Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

INTRODUCTION

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.

METHODS

We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.

RESULTS

Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.

CONCLUSIONS

The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Evaluation of Delirium Among Elders in the Emergency Department: A Cross-Sectional Study

BACKGROUND

Health care professionals underestimate the recognition of delirium in emergency departments (EDs). In these settings, between 57% and 83% of cases of delirium go undetected. When delirium occurs, it causes an increase in the length of hospitalization, readmissions within 30 days, and mortality. No studies were carried out in Italy to assess the prevalence of delirium among elders in EDs.

OBJECTIVES

The primary goal of the study was to evaluate the prevalence of the risk of delirium in people 65 years and older hospitalized in the ED for a minimum of 8 hours. The study's secondary goal was to identify the variables that influenced the risk of delirium.

METHOD

A multicenter cross-sectional study was conducted in 2 EDs. The risk of delirium was assessed using the delirium screening tool 4 A's test. One hundred patients were enrolled. Data collection took place from June 28 to August 31, 2022.

RESULTS

The risk of delirium was detected in 29% of the sample, whereas the risk of cognitive impairment was 13%. The use of psychotropic drugs increased the risk of delirium by 11.8 times (odds ratio [OR], 11.80; P = .003). Bed confinement increased the risk by 4.3 times (OR, 4.31; P = .009). Being dehydrated increased the risk of onset by 4.6 times (OR, 4.62; P = .010). Having dementia increased the risk of delirium manifestation by 4.4 times (OR, 4.35; P = .021).

DISCUSSION

The risk of delirium was detected in a considerable portion of the sample. The results of this study can be used by health care professionals to implement preventive measures as well as support clinical judgment and establish priorities of care for patients at risk of developing delirium.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study

BACKGROUND

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS

A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.

RESULTS

Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.

CONCLUSION

Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study

BACKGROUND

Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited.

AIMS

To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation.

METHODS

A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken.

RESULTS

A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes.

CONCLUSIONS

Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Delirium risk screening and assessment among older patients in general wards and the emergency department: a best practice implementation project

OBJECTIVES

The aim of this project was to improve compliance with evidence-based criteria regarding risk of delirium and the assessment of delirium among older patients in the general hospitalization wards and the emergency department.

INTRODUCTION

More than 50% of older hospitalized patients experience delirium. Some studies have highlighted the need to implement an orientation protocol in the emergency department and to continue this in the general wards, with the aim of decreasing the delirium rate among older patients admitted to hospital.

METHODS

The project followed the JBI evidence implementation framework. We conducted a baseline audit, a half-way audit, and final audit of 50 patients at risk of delirium admitted to the emergency department and the general wards, respectively. The audits measured compliance with eight criteria informed by the available evidence.

RESULTS

In the final audit, three of the eight criteria achieved more than 50% compliance in the general wards: pressure injury screening (96%); monitoring changes (74%); and performing interventions (76%). In the emergency department, worse results were reported because of the service conditions. The exception was the criterion on the training of nurses on the topic, with 98%. The integration of a tool to screen for delirium in older patients in the hospital's electronic clinical history records increased the percentage of compliance with audit criteria regarding the use of the scale and delirium detection (rising from 0% to 32% in the final audit in the general wards).

CONCLUSION

Through the implementation of this project, validated and evidence-based evaluation will ensure that nurses are supported through appropriate measures to reduce patient confusion and aggression resulting from delirium.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review

RATIONALE

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs) translate evidence into recommendations to improve practice.

AIM

To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients.

METHODS

We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) instruments. A threshold of 70% or greater in the AGREE-II Rigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis.

RESULTS

AGREE-II Rigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REX overall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations.

CONCLUSION

This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED.

REGISTRATION

This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.

