried criteria. Our final sample consisted of 7702 community-dwelling older adults (3630 men and 4072 adults). Of these, 25.3% had low health literacy. The proportion of respondents who had two or more disabilities in terms of ADLs or instrumental ADLs was higher among the women (36.4% and 12.6%, respectively), and regular exercise was more common among the men (19.6%). Frailty was more prevalent among the women; the prevalence of frailty among the male and female respondents was 4.5% and 8.1%, respectively. High health literacy and regular exercise were protective factors for frailty. According to our results, poor health literacy is a risk factor for prefrailty and frailty, and regular exercise is significantly negatively associated with prefrailty and frailty. Additional studies are necessary to define practical strategies for reducing the risks of disability and death for older adults with low health literacy who do not exercise regularly, thereby improving their quality of life.

The Pharmacogenetics of Opiates and Its Impact on Delirium in Mechanically Ventilated Adults: A Pilot Study

Background: Pharmacogenetics may explain a substantial proportion of the variation seen in the efficacy and risk profile of analgesosedative drugs and the incidence of delirium in critically ill adults. Objectives: Conduct a feasibility study to demonstrate the reliability of collecting and analyzing pharmacogenetic information from critically ill patients and to assess the impact of pharmacogenetics on intensive care unit (ICU) outcomes. Methods: We prospectively enrolled subjects from the Medical ICU at the University of North Carolina (UNC). DNA was obtained via a buccal swab and evaluated using the DNA2Rx assay. We collected data on demographics, daily cumulative psychoactive medication exposure, and severity of illness. We performed daily delirium assessments via the CAM-ICU. We analyzed associations between select single nucleotide polymorphisms (SNPs) and delirium. Results: From June, 2018 through January, 2019, we screened 244 patients and enrolled 50. The median age was 62.0 years old (range: 28-82 years old), and 27 (54%) of the subjects were female. In all, 49 (98%) samples were both high quality and sufficient quantity. In secondary analyses, we found that 80% (12/15) of patients with two 2 copies of a G allele at rs4680 on COMT experienced delirium, whereas 44% (4/9) of patients with 2 copies of an A allele at this location had delirium. In all, 44% (4/9) of patients with 2 T allele copies at rs7439366 on UGT2B7 experienced delirium compared to 73% (11/15) of patients with 2 C allele copies at this location. Conclusions: We can feasibly collect genetic information from critically ill adults. We were able to efficiently collect high quality DNA of sufficient quantity to conduct pharmacogenetic analysis in this critically ill population. Although the sample size of our current study is too small to conduct robust inferential analyses, it suggests potential SNP targets for a future larger study.

The association between geriatric treatment and 30-day readmission risk among medical inpatients aged ≥75 years with multimorbidity

Background

Readmission to hospital is frequent among older patients and reported as a post-discharge adverse outcome. The effect of treatment in a geriatric ward for acutely admitted older patients on mortality and function is well established, but less is known about the possible influence of such treatment on the risk of readmission, particularly in the oldest and most vulnerable patients. Our aim was to assess the risk for early readmission for multimorbid patients > 75 years treated in a geriatric ward compared to medical wards and to identify risk factors for 30-day readmissions.

Methods

Prospective cohort study of patients acutely admitted to a medical department at a Norwegian regional hospital. Eligible patients were community-dwelling, multimorbid, receiving home care services, and aged 75+. Patients were consecutively included in the period from 1 April to 31 October 2012. Clinical data were retrieved from the referral letter and medical records.

Results

We included 227 patients with a mean (SD) age of 86.0 (5.7) years, 134 (59%) were female and 59 (26%) were readmitted within 30 days after discharge. We found no statistically significant difference in readmission rate between patients treated in a geriatric ward versus other medical wards. In adjusted Cox proportional hazards regression analyses, lower age (hazard ratio (95% confidence interval) 0.95 (0.91–0.99) per year), female gender (2.17 (1.15–4.00)) and higher MMSE score (1.03 (1.00–1.06) per point) were significant risk factors for readmission.

Conclusions

Lower age, female gender and higher cognitive function were the main risk factors for 30-day readmission to hospital among old patients with multimorbidity. We found no impact of geriatric care on the readmission rate.

Peripheral viral challenge increases c-fos level in cerebral neurons

Peripheral viral infection can substantially alter brain function. We have previously shown that intraperitoneal (i.p.) injection of a viral mimetic, polyinosinic-polycytidylic acid (PIC), engenders hyperexcitability of cerebral neurons. Because neuronal activity is invariably associated with their expression of the Cfos gene, the present study was undertaken to determine whether PIC challenge also increases neuronal c-fos protein level. Female C57BL/6 mice were i.p. injected with PIC, and neuronal c-fos was analyzed in the motor cortex by immunohistochemistry. PIC challenge instigated a robust increase in the number of c-fos-positive neurons. This increase reached approximately tenfold over control at 24 h. Also, the c-fos staining intensity of individual neurons increased. AMG-487, a specific inhibitor of the chemokine receptor CXCR3, profoundly attenuated the accumulation of neuronal c-fos, indicating the activation of CXCL10/CXCR3 axis as the trigger of the process. Together, these results show that the accumulation of c-fos is a viable readout to assess the response of cerebral neurons to peripheral PIC challenge, and to elucidate the underlying molecular mechanisms.

