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DeMaagd GA, DeMaagd DR, Philip A, Coalter CF. Delirium and Its Pharmacological Causes in Older People, Part 1. Sr Care Pharm 2021; 36:477-488. [PMID: 34593089 DOI: 10.4140/tcp.n.2021.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. This article will review the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Preoperative Nutritional Status and Risk for Subsyndromal Delirium in Older Adults Following Joint Replacement Surgery. Orthop Nurs 2020; 39:384-392. [PMID: 33234908 DOI: 10.1097/nor.0000000000000710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Subsyndromal delirium following surgery in older adults is related to increased lengths of hospital stay and increased admissions to long-term care. Impaired nutrition increases risk for delirium, but its relationship to subsyndromal delirium remains unclear. PURPOSE This correlational study examined the relationship between nutritional status and subsyndromal delirium in older adults. METHODS Assessments for subsyndromal delirium in 53 adults 65 years or older were completed for three consecutive days following joint replacement surgery. Relationships between nutritional status and subsyndromal delirium were analyzed. Level of significance for all tests was set at p ≤ .05. RESULTS Participants' scores from the Mini Nutritional Assessment screen were significantly related (p = .05) to subsyndromal delirium severity after accounting for variability posed by age and cognition status. CONCLUSION When preoperative risk assessment of older adults indicates nutritional risk, preoperative optimization may improve effectiveness of delirium prevention efforts.
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Denny DL, Lindseth GN. Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery. West J Nurs Res 2019; 42:165-176. [PMID: 31096866 DOI: 10.1177/0193945919849096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.
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Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs 2018; 27:2109-2119. [PMID: 29603815 DOI: 10.1111/jocn.14365] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2018] [Indexed: 01/10/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the relationship of delirium and risk factors for cardiology intensive care unit (ICU) patients with the nursing workload. BACKGROUND Delirium is a common syndrome in patients with cardiac problems. The risk factors causing delirium and the presence and type of delirium affect the nurse workload and patient care quality adversely. DESIGN This cross-sectional study was conducted with 133 patients staying at the cardiology ICU of a university hospital between 5 January-31 March 2017. METHOD The study data were collected using the Patient Information Form, Delirium Risk Factors' Form and Therapeutic Intervention Scoring System-28 (TISS-28) scale to identify the nurse workload. The statistical analysis of the data was performed using frequency, chi-square, Mann-Whitney U, correlation and regression analyses. RESULTS It was found that patients who developed delirium were 65 years or older, they had more nasogastric/total parenteral nutrition (NG/TPN), benzodiazepine and physical restraints in comparison with those with no delirium development, and that the prevalence of hypoxia and hypoalbuminemia were higher in these patients. The mean TISS-28 score was higher in patients with delirium, compared with those without delirium. There was a positive correlation between the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and the mean TISS-28 score of the patients. The mean TISS-28 score was found to significantly increase with being at the age of 65 and above and the administration of mechanical ventilation. The patients with delirium required a mean of 60-min additional care. CONCLUSIONS Our study results suggest that the presence of delirium and the delirium risk factors, irrespective of delirium, increase the nurse workload. RELEVANCE TO CLINICAL PRACTICE An effective management of delirium risk factors can improve the patient care quality by reducing delirium occurrence and nurse workload.
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Affiliation(s)
| | - Tülin Bedük
- Ankara University Faculty of Health Sciences, Ankara, Turkey
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Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs 2017; 41:33-42. [PMID: 28214083 DOI: 10.1016/j.iccn.2016.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 08/25/2016] [Accepted: 08/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aims to investigate the effect of nonpharmacological intervention training on delirium recognition and the intervention strategies of intensive care (ICU) nurses. METHOD This is a quasi-experimental study conducted using a pretest-posttest design. The study sample included a total of 95 patients staying in the medical ICU of a university hospital and 19 nurses working in these units. The data were collected using the Patient and Nurse Introduction, Confusion Assessment Method for the ICU, and Delirium Risk Factors, and Non-pharmacological Interventions in Delirium Prevention Forms. RESULTS Delirium was identified in 26.5% and 20.9% of the patients in the pre- and posttraining phase, respectively. Patients with delirium had a longer duration of stay in the ICU, lower mean Glasgow Coma Scale score and a higher number of medications in daily treatment (p<0.05). The risk of delirium increased 8.5-fold by physical restriction and 3.4-fold by the presence of hypo/hypernatremia. The delirium recognition rate of nurses increased from 7.7% to 33.3% in the post-training phase. CONCLUSION Our study results show that training can increase the efficiency of ICU nurses in the management of delirium.