Pharmacological Management of Agitation and Delirium in Older Adults: a Survey of Practices in Canadian Emergency Departments

Agitation is a common presenting symptom of delirium for older adults in the emergency department (ED). No medications have been found to reduce delirium severity, symptoms, or mortality, yet they may cause harm. Guidelines suggest using medications only when patients are posing a risk of harm, situations which may arise frequently in the ED. We sought to characterize prescribing patterns of medications for agitation by ED physicians in Canadian hospitals. In this multicenter study, we surveyed physicians in Vancouver, Toronto, and Sherbrooke. Descriptive statistics were used to summarize group characteristics and starting doses were compared to order sets. Fisher exact tests were used for demographic comparison. Ordinal linear regression models were run to identify a relationship between starting dose of medications and location. Of the 137 physicians invited, 77 (56%) completed the survey. Use of order sets was greatest in Sherbrooke and least in Vancouver. The most common medications used across sites were haloperidol, lorazepam, and quetiapine. Benzodiazepines were used across all sites but were used significantly more frequently in Vancouver than the other sites. Practice location was a significant predictor of starting dose of haloperidol, with Sherbrooke and Toronto having a lower starting dose than Vancouver. Higher use of order sets correlated with lower and more consistent starting doses. Benzodiazepines are used across EDs in Canada despite little evidence for efficacy in delirium and risk of harm. Implementation of order sets may be a useful way to standardize ED management of older adults experiencing hyperactive delirium.

Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process

INTRODUCTION

Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS AND ANALYSIS

This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses.

ETHICS AND DISSEMINATION

Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies.

Initial Development of a Patient-Reported Experience Measure for Older Adults Attending the Emergency Department: Part II-Focus Groups with Professional Caregivers

A wide range of healthcare professionals provide care for patients in the emergency department (ED). This study forms part of a wider exploration of the determinants of patient experience for older adults in the ED, to assist the development of a new patient-reported experience measure (PREM). Inter-professional focus groups aimed to build on findings from earlier interviews with patients conducted in the ED, by exploring professional perspectives on caring for older people in this setting. A total of thirty-seven clinicians, comprising nurses, physicians and support staff, participated in seven focus groups across three EDs in the United Kingdom (UK). The findings reinforced that meeting patients' communication, care, waiting, physical, and environmental needs are all central to the delivery of an optimal experience. Meeting older patients' basic needs, such as access to hydration and toileting, is a priority often shared by all ED team members, irrespective of their professional role or seniority. However, due to issues including ED crowding, a gap exists between the desirable and actual standards of care delivered to older adults. This may contrast with the experience of other vulnerable ED user groups such as children, where the provision of separate facilities and bespoke services is commonplace. Therefore, in addition to providing original insights into professional perspectives of delivering care to older adults in the ED, this study demonstrates that the delivery of suboptimal care to older adults may be a significant source of moral distress for ED staff. Findings from this study, earlier interviews, and the literature will be triangulated to formulate a comprehensive list of candidate items for inclusion in a newly developed PREM, for patients aged 65 years and older.

"Older People Want to Be in Their Own Homes": A Service Evaluation of Patient and Carer Feedback after Pathfinder Responded to Their Emergency Calls

OBJECTIVE

Older people experience high rates of adverse outcomes following emergency department (ED) presentation. There is growing evidence to support alternative care pathways for certain types of emergency medical services (EMS) calls. Pathfinder is one such service and targets patients aged 65 years and over, whose presenting issues can be safely managed at home by immediate paramedic, occupational therapy, and/or physiotherapy interventions. The aim of this service evaluation was to understand how older people feel about being treated at home as a result of EMS calls and to understand their experiences of the Pathfinder service.

METHODS

This was a thematic analysis of open-ended responses recorded from telephone interviews during routine service evaluation with service users (patients or their next-of-kin).

RESULTS

Of 573 service users, telephone interviews were conducted with 429 (75%). Five primary themes were identified: (1) professionalism of the multidisciplinary clinical team; (2) "the right service, in the right place, at the right time"; (3) role of Pathfinder in "getting the ball rolling"; (4) lasting effects of the experience on the patient and his or her next-of-kin; (5) value of skilled communication with the older person.

CONCLUSION

Older people and their next-of-kin voiced a clear preference for hospital avoidance, and strongly valued the opportunity to be treated in their homes at the time of an EMS call rather than default conveyance to the ED. They appreciated the importance of a skilled multidisciplinary team with a follow-up service that effectively positions itself between the acute hospital and community services.

A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol

BACKGROUND

Up to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients.

