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Almuhairi ES, Badejo M, Peer A, Pitkanen M, McKenzie CA. The Validity and Applicability of the Revised Delirium Rating Scale (DRS-R98) for Delirium Severity Assessment in a Critical Care Setting. J Intensive Care Med 2024; 39:240-249. [PMID: 37670545 PMCID: PMC10845842 DOI: 10.1177/08850666231199986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome common in critical illness. Worsening delirium severity is associated with poorer clinical outcomes, yet its assessment remains under-reported with most severity assessment tools not validated for critical care. The DRS-R98 is a widely applied and validated tool. The aim of this project is to report the validation and utility of the DRS-R98 in critical illness. METHODS This prospective, cohort study was conducted in adults with delirium admitted to a critical care unit and predicted to stay for ≥ 24 h. We excluded patients with severe neurological or communication barriers that would have interfered with the DRS-R98 assessment. Patients were screened using a delirium detection algorithm and the Confusion Assessment Method for the Intensive Care Unit. Eligible patient informations were collected and reported to qualified assessor/s before visiting clinical areas, confirming delirium presence and undertaking DRS- R98 assessments. To assess the tool's construct validity, an intensivist completed the Clinical Global Impression-Scale (CGI-S). To calculate the inter-rater reliability (IRR) a subset of patients were simultaneously evaluated by two assessors. RESULTS We assessed 22 patients, 73% were male, with a median age of 65 years (IQR14). The DRS -R98 mean (SD) severity score was 24 (+/-7.7), total scale was 29 (+/18.0), and CGI-S 3.5 (+/11.5). Assessment duration was 90 min (+/-55) and 15 min (+/-5) for record data extraction and clinical assessment respectively. The CGI-S significantly correlated with DRS-R98 severity (r = 0.626) and total (r = 0.628) scales. The DRS-R98 Cronbach's alpha was 0.896 for severity scale and 0.886 for total scale. The inter-rater reliability (IRR) was assessed in six patients and reported an inter-correlation coefficient of 0.505 (p = 0.124) and 0.565 (p = 0.93) for the severity and total scale respectively. CONCLUSIONS In critical care, the Delirium Rating Scale R98 had good construct validity, excellent internal consistency, and moderate inter-rater reliability.
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Affiliation(s)
- Eiman Saeed Almuhairi
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
| | - Monica Badejo
- Department of Social, Therapeutic and Community Studies, Goldsmiths College, University of London, London, UK
| | - Aneesa Peer
- Lambeth Southeast Focussed Support, Clozapine Plus Service, Orchard House - Lambeth Hospital, London, UK
| | - Mervi Pitkanen
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
| | - Cathrine A McKenzie
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College, London, UK
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
- Department of Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- School of Medicine, University of Southampton, National Institute of Health and Care Research (NIHR), Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, Southampton, UK
- NIHR Applied Research Collaborative Wessex, Southampton, UK
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Glynn K, McKenna F, Lally K, Grover S, Chakrabarti S, Mattoo SK, Avasthi A, Sharma A, Adamis D, Awan F, Dunne CP, McFarland J, Jabbar F, O’Connell H, Leonard M, Meagher DJ. Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study. J Geriatr Psychiatry Neurol 2024; 37:125-133. [PMID: 37566435 PMCID: PMC10802083 DOI: 10.1177/08919887231195232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K. Mattoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajita Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dimitrios Adamis
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
- Sligo Mental Health Services, Sligo, Ireland
| | - Fahad Awan
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Colum P. Dunne
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - John McFarland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Faiza Jabbar
- Psychiatry for Later Life Service, University College Hospital, Galway, Ireland
| | - Henry O’Connell
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - David J. Meagher
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
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Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
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Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Dolan C, Mohd Zubir M, Melvin V, McCarthy G, Meagher D, Adamis D. Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study. Ir J Psychol Med 2023; 40:369-377. [PMID: 33455597 DOI: 10.1017/ipm.2020.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors. METHODS This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission. RESULTS Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium. CONCLUSIONS In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.