Factors for Timely Identification of Possible Occurrence of Delirium in Palliative Care: A Prospective Observational Study

Delirium occurs in 50–80% of end-of-life patients but is often misdiagnosed. Identification of clinical factors potentially associated with delirium onset can lead to a correct early diagnosis. To this aim, we conducted a prospective cohort study on patients from an Italian palliative care unit (PCU) admitted in 2018–2019. We evaluated the presence of several clinical factors at patient admission and compared their presence in patients who developed delirium and in those who did not develop it during follow-up. Among 503 enrolled patients, after a median follow-up time of 16 days (interquartile range 6–40 days), 95 (18.9%) developed delirium. Hazard ratios (HR) and corresponding 95% confidence intervals were computed using Cox proportional hazard models. In univariate analyses, factors significantly more frequent in patients with delirium were care in hospice, compromised performance status, kidney disease, fever, renal failure, hypoxia, dehydration, drowsiness, poor well-being, breathlessness, and “around the clock” therapy with psychoactive drugs, particularly haloperidol. In multivariate analyses, setting of care (HR 2.28 for hospice versus home care, 95% CI 1.45–3.60; p < 0.001), presence of breathlessness (HR 1.71, 95% CI 1.03–2.83, p = 0.037), and administration of psychoactive drugs, particularly haloperidol (HR 2.17 for haloperidol, 95% CI 1.11–4.22 and 1.53 for other drugs, 95% CI 0.94–2.48; p = 0.048) were significantly associated with the risk of developing delirium. The study indicates that some clinical factors are associated with the probability of delirium onset. Their evaluation in PC patients could help healthcare professionals to identify the development of delirium in those patients in a timely manner.

The Effects of Propofol and Sevoflurane on Postoperative Delirium in Older Patients: A Randomized Clinical Trial Study

BACKGROUND

Postoperative delirium is associated with adverse postoperative outcomes. However, whether intravenous and inhalation anesthetics are associated with different risks of postoperative delirium remains unknown.

OBJECTIVE

We set up to determine the incidence and duration of postoperative delirium in older patients who had surgery under the intravenous anesthetic propofol or the inhalational anesthetic sevoflurane.

METHODS

Participants were patients who had total hip/knee replacements and were randomized to propofol (N = 106) or sevoflurane (N = 103) anesthesia group. The Confusion Assessment Method was employed by investigators who were blinded to the anesthesia regimen to assess the incidence and duration (days of postoperative delirium per person) of postoperative delirium on postoperative days 1, 2, and 3.

RESULTS

A total of 209 participants (71.2±6.7 years old, 29.2% male) were included in the final data analysis. The incidence of postoperative delirium was 33.0% with propofol anesthesia and 23.3% with sevoflurane anesthesia (p = 0.119, Chi-square test), and we estimated that we would need 316 participants in each arm to detect a potential statistically significant difference. Days of postoperative delirium per person were higher in the propofol (0.5±0.8) anesthesia group compared to the sevoflurane anesthesia group (0.3±0.5, p = 0.049, Student's t-test).

CONCLUSION

This pilot study established a system to compare effects of different anesthetics and generated a hypothesis that propofol trended to have a higher incidence and had longer duration of postoperative delirium than sevoflurane. Additional studies with a larger sample size are needed to test this hypothesis.

Effect of atorvastatin on delirium status of patients in the intensive care unit: a randomized controlled trial

INTRODUCTION

Delirium is one of the most prevalent complications in intensive care unit (ICU) patients, which is related to worse clinical outcomes including a longer ICU stay, longer duration of mechanical ventilation, higher mortality rates and increased risk of cognitive impairment. Observational studies have suggested that statins might have a positive effect on delirium status of hospitalized patients. To date, there has been no trial assessing the effect of atorvastatin on delirium status in critically ill patients. Thus, the aim of the current study was to determine the efficacy of atorvastatin on delirium status of patients in the ICU.

METHODS

In this randomized, double-blind and controlled trial, a total of 90 patients in the general ICU who had delirium for at least 2 days were randomly divided into atorvastatin (40 mg/day) (n = 40) and control (n = 50) groups. Delirium status of the patients was determined twice a day at 10:00 a.m. and 18:00 p.m. using the Richmond Agitation-Sedation Scale (RASS).

RESULTS

Administration 40 mg/day of atorvastatin significantly reduced the mean RASS score and increased delirium-free days at both morning and afternoon time points compared to the control group (p < 0.05).

CONCLUSIONS

Administration of atorvastatin had a significant positive effect on delirium status in patients admitted to the ICU.

Prognostic Value of Glycated Hemoglobin in Frail Older Diabetic Patients With Hip Fracture

BACKGROUND

Previous studies have shown increased risk of fracture in older patients with poor or strict glycemic control (glycated hemoglobin, HbA1c, ≥ 8% or < 6-7% respectively); however, these reports did not investigate the oldest-old population. Comprehensive geriatric assessment (CGA) and a patient-centered approach have been proven to improve the quality of care in the management of Type 2 Diabetes Mellitus (T2DM) in the older patients, but data regarding T2DM in patients with fragility fractures are still lacking.

AIM

To investigate the prognostic role of HbA1c and frailty level in older diabetic patients admitted for hip fracture.

METHODS

Prospective observational cohort study conducted on diabetic geriatric patients consecutively hospitalized for hip fracture in the orthogeriatric unit of a tertiary care hospital. Preoperative comprehensive geriatric assessment (CGA) was performed. Using the Clinical Frailty Scale (CFS), diabetic patients were categorized in robust (CFS < 5) and frail (CFS ≥ 5), and further stratified according to HbA1c values [Tertile 1 (T1) HbA1c < 48 mmol/mol, Tertile 2 (T2) 48-58 mmol/mol and Tertile 3 (T3) > 58 mmol/mol). Comparisons between continuous variables were performed with analysis of non-parametric test for independent samples, while relationships between categorical variables were assessed by chi-square test. Using logistic multivariate regression, we evaluated the determinants of 1-year all-cause mortality in diabetic older patients with hip fracture.

RESULTS

Among the 1319 older patients (mean age 82.8 ± 7.5 years, 75.9% females) hospitalized for hip fracture, 204 (15.5%) had a previous diagnosis of T2DM. T2DM patients showed an increased proportion of multiple concurrent fractures occurred during the accidental fall or syncope (12.7% vs 11.2%, p=0.02). One-year mortality after hip fracture surgery was significantly higher in T2DM as compared to not diabetic patients (21.2% vs 12.5%, p<0.001). No significant difference in mortality was found across HbA1c tertiles; however, frail diabetic patients in the second and third HbA1c tertiles showed higher mortality risk compared to the robust counterparts (26.9% vs 5%, p=0.001 for T2 and 43.5% vs 13.3%, p=<0.05 for T3), while no difference was observed among those in T1.

