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Alshurtan K, Ali Alshammari F, Alshammari AB, Alreheili SH, Aljassar S, Alessa JA, Al Yateem HA, Almutairi M, Altamimi AF, Altisan HA. Delirium Knowledge, Risk Factors, and Attitude Among the General Public in Saudi Arabia: A Cross-Sectional Study. Cureus 2024; 16:e59263. [PMID: 38813288 PMCID: PMC11134522 DOI: 10.7759/cureus.59263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction Delirium is a common and serious neuropsychiatric disorder, of acute onset, present at any age, but more common in older adults, and very common in clinical practice. It combines mental and behavioral symptoms with a fluctuating course, with worsening of the condition in the afternoon and at night, with important repercussions on increased mortality, greater risk of cognitive impairment, and hospitalization costs. Delirium's impact extends to patients, families, and healthcare systems, emphasizing the need for public awareness and education in Saudi Arabia. Methodology It is a cross-sectional conducted in Saudi Arabia that aims to assess knowledge, risk factors, and attitudes regarding delirium among all Saudi and non-Saudi residents aged 18 and older. A 36 self-administered questionnaire, standardized Nordic, was used. Data were cleaned in Microsft Excel (Microsoft Corporation, USA) and analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY). This study was conducted in Saudi Arabia from May 2023 till March 2024. Results Our study involved 1,470 participants from Saudi Arabia, primarily females (79.1%), Saudi nationals (89.9%), and unmarried individuals (65.4%). Most participants were aged 18-24 (59.5%) and held bachelor's degrees (57.3%). Commonly recognized delirium risk factors included increasing age (63.3%), dementia (58.2%), and longer ICU stays (48.7%). The participants showed moderate knowledge of delirium symptoms and consequences. Attitudes varied, with many agreeing that delirium requires intervention (30.7%) but fewer considering it preventable (17.1%). Sociodemographic factors, including gender and age, significantly influenced knowledge and attitudes, while education levels did not. Conclusion Our study found that gender and age influenced knowledge and attitudes, highlighting the importance of targeted education. Future research should further investigate the effectiveness of such interventions in enhancing knowledge and awareness and promoting preventive actions.
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Affiliation(s)
- Kareema Alshurtan
- Internal Medicine, University of Hail College of Medicine, Hail, SAU
| | | | | | | | | | | | | | | | | | - Hamad A Altisan
- Medicine and Surgery, University of Hail College of Medicine, Hail, SAU
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Merrick M, Grange R, Rudd S, Shipway D. Evaluation and Treatment of Acute Trauma Pain in Older Adults. Drugs Aging 2023; 40:869-880. [PMID: 37563445 DOI: 10.1007/s40266-023-01052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.
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Affiliation(s)
- Minnie Merrick
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Robert Grange
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Sarah Rudd
- Library and Knowledge Service, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.
- University of Bristol, Bristol, UK.
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Shcherbakova MM. Differential clinical signs of aphasia syndrome in acute and residual recovery periods. Directions of neurorehabilitation of patients with aphasia syndrome depending on the recovery period. CONSILIUM MEDICUM 2023. [DOI: 10.26442/20751753.2022.12.201952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background. Speech and cognitive disorders of vascular genesis account for a significant percentage of the existing consequences of local disorders of cerebral circulation. Approximately 2140% of stroke patients suffer from persistent aphasia, which gradually worsens the quality of life and rehabilitation results.
Aim. Improving the quality of neurorehabilitation of patients who have suffered a brain stroke.
Materials and methods. The analysis of differential clinical signs of aphasia syndrome in patients of neuro-intensive care and vascular neurological departments was carried out. The typical clinical symptoms of aphasia syndrome characteristic of ICU patients were identified, a rehabilitation direction was proposed that promotes rapid compensation of syndromes in the acute recovery period (up to 88% of cases). The clinical signs of aphasia syndrome at the late, residual recovery stage have been clarified. An effective method of neurorehabilitation of patients with aphasia syndrome in the late recovery period (significant positive dynamics up to 85% of cases) is proposed.
Results. Achieved high results in the reversibility of the aphasia syndrome, both at an early and late, residual, recovery stage.
Conslusion. Aphasia syndrome in acute and residual recovery periods has a certain specificity of its clinical manifestation. This factor must be taken into account: 1) when making speech diagnoses; 2) when planning rehabilitation programs. An effective rehabilitation technique for the aphasia syndrome involves a functional reorganization of mental processes, which allows speech thinking to either completely return or get as close as possible to its original state, regardless of the stage of recovery work.
