Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU)

A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study

OBJECTIVES

The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients.

METHODS

We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected.

RESULTS

Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001).

CONCLUSIONS

The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.

A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle

BACKGROUND

Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery.

METHODS

We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded.

RESULTS

Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element.

CONCLUSIONS

We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.

CLINICAL TRIALS REGISTRATION

NCT05110690 (11/08/2021).

Barriers to and recommendations for integrating the age-friendly 4-Ms framework into electronic health records

BACKGROUND

The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms.

METHODS

Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media.

RESULTS

Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts.

CONCLUSIONS

The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study

OBJECTIVE

ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room.

METHOD

This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis.

RESULTS

Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81).

CONCLUSION

DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.

Brain injury biomarkers do not predict delirium in acutely ill older patients: a prospective cohort study

Delirium is a common, serious, and often preventable neuropsychiatric emergency mostly characterized by a disturbance in attention and awareness. Systemic insult and inflammation causing blood-brain-barrier (BBB) damage and glial and neuronal activation leading to more inflammation and cell death is the most accepted theory behind delirium's pathophysiology. This study aims to evaluate the relationship between brain injury biomarkers on admission and delirium in acutely ill older patients. We performed a prospective cohort study which analyzed plasma S100B levels at admission in elderly patients. Our primary outcome was delirium diagnosis. Secondary outcomes were association between S100B, NSE and Tau protein and delirium diagnosis and patients' outcomes (admissions to intensive care, length of hospital stay, and in-hospital mortality). We analyzed 194 patients, and 46 (24%) developed delirium, 25 on admission and 21 during hospital stay. Median of S100B at admission in patients who developed delirium was 0.16 and median was 0.16 in patients who didn't develop delirium (p: 0.69). Levels S100B on admission did not predict delirium in acutely ill elderly patients.Trial registration: The study was approved by the local institutional review board (CAPPESq, no. 77169716.2.0000.0068, October 11, 2017) and registered in Brazilian Clinical Trials Registry (ReBEC, no. RBR-233bct).

Rationale, Design, and Characteristics of the VALIANT (COVID-19 in Older Adults: A Longitudinal Assessment) Cohort

BACKGROUND

Most older adults hospitalized with COVID-19 survive their acute illness. The impact of COVID-19 hospitalization on patient-centered outcomes, including physical function, cognition, and symptoms, is not well understood. To address this knowledge gap, we collected longitudinal data about these issues from a cohort of older survivors of COVID-19 hospitalization.

METHODS

We undertook a prospective study of community-living persons age ≥ 60 years who were hospitalized with COVID-19 from June 2020-June 2021. A baseline interview was conducted during or up to 2 weeks after hospitalization. Follow-up interviews occurred at one, three, and six months post-discharge. Participants completed comprehensive assessments of physical and cognitive function, symptoms, and psychosocial factors. An abbreviated assessment could be performed with a proxy. Additional information was collected from the electronic health record.

RESULTS

Among 341 participants, the mean age was 71.4 (SD 8.4) years, 51% were women, and 37% were of Black race or Hispanic ethnicity. Median length of hospitalization was 8 (IQR 6-12) days. All but 4% of participants required supplemental oxygen, and 20% required care in an intensive care unit or stepdown unit. At enrollment, nearly half (47%) reported at least one preexisting disability in physical function, 45% demonstrated cognitive impairment, and 67% were pre-frail or frail. Participants reported a mean of 9 of 14 (SD 3) COVID-19-related symptoms. At the six-month follow-up interview, more than a third of participants experienced a decline from their pre-hospitalization function, nearly 20% had cognitive impairment, and burdensome symptoms remained highly prevalent.

CONCLUSIONS

We enrolled a diverse cohort of older adults hospitalized with COVID-19 and followed them after discharge. Functional decline was common, and there were high rates of persistent cognitive impairment and symptoms. Future analyses of these data will advance our understanding of patient-centered outcomes among older COVID-19 survivors.

A quality improvement project addressing the underreporting of delirium in hip fracture patients

INTRODUCTION

After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred.

METHODS

Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations.

RESULTS

The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001).

CONCLUSIONS

Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

Pharmacologic Management of Delirium in the Intensive Care Unit

Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit. It concludes by outlining some emerging treatments of delirium.