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Affiliation(s)
- C Dolan
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - M Mohd Zubir
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - V Melvin
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
| | - G McCarthy
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
- Sligo Medical Academy, NUI Galway, The Mall, Rathquarter, Sligo, Ireland
| | - D Meagher
- Cognitive Impairment Research Group (CIRG), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - D Adamis
- Sligo Leitrim Mental Health Services, Ballytivnan, Sligo, Ireland
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la Cour KN, Andersen-Ranberg NC, Weihe S, Poulsen LM, Mortensen CB, Kjer CKW, Collet MO, Estrup S, Mathiesen O. Distribution of delirium motor subtypes in the intensive care unit: a systematic scoping review. Crit Care 2022; 26:53. [PMID: 35241132 PMCID: PMC8896322 DOI: 10.1186/s13054-022-03931-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.
Methods This systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model. Results We included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0–54.7]), followed by mixed delirium (27.7% [95% CI 24.1–31.3]) and hyperactive delirium (22.7% [95% CI 19.0–26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium. Conclusions Hypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03931-3.
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Affiliation(s)
- Kirstine N la Cour
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark.
| | - Nina C Andersen-Ranberg
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Sarah Weihe
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Lone M Poulsen
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Camilla B Mortensen
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Cilia K W Kjer
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Stine Estrup
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark
| | - Ole Mathiesen
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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Individual Pharmacotherapy Management (IPM) - I: a group-matched retrospective controlled clinical study on prevention of complicating delirium in the elderly trauma patients and identification of associated factors. BMC Geriatr 2022; 22:29. [PMID: 34991474 PMCID: PMC8740502 DOI: 10.1186/s12877-021-02630-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background Delirium is one of the most frequent complications in hospitalized elderly patients with additional costs such as prolongation of hospital stays and institutionalization, with risk of reduced functional recovery, long-term cognitive impairment, and increased morbidity and mortality. We analyzed the effect of individual pharmacotherapy management (IPM) in the University Hospital Halle in geriatric trauma patients on complicating delirium and aimed to identify associated factors. Methods In a retrospective controlled clinical study of 404 hospitalized trauma patients ≥70 years we compared the IPM intervention group (IG) with a control group (CG) before IPM implementation. Delirium was recorded from the hospital discharge letter. The medication review and data records included baseline data, all medications, diagnoses, electrocardiogram (ECG), laboratory and vital parameters during hospitalization. The IPM internist and the senior trauma physician guaranteed personnel and structural continuity in the implementation of the interdisciplinary patient rounds. Results There was a highly matched congruence between CG and IG in terms of age, gender, residency, BMI, most diagnoses, and injury patterns to compare the two groups. The total number of medications per patient was 11.1 ± 4.9 (CG) versus 10.4 ± 3.6 (IG). Our targeted IPM focus on 6 frontline aspects with reduction of antipsychotics, anticholinergic burden, benzodiazepines, serotonergic opioids, elimination of pharmacokinetic and pharmacodynamic drug interactions and overdosage reduced complicating delirium from 5% to almost zero at 0.5%. The association of IPM with a significant 10-fold reduction, OR = 0.09 [95% CI 0.01–0.7], in univariable regression, maintained of clinical relevance in multivariable regression OR = 0.1 [95% CI 0.01–1.1]. Factors most strongly associated with complicating delirium in univariable regression were cognitive dysfunction, nursing home residency, muscle relaxants, antiparkinsonian agents, xanthines, transient disorientation documented in the fall risk scale, antibiotic-requiring infections, antifungals, antipsychotics, and intensive care stay, the two latter maintaining significance in multivariable regression. Conclusions IPM is associated with a highly effective prevention of complicating delirium in the elderly trauma patients. For patient safety it should be integrated as an essential preventative contribution. The associated factors help identify patients at risk.