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Marquetand J, Bode L, Fuchs S, Ernst J, von Känel R, Boettger S. Delirium: Prevalence and outcome in the very old in 27 medical departments during a one-year prospective study. Palliat Support Care 2022; 20:779-784. [PMID: 36942581 DOI: 10.1017/s1478951521001814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The prevalence and effects of delirium in very old individuals aged ≥80 years have not yet been systematically evaluated. Therefore, this large single-center study of the one-year prevalence of delirium in 3,076 patients in 27 medical departments of the University Hospital of Zurich was conducted. METHODS Patient scores on the Delirium Observation Screening scale, Intensive Care Delirium Screening Checklist, Diagnostic and Statistical Manual, 5th edition, and electronic Patient Assessment-Acute Care (nursing tool) resulted in the inclusion of 3,076 individuals in 27 departments. The prevalence rates were determined by simple logistic regressions, odds ratios (ORs), and confidence intervals. RESULTS Of the 3,076 patients, 1,285 (41.8%) developed delirium. The prevalence rates in the 27 departments ranged from 15% in rheumatology (OR = 0.30) to 73% in intensive care (OR = 5.25). Delirious patients were more likely to have been admitted from long-term care facilities (OR = 2.26) or because of emergencies (OR = 2.24). The length of their hospital stay was twice as long as that for other patients. Some died before discharge (OR = 24.88), and others were discharged to nursing homes (OR = 2.96) or assisted living facilities (OR = 2.2). CONCLUSION This is the largest study to date regarding the prevalence of delirium in patients aged ≥80 years and the medical characteristics of these patients. Almost two out of five patients developed delirium, with a high risk of loss of independence and mortality.
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Affiliation(s)
- Justus Marquetand
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tubingen, Tubingen, Germany
- Department of Neural Dynamics and Magnetoencephalography, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- MEG-Center, University of Tübingen, Tübingen, Germany
| | - Leonie Bode
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Institute of Nursing Science, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Soenke Boettger
- University Hospital Zurich, University Zurich, Zurich, Switzerland
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Hoch J, Bauer JM, Bizer M, Arnold C, Benzinger P. Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatr 2022; 22:879. [PMCID: PMC9675220 DOI: 10.1186/s12877-022-03573-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium. Methods The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models. Results The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants. Conclusions Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03573-8.
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Affiliation(s)
- Jonas Hoch
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jürgen M. Bauer
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.7700.00000 0001 2190 4373Network Aging Research (NAR), Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
| | - Martin Bizer
- grid.5253.10000 0001 0328 4908Department of Internal Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Christine Arnold
- grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Petra Benzinger
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.200773.10000 0000 9807 4884Institute of Health and Generations, University of Applied Sciences Kempten, Bahnhofstrasse 61, 87435 Kempten, Germany
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Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults? Int Psychogeriatr 2022; 34:889-903. [PMID: 33757611 DOI: 10.1017/s1041610221000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This systematic review aims to identify published randomized controlled trials (RCTs) that evaluated the use of anticonvulsants for the prevention and/or treatment of delirium among older adults. METHODS A comprehensive search of databases: MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection and Cochrane Central Register of Controlled was conducted. RESULTS The search identified four RCTs that evaluated the use of anticonvulsants among older adults with delirium. One RCT evaluated the perioperative use of gabapentin among individuals undergoing spinal surgery and the development of postoperative delirium. One RCT evaluated the relationship between the use of perioperative gabapentin and the development of postoperative delirium among individuals undergoing spinal surgery and hip and knee arthroplasty. Two post-hoc analyses of RCTs evaluated the use of gabapentin and pregabalin among individuals undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). The perioperative use of gabapentin reduced the incidence of postoperative delirium among older adults undergoing spinal surgery. The perioperative use of gabapentin did not reduce the rates, severity or duration of postoperative delirium among older adults who were undergoing spine and hip and knee arthroplasty. The perioperative use of gabapentin did not reduce the incidence or duration of postoperative delirium among older adults undergoing elective TKA. The perioperative use of pregabalin did not reduce the incidence of postoperative delirium among older adults undergoing elective THA. Gabapentin and pregabalin were well tolerated among the individuals enrolled in these trials. There were no RCTs identified that evaluated the use of other anticonvulsants for the prevention and/or treatment of delirium among older adults. CONCLUSIONS Based on current evidence, the routine use of anticonvulsants for the prevention and/or treatment of delirium among older adults cannot be recommended.