METHODS

We will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation - Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations.

DISCUSSION

This review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients.

TRIAL REGISTRATION

This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6 .

Implementing delirium screening in the emergency department: a quality improvement project

Introduction

Delirium is a serious medical condition that is common in older adults in acute settings. Clinical practice guidelines recommend that all older patients in acute care settings should be screened for delirium using standardised outcome measures.

Problem

In our institution, an audit showed that only 16% of older adults presenting to the emergency department were screened for delirium. The goal of this project was to increase the number of patients being screened for delirium using Lean Six Sigma (LSS) methodology and tools and a multidisciplinary approach.

Method

A multidisciplinary team in the emergency department used LSS tools and methodology over a 12-week period to first identify why patients were not being screened for delirium using root cause analysis and second to implement a multifaceted intervention including education, audits and feedback, documentation changes and team huddles. An audit was performed at the 11th week of the project to measure how many patients were being screened for delirium post project intervention.

Results

Results at 5 weeks post intervention (11th week of project) showed that the percentage of patients being screened for delirium had increased from 16% to 82%. A follow-up audit at 17 weeks post intervention showed a further improvement in delirium screening to 92%.

Conclusion

Applying LSS tools and methodology resulted in a healthcare quality improvement. Delirium screening in an emergency department can be improved through multifaceted interventions including education, documentation changes and team huddle changes.

Pathfinder; alternative care pathways for older adults who phone the emergency medical services in North Dublin: a case study

Purpose

Emergency Department (ED) presentations in older people are associated with a wide range of adverse events, which increase the risk of lengthy hospitalisation and poor outcomes. Pathfinder is an inter-organisational initiative delivered in partnership between Beaumont Hospital Occupational Therapy and Physiotherapy departments and the National Ambulance Service. Pathfinder responds to non-serious and non-life-threatening emergency medical service (EMS) calls. This study aims to demonstrate how Pathfinder can safely treat a proportion of older people at home by using alternative care pathways (ACPs), therefore avoiding unnecessary ED presentations. Once a decision has been reached to treat the person at home, the Pathfinder follow-up team delivers functional rehabilitation and case management in the persons’ home over the subsequent days.

Design/methodology/approach

This paper outlines the Pathfinder assessment, management and interventions in one clinical case example. Outcome measures include the level of patient satisfaction obtained via routine telephone feedback questionnaire and re-presentation to Beaumont Hospital within 30 days.

Findings

This paper illustrates through a case example the benefit of a collaborative multi-disciplinary rapid response team for non-serious and non-life-threatening EMS calls in older adults. The patient in this case example had no further EMS calls or ED presentations for 30 days after Pathfinder intervention and reported a high level of satisfaction with the service.

Research limitations/implications

ED presentation was avoided through comprehensive multi-disciplinary assessment, including immediate access to intensive follow-up support in the person’s own home.

Practical implications

The Pathfinder service is improving access to ACPs for older people in the Beaumont Hospital catchment area. Pathfinder will now be spread nationally, with local adaptation, so that older people in other parts of Ireland will also benefit from this integrated model of care.

Originality/value

Patient feedback surveys confirm older adults want access to alternative care pathways.

Structured delirium management in the hospital—a randomized controlled trial

BACKGROUND

Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients.

METHODS

The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]).

RESULTS

The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02).

CONCLUSION

Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.

Delirium in the elderly admitted to an emergency hospital service

ABSTRACT Objective: To check for the presence of delirium in the elderly entering the emergency room (ER) of the University Hospital of Santa Maria (HUSM) and their relationship with sociodemographic variables, reason and time of hospitalization, comorbidities, and death. Methods: A quantitative, cross-sectional exploratory study, which analyzed data from the sociodemographic profile, Confusion Assessment Method, Charlson Comorbidities Index, and follow-up of the outcomes “in-hospital death” and “length of hospitalization.” The period analyzed in the study was between July and December 2019. Results: Of the 732 participants, 394 (53.90%) were men, with an average age of 72 years. The study identified Delirium in 99 (13.52%) participants, and death, in 120 (16.39%). There was an association of this disorder with age, comorbidities, length of hospitalization, death, and some reasons for hospitalization, such as diseases of the circulatory, respiratory and genitourinary systems. Conclusion: The results warn of the high incidence of delirium in emergency units and their relationship with a worse prognosis.

Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study

Aim

To study delirium screening upon Emergency Department admission among patients admitted with suspected sepsis.

Findings

Delirium screening upon Emergency Department admission, using 4AT, was useful among patients aged ≥65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission.

Message

This study suggest increased awareness of delirium among older patients with suspected sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00558-5.

Purpose

We aimed to study the use of The 4 ‘A’s test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission, and to characterize older patients admitted to the ED with and without sepsis in terms of delirium features.

Methods

In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the ED with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria.

Results

Out of the 196 patients included (mean age 81 years, 60% men), 100 patients fulfilled the sepsis diagnosis criteria. The mean 4AT screening time was 2.5 Minutes. In total, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Out of the 100 patients with sepsis, 68 (68%) had delirium during the hospital stay, as compared to 34 out of 96 patients (35%) without sepsis (p < 0.05).

Conclusion

Delirium screening upon ED admission, using 4AT, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission. The prevalence of delirium during the hospital stay was high, particularly in patients with sepsis.

Graphic abstract

Is Pathfinder a safe alternative to the emergency department for older patients? An observational analysis

BACKGROUND

many patients brought to emergency departments (EDs) following an emergency medical services (EMS) call have non-urgent needs that could be treated elsewhere. Older people are particularly vulnerable to adverse events while attending the ED. Alternative care pathway models can reduce ED crowding and improve outcomes. Internationally, there is no consensus on which model is recommended.

AIM

the aim of this study is to investigate the impact of the Pathfinder model on ED conveyance rates and patient safety.

METHODS

the Pathfinder service is a collaboration between the National Ambulance Service and Beaumont Hospital Occupational Therapy and Physiotherapy Departments. It is supported by the Government of Ireland's Sláintecare Integration fund. This is a retrospective cohort study of the Pathfinder service over a 5-month period.

RESULTS

one-hundred and seventy-eight patients were responded to by the Pathfinder 'Rapid Response Team'. Average age was 79.6 years (standard deviation 7.6), median clinical frailty score was 6 (interquartile range: 5-6). Sixty-four percent remained at home following initial review. None re-presented to the ED within 24 hours, and 10% re-presented within 7 days. The majority (67%) of patients required follow-up by the Pathfinder 'Follow-Up Team' and/or another community-based service. Feedback demonstrates 99% patient satisfaction with the service.

CONCLUSION

the Pathfinder service is a safe alternative to ED conveyance for older people following an EMS call. It is the first model of this kind to be evaluated in Ireland. The overwhelmingly positive feedback confirms that older people want this service. This model could expand, with local adaptation, nationally and internationally.

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium

Introduction

Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development.

Methods

This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway.

Results

A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83).

Conclusion

Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.

Succinct Approach to Delirium in the Emergency Department

Purpose of Review

This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework.

Recent Findings

Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort.

Summary

Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.

Age-Friendly Health Care: A Systematic Review

Background: Health care provided to older adults must take into account the characteristics of chronic diseases and the comorbidities resulting from ageing. However, health services are still too oriented towards acute situations. To overcome this problem, the World Health Organization (WHO) proposed a set of Age-Friendly Principles that seek to optimize the provision of health care for this population. This article aims to understand how such Principles are considered in the implementation of age-friendly health care worldwide. Methods: A systematic review was conducted to synthesize the literature on age-friendly health care in accordance with the PRISMA recommendations in the PubMed, Web of Science, and Scopus databases. Results: The research identified 34 articles, with only seven recognizing the WHO Principles and only four using the implementation toolkit. In addition, in the context of primary care, three studies recognize the WHO Principles, but only two use the toolkit. Conclusions: The WHO Principles are being implemented in health care, but in a smaller scale than desired, which reveals possible flaws in their dissemination and standardization. Thus, a greater scientific investment in age-friendly health care should be considered, which represents a greater operationalization of the Principles and an evaluation of their effectiveness and impacts.