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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Delirium Severity Trajectories and Outcomes in ICU Patients. Defining a Dynamic Symptom Phenotype. Ann Am Thorac Soc 2021; 17:1094-1103. [PMID: 32383964 DOI: 10.1513/annalsats.201910-764oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Delirium severity and duration are independently associated with higher mortality and morbidity. No studies to date have described a delirium trajectory by integrating both severity and duration.Objectives: The primary aim was to develop delirium trajectories by integrating symptom severity and duration. The secondary aim was to investigate the association among trajectory membership, clinical characteristics, and 30-day mortality.Methods: A secondary analysis of the PMD (Pharmacologic Management of Delirium) randomized control trial (ClinicalTrials.gov Identifier: NCT00842608; N = 531) was conducted. The presence of delirium and symptom severity were measured at least daily for 7 days using the Confusion Assessment Method for the intensive care unit (CAM-ICU) and CAM-ICU-7 (on a scale of 0-7, with 7 being the most severe). Delirium trajectories were defined using an innovative, data-driven statistical method (group-based trajectory modeling [GBTM]) and SAS v9.4.Results: A total of 531 delirious participants (mean age 60 yr [standard deviation = 16], 55% female, and 46% African American) were analyzed. Five distinct delirium trajectories were described (CAM-ICU-7: mean [standard deviation]); mild-brief (CAM-ICU-7: 0.5 [0.5]), severe-rapid recovers (CAM-ICU-7: 2.1 [1.0]), mild-accelerating (CAM-ICU-7: 2.2 [0.9]), severe-slow recovers (CAM-ICU-7: 3.9 [0.9]), and severe-nonrecovers (CAM-ICU-7: 5.9 [1.0]). Baseline cognition and race were associated with trajectory membership. Trajectory membership independently predicted 30-day mortality while controlling for age, sex, race, cognition, illness severity, and comorbidities.Conclusions: This secondary analysis described five distinct delirium trajectories based on delirium symptom severity and duration using group-based trajectory modeling. Trajectory membership predicted 30-day mortality.
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10
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Glynn K, McKenna F, Lally K, O'Donnell M, Grover S, Chakrabarti S, Avasthi A, Mattoo SK, Sharma A, Gosh A, Shah R, Hickey D, Fitzgerald J, Davis B, O'Regan N, Adamis D, Williams O, Awan F, Dunne C, Cullen W, McInerney S, McFarland J, Jabbar F, O'Connell H, Trzepacz PT, Leonard M, Meagher D. How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients. BMJ Open 2021; 11:e041214. [PMID: 33853791 PMCID: PMC8054089 DOI: 10.1136/bmjopen-2020-041214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN Cross-sectional study. SETTING International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Muireann O'Donnell
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Sandeep Grover
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajit Avasthi
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K Mattoo
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Gosh
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ruchita Shah
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David Hickey
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - James Fitzgerald
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Brid Davis
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - Olugbenja Williams
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Fahad Awan
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - C Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - John McFarland
- Clare Mental Health Services, Ennis General Hospital, Clare, Ireland
| | | | | | - Paula T Trzepacz
- Lilly Research Laboratories, Indianapolis, Indiana, USA
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - David Meagher
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Abstract
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles (
n
= 81), and these were followed by, case reports (
n
= 58), review articles (
n
= 10), letter to the editor (not as case reports but as a communication;
n
= 13), editorials (
n
= 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devakshi Dua
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Zhang H, Yuan J, Chen Q, Cao Y, Wang Z, Lu W, Bao J. Development and validation of a predictive score for ICU delirium in critically ill patients. BMC Anesthesiol 2021; 21:37. [PMID: 33546592 PMCID: PMC7863543 DOI: 10.1186/s12871-021-01259-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/22/2021] [Indexed: 11/19/2022] Open
Abstract
Background The incidence of delirium in intensive care unit (ICU) patients is high and associated with a poor prognosis. We validated the risk factors of delirium to identify relevant early and predictive clinical indicators and developed an optimized model. Methods In the derivation cohort, 223 patients were assigned to two groups (with or without delirium) based on the CAM-ICU results. Multivariate logistic regression analysis was conducted to identify independent risk predictors, and the accuracy of the predictors was then validated in a prospective cohort of 81 patients. Results A total of 304 patients were included: 223 in the derivation group and 81 in the validation group, 64(21.1%)developed delirium. The model consisted of six predictors assessed at ICU admission: history of hypertension (RR = 4.367; P = 0.020), hypoxaemia (RR = 3.382; P = 0.018), use of benzodiazepines (RR = 5.503; P = 0.013), deep sedation (RR = 3.339; P = 0.048), sepsis (RR = 3.480; P = 0.018) and mechanical ventilation (RR = 3.547; P = 0.037). The mathematical model predicted ICU delirium with an accuracy of 0.862 (P < 0.001) in the derivation cohort and 0.739 (P < 0.001) in the validation cohort. No significant difference was found between the predicted and observed cases of ICU delirium in the validation cohort (P > 0.05). Conclusions Patients’ risk of delirium can be predicted at admission using the early prediction score, allowing the implementation of early preventive interventions aimed to reduce the incidence and severity of ICU delirium.