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Jing GW, Xie Q, Tong J, Liu LZ, Jiang X, Si L. Early Intervention of Perioperative Delirium in Older Patients (>60 years) with Hip Fracture: A Randomized Controlled Study. Orthop Surg 2022; 14:885-891. [PMID: 35441485 PMCID: PMC9087462 DOI: 10.1111/os.13244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/13/2022] [Accepted: 02/18/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To explore the effect of early intervention for perioperative delirium in older (> 60 years) hip fracture patients. Methods This prospective study enrolled hip fracture patients aged ≥60 years who were admitted into our hospital between July 2011 and August 2019. Hip fractures were classified according to the Arbeitsgemeinschaft für Osteo‐synthesefragen (AO) classification. This study included patients with isolated hip fracture and excluded patients with pathological or peri prosthetic fracture or patients with multiple traumatic injuries and high‐energy trauma. They were randomized to receive conventional orthopedic care group (n = 65) or comprehensive orthopedic care group including preoperative psychological counseling and preventative risperidone (n = 63). Daily assessment was based on patient interview with the CAM‐CR, and delirium was diagnosed by the Delirium Rating Scale (DRS‐R‐98). The rate, severity and duration of perioperative delirium and the length of postoperative stay were analyzed. Results Totally 200 patients were screened for eligibility. Twenty patients were excluded due to alcohol abuse and 40 were excluded because of brain lesions on head CT. In addition, 12 patients were excluded because of impaired cognition. Finally 128 patients were enrolled. Their mean age was 75.3 ± 2.2 years for the comprehensive orthopedic care group and 73.5 ± 6.1 years for the conventional orthopedic care group, and 53.9% of the patients were female. Sixty‐eight (53.1%) patients had intertrochanteric fracture, 39.8% patients had femoral head fracture, and 7.0% patients had subtrochanteric fracture. In addition, 58.6% patients underwent internal fixation and 41.4% patients received arthroplasty. In this study, 63 patients were randomized to the comprehensive orthopedic care group and 65 patients to the conventional orthopedic care group. The two groups were comparable in demographic and baseline characteristics (P > 0.05). The rate of perioperative delirium was significantly lower in the comprehensive care group vs the conventional care group (15.9% vs. 30.8%; P < 0.05). The comprehensive care group had significantly reduced length of postoperative hospital stay vs the conventional care group (11.3 ± 2.5 days vs. 14.2 ± 2.2 days, P < 0.01). The mean DRS‐R‐98 score was 7.1 ± 2.7 for the comprehensive care group, and was significantly lower than that of the conventional orthopedic care group (11.2 ± 3.0; P < 0.05). Conclusions Our early intervention may reduce the incidence of perioperative delirium in elderly hip fracture patients (>60 years).
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Affiliation(s)
- Guang-Wu Jing
- Department of Orthopedics, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Qin Xie
- Wuhan Mental Health Center, Wuhan, China
| | - Jie Tong
- Department of Orthopedics, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | | | - Xue Jiang
- Wuhan Mental Health Center, Wuhan, China
| | - Liang Si
- Wuhan Mental Health Center, Wuhan, China
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Risk factors for postoperative delirium and subsyndromal delirium in older patients in the surgical ward: A prospective observational study. PLoS One 2021; 16:e0255607. [PMID: 34339463 PMCID: PMC8328296 DOI: 10.1371/journal.pone.0255607] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
Postoperative delirium (POD) and subsyndromal delirium (SSD) among older patients is a common, serious condition associated with a high incidence of negative outcomes. However, there are few accurate methods for the early detection of POD and SSD in surgical wards. This study aimed to identify risk factors of POD and SSD in older patients who were scheduled for surgery in a surgical ward. This was a prospective observational study. Study participants were older than 65 years, underwent urology surgery, and were hospitalized in the surgical ward between April and September 2019. Delirium symptoms were assessed using the Confusion Assessment Method (CAM) on the preoperative day, the day of surgery, and postoperative days 1–3 by the surgical ward nurses. SSD was defined as the presence of one or more CAM criteria and the absence of a diagnosis of delirium based on the CAM algorithm. Personal characteristics, clinical data, cognitive function, physical functions, laboratory test results, medication use, type of surgery and anesthesia, and use of physical restraint and bed sensor were collected from medical records. Multiple logistic regression analyses were conducted to identify the risk factors for both POD and SSD. A total of 101 participants (mean age 74.9 years) were enrolled; 19 (18.8%) developed POD (n = 4) and SSD (n = 15). The use of bed sensors (odds ratio 10.2, p = .001) was identified as a risk factor for both POD and SSD. Our findings suggest that the use of bed sensors might be related to the development of both POD and SSD among older patients in surgical wards.