CONCLUSIONS

Frail patients with HbA1c ≥ 48 mmol/L showed an increased mortality risk as compared to robust counterparts. CFS represents an important tool to select diabetic subjects with higher likelihood of adverse outcome.

Risk factors for delirium among older adults in the emergency department: a systematic review protocol

INTRODUCTION

Delirium is commonly missed in older adults presenting to the emergency department (ED). Although current recommendations for active screening of delirium in the ED, this might not be feasible or practical. Identifying patients at high risk for prevalent and incident delirium in the ED will help to improve the screening process and to build interventions. There is currently scattered synthesis of evidence on risk factors associated with delirium in the ED. To address this gap, we are conducting a systematic review to describe the risk factors (patient vulnerability factors and precipitating factors) for delirium in the ED.

METHODS AND ANALYSIS

A literature search was performed from inception to March 2020 in Ovid EBM Reviews, Ovid EMBASE, Ovid MEDLINE, Scopus and Web of Science. We will include original research studies that report a quantitative relationship between at least one risk factor and delirium in the ED setting. Two investigators will use eligibility criteria from this protocol to independently screen titles and abstracts, and select studies based on full-text review of potentially eligible studies. After arriving at a final set of included studies, two investigators will extract data using a standardised data collection form. If appropriate, data regarding each risk factor will be pooled through a random-effect meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to evaluate the overall quality of evidence.

ETHICS AND DISSEMINATION

To our knowledge, this will be the first systematic review evaluating risk factors for prevalent and incident delirium specifically related to the ED setting. Results of this study will aid in the identification of older adults at risk for delirium in the ED. We aim to publish the results of this systematic review in a peer-reviewed journal with good visibility for the fields of emergency medicine and geriatrics.PROSPERO registration numberCDR42020175261.

Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis

OBJECTIVES

Hospital-associated disability (HAD), defined as loss of independence in activities of daily living (ADL) following acute hospitalization, is observed among older adults. The study objective is to determine overall prevalence of HAD among older adults hospitalized in acute care, and to assess the impact of study initiation year in moderation of prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, and prospective cohort studies. English-language searches to identify included studies were completed February 2018 and updated May 2018 of electronic databases and reference lists of studies and reviews. Included studies were human subjects investigations that measured ADL ≥2 time points before or during and after hospitalization and reported prevalence of ADL decline among older adults.

SETTING

Acute care hospital units.

PARTICIPANTS

Adults aged ≥65 years hospitalized in medical-surgical acute care; total sample size across all included studies was 7375.

METHODS

Independence in ADL was assessed using the Katz Index of Independence in Activities of Daily Living and Barthel Index of Independence in Activities of Daily Living.

RESULTS

Random effects meta-analysis across included studies identified combined prevalence of HAD as 30% (95% CI 24%, 33%; P < .001). The effect of study initiation year on the prevalence rate was minimal. A large amount of heterogeneity was observed between studies, which may be due in part to nonstandardized measurement of ADL impairment or other methodological differences.

CONCLUSIONS AND IMPLICATIONS

Hospitalization in acute care poses a significant risk to functional independence of older adults, and this risk is unchanged despite shorter lengths of stay. The evidence supports the continued need for hospital-based programs that provide assessment of functional ability and identification of at-risk older adults in order to better treat and prevent HAD.

Neuronal CXCL10/CXCR3 Axis Mediates the Induction of Cerebral Hyperexcitability by Peripheral Viral Challenge

Peripheral infections can potently exacerbate neuropathological conditions, though the underlying mechanisms are poorly understood. We have previously demonstrated that intraperitoneal (i.p.) injection of a viral mimetic, polyinosinic-polycytidylic acid (PIC) induces a robust generation of CXCL10 chemokine in the hippocampus. The hippocampus also features hyperexcitability of neuronal circuits following PIC challenge. The present study was undertaken to determine the role of CXCL10 in mediating the development of hyperexcitability in response to PIC challenge. Briefly, young female C57BL/6 mice were i.p. injected with PIC, and after 24 h, the brains were analyzed by confocal microscopy. CXCL10 staining of neuronal perikarya and a less intense staining of the neuropil was observed in the hippocampus and cortex. CXCL10 staining was also evident in a subpopulation of astrocytes, whereas microglia were CXCL10 negative. CXCR3, the cognate receptor of CXCL10 was present exclusively on neurons, indicating that the CXCL10/CXCR3 axis operates through an autocrine/paracrine neuronal signaling. Blocking cerebral CXCR3 through intracerebroventricular injection of a specific inhibitor, AMG487, abrogated PIC challenge-induced increase in basal synaptic transmission and long-term potentiation (LTP), as well as the reduction of paired-pulse facilitation (PPF), in the hippocampus. The PIC-mediated abolishment of hippocampal long-term depression (LTD) was also restored after administration of AMG487. Moreover, CXCR3 inhibition attenuated seizure hypersensitivity induced by PIC challenge. The efficacy of AMG487 strongly strengthens the notion that CXCL10/CXCR3 axis mediates the induction of cerebral hyperexcitability by PIC challenge.

The role of physical exercise and rehabilitation in delirium

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome

BACKGROUND

With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment).

OBJECTIVES

To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay.

METHOD

This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models.

RESULTS

The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67; OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009).

CONCLUSION

Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.

Economic impact of delirium in Australia: a cost of illness study

OBJECTIVES

To estimate the economic impact of delirium in the Australian population in 2016-2017, including financial costs, and its burden on health.

DESIGN, SETTING AND PARTICIPANTS

A cost of illness study was conducted for the Australian population in the 2016-2017 financial year. The prevalence of delirium in 2016-2017 was calculated to inform cost estimations. The costs estimated in this study also include dementia attributable to delirium.

MAIN OUTCOME MEASURES

The total and per capita costs were analysed for three categories: health systems costs, other financial costs including productivity losses and informal care and cost associated with loss of well-being (burden of disease). Costs were expressed in 2016-2017 pound sterling (£) and Australian dollars ($A).