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Affiliation(s)
- Huijuan Zhang
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Jing Yuan
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Qun Chen
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Yingya Cao
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Zhen Wang
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Weihua Lu
- Department of Intensive Care Unit, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Juan Bao
- Department of Nursing, Yijishan Hospital, First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China.
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13
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Shim EJ, Ha H, Kim WH, Lee MH, Park J, Lee KM, Son KL, Yeom CW, Hahm BJ. Phenomenological examinations of delirium in advanced cancer patients: exploratory structural equation modelling and latent profile analysis. BMC Palliat Care 2020; 19:162. [PMID: 33076898 PMCID: PMC7574192 DOI: 10.1186/s12904-020-00668-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study examined phenomenological manifestations of delirium in advanced cancer patients by examining the factor structure of the Delirium Rating Scale-Revised-98 (DRS-R-98) and profiles of delirium symptoms. Methods Ninety-three patients with advanced cancer admitted to inpatient palliative care units in South Korea were examined by psychiatrists using the DRS-R-98 and the Confusion Assessment Method (CAM). The factor structure of the DRS-R-98 was examined by exploratory structural equation modelling analysis (ESEM) and profiles of delirium were examined by latent profile analysis (LPA). Results CAM-defined delirium was present in 66.6% (n = 62) of patients. Results from the ESEM analysis confirmed applicability of the core and noncore symptom factors of the DRS-R-98 to advanced cancer patients. LPA identified three distinct profiles of delirium characterizing the overall severity of delirium and its core and noncore symptoms. Class 1 (n = 55, 59.1%) showed low levels of all delirium symptoms. Class 2 (n = 17, 18.3%) showed high levels of core symptoms only, whereas Class 3 (n = 21, 22.6%) showed high levels of both core and noncore symptoms except motor retardation. Conclusions Clinical care for delirium in advanced cancer patients may benefit from consideration of the core and noncore symptom factor structure and the three distinct phenomenological profiles of delirium observed in the present study.
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Affiliation(s)
- Eun-Jung Shim
- Department of Psychology, Pusan National University, Busan, Republic of Korea
| | - Hyeju Ha
- Department of Psychology, Pusan National University, Busan, Republic of Korea
| | - Won-Hyoung Kim
- Department of Psychiatry, Inha University Hospital, Incheon, Republic of Korea
| | - Moon-Hee Lee
- Department of Hematology-Oncology, Inha University Hospital, Incheon, Republic of Korea
| | - Jisun Park
- Department of Hematology-Oncology, Inha University Hospital, Incheon, Republic of Korea
| | | | - Kyung-Lak Son
- Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Chan-Woo Yeom
- Department of Psychiatry, National Rehabilitation Center, Seoul, Republic of Korea
| | - Bong-Jin Hahm
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea. .,Department of Psychiatry and Behavioral Sciences, Seould National University College of Medicine, Seoul, Republic of Korea.
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14
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Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC Med 2019; 17:229. [PMID: 31837711 PMCID: PMC6911703 DOI: 10.1186/s12916-019-1458-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Delirium is a common severe neuropsychiatric condition secondary to physical illness, which predominantly affects older adults in hospital. Prior to this study, the UK point prevalence of delirium was unknown. We set out to ascertain the point prevalence of delirium across UK hospitals and how this relates to adverse outcomes. METHODS We conducted a prospective observational study across 45 UK acute care hospitals. Older adults aged 65 years and older were screened and assessed for evidence of delirium on World Delirium Awareness Day (14th March 2018). We included patients admitted within the previous 48 h, excluding critical care admissions. RESULTS The point prevalence of Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) delirium diagnosis was 14.7% (222/1507). Delirium presence was associated with higher Clinical Frailty Scale (CFS): CFS 4-6 (frail) (OR 4.80, CI 2.63-8.74), 7-9 (very frail) (OR 9.33, CI 4.79-18.17), compared to 1-3 (fit). However, higher CFS was associated with reduced delirium recognition (7-9 compared to 1-3; OR 0.16, CI 0.04-0.77). In multivariable analyses, delirium was associated with increased length of stay (+ 3.45 days, CI 1.75-5.07) and increased mortality (OR 2.43, CI 1.44-4.09) at 1 month. Screening for delirium was associated with an increased chance of recognition (OR 5.47, CI 2.67-11.21). CONCLUSIONS Delirium is prevalent in older adults in UK hospitals but remains under-recognised. Frailty is strongly associated with the development of delirium, but delirium is less likely to be recognised in frail patients. The presence of delirium is associated with increased mortality and length of stay at one month. A national programme to increase screening has the potential to improve recognition.