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Ding G, Hua S, Chen J, Yang S, Xie R. Does cognitive decline/dementia increase Delirium risk after stroke? Psychogeriatrics 2021; 21:605-611. [PMID: 34018278 DOI: 10.1111/psyg.12720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delirium is a common contributor to mortality and hospital costs in stroke patients. Different observational studies have showed inconsistent results regarding the association between cognitive decline/dementia and delirium after acute stroke. Therefore, we performed this meta-analysis with the aim of determining whether cognitive decline/dementia is related to the risk of delirium after acute stroke. METHODS We systematically searched PubMed, Embase, Google Scholar, and Web of Science for relevant studies from inception to September 2020. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) by using fixed or random effects models based on heterogeneity measured by the I2 index. RESULTS The association between cognitive decline/dementia and post-stroke delirium was examined in 13 studies with 3183 participants. After pooled analysis, we found that cognitive decline/dementia was significantly associated with susceptibility to delirium in post-stroke patients (OR = 3.70, 95%CI: 2.90-4.71, P < 0.001). Subgroup analysis suggested that cognitive decline/dementia was associated with an increased risk of delirium in Caucasians (OR = 3.73, 95%CI: 2.73-5.11, P < 0.001), non-Caucasians (OR = 3.65, 95%CI: 2.50-5.33, P < 0.001), samples with <200 subjects (OR = 3.70, 95%CI: 2.17-6.31, P < 0.001), samples with ≥200 subjects (OR = 3.70, 95%CI: 2.82-4.85, P < 0.001), studies published in 1990-2009 (OR = 3.17, 95%CI: 1.48-6.77, P = 0.003), and studies published in 2010-2020 (OR = 3.76, 95%CI: 2.92-4.86, P < 0.001). CONCLUSIONS We identified an association between cognitive decline/dementia and the risk of developing delirium. Cognitive decline/dementia may be a promising predictor for delirium in post-stroke patients.
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Affiliation(s)
- Guanfu Ding
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shunde Hua
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Jinming Chen
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shaochun Yang
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Ruilu Xie
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
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Marquetand J, Bode L, Fuchs S, Ernst J, von Känel R, Boettger S. Predisposing and Precipitating Factors for Delirium in the Very Old (≥80 Years): A Prospective Cohort Study of 3,076 Patients. Gerontology 2021; 67:599-607. [PMID: 33789299 PMCID: PMC8619779 DOI: 10.1159/000514298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Predisposing and precipitating factors for delirium for the elderly, over the age of 65 years, are known, but not for the very old, over 80 years. As the society is getting older and evermore patients will reach >80 years, more evidence of the factors and their contribution to delirium is required in this patient group. METHODS In the course of 1 year, 3,076 patients above 80 years were screened prospectively for delirium based on a Delirium Observation Screening (DOS) scale, Intensive Care Delirium Screening Checklist (ICDSC), and a DSM (Diagnostic and Statistical Manual)-5 nursing instrument (ePA-AC) construct. Relevant predisposing and precipitating factors for delirium were assessed with a multiple regression analysis. RESULTS Of 3,076 patients above 80 years, 1,285 (41.8%) developed a delirium, which led to twice prolonged hospitalization (p < 0.001), requirement for subsequent assisted living (OR 2.2, CI: 1.73-2.8, p < 0.001), and increased mortality (OR 24.88, CI: 13.75-45.03, p < 0.001). Relevant predisposing factors were dementia (OR 15.6, CI: 10.17-23.91, p < 0.001), pressure sores (OR 4.61, CI: 2.74-7.76, p < 0.001), and epilepsy (OR 3.65, CI: 2.12-6.28, p < 0.0001). Relevant precipitating factors were acute renal failure (4.96, CI: 2.38-10.3, p < 0.001), intracranial hemorrhage (OR 8.7, CI: 4.27-17.7, p < 0.001), and pleural effusions (OR 3.25, CI: 1.77-17.8, p < 0.001). CONCLUSION Compared to the general delirium rate of approximately 20%, the prevalence of delirium doubled above the age of 80 years (41.8%) due to predisposing factors uncommon in younger patients.