RESULTS

There were an estimated 132 595 occurrences of delirium in 2016-2017, and more than 900 deaths were attributed to delirium in 2016-2017. Delirium causes an estimated 10.6% of dementia in Australia. The total costs of delirium in Australia were estimated to be £4.3 billion ($A8.8 billion) in 2016-2017, ranging between £2.6 billion ($A5.3 billion) and £5.9 billion ($A12.1 billion). The total estimated costs comprised financial costs of £1.7 billion and the value of healthy life lost of £2.5 billion. Dementia attributable to delirium accounted for £2.2 billion of the total cost of delirium.

CONCLUSIONS

These findings highlight the substantial burden that delirium imposes on Australian society-both in terms of financial costs associated with health system expenditure and the increased need for residential aged care due to the functional and cognitive decline associated with delirium and dementia. To reduce the substantial well-being costs of delirium, further research should seek to better understand the potential pathways from an episode of delirium to subsequent mortality and reduced cognitive functioning outcomes.

Post-Acute Care as a Key Component in a Healthcare System for Older Adults

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Effect of dynamic light at the coronary care unit on the length of hospital stay and development of delirium: a retrospective cohort study

Background

Disturbed circadian rhythm is a potential cause of delirium and is linked to disorganisation of the circadian rhythmicity. Dynamic light (DL) could reset the circadian rhythm by activation of the suprachiasmatic nucleus to prevent delirium. Evidence regarding the effects of light therapy is predominantly focused on psychiatric disorders and circadian rhythm sleep disorders. In this study, we investigated the effect of DL on the total hospital length of stay (LOS) and occurrence of delirium in patients admitted to the Coronary Care Unit (CCU).

Methods

This was a retrospective cohort study. Patients older than 18 years, who were hospitalized longer than 12 h at the CCU and had a total hospital LOS for at least 24 h, were included. Patients were assigned to a room with DL (n = 369) or regular lighting conditions (n = 379). DL was administered at the CCU by two ceiling-mounted light panels delivering light with a colour temperature between 2700 and 6500 degrees Kelvin. Reported outcome data were: total hospital LOS, delirium incidence, consultation of a geriatrician and the amount of prescripted antipsychotics.

Results

Between May 2015 and May 2016, data from 748 patients were collected. Baseline characteristics, including risk factors provoking delirium, were equal in both groups. Median total hospital LOS in the DL group was 100.5 (70.8–186.0) and 101.0 (73.0–176.4) h in the control group (P = 0.935). The incidence of delirium in the DL and control group was 5.4% (20/369) and 5.0% (19/379), respectively (P = 0.802). No significant differences between the DL and control group were observed in secondary endpoints. Subgroup analysis based on age and CCU LOS also showed no differences.

Conclusion

Our study suggests exposure to DL as an early single approach does not result in a reduction of total hospital LOS or reduced incidence of delirium. When delirium was diagnosed, it was associated with poor hospital outcome.

Delirium

Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.

Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium

Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.

Delirium in the Emergency Department and Its Extension into Hospitalization (DELINEATE) Study: Effect on 6-month Function and Cognition

BACKGROUND

The natural course and clinical significance of delirium in the emergency department (ED) is unclear.

OBJECTIVES

We sought to (1) describe the extent to which delirium in the ED persists into hospitalization (ED delirium duration) and (2) determine how ED delirium duration is associated with 6-month functional status and cognition.

DESIGN

Prospective cohort study.

SETTING

Tertiary care, academic medical center.

PARTICIPANTS

ED patients ≥65 years old who were admitted to the hospital.

MEASUREMENTS

The modified Brief Confusion Assessment Method was used to ascertain delirium in the ED and hospital. Premorbid and 6-month function were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire which ranged from 0 (completely dependent) to 28 (completely dependent). Premorbid and 6-month cognition were determined using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranged from 1 to 5 (severe dementia). Multiple linear regression was performed to determine if ED delirium duration was associated with 6-month function and cognition adjusted for baseline OARS ADL and IQCODE, and other confounders.

RESULTS

A total of 228 older ED patients were enrolled. Of the 105 patients who were delirious in the ED, 81 (77.1%) patients' delirium persisted into hospitalization. For every ED delirium duration day, the 6-month OARS ADL decreased by 0.63 points (95% CI: -1.01 to -0.24), indicating poorer function. For every ED delirium duration day, the 6-month IQCODE increased 0.06 points (95% CI: 0.01-0.10) indicating poorer cognition.

CONCLUSIONS

Delirium in the ED is not a transient event and frequently persists into hospitalization. Longer ED delirium duration is associated with an incremental worsening of 6-month functional and cognitive outcomes.

Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes

OBJECTIVES

To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery.

DESIGN

Prospective observational study.

SETTING

Academic medical center.

PARTICIPANTS

Individuals aged 70 and older undergoing spine surgery (N = 89).

MEASUREMENTS

Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state.

RESULTS

Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home.

CONCLUSION

Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.

Association of cognition with functional trajectories in patients admitted to geriatric wards: A retrospective observational study

AIM

Impaired cognition is common among older patients admitted to acute hospitals, but its association with functional trajectories has not been well studied.

METHODS

A retrospective observational study was carried out in an English tertiary university hospital. We analyzed all first episodes of county residents aged ≥75 years admitted to the Department of Medicine for the Elderly wards between December 2014 and May 2015. A history of dementia or a cognitive concern in the absence of a known diagnosis of dementia were recorded on admission. A cognitive concern included possible undiagnosed dementia or delirium. Function was retrospectively measured with the modified Rankin Scale at preadmission baseline, admission and discharge.

RESULTS

There were 663 first hospital episodes over the period, of which 590 patients survived. Among the latter, 244 had no cognitive impairment, 134 a diagnosis of dementia, 66 a cognitive concern in the absence of a known dementia and 146 had missing cognitive data. When frailty, acuity, age and comorbidity were controlled for, people with known dementia had a similar functional recovery compared with those with no cognitive impairment. People with a cognitive concern, but no known dementia, had lesser functional recovery and greater disability at discharge than those with no cognitive impairment (mean discharge modified Rankin Scale 3.4 compared with 3.1, P = 0.011).