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15
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Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions. Am J Geriatr Psychiatry 2018; 26:1204-1212. [PMID: 30131288 DOI: 10.1016/j.jagp.2018.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 07/08/2018] [Accepted: 07/10/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions. METHODS Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories. RESULTS Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]). CONCLUSION Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.
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16
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The Motoric Types of Delirium and Estimated Blood Loss during Perioperative Period in Orthopedic Elderly Patients. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9812041. [PMID: 30515421 PMCID: PMC6236653 DOI: 10.1155/2018/9812041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/18/2018] [Accepted: 10/16/2018] [Indexed: 11/29/2022]
Abstract
Background Delirium is a common and serious syndrome in elderly patients. The hypoactive type of delirium is known to have different characteristics, but further studies are needed to define the specificities of these characteristics. Our study aims at finding specific risk factors, especially estimated blood loss during operations of hyper- and hypoactive delirium in orthopedic elderly patients. Methods One hundred and seventy-five elderly patients were evaluated using the Confusion Assessment Method (CAM) and the 4th edition text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Trained psychiatrists interviewed the subjects directly at pre- and postoperative time points. We reviewed medical records after the patients were discharged. Results Thirty-nine patients (22.3%) were diagnosed with multiple types of delirium, which included 17 hyperactive types (65.9%), 13 hypoactive types (33.3%), and 9 mixed types (23.1%). Although the mean estimated blood loss in patients with either hyper- or hypoactive symptoms was larger than in patients lacking these symptoms, the odds ratio was only significant in patients with hyperactive symptoms. In addition, age, preoperative daily function, and preoperative hyponatremia were found to be risk factors for hyperactive but not hypoactive symptoms. Conclusion Patients with hypoactive symptoms had different risk factors than patients with hyperactive symptoms of delirium. The estimated blood loss, well-known risk factors for delirium, might be risk factors for only hyperactive delirium. The acute precipitating factors seemed to show stronger correlation with the hyperactive type of delirium than with the hypoactive type.
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17
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Kim SY, Kim JM, Kim SW, Kim ES, Kang HJ, Lee JY, Bae KY, Shin IS, Yoon JS. Do the Phenotypes of Symptom Fluctuation Differ Among Motor Subtypes in Patients With Delirium? J Pain Symptom Manage 2018; 56:667-677. [PMID: 30096443 DOI: 10.1016/j.jpainsymman.2018.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/30/2018] [Accepted: 07/30/2018] [Indexed: 01/10/2023]
Abstract
CONTEXT Fluctuation in symptoms is a core feature of delirium. However, it is not well known whether the fluctuating nature would differ or not among the delirium subtype groups. OBJECTIVE This study compared phenotypes of diurnal fluctuation among different delirium subtypes using a prospective design. METHODS The motor subtypes of delirium patients were determined using the Delirium Motor Subtype Scale, fluctuations in consciousness levels were monitored with the Richmond Agitation-Sedation Scale (RASS), and symptom severity was assessed with the Nursing Delirium Screening Scale (Nu-DESC). All scales were administered at three time points over 24 hours; fluctuations in and phenotypes of symptoms were compared according to subtype of delirium using repeated-measures analysis of variance after adjustment for covariates. RESULTS This study included 224 delirium patients. Of this patients, 144 (64.3%) were classified as hyperactive, 25 (11.2%) as hypoactive, 33 (14.7%) as mixed, and 22 (9.9%) as no subtype. Scores on the RASS and Nu-DESC significantly changed during the evening and/or night and there were significant subtype group × time interaction for the RASS and Nu-DESC (F = 9.66, P < 0.001 and F = 5.11, P < 0.001, respectively). Post hoc analyses revealed that the hyperactive and mixed subtype groups had higher mean RASS scores and greater ranges of fluctuation than the other groups. The mixed subtype group was differentiated from hyperactive and hypoactive subtype groups by the range of fluctuation in psychomotor activity. CONCLUSIONS The phenotypes of symptom fluctuation differed among the motor subtypes. These findings further support the rationale that fluctuations are a core feature of delirium and could differentiate delirium subtypes.