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Affiliation(s)
- Justus Marquetand
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zurich, Switzerland.,Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Leonie Bode
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Jutta Ernst
- Institute of Nursing Science, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Sönke Boettger
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zurich, Switzerland
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Delirium in trauma patients: a 1-year prospective cohort study of 2026 patients. Eur J Trauma Emerg Surg 2021; 48:1017-1024. [PMID: 33538844 PMCID: PMC9001539 DOI: 10.1007/s00068-021-01603-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/02/2021] [Indexed: 12/11/2022]
Abstract
Background Delirium in trauma surgery is common, especially post-operatively, but medical characteristics, risk factors and residence post-discharge have not comprehensively been investigated in all trauma patients. Methods Over 1 year, 2026 trauma patients were prospectively screened for delirium with the following tools: Delirium Observation screening scale (DOS), Intensive Care Delirium Screening Checklist (ICDSC) and a DSM (Diagnostic and Statistical Manual)-5, nursing tool (ePA-AC) construct. Risk factors—predisposing und precipitating—for delirium were assessed via multiple regression analysis. Results Of 2026 trauma patients, 440 (21.7%) developed delirium, which was associated with an increased risk of assisted living (OR 6.42, CI 3.92–10.49), transfer to nursing home (OR 4.66, CI 3.29–6.6), rehabilitation (OR 3.96, CI 3.1–5.1), or death (OR 70.72, CI 22–227.64). Intensive care management (OR 18.62, CI 14.04–24.68), requirement of ventilation (OR 32.21, CI 21.27–48.78), or its duration (OR 67.22, CI 33.8–133.71) all increased the risk for developing delirium. Relevant predisposing risk factors were dementia (OR 50.92, CI 15.12–171.45), cardiac insufficiency (OR 11.76, CI 3.6–38.36), and polypharmacy (OR 5.9, CI 4.01–8.68).Relevant precipitating risk factors were brain edema (OR 40.53, CI 4.81–341.31), pneumonia (OR 39.66, CI 8.89–176.93) and cerebral inflammation (OR 21.74, CI 2.34–202.07). Conclusion Delirium in trauma patients is associated with poor outcome as well as with intensive care management and various predisposing and/or precipitating factors. Three quarters of patients who had undergone delirium were not able to live independently at home any more. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01603-5.
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Marquetand J, Bode L, Fuchs S, Hildenbrand F, Ernst J, von Kaenel R, Boettger S. Risk Factors for Delirium Are Different in the Very Old: A Comparative One-Year Prospective Cohort Study of 5,831 Patients. Front Psychiatry 2021; 12:655087. [PMID: 34045981 PMCID: PMC8144286 DOI: 10.3389/fpsyt.2021.655087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background: In an ever-aging society, health care systems will be confronted with an increasing number of patients over 80 years ("the very old"). Currently, knowledge about and recommendations for delirium management are often based on studies in patients aged 60 to 65 years. It is not clear whether these findings apply to patients ≥80 years. Aim: Comparison of younger and older patients with delirium, especially regarding risk factors. Methods: In this prospective cohort study, within 1-year, 5,831 patients (18-80 years: n = 4,730; ≥80: n = 1,101) with delirium were enrolled. The diagnosis of delirium was based on the Delirium Observation screening scale (DOS), Intensive Care Delirium Screening Checklist (ICDSC) and a DSM (Diagnostic and Statistical Manual)-5 construct of nursing instrument. Sociodemographic trajectories, as well as the relevant predisposing and precipitating factors for delirium, were assessed via a multiple regression analysis. Results: The very old were more commonly admitted as emergencies (OR 1.42), had a greater mortality risk (OR 1.56) and displayed fewer precipitating risk factors for the development of a delirium, although the number of diagnoses were not different (p = 0.325). Predisposing factors were sufficient almost alone for the development of delirium in patients ≥ 80 years of age; in 18-80 years of age, additional precipitating factors had to occur to make a delirium possible. Conclusion: When relevant predisposing factors for delirium are apparent, patients over 80 years of age require comparatively few or no precipitating factors to develop delirium. This finding should be taken into account at hospitalization and may allow better treatment of delirium in the future.