Neurofilament light increases over time in severe COVID-19 and is associated with delirium

Neurological monitoring in sedated Intensive Care Unit patients is constrained by the lack of reliable blood-based biomarkers. Neurofilament light is a cross-disease biomarker for neuronal damage with potential clinical applicability for monitoring Intensive Care Unit patients. We studied the trajectory of neurofilament light over a month in Intensive Care Unit patients diagnosed with severe COVID-19 and explored its relation to clinical outcomes and pathophysiological predictors. Data were collected over a month in 31 Intensive Care Unit patients (166 plasma samples) diagnosed with severe COVID-19 at Amsterdam University Medical Centre, and in the first week after emergency department admission in 297 patients with COVID-19 (635 plasma samples) admitted to Massachusetts General hospital. We observed that Neurofilament light increased in a non-linear fashion in the first month of Intensive Care Unit admission and increases faster in the first week of Intensive Care Unit admission when compared with mild-moderate COVID-19 cases. We observed that baseline Neurofilament light did not predict mortality when corrected for age and renal function. Peak neurofilament light levels were associated with a longer duration of delirium after extubation in Intensive Care Unit patients. Disease severity, as measured by the sequential organ failure score, was associated to higher neurofilament light values, and tumour necrosis factor alpha levels at baseline were associated with higher levels of neurofilament light at baseline and a faster increase during admission. These data illustrate the dynamics of Neurofilament light in a critical care setting and show associations to delirium, disease severity and markers for inflammation. Our study contributes to determine the clinical utility and interpretation of neurofilament light levels in Intensive Care Unit patients.

Transcutaneous Electrical Acupoint Stimulation Combined With Auricular Acupressure Reduces Postoperative Delirium Among Elderly Patients Following Major Abdominal Surgery: A Randomized Clinical Trial

Background

Postoperative delirium is common in elderly patients following major surgery. This study aimed to assess the effect of transcutaneous electrical acupoint stimulation combined with auricular acupressure on the incidence of postoperative delirium among older patients undergoing major abdominal surgery.

Methods

In this single-center, randomized controlled clinical trial, 210 patients aged 65 years or older undergoing major abdominal surgery were randomized to receive either intervention treatment (transcutaneous electrical acupoint stimulation started at 30 min before anesthesia until the end of the surgery, followed by intermittent auricular acupressure in the first three postoperative days; n = 105) or standard care (n = 105). The primary outcome was the incidence of delirium at the first seven postoperative days or until hospitalization depended on which came first. Secondary outcomes included delirium severity, opioid consumption, postoperative pain score, sleep quality, length of postoperative hospital stay, and postoperative 30-day complications. Enrollment was from April 2019 to March 2020, with follow-up ending in April 2020.

Results

All of the 210 randomized patients [median age, 69.5 years, 142 (67.6%) male] completed the trial. The incidence of postoperative delirium was significantly reduced in patients received intervention treatment (19/105 (18.1%) vs. 8/105 (7.6%), difference, –10.5% [95% CI, –1.5% to –19.4%]; hazard ratio, 0.41 [95% CI, 0.18 to 0.95]; P= 0.023). Patients in the control group had a higher postoperative Memorial Delirium Assessment Scale (4 vs. 3; difference, –1; 95% CI, –1 to 0; P = 0.014) and a greater increase in Pittsburgh Sleep Quality Index score from baseline to postoperative day three (2.5 vs. 2.0; difference, –1; 95% CI, –2 to –1; P &lt; 0.001) than patients in the intervention group. No significant difference was observed as of other secondary outcomes.

Conclusion

In elderly patients undergoing major abdominal surgery, transcutaneous electrical acupoint stimulation combined with auricular acupressure reduced the incidence of postoperative in-hospital delirium compared with standard care. A multicenter, randomized clinical trial with a larger sample size is necessary to verify these findings.

Clinical Trial Registration

[https://clinicaltrials.gov], identifier [NCT03726073].

Delirium in Older Adults: What a Surgeon Needs to Know

Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease.

Delirium Variability is Influenced by the Sound Environment (DEVISE Study): How Changes in the Intensive Care Unit soundscape affect delirium incidence

Quantitative data on the sensory environment of intensive care unit (ICU) patients and its potential link to increased risk of delirium is limited. We examined whether higher average sound and light levels in ICU environments are associated with delirium incidence. Over 111 million sound and light measurements from 143 patient stays in the surgical and trauma ICUs were collected using Quietyme® (Neshkoro, Wisconsin) sensors from May to July 2018 and analyzed. Sensory data were grouped into time of day, then normalized against their ICU environments, with Confusion Assessment Method (CAM-ICU) scores measured each shift. We then performed logistic regression analysis, adjusting for possible confounding variables. Lower morning sound averages (8 am-12 pm) (OR = 0.835, 95% OR CI = [0.746, 0.934], p = 0.002) and higher daytime sound averages (12 pm-6 pm) (OR = 1.157, 95% OR CI = [1.036, 1.292], p = 0.011) were associated with an increased odds of delirium incidence, while nighttime sound averages (10 pm-8 am) (OR = 0.990, 95% OR CI = [0.804, 1.221], p = 0.928) and the ICU light environment did not show statistical significance. Our results suggest an association between the ICU soundscape and the odds of developing delirium. This creates a future paradigm for studies of the ICU soundscape and lightscape.