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Affiliation(s)
- Seon-Young Kim
- Mental Health Clinic Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea; Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jae-Min Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea; Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sung-Wan Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea; Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Eun-Song Kim
- Mental Health Clinic Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Hee-Ju Kang
- Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ju-Yeon Lee
- Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung-Yeol Bae
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea; Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Il-Seon Shin
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea; Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jin-Sang Yoon
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea; Department of Psychiatry, Chonnam National University Hospital, Gwangju, Republic of Korea
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Impact of psychotic symptoms on clinical outcomes in delirium. PLoS One 2018; 13:e0200538. [PMID: 30005081 PMCID: PMC6044533 DOI: 10.1371/journal.pone.0200538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 06/28/2018] [Indexed: 11/19/2022] Open
Abstract
Delirium is an acute disturbance in attention and awareness in response to one or more physiological stressors that is closely related to poor clinical outcomes. The aim of this study is to investigate whether delirium patients with psychotic symptoms (PS) would have unique clinical characteristics and outcomes. A retrospective chart review was performed on the patients with delirium due to general medical conditions to assess clinical characteristics and outcomes. All patients were assessed by Delirium Rating Scale-revised-98 and classified as having PS when scored two or more on at least one of the psychotic symptom items (perceptual disturbances, delusions, and thought process abnormalities). Of 233 patients with delirium, 116 (49.8%) manifested PS. Patients with PS were younger, more likely to use antipsychotics to manage delirium, and had more hyperactive motor subtype than patients without PS. Logistic regression analysis showed that odds ratio of psychotic symptoms for having in-hospital mortality was 0.27 (95% CI = 0.08-0.94) after controlling age, sex, disease severity, comorbidity, number of medications, etiologies, motor subtypes, delirium severity and use of antipsychotics. The present study demonstrated that PS of delirium was associated with unique clinical characteristics and may affect the clinical course in a psychiatry-referral sample.
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FitzGerald JM. Delirium clinical motor subtypes: a narrative review of the literature and insights from neurobiology. Aging Ment Health 2018; 22:431-443. [PMID: 28394177 DOI: 10.1080/13607863.2017.1310802] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Clinical motor subtypes have been long recognised in delirium and, despite a growing body of research, a lack of clarity exists regarding the importance of these motor subtypes. The aims of this review are to (1) examine how the concept of motor subtypes has evolved, (2) explore their relationship to the clinical context, (3) discuss the relationship between the phenomenology of delirium and motor activity, (4) discuss the application of neurobiology to the theory of delirium motor subtypes, and (5) identify methodological issues and provide solutions for further studies. METHODS The following databases were searched: PubMed, PsychInfo, EBSCO, Medline, BioMed central and Science Direct. Inclusion criteria specified peer-reviewed research assessing delirium motor subtypes published between 1990 and 2016. RESULTS Sixty-one studies met the inclusion criteria. The majority of studies (n = 50) were found to use validated psychometric tools, while the remainder (n = 11) used clinical criteria. The majority of studies (n = 45) were conducted in the medical setting, while the remainder were in the ICU/post-operative setting (n = 17). CONCLUSION Although host sensitivities (e.g. frailty) and exogenous factors (e.g. medication exposure) may determine the type of motor disturbance, it remains unclear to what extent motor subtypes are influenced by other features of delirium. The use of more specialised tools (e.g. delirium motor subtyping scale), may enable researchers to develop an approach to delirium that has a greater nosological consistency. Future studies investigating delirium motor subtypes may benefit from enhanced theoretical considerations of the dysfunctional neural substrate of the delirious state.