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Affiliation(s)
- Justus Marquetand
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zurich, Zurich, Switzerland.,Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tubingen, Tubingen, Germany
| | - Leonie Bode
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Florian Hildenbrand
- Department of Gastroenterology University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Institute of Nursing Science, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roland von Kaenel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Soenke Boettger
- University Hospital Zurich, University Zurich, Zurich, Switzerland
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Cursano S, Battaglia CR, Urrutia-Ruiz C, Grabrucker S, Schön M, Bockmann J, Braumüller S, Radermacher P, Roselli F, Huber-Lang M, Boeckers TM. A CRHR1 antagonist prevents synaptic loss and memory deficits in a trauma-induced delirium-like syndrome. Mol Psychiatry 2021; 26:3778-3794. [PMID: 32051550 PMCID: PMC8550963 DOI: 10.1038/s41380-020-0659-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 12/15/2022]
Abstract
Older patients with severe physical trauma are at high risk of developing neuropsychiatric syndromes with global impairment of cognition, attention, and consciousness. We employed a thoracic trauma (TxT) mouse model and thoroughly analyzed age-dependent spatial and temporal posttraumatic alterations in the central nervous system. Up to 5 days after trauma, we observed a transient 50% decrease in the number of excitatory synapses specifically in hippocampal pyramidal neurons accompanied by alterations in attention and motor activity and disruption of contextual memory consolidation. In parallel, hippocampal corticotropin-releasing hormone (CRH) expression was highly upregulated, and brain-derived neurotrophic factor (BDNF) levels were significantly reduced. In vitro experiments revealed that CRH application induced neuronal autophagy with rapid lysosomal degradation of BDNF via the NF-κB pathway. The subsequent synaptic loss was rescued by BDNF as well as by specific NF-κB and CRH receptor 1 (CRHR1) antagonists. In vivo, the chronic application of a CRHR1 antagonist after TxT resulted in reversal of the observed histological, molecular, and behavioral alterations. The data suggest that neuropsychiatric syndromes (i.e., delirium) after peripheral trauma might be at least in part due to the activation of the hippocampal CRH/NF-κB/BDNF pathway, which results in a dramatic loss of synaptic contacts. The successful rescue by stress hormone receptor antagonists should encourage clinical trials focusing on trauma-induced delirium and/or other posttraumatic syndromes.
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Affiliation(s)
- Silvia Cursano
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany ,International Graduate School in Molecular Medicine, IGradU, 89081 Ulm, Germany
| | - Chiara R. Battaglia
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany ,International Graduate School in Molecular Medicine, IGradU, 89081 Ulm, Germany
| | - Carolina Urrutia-Ruiz
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Stefanie Grabrucker
- grid.10049.3c0000 0004 1936 9692Department of Biological Sciences, University of Limerick, Limerick, V94 PH61 Ireland
| | - Michael Schön
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Jürgen Bockmann
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Sonja Braumüller
- grid.6582.90000 0004 1936 9748Institute for Anesthesiological Pathophysiology, Ulm University, Helmholtzstr. 8/1, 89081 Ulm, Germany
| | - Peter Radermacher
- grid.6582.90000 0004 1936 9748Institute for Anesthesiological Pathophysiology, Ulm University, Helmholtzstr. 8/1, 89081 Ulm, Germany
| | - Francesco Roselli
- grid.6582.90000 0004 1936 9748Clinic for Neurology, Ulm University, 89081 Ulm, Germany
| | - Markus Huber-Lang
- grid.6582.90000 0004 1936 9748Institute of Clinical and Experimental Trauma-Immunology, Ulm University, 89081 Ulm, Germany
| | - Tobias M. Boeckers
- grid.6582.90000 0004 1936 9748Institute for Anatomy and Cell Biology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
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Mansutti I, Saiani L, Morandini M, Palese A. Post-stroke delirium risk factors, signs and symptoms of onset and outcomes as perceived by expert nurses: A focus group study. J Stroke Cerebrovasc Dis 2020; 29:105013. [PMID: 32807428 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/19/2020] [Accepted: 05/30/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Higher rates of delirium have been reported among patients with acute stroke. However, poorly modifiable risk factors have been documented to date while sign and symptoms capable of early detecting its onset and outcomes in this specific population have been largely neglected. The aim of this study was to emerge nurses' clinical knowledge and experiences regarding post-stroke delirium (a) risk factors, (b) signs and symptoms of delirium onset, and (c) outcomes. METHOD A qualitative study based upon focus groups have been performed on 2019 and here reported according to the COnsolidated criteria for REporting Qualitative research. A purposeful sample of 28 nurses was invited to participate in focus groups at two Italian hospitals, and 20 participated. A semi-structured question guide was developed; all focus groups were audio recorded and then transcribed verbatim. Two researchers independently analysed, coded and categorised the findings according to the main research question. A member checking with ten nurses was also performed to ensure rigour. RESULTS Four risk factors emerged (a) at the individual level; (b) associated with previous (e.g., dementia) and the current clinical condition (stroke), (c) associated with the nursing care delivered, and (d) associated with the hospital environment. In their daily practice, nurses suspect the onset of delirium when some motor, verbal or multidimensional signs and symptoms occur. The delirium episodes affect outcomes at the individual, family, and at the system levels. CONCLUSIONS In a field of research in need of study, we have involved expert nurses who shared their tacit knowledge to gain insights regarding risk factors, early signs and symptoms of delirium and its outcomes to address future directions of this research field.