CONCLUSIONS

Dementia per se might not be a marker of poor rehabilitation potential. Older people with acute cognitive concerns might be more vulnerable to poor functional recovery. Our cognitive variables are not gold standard, and further research is required to clarify this relationship. Geriatr Gerontol Int 2017; 17: 1438-1443.

Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment

BACKGROUND AND AIMS

Postoperative delirium (POD) is a common and serious surgical complication among the elderly, especially in those with amnestic mild cognitive impairment (aMCI). Dexmedetomidine (DEX) is neuroprotective for delirium. In this study, we determined the effect of intravenously administered DEX during general anesthesia on POD in elderly aMCI patients undergoing elective hip joint or knee joint or shoulder joint replacement surgery.

METHODS

This was a prospective, randomized parallel-group study of aMCI (n = 80) and normal elderly patients (n = 120). Prior to surgery, all subjects underwent neuropsychological assessment and were assigned to one of four groups: the aMCI DEX group (MD group, n = 40), the aMCI normal saline group (MN group, n = 40), the control DEX group (CD group, n = 60), and the control normal saline group (CN group, n = 60). The confusion assessment method was used to screen POD on postoperative days 1, 3, and 7.

RESULTS

We found patients age was positively correlated with POD incidence in the MN group (p < 0.05) but not in the CN group (p < 0.05). DEX treatment significantly decreased POD incidence in both control and aMCI groups relative to their respective placebo groups (all p < 0.05). The fraction of patients whose normal cognitive function was not restored by day 7 after surgery was significantly higher in the MN group than the MD and CN groups (all p < 0.05).

CONCLUSIONS

These findings suggested that DEX treatment during surgery significantly reduced POD incidence in both normal and aMCI elderly patients, suggesting that it may be an effective option for the prevention of POD.

Predictors of Mortality for Delirium in Palliative Care

INTRODUCTION

Delirium has a high mortality rate. Understanding predictors of prognosis in patients with delirium will aid treatment decisions and communication. This study aimed to explore variables associated with death during an established episode of delirium in palliative care when haloperidol treatment had been commenced.

METHODS

A consecutive cohort of palliative care patients, from 14 centers across four countries, is reported. The outcome of interest was death within 14 days from commencement of haloperidol treatment for delirium. Clinicodemographic variables explored were delirium severity, age, gender, primary life limiting illness, body mass index (BMI), total daily haloperidol dose at baseline (mg), functional status, and comorbidities.

RESULTS

One hundred and sixteen palliative care patients where vital status was known were included in the analysis; 45% (n = 52) died within 10 days, and 56% (n = 65) died within 14 days. In multivariate analyses no clinical or demographic variables predicted death, apart from lower BMI in noncancer patients.

CONCLUSION

This study has shown a very high mortality rate within two weeks of commencing haloperidol for delirium in palliative care, with no clear clinical predictors for those with a higher chance of dying. Having a higher BMI offered some benefit in survival, but only in noncancer patients. When delirium occurs in advanced illness, discussion should be initiated about the gravity of the clinical situation.

Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses

Background

Delirium is a common condition in hospitalized seniors that nonetheless often goes undetected by nurses or is delayed in being detected which negatively impacts quality of care and outcomes. We sought to develop a new screening tool for delirium, The Sour Seven Questionnaire, a 7-item questionnaire suitable to be completed from informal or untrained caregiver observation. The study aimed to develop the scoring criteria for a positive delirium screen and assess concurrent validity of the questionnaire against a geriatric psychiatrist’s assessment.

Methods

A pilot study of 80 hospitalized seniors over age 65 recruited from three units (2 medical, 1 orthopedic). Participants were assessed using the Confusion Assessment Method (CAM) with a brief cognitive screen and the Sour Seven Questionnaire posed to the appointed informal caregiver (family member) or untrained nurse for up-to 7 days. Subjects testing positive on the CAM and a random sample of negatively CAM screened subjects were assessed by the geriatric psychiatrist.

Results

From 80 participants, 21 screened positive for delirium on the CAM. 18 of the 21 CAM positive screens were diagnosed to have delirium by the geriatric psychiatrist, and 17 of the 18 randomly assigned negative CAM screens were confirmed as not having delirium. From the questionnaires on these 39 participants, weighted scoring for each of the 7 questions of the Sour Seven Questionnaire was developed based on their relative risks for correctly predicting delirium when compared to the geriatric psychiatrist’s clinical assessment. Total scoring of the questionnaire resulted in the following positive predictive values for delirium: 89 % with a total score of 4 (sensitivity 89.5 %, specificity 90 %), and 100 % with a total score of 9 (sensitivity 63.2 %, specificity 100 %). Comparison between scoring on questionnaires posed to informal caregivers versus untrained nurses showed no differences.

Conclusion

A weighted score of 4 in the Sour Seven Questionnaire has concurrent validity as a screening tool for delirium and a score of 9 is diagnostic for delirium. The Sour Seven Questionnaire is the first screening tool for delirium shown to be suitable for use by informal caregivers and untrained nurses in hospitalized seniors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0217-2) contains supplementary material, which is available to authorized users.

The Influence of Patient Characteristics on Anticholinergic Events in Older People

Aims

To examine patient characteristics that predict adverse anticholinergic-type events in older people.

Methods

This retrospective population-level study included 2,248 hospitalised patients. Individual data on medicines that are commonly associated with anticholinergic events (delirium, constipation and urinary retention) were identified. Patient characteristics examined were medicines with anticholinergic effects (ACh burden), age, sex, non-anticholinergic medicines (non-ACM), Charlson comorbidity index scores and ethnicity. The Akaike information criterion was used for model selection. The data were analysed using logistic regression models for anticholinergic events using the software NONMEM.

Results

ACh burden was found to be a significant independent predictor for developing an anticholinergic event [adjusted odds ratio (aOR): 3.21, 95% CI: 1.23-5.81] for those taking an average of 5 anticholinergic medicines compared to those taking 1. Both non-ACM and age were also independent risk factors (aOR: 1.41, 95% CI: 1.31-1.51 and aOR: 1.08, 95% CI: 1.05-1.10, respectively).