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Affiliation(s)
- Ayşegül Öztürk Birge
- Ankara University, Faculty of Health Sciences, Nursing Department, Ankara, Turkey.
| | - Hatice Tel Aydin
- Cumhuriyet University, Faculty of Health Sciences, Nursing Department, Sivas, Turkey.
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Abstract
Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).
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Cole MG, Bailey R, Bonnycastle M, McCusker J, Fung S, Ciampi A, Belzile E. Frequency of full, partial and no recovery from subsyndromal deliriumin older hospital inpatients. Int J Geriatr Psychiatry 2016; 31:544-50. [PMID: 26526733 DOI: 10.1002/gps.4372] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/03/2015] [Accepted: 09/15/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium. METHODS SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium. RESULTS Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium. CONCLUSION Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients.
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Affiliation(s)
- Martin G Cole
- Department of Psychiatry, McGill University; and St Mary's Hospital Center, Montreal, Quebec, Canada.,St. Mary's Research Centre, St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Robert Bailey
- Division of Geriatric Medicine, McGill University; and St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Michael Bonnycastle
- Department of Medicine, McGill University; and St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Jane McCusker
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,St. Mary's Research Centre, St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Shek Fung
- Division of Geriatric Medicine, McGill University; and St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Antonio Ciampi
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,St. Mary's Research Centre, St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Eric Belzile
- St. Mary's Research Centre, St. Mary's Hospital Center, Montreal, Quebec, Canada
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Cole MG, Bailey R, Bonnycastle M, McCusker J, Fung S, Ciampi A, Belzile E, Bai C. Partial and No Recovery from Delirium in Older Hospitalized Adults: Frequency and Baseline Risk Factors. J Am Geriatr Soc 2015; 63:2340-8. [PMID: 26515438 DOI: 10.1111/jgs.13791] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To determine the frequency and baseline risk factors for partial and no recovery from delirium in older hospitalized adults. DESIGN Cohort study with assessment of recovery status approximately 1 and 3 months after enrollment. SETTING University-affiliated, primary, acute-care hospital. PARTICIPANTS Medical or surgical inpatients aged 65 and older with delirium (N = 278). MEASUREMENTS The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), and activities of daily living (ADLs) were completed at enrollment and each follow-up. Primary outcome categories were full recovery (absence of CAM core symptoms of delirium), partial recovery (presence of ≥1 CAM core symptoms but not meeting criteria for delirium), no recovery (met CAM criteria for delirium), or death. Secondary outcomes were changes in MMSE, DI, and ADL scores between the baseline and last assessment. Potential risk factors included many clinical and laboratory variables. RESULTS In participants with dementia, frequencies of full, partial, and no recovery and death at first follow-up were 6.3%, 11.3%, 74.6%, and 7.7%, respectively; in participants without dementia, frequencies were 14.3%, 17%, 50.9%, and 17.9%, respectively. In participants with dementia, frequencies at the second follow-up were 7.9%, 15.1%, 57.6%, and 19.4%, respectively; in participants without dementia, frequencies were 19.2%, 20.2%, 31.7%, and 28.8%, respectively. Frequencies were similar in participants with prevalent and incident delirium and in medical and surgical participants. The DI, MMSE, and ADL scores of many participants with partial and no recovery improved. Independent baseline risk factors for delirium persistence were chart diagnosis of dementia (odds ratio (OR) = 2.51, 95% confidence interval (CI) =1.38, 4.56), presence of any malignancy (OR = 5.79, 95% CI = 1.51, 22.19), and greater severity of delirium (OR =9.39, 95% CI = 3.95, 22.35). CONCLUSION Delirium in many older hospitalized adults appears to be much more protracted than previously thought, especially in those with dementia, although delirium symptoms, cognition, and function improved in many participants with partial and no recovery. It may be important to monitor the longer-term course of delirium in older hospitalized adults and develop strategies to ensure full recovery.