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Affiliation(s)
- Irene Mansutti
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Luisa Saiani
- Department of Diagnostics and Public Health, University of Verona, Italy.
| | - Marzia Morandini
- Department of Medical Science, University of Udine, Viale Ungheria 20, 33100 Udine, Italy.
| | - Alvisa Palese
- Department of Medical Science, University of Udine, Viale Ungheria 20, 33100 Udine, Italy.
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Episodes of psychomotor agitation among medical patients: findings from a longitudinal multicentre study. Aging Clin Exp Res 2020; 32:1101-1110. [PMID: 31378845 DOI: 10.1007/s40520-019-01293-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The management of delirium among older in-hospital patients is a challenge, leading to worse outcomes, including death. Specifically, psychomotor agitation, one of the main characteristics of hyperactive delirium, requires a significant amount of medical and nursing surveillance. However, despite its relevance, to date incidence and/or prevalence of psychomotor agitation, its predictors and outcomes have not been studied among Italian older patients admitted in medical units. AIMS To describe the incidence and the prevalence of psychomotor agitation among patients aged > 65 years admitted to medical units and identify predictors at the individual, nursing care and hospital levels. METHODS A longitudinal multicentre study was conducted involving 12 medical units in 12 northern Italian hospitals. Descriptive, bivariate and multivariate logistic regression analyses were performed. RESULTS Among the 1464 patients included in the study, two hundred (13.6%) have manifested episode(s), with an average of 3.46/patient (95% confidence of interval [CI] 2.73-4.18). In 108 (54.0%) patients, episode(s) were present also in the week prior to hospitalisation: therefore, in-hospital-acquired psychomotor agitation was reported in 92 patients (46%). The multivariate logistic regression analysis explained the 25.4% of the variance and identified the following variables as psychomotor agitation predictors: the risk of falls (relative risk [RR] 1.314, 95% CI 1.218-1.417), the amount of missed nursing care (RR 1.078, 95% CI 1.037-1.12) and the patient's age (RR 1.018, 95% CI 1.002-1.034). Factors preventing the occurrence of episode(s) were: the amount of care received from graduated nurses (RR 0.978; 95% CI 0.965-0.992) and the lower functional dependence at admission (RR 0.987, 95% CI 0.977-0.997). CONCLUSIONS A considerable number of elderly patients admitted in medical units develop psychomotor agitation; its predictors need to be identified early to inform decisions regarding the personal care needed to prevent its occurrence, especially by acting on modifiable factors, such as the risk of falls, missed nursing care and functional dependence.
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Kijima E, Kayama T, Saito M, Kurosaka D, Ikeda R, Hayashi H, Kubota D, Hyakutake T, Marumo K. Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty. BMC Musculoskelet Disord 2020; 21:279. [PMID: 32359366 PMCID: PMC7196215 DOI: 10.1186/s12891-020-03206-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Delirium is a well-known complication following surgery, especially with the increasing age of patients undergoing surgery. The increasing demands resulting from a prolonged healthy life expectancy has resulted in more arthroplasties despite their age and existing comorbidities. The purpose of this study is to explore the various risk factors that may contribute to delirium in unilateral and bilateral total knee arthroplasties in the elderly population. METHODS 170 patients who underwent unilateral or bilateral total knee arthroplasties were analyzed retrospectively for delirium. Age, sex, comorbidities, use of sedative-hypnotics, peri-operative blood loss, pre- and post-operative laboratory blood test results were investigated and analyzed. RESULTS The incidence of post-operative delirium was 6.5% (11 out of 170 patients) with a mean age of 79.5 (± 6.9) years, compared to 73.0 (± 9.0) years in the non-delirium group. Higher age, use of sedative-hypnotics, low pre-operative Hb and Ht, low post-operative Hb, Ht and BUN were observed in the delirium group. Multivariate logistic regression analysis identified that the use of sedative-hypnotics and pre-operative Hb level were independent risk factors for post-operative delirium after TKA. The odds ratios for the use of sedative-hypnotics and pre-operative Hb level were 4.6 and 0.53, respectively. Receiver operating characteristic curve analysis showed that pre-operative Hb of less than 11.1 g/dL was a predictor for the development of delirium, with a sensitivity of 54.6% and a specificity of 91.6%. CONCLUSION Patients with a pre-operative Hb level of < 11.1 g/dL or those using sedative-hypnotics are associated with post-operative delirium. Peri-operative management and preventative measures are therefore needed to reduce the risks of post-operative delirium in such patients.