Functional and cognitive decline in older delirious adults after an emergency department visit

BACKGROUND

the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient's functional and cognitive status at 60 days post ED visit.

METHODS

this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m.

RESULTS

a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of -2.9/28 [95%CI: -3.9, -2.0] points on the OARS scale compared to non-delirious patients who lost -1.6 [95%CI: -1.9, -1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by -1.6 [95%CI: -3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: -0.1, 1.1] (P = 0.03).

CONCLUSION

seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study

OBJECTIVE

The objective of this study was to identify the predictors of incident delirium in this high-risk population.

METHODS

This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium.

RESULTS

Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001).

CONCLUSION

More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.

A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial

Introduction

Although various preventive strategies have been advocated, delirium is common in critically ill patients and is associated with increased morbidity, mortality, and long-term adverse effects. The efficacy of a novel delirium prevention bundle in mechanically ventilated critically ill patients was investigated in this study.

Methods

In this randomized controlled trial, 50 mechanically ventilated adult patients in a tertiary care medical-surgical intensive care unit (ICU) were randomized to receive either delirium prevention bundle protocol or standard of care protocol. Delirium was assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU) score by an independent investigator up to 28 days or death or discharge. The primary outcome was the incidence of new-onset delirium. Secondary outcomes were duration of mechanical ventilation, ICU length of stay (ICU-LOS), hospital LOS, and other adverse events.

Results

There was a 20% reduction in the incidence of delirium in the intervention group (36 vs 56%; p = 0.156). The 28-day mortality (28 vs 24%; p = 0.747), duration of mechanical ventilation (9 vs 12 days; p = 0.281), ICU-LOS (11 vs 12 days; p = 0.221), and hospital LOS (16 vs 20 days; p = 0.062) were similar between the groups.

Conclusion

Implementation of delirium prevention bundle does not reduce the incidence of delirium compared to standard of care protocol in mechanically ventilated critically ill patients.

How to cite this article

Malik AK, Baidya DK, Anand RK, Subramaniam R. A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial. Indian J Crit Care Med 2021;25(7):754–760.

Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

OBJECTIVES

To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.

DESIGN

A prospective cohort study.

SETTING

A tertiary care hospital with postacute intensive care units (ICUs) in Germany.

PARTICIPANTS

N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure.

INTERVENTIONS

None.

MEASURES

Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed.

RESULTS

Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2).

CONCLUSIONS

Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU.

TRIAL REGISTRATION NUMBER

DRKS00003386.

Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients

Aim

Polypharmacy in elderly people is a social issue and has been reported to cause not only drug adverse events, but also falls, dysfunction and cognitive decline. Those events may trigger prolonged length of hospitalization. Therefore, the aim of this study was to investigate whether polypharmacy has a prolonging effect on hospitalization.

Methods

The study subjects were 584 patients in a university hospital in Japan who had been admitted for hepatectomy, pancreaticoduodenectomy, gastrectomy or colectomy, and to whom clinical pathways had been applied. In this study, polypharmacy was defined as taking five or more regular oral medications, and prolonged hospitalization was defined as hospitalization longer than that determined by the clinical pathway. Multiple logistic regression analysis was performed to investigate whether polypharmacy affects the length of hospitalization.

Results

The subjects were 348 males and 236 females, mean ± SD age of 65.8 ± 12.9 years. Among all subjects, 228 (39.0%) were receiving polypharmacy at admission, and the number of patients with prolonged hospitalization was 262 (44.9%). Multiple logistic regression analysis revealed that the following variables were significantly associated with prolonged hospitalization; polypharmacy (odds ratio = 1.532; 95% confidence interval = 1.010–2.327), age 50–59; 2.971 (1.216–7.7758), age 60–69; 2.405 (1.059–5.909), organ pancreas; 0.298 (0.122–0.708), operation time ≥386 min; 2.050 (1.233–3.432), intraoperative bleeding volume ≥401 mL; 2.440 (1.489–4.038), postoperative delirium; 2.395 (1.240–4.734), postoperative infection; 10.715 (4.270–33.059).

Conclusion

The current study revealed that polypharmacy at admission was an independent factor for prolonged hospitalization. In future, measures against polypharmacy are required, collaborating with outpatient clinics, family doctors and dispensing pharmacies. Geriatr Gerontol Int 2020; 20: 1085–1090..

Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients

OBJECTIVES

Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients.

METHODS

A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented.

RESULTS

A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65.

CONCLUSIONS

Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.

Is the fast-track process efficient and safe for older adults admitted to the emergency department?

BACKGROUND

The efficiency of the fast-track (FT) process in the management of patients in Emergency Departments is well demonstrated, but there is a lack of research focused on older adults. The aim of our study was to verify whether the FT process is efficient and safe for older adults admitted to ED.

METHODS

Observational case-control single-centre study.

RESULTS

Five hundred four cases and 504 controls were analysed. The mean age was 75 years, and there was a predominance of women. In total 96% of subjects were classified with a "less-urgent" tag. The length of stay was significantly lower in the fast-track group than in the control group (median 178 min, interquartile range 184 min, and 115 min, interquartile range 69 min, respectively, p < 0.001), as well as the time spent between the ED physician's visit and patient discharge (median 78 min, interquartile range 120 min, and median 3 min, interquartile range 6 min, respectively, p < 0.001). There weren't any increases in the number of unplanned readmissions within 48 h, 7 days and 30 days.

CONCLUSIONS

The fast-track appears to be an efficient and safe strategy to improve the management of older adults admitted to the ED with minor complaints.

Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery

BACKGROUND

The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients.

STUDY DESIGN

We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery.

RESULTS

A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01).

CONCLUSIONS

The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers

BACKGROUND

delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients.

OBJECTIVES

to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients.

DESIGN

a prospective observational multicenter cohort study.

SETTING

four Quebec EDs.

PARTICIPANTS

independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation.

MEASUREMENTS

eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated.

RESULTS

we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%).

CONCLUSION

serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Optimizing the month of the year backwards test for delirium screening of older patients in the emergency department

INTRODUCTION

Different scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT.

METHODS

This is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED.

DATA COLLECTION

Research assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA.

RESULTS

For the scoring method "number of errors", optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method "number of errors in combination with time needed" resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method "last month in correct order", optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89.

DISCUSSION

We suggest omitting the factor time and using a more practical scoring method with good performance: "last month in correct order" with the requirement to reach September to rule out delirium.

Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department

BACKGROUND

Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium.

AIM

To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland.

METHOD

A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver.

RESULTS

The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference.

CONCLUSION

Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.

Addition of Suvorexant to Ramelteon Therapy for Improved Sleep Quality with Reduced Delirium Risk in Acute Stroke Patients

BACKGROUND AND PURPOSE

Delirium in acute stroke is associated with poor clinical outcome. The purpose of this study was to examine the effect of sleep medications on sleep quality and delirium in acute stroke.

METHODS

In this retrospective cohort study, sleep disturbances, and delirium were investigated in acute stroke patients treated in April 2013-March 2017 who were prescribed ramelteon plus either an alpha-aminobutyric acid receptor (GABAR) agonist or a selective dual orexin receptor antagonist (suvorexant).

RESULTS

Of the patients included, 104 received a GABAR agonist and 128 received suvorexant in addition to ramelteon. Patient characteristics did not differ significantly between the groups, except for a higher proportion of cerebral infarction in suvorexant group (P = .033). Subjective sleep quality was significantly improved in suvorexant group compared to GABAR agonist group (difficulty staying asleep: 6.3% versus 34%, P < .001; daytime sleepiness: 33% versus 63%, P < .001). Delirium was significantly less frequent in suvorexant group than GABAR agonist group (7.0% versus 31%, P < .001). The length of hospital stay was significantly shorter in suvorexant group than in GABAR agonist group (in days, 21 [15-29] versus 25 [18-33]; P = .019). Multivariable logistic regression analysis revealed that the addition of suvorexant was significantly associated with a reduced occurrence of delirium (odds ratios .19, 95% confidence interval .085-.43, P < .001).

CONCLUSIONS

Addition of suvorexant to ramelteon therapy, rather than a GABA receptor agonist, can improve subjective sleep quality without inducing delirium in acute stroke patients.