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Affiliation(s)
- Martin G Cole
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,St. Mary's Research Centre, Montreal, Quebec, Canada.,St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Robert Bailey
- St. Mary's Hospital Center, Montreal, Quebec, Canada.,Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada
| | - Michael Bonnycastle
- St. Mary's Hospital Center, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Jane McCusker
- St. Mary's Research Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Shek Fung
- St. Mary's Hospital Center, Montreal, Quebec, Canada.,Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada
| | - Antonio Ciampi
- St. Mary's Research Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Eric Belzile
- St. Mary's Research Centre, Montreal, Quebec, Canada
| | - Chun Bai
- St. Mary's Research Centre, Montreal, Quebec, Canada
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Core symptoms not meeting criteria for delirium are associated with cognitive and functional impairment and mood and behavior problems in older long-term care residents. Int Psychogeriatr 2014; 26:1181-9. [PMID: 24622467 DOI: 10.1017/s1041610214000313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The immediate clinical significance of Confusion Assessment Method (CAM)-defined core symptoms of delirium not meeting criteria for delirium is unclear. This study proposed to determine if such symptoms are associated with cognitive and functional impairment, mood and behavior problems and increased Burden of Care (BOC) in older long-term care (LTC) residents. METHODS The study was a secondary analysis of data collected for a prospective cohort study of delirium. Two hundred and fifty-eight LTC residents aged 65 years and older in seven LTC facilities had monthly assessments (for up to six months) of CAM - defined core symptoms of delirium (fluctuation, inattention, disorganized thinking, and altered level of consciousness) and five outcome measures: Mini-Mental State Exam, Barthel Index, Cornell Scale for Depression, Nursing Home Behavioral Problems Scale, and Burden of Care. Associations between core symptoms and the five outcome measures were analyzed using generalized estimating equations. RESULTS Core symptoms of delirium not meeting criteria for delirium among residents with and without dementia were associated with cognitive and functional impairment and mood and behavior problems but not increased BOC. The associations appear to be intermediate between those of full delirium and no core symptoms and were greater for residents with than without dementia. CONCLUSION CAM-defined core symptoms of delirium not meeting criteria for delirium appear to be associated with cognitive and functional impairment and mood and behavior problems in LTC residents with or without dementia. These findings may have implications for the prevention and management of such impairments and problems in LTC settings.
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Abstract
BACKGROUND Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium. METHODS The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium. RESULTS Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2). CONCLUSION The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.
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Abstract
Delirium is a cognitive disorder characterized by acute onset, fluctuating course, altered level of consciousness, inattention, disorganized thinking, disorientation, memory impairment, and perceptual and motor disturbances (American Psychiatric Association, 2000; World Health Organization, 2010). It occurs in hyperactive, hypoactive, or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006) and 70% of older long-term care residents (McCusker et al., 2011). In both settings, delirium is independently associated with poor outcomes (Siddiqi et al., 2006; McCusker et al., 2010; Witlox et al., 2010).
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McCusker J, Cole MG, Voyer P, Vu M, Ciampi A, Monette J, Champoux N, Belzile E, Dyachenko A. Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium. J Am Geriatr Soc 2013; 61:502-11. [PMID: 23581909 DOI: 10.1111/jgs.12164] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify potentially modifiable environmental factors (including number of medications) associated with changes over time in the severity of delirium symptoms and to explore the interactions between these factors and resident baseline vulnerability. DESIGN Prospective, observational cohort study. SETTING Seven long-term care (LTC) facilities. PARTICIPANTS Two hundred seventy-two LTC residents aged 65 and older with and without delirium. MEASUREMENTS Weekly assessments (for up to 6 months) of the severity of delirium symptoms using the Delirium Index (DI), environmental risk factors, and number of medications. Baseline vulnerability measures included a diagnosis of dementia and a delirium risk score. Associations between environmental factors, medications, and weekly changes in DI were analyzed using a general linear model with correlated errors. RESULTS Six potentially modifiable environmental factors predicted weekly changes in DI (absence of reading glasses, aids to orientation, family member, and glass of water and presence of bed rails and other restraints) as did the prescription of two or more new medications. Residents with dementia appeared to be more sensitive to the effects of these factors. CONCLUSION Six environmental factors and prescription of two or more new medications predicted changes in the severity of delirium symptoms. These risk factors are potentially modifiable through improved LTC clinical practices.
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Affiliation(s)
- Jane McCusker
- St. Mary's Research Centre, St. Mary's Hospital, Montreal, Quebec, Canada.
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