Conclusion

To our knowledge, this is the first study that has examined population-level data in a nonlinear model framework to predict anticholinergic-type adverse events. This study evaluated the relationship between important patient characteristics and the occurrence of anticholinergic-type events. These findings reinforce the clinical significance of reviewing anticholinergic medicines in older people.

Cerebral Response to Peripheral Challenge with a Viral Mimetic

It has been well established that peripheral inflammation resulting from microbial infections profoundly alters brain function. This review focuses on experimental systems that model cerebral effects of peripheral viral challenge. The most common models employ the induction of the acute phase response via intraperitoneal injection of a viral mimetic, polyinosinic-polycytidylic acid (PIC). The ensuing transient surge of blood-borne inflammatory mediators induces a "mirror" inflammatory response in the brain characterized by the upregulated expression of a plethora of genes encoding cytokines, chemokines and other inflammatory/stress proteins. These inflammatory mediators modify the activity of neuronal networks leading to a constellation of behavioral traits collectively categorized as the sickness behavior. Sickness behavior is an important protective response of the host that has evolved to enhance survival and limit the spread of infections within a population. However, a growing body of clinical data indicates that the activation of inflammatory pathways in the brain may constitute a serious comorbidity factor for neuropathological conditions. Such comorbidity has been demonstrated using the PIC paradigm in experimental models of Alzheimer's disease, prion disease and seizures. Also, prenatal or perinatal PIC challenge has been shown to disrupt normal cerebral development of the offspring resulting in phenotypes consistent with neuropsychiatric disorders, such as schizophrenia and autism. Remarkably, recent studies indicate that mild peripheral PIC challenge may be neuroprotective in stroke. Altogether, the PIC challenge paradigm represents a unique heuristic model to elucidate the immune-to-brain communication pathways and to explore preventive strategies for neuropathological disorders.

Incidence and impact of delirium on clinical and functional outcomes in older patients hospitalized for acute cardiac diseases

BACKGROUND

Delirium is one of the most frequent complications of hospitalization in elderly patients. Its influence on prognosis in patients admitted for acute cardiac diseases is not well known. The objective of this study is to assess the incidence of delirium and its impact on clinical and functional outcomes in older patients hospitalized for acute cardiac diseases.

METHODS

We prospectively analyzed 203 patients aged 75years or older admitted to a cardiology unit. Delirium was diagnosed with the Confusion Assessment Method. Logistic regression analysis was used to assess independent predictors of in-hospital delirium and to examine the independent risk of mortality, readmission, functional decline, and need for new help at discharge, at 1month and 12months associated with the development of delirium, after adjusting for age, comorbidity, and initial diagnosis.

RESULTS

The incidence of delirium was 17.2%. Patients with delirium were older (83±5 vs 81±5years, P=.016) and showed a higher prevalence of major geriatric syndromes (82.9% vs 54.5%, P=.002). Aggressive ventilation modes, urinary catheters, prolonged fluid therapy, night treatments, longer immobilization, and physical restrain were associated with the incidence of delirium. Patients with delirium presented longer stays (8.9±6.2 vs 6.5±4.0days, P=.016) and a greater adjusted risk of functional decline at discharge (odds ratio 2.94, 95% CI 1.10-7.86, P=.032) and of 12-month mortality (odds ratio 4.20, 95% CI 1.81-9.74, P=.001).

CONCLUSION

Delirium is a common preventable complication in older patients with acute cardiac diseases. It is associated with poorer in-hospital functional and clinical outcomes, and increased postdischarge mortality.

Predicting Functional Decline and Recovery for Residents in Veterans Affairs Nursing Homes

PURPOSE OF THE STUDY

This article describes methods and accuracy of predicting change in activities of daily living (ADLs) for nursing home patients following hospitalization.

DESIGN AND METHODS

Electronic Health Record data for 5,595 residents of Veterans Affairs' (VAs') Community Living Centers (CLCs) aged 70 years and older were analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 7,106 inpatient records, 21,318 functional status evaluations, and 69,140 inpatient diagnoses. The Barthel Index extracted from CLC's Minimum Data Set was used to assess ADLs loss and recovery. Patients' diagnoses on hospital admission, ADL status prior to hospitalization, age, and gender were used alone or in combination to predict ADL loss/gain following hospitalization. Area under the Receiver-Operator Curve (AUC) was used to report accuracy of predictions in short (14 days) and long-term (15-365 days) follow-up post-hospitalization.

RESULTS

Admissions fell into 7 distinct patterns of recovery and loss: early recovery 19%, delayed recovery 9%, delayed recovery after temporary decline 9%, early decline 29%, delayed decline 10%, delayed decline after temporary recovery 6%, and no change 18%. Models accurately predicted ADL's 14-day post-hospitalization (AUC for bathing 0.917, bladder 0.842, bowels 0.875, dressing 0.871, eating 0.867, grooming 0.902, toileting 0.882, transfer 0.852, and walking deficits was 0.882). Accuracy declined but remained relatively high when predicting 14-365 days post-hospitalization (AUC ranging from 0.798 to 0.875).

IMPLICATIONS

Predictive modeling may allow development of more personalized predictions of functional loss and recovery after hospitalization among nursing home patients.

Course of functional status in elderly patients after coronary artery bypass surgery: 6-month follow up

AIM

To determine longitudinal changes in functional status using three functional assessment scales in elderly patients undergoing coronary artery bypass grafting.

METHODS

This was a prospective observational cohort study of 73 patients aged ≥60 years undergoing elective coronary artery bypass grafting. Patients were assessed for functional status before admission, at hospital discharge, and at 1 and 6 months after discharge using the Functional Independence Measure, Katz Activities of Daily Living scale, and Lawton Instrumental Activities of Daily Living scale. Data were stratified by age (≥70 years and <70 years) and complications (with and without) for analysis.