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Intensive Care Unit Delirium: A Review of Diagnosis, Prevention, and Treatment. Anesthesiology 2018; 125:1229-1241. [PMID: 27748656 DOI: 10.1097/aln.0000000000001378] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Kim H, Lee M, Kwon IS, Kim JL. Validation of the Korean Version of the Delirium Motor Subtype Scale. Psychiatry Investig 2018; 15:6-12. [PMID: 29422920 PMCID: PMC5795032 DOI: 10.4306/pi.2018.15.1.6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/03/2017] [Accepted: 09/11/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE The Delirium Motor Subtype Scale (DMSS) is a validated and reliable instrument developed from various methods previously used to assess delirium motor subtypes. It focuses on pure motor disturbances with a relative specificity for delirium. The aim of this study was to investigate the validity and reliability of a Korean version of the DMSS (K-DMSS). METHODS We recruited 145 patients who were older than 60 years and had been referred for psychiatric consultation for delirium. These patients were evaluated using the K-DMSS, Liptzin & Levkoff criteria, and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-R98) to compare delirium motor subtypes. RESULTS The internal consistency of the K-DMSS in assessing delirium motor subtypes was acceptable (Cronbach's alpha=0.79). Delirium motor subtypes identified with the K-DMSS and K-DRS-R98 showed almost perfect agreement (Cohen's Kappa=0.81), while those identified with the K-DMSS and Liptzin & Levkoff criteria showed substantial agreement (Cohen's Kappa=0.78). CONCLUSION Our results suggest that the K-DMSS is a valid and reliable tool for identifying delirium subtypes.
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Affiliation(s)
- Hyunkyung Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Miji Lee
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - In Sun Kwon
- Chungnam National University Hospital Clinical Trials Center, Daejeon, Republic of Korea
| | - Jeong Lan Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Psychiatry, School of Medicine, Chungnam National University, Daejeon, Republic of Korea
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Ahn SH, Choi JH, Im CS, Kim TS, Kim JL. A Comparison of the Severe Cognitive Impairment Rating Scale With the Mini-Mental State Examination and Delirium Rating Scale-Revised-98 for Delirium: A Cross-sectional Study. PSYCHOSOMATICS 2017; 58:643-651. [PMID: 29032807 DOI: 10.1016/j.psym.2017.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cognitive impairment including attention deficits, disorientation, memory impairment, language disturbance, and impaired visuospatial ability are core symptoms of delirium. The Severe Cognitive Impairment Rating Scale (SCIRS) was developed to assess cognition in patients with severe dementia, but may also be useful in elderly people with delirium. OBJECTIVE We investigated the use of the SCIRS to assess cognition in elderly patients with delirium. METHODS We recruited 147 participants, aged ≥65 years, referred for psychiatric consultation at a tertiary-care university hospital. The diagnosis and severity of delirium were assessed using the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). Cognitive function was assessed using the SCIRS and the Mini-Mental State Examination (MMSE) in the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Assessment Packet (MMSE-KC). RESULTS There was a strong correlation of SCIRS scores with K-DRS-98 cognition domain (r = -0.796), severity scores (r = -0.742), total scores (r = -0.734), and the MMSE-KC (r = 0.905). Analysis of variance incorporating the severity of delirium suggested that while the MMSE showed a floor effect, the SCIRS could discriminate between moderate and severe delirium. CONCLUSION The SCIRS is a useful instrument to assess cognitive function in elderly patients with moderate to severe delirium.
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Affiliation(s)
- So-Hyun Ahn
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jin-Hoon Choi
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Chae-Sung Im
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Tae-Sung Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jeong Lan Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea.
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Pinkhasov A, James SA, Fazzari M, Singh D, Lam S. Role of Ramelteon in Reduction of As-Needed Antipsychotics in Elderly Patients with Delirium in a General Hospital Setting. Clin Drug Investig 2017; 37:1137-1141. [PMID: 28933013 DOI: 10.1007/s40261-017-0573-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Abnormalities in melatonin levels have been linked to delirium. This dysregulation may be offset with the use of ramelteon, a melatonin receptor agonist. The purpose of this study was to evaluate the role of ramelteon in decreasing the need for as-needed (PRN) use of antipsychotics in elderly patients with delirium. METHODS This was a single-center, retrospective study involving 488 patients who were placed on constant observation and received care by psychiatric service from May 2015 through October 2015. Of these patients, 125 patients were age 65 years or above, had a diagnosis of delirium, and had no standing orders for antipsychotics. These 125 patients were divided into the non-ramelteon group (who received no ramelteon and PRN antipsychotics) and the ramelteon group (who received ramelteon plus PRN antipsychotics). The use of PRN antipsychotics for agitation in each group was recorded. RESULTS The ramelteon group had a lower incidence of PRN antipsychotic use compared to those not given ramelteon (60 vs. 80%, p value = 0.001). After adjustment for race, age, length of stay, and gender, patients in the non-ramelteon group were more likely to have been given antipsychotics compared to those in the ramelteon group (odds ratio = 4.3, p value = 0.002). CONCLUSION Ramelteon use in elderly patients with delirium may be associated with statistically significant reduction of PRN antipsychotic use for agitation.