RESULTS

In patients aged ≥70 years (n = 38), Functional Independence Measure scores ranged from 121.30 ± 6.42 (pre-admission) to 112.10 ± 17.10 (1 month) and 117.80 ± 13.50 (6 months), Katz scores from 5.88 ± 0.32 (pre-admission) to 5.45 ± 1.04 (1 month) and 5.83 ± 0.65 (6 months), and Lawton scores from 25.40 ± 3.30 (pre-admission) to 20.05 ± 4.93 (1 month) and 24.50 ± 4.10 (6 months; P < 0.001 for all). No significant changes were found in scale scores over time between groups with (n = 34) and without (n = 39) complications. When groups aged ≥70 years (n = 38) and <70 (n = 35) were compared, Functional Independence Measure scores showed a difference toward recovery over time in older patients (discharge - pre-admission, P = 0.010; 1 month - pre-admission, P = 0.0004; and 6 months - pre-admission, P = 0.079).

CONCLUSIONS

The Functional Independence Measure was able to detect significant functional loss over a 6-month period in elderly patients undergoing coronary artery bypass grafting, suggesting that this scale is a promising tool for the assessment of functional recovery over time after cardiac surgery, especially in patients aged older than 70 years. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults

A comparative trial using a repeated-measures design was designed to evaluate the feasibility and outcomes of the Family-Centered Function-Focused-Care (Fam-FFC) intervention, which is intended to promote functional recovery in hospitalized older adults. A family-centered resource nurse and a facility champion implemented a three-component intervention (environmental assessment and modification, staff education, individual and family education and partnership in care planning with follow-up after hospitalization for an acute illness). Control units were exposed to function-focused-care education only. Ninety-seven dyads of medical patients aged 65 and older and family caregivers (FCGs) were recruited from three medical units of a community teaching hospital. Fifty-three percent of patients were female, 89% were white, 51% were married, and 40% were widowed, and they had a mean age of 80.8 ± 7.5. Seventy-eight percent of FCGs were married, 34% were daughters, 31% were female spouses or partners, and 38% were aged 46 to 65. Patient outcomes included functional outcomes (activities of daily living (ADLs), walking performance, gait, balance) and delirium severity and duration. FCG outcomes included preparedness for caregiving, anxiety, depression, role strain, and mutuality. The intervention group demonstrated less severity and shorter duration of delirium and better ADL and walking performance but not better gait and balance performance than the control group. FCGs who participated in Fam-FFC showed a significant increase in preparedness for caregiving and a decrease in anxiety and depression from admission to 2 months after discharge but no significant differences in strain or quality of the relationship with the care recipient from FCGs in the control group. Fam-FFC is feasible and has the potential to improve outcomes for hospitalized older adults and their caregivers.

Length of red cell unit storage and risk for delirium after cardiac surgery

BACKGROUND

The time that red cell units are stored before transfusion may be associated with postoperative complications, although the evidence is conflicting. However, the association between the length of red cell unit storage and postoperative delirium has not been explored. We hypothesized that the length of storage of transfused red cell units would be associated with delirium after cardiac surgery.

METHODS

We conducted a case-control study in which patients undergoing coronary artery bypass, valve, or ascending aorta surgery with cardiopulmonary bypass at Johns Hopkins from 2005 to 2011 were eligible for inclusion. Patients were excluded if they did not receive red cell units, received >4 red cell units during hospitalization, received any transfusion after the first postoperative day, or received red cell units that were not exclusively stored for ≤14 days or >14 days. Eighty-seven patients met transfusion-related inclusion criteria and developed postoperative delirium. Controls who did not develop delirium were selected from the same source population of eligible patients and were matched 1:1 based on age (± 5 years), 2- to 2.5-year band of date of surgery, and surgical procedure. For each patient, we calculated the average storage duration of all transfused red cell units. The primary outcome was odds of delirium in patients who were transfused red cell units with exclusive storage duration >14 days compared with that of ≤14 days. Secondary outcomes were odds of delirium with each increasing day of average red cell unit storage duration. We used conditional multivariable regression to test our hypotheses.

RESULTS

In conditional multivariable analysis of 87 case-control pairs, there was no difference in the odds of patients developing delirium if they were transfused red cell units with an exclusive storage age >14 days compared with that ≤14 days (odds ratio [OR] 1.83; 95% confidence interval, 0.73-4.58, P = 0.20). Each additional day of average red cell unit storage beyond 14 days was associated with a 1.01- to 1.13-fold increase in the odds of postoperative delirium (OR, 1.07; P = 0.03). Each additional day of average storage beyond 21 days was associated with a 1.02- to 1.23-fold increase in the odds of postoperative delirium (OR, 1.12; P = 0.02).

CONCLUSIONS

Transfusion of red cell units that have been stored for >14 days is not associated with increased odds of delirium. However, each additional day of storage >14 or 21 days may be associated with increased odds of postoperative delirium in patients undergoing cardiac surgery. More research is needed to further characterize the association between delirium and storage duration of transfused red cell units.

Tryptophan supplementation and postoperative delirium--a randomized controlled trial

OBJECTIVES

To determine whether the postoperative administration of tryptophan would be beneficial for elderly adults undergoing surgery who are at risk of developing postoperative delirium.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Denver Veterans Affairs Medical Center.

PARTICIPANTS

Individuals aged 60 and older undergoing major elective operations requiring a postoperative intensive care unit (ICU) admission (n = 325).

INTERVENTION

L-tryptophan, 1 g orally three times a day or placebo was started after surgery and continued for up to 3 days postoperatively.

MEASUREMENTS

Delirium and its motor subtypes were measured using the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) and the Richmond Agitation and Sedation Scale. The primary outcome for between-group comparison was the incidence of excitatory (mixed and hyperactive) postoperative delirium. The secondary outcomes for comparison were the incidence and duration of overall postoperative delirium.

RESULTS

The overall incidence of postoperative delirium was 39% (95% confidence interval = 34-44%) (n = 116). Seventeen percent of participants in the tryptophan group and 9% in the placebo group had excitatory delirium (P = .18), and the duration of excitatory delirium was 3.3 ± 1.7 days for tryptophan and 3.1 ± 1.9 days for placebo (P = .74). Forty percent of participants in the tryptophan group and 37% in the placebo group had overall delirium (P = .60), and the duration of overall delirium was 2.9 ± 1.8 days for tryptophan and 2.4 ± 1.6 days for placebo (P = .17).

CONCLUSION

Postoperative tryptophan supplementation in older adults undergoing major elective operations requiring postoperative ICU admission did not reduce the incidence or duration of postoperative excitatory delirium or overall delirium.

Delirium in elderly patients hospitalized in internal medicine wards

A prospective observational study was conducted to evaluate the impact of delirium on geriatric inpatients in internal medical wards and to identify predisposing factors for the development of delirium. The study included all patients aged 65 years and older, who were consecutively admitted to the internal medicine wards of two public hospitals in Florence, Italy. On admission, 29 baseline risk factors were examined, cognitive impairment was evaluated by Short Portable Mental Status Questionnaire, and prevalent delirium cases were diagnosed by Confusion Assessment Method (CAM). Enrolled patients were evaluated daily with CAM to detect incident delirium cases. Among the 560 included patients, 19 (3 %) had delirium on admission (prevalent) and 44 (8 %) developed delirium during hospitalization (incident). Prevalent delirium cases were excluded from the statistical analysis. Incident delirium was associated with increased length of hospital stay (p < 0.01) and institutionalization (p < 0.01, OR 3.026). Multivariate analysis found that cognitive impairment on admission (p < 0.0002), diabetes (p < 0.05, OR 1.936), chronic kidney failure (p < 0.05, OR 2.078) and male gender (p < 0.05, OR 2.178) was significantly associated with the development of delirium during hospitalization. Results show that delirium impact is relevant to older patients hospitalized in internal medicine wards. The present study confirms cognitive impairment as a risk factor for incident delirium. The cognitive evaluation proved to be an important instrument to improve identification of patients at high risk for delirium. In this context, our study may contribute to improve application of preventive strategies.

Outcomes of an innovative model of acute delirium care: the Geriatric Monitoring Unit (GMU)

Objective

Delirium is associated with poor outcomes following acute hospitalization. The Geriatric Monitoring Unit (GMU) is a specialized five-bedded unit for acute delirium care. It is modeled after the Delirium Room program, with adoption of core interventions from the Hospital Elder Life Program and use of evening light therapy to consolidate circadian rhythms and improve sleep in older inpatients. This study examined whether the GMU program improved outcomes in delirious patients.

Method

A total of 320 patients, including 47 pre-GMU, 234 GMU, and 39 concurrent control subjects, were studied. Clinical characteristics, cognitive status, functional status (Modified Barthel Index [MBI]), and chemical restraint-use data were obtained. We also looked at in-hospital complications of falls, pressure ulcers, nosocomial infection rate, and discharge destination. Secondary outcomes of family satisfaction (for the GMU subjects) were collected.

Results

There were no significant demographic differences between the three groups. Pre-GMU subjects had longer duration of delirium and length of stay. MBI improvement was most evident in the GMU compared with pre-GMU and control subjects (19.2±18.3, 7.5±11.2, 15.1±18.0, respectively) (P<0.05). The GMU subjects had a zero restraint rate, and pre-GMU subjects had higher antipsychotic dosages. This translated to lower pressure ulcer and nosocomial infection rate in the GMU (4.1% and 10.7%, respectively) and control (1.3% and 7.7%, respectively) subjects compared with the pre-GMU (9.1% and 23.4%, respectively) subjects (P<0.05). No differences were observed in mortality or discharge destination among the three groups. Caregivers of GMU subjects felt the multicomponent intervention to be useful, with scheduled activities voted the most beneficial in patient’s recovery from the delirium episode.

Conclusion

This study shows the benefits of a specialized delirium management unit for older persons. The GMU model is thus a relevant system of care for rapidly “graying” nations with high rates of frail elderly hospital admissions, which can be easily transposed across acute care settings.

Delirium in the ICU and subsequent long-term disability among survivors of mechanical ventilation

OBJECTIVE

Survivors of critical illness are frequently left with long-lasting disability. The association between delirium and disability in critically ill patients has not been described. We hypothesized that the duration of delirium in the ICU would be associated with subsequent disability and worse physical health status following a critical illness.

DESIGN

Prospective cohort study nested within a randomized controlled trial of a paired sedation and ventilator weaning strategy.

SETTING

A single-center tertiary-care hospital.

PATIENTS

One hundred twenty-six survivors of a critical illness.

MEASUREMENTS AND MAIN RESULTS

Confusion Assessment Method for the ICU, Katz activities of daily living, Functional Activities Questionnaire (measuring instrumental activities of daily living), Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score, and Awareness Questionnaire were used. Associations between delirium duration and outcomes were determined via proportional odds logistic regression with generalized estimating equations (for Katz activities of daily living and Functional Activities Questionnaire scores) or via generalized least squares regression (for Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score and Awareness Questionnaire scores). Excluding patients who died prior to follow-up but including those who withdrew or were lost to follow-up, we assessed 80 of 99 patients (81%) at 3 months and 63 of 87 patients (72%) at 12 months. After adjusting for covariates, delirium duration was associated with worse activities of daily living scores (p = 0.002) over the course of the 12-month study period but was not associated with worse instrumental activities of daily living scores (p = 0.15) or worse Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score (p = 0.58). Duration of delirium was also associated with lower Awareness Questionnaire Motor/Sensory Factors scores (p 0.02).

CONCLUSION

In the setting of critical illness, longer delirium duration is independently associated with increased odds of disability in activities of daily living and worse motor-sensory function in the following year. These data point to a need for further study into the determinants of functional outcomes in ICU survivors.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients

Objective

Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation.

Design

Prospective cohort study.

Setting

Hospital rehabilitation unit.

Participants

A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006.

Measurements

Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations.

Results

The median age was 77 years (interquartile range: 71–83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6–42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8–8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1–2.8; P = .01).

Conclusions

DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.