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Affiliation(s)
- Aaron Pinkhasov
- Department of Behavioral Health, NYU Winthrop Hospital, 259 1st St, Mineola, NY, 11501, USA.
| | - Sara A James
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY, USA
| | - Melissa Fazzari
- Department of Biostatistics, NYU Winthrop Hospital, Mineola, NY, USA
| | - Deepan Singh
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY, USA
| | - Sum Lam
- Department of Clinical Health Professions, St. John's University, Queens, NY, USA
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Lawley H, Hewison A. An integrative literature review exploring the clinical management of delirium in patients with advanced cancer. J Clin Nurs 2017; 26:4172-4183. [DOI: 10.1111/jocn.13960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hayley Lawley
- Ward 622; Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - Alistair Hewison
- University of Birmingham-School of Health Sciences; Birmingham UK
- The University of Birmingham; Birmingham UK
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Scholtens RM, van Munster BC, Adamis D, de Jonghe A, Meagher DJ, de Rooij SEJA. Variability of Delirium Motor Subtype Scale-Defined Delirium Motor Subtypes in Elderly Adults with Hip Fracture: A Longitudinal Study. J Am Geriatr Soc 2016; 65:e45-e50. [DOI: 10.1111/jgs.14582] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rikie M. Scholtens
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Barbara C. van Munster
- Department of Geriatrics; Gelre Hospitals; Apeldoorn The Netherlands
- University Center for Geriatric Medicine; University Medical Center Groningen; Groningen the Netherlands
| | - Dimitrios Adamis
- Sligo Mental Health Services; Ballytivnan Sligo Ireland
- Research and Academic Institute of Athens; Athens Greece
- Cognitive Impairment Research Group; Centre for Interventions in Infection; Inflammation and Immunity; Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | | | - David J. Meagher
- Cognitive Impairment Research Group; Centre for Interventions in Infection; Inflammation and Immunity; Graduate Entry Medical School; University of Limerick; Limerick Ireland
- Department of Psychiatry; University Hospital Limerick; Limerick Ireland
| | - Sophia E. J. A. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
- University Center for Geriatric Medicine; University Medical Center Groningen; Groningen the Netherlands
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Recent Insights on Prevalence and Corelations of Hypoactive Delirium. Behav Neurol 2015; 2015:416792. [PMID: 26347584 PMCID: PMC4546955 DOI: 10.1155/2015/416792] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/27/2015] [Accepted: 07/05/2015] [Indexed: 01/21/2023] Open
Abstract
Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.
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Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, Riba M. Management of delirium in palliative care: a review. Curr Psychiatry Rep 2015; 17:550. [PMID: 25663153 DOI: 10.1007/s11920-015-0550-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Delirium is a complex but common disorder in palliative care with a prevalence between 13 and 88 % but a particular frequency at the end of life (terminal delirium). By reviewing the most relevant studies (MEDLINE, EMBASE, PsycLit, PsycInfo, Cochrane Library), a correct assessment to make the diagnosis (e.g., DSM-5, delirium assessment tools), the identification of the possible etiological factors, and the application of multicomponent and integrated interventions were reported as the correct steps to effectively manage delirium in palliative care. In terms of medications, both conventional (e.g., haloperidol) and atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine, aripiprazole) were shown to be equally effective in the treatment of delirium. No recommendation was possible in palliative care regarding the use of other drugs (e.g., α-2 receptors agonists, psychostimulants, cholinesterase inhibitors, melatonergic drugs). Non-pharmacological interventions (e.g., behavioral and educational) were also shown to be important in the management of delirium. More research is necessary to clarify how to more thoroughly manage delirium in palliative care.
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Affiliation(s)
- Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Corso Giovecca 203, 44121, Ferrara, Italy,
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