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Affiliation(s)
- Eiji Kijima
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomohiro Kayama
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daisaburo Kurosaka
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryo Ikeda
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroteru Hayashi
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daisuke Kubota
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takashi Hyakutake
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keishi Marumo
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Bowman K, Jones L, Masoli J, Mujica-Mota R, Strain D, Butchart J, Valderas JM, Fortinsky RH, Melzer D, Delgado J. Predicting incident delirium diagnoses using data from primary-care electronic health records. Age Ageing 2020; 49:374-381. [PMID: 32239180 PMCID: PMC7297278 DOI: 10.1093/ageing/afaa006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE risk factors for delirium in hospital inpatients are well established, but less is known about whether delirium occurring in the community or during an emergency admission to hospital care might be predicted from routine primary-care records. OBJECTIVES identify risk factors in primary-care electronic health records (PC-EHR) predictive of delirium occurring in the community or recorded in the initial episode in emergency hospitalisation. Test predictive performance against the cumulative frailty index. DESIGN Stage 1: case-control; Stages 2 and 3: retrospective cohort. SETTING clinical practice research datalink: PC-EHR linked to hospital discharge data from England. SUBJECTS Stage 1: 17,286 patients with delirium aged ≥60 years plus 85,607 controls. Stages 2 and 3: patients ≥ 60 years (n = 429,548 in 2015), split into calibration and validation groups. METHODS Stage 1: logistic regression to identify associations of 110 candidate risk measures with delirium. Stage 2: calibrating risk factor weights. Stage 3: validation in independent sample using area under the curve (AUC) receiver operating characteristic. RESULTS fifty-five risk factors were predictive, in domains including: cognitive impairment or mental illness, psychoactive drugs, frailty, infection, hyponatraemia and anticholinergic drugs. The derived model predicted 1-year incident delirium (AUC = 0.867, 0.852:0.881) and mortality (AUC = 0.846, 0.842:0.853), outperforming the frailty index (AUC = 0.761, 0.740:0.782). Individuals with the highest 10% of predicted delirium risk accounted for 55% of incident delirium over 1 year. CONCLUSIONS a risk factor model for delirium using data in PC-EHR performed well, identifying individuals at risk of new onsets of delirium. This model has potential for supporting preventive interventions.
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Affiliation(s)
- Kirsty Bowman
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Lindsay Jones
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Jane Masoli
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Ruben Mujica-Mota
- The Health Economics Group, Institute of Health Research, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - David Strain
- Diabetes, Cardiovascular Risk and Ageing, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Joe Butchart
- Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, RD&E, Exeter EX2 5DW, UK
| | - José M Valderas
- The Health Services and Policy Research Group, Institute of Health Research, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - Richard H Fortinsky
- University of Connecticut, School of Medicine, Center on Aging, Mansfield, CT 06030-5215, USA
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - João Delgado
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
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Hercus C, Hudaib AR. Delirium misdiagnosis risk in psychiatry: a machine learning-logistic regression predictive algorithm. BMC Health Serv Res 2020; 20:151. [PMID: 32106845 PMCID: PMC7045404 DOI: 10.1186/s12913-020-5005-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/17/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Delirium is a frequent diagnosis made by Consultation-Liaison Psychiatry (CLP). Numerous studies have demonstrated misdiagnosis prior to referral to CLP. Few studies have considered the factors underlying misdiagnosis using multivariate approaches. OBJECTIVES To determine the number of cases referred to CLP, which are misdiagnosed at time of referral, to build an accurate predictive classifier algorithm, using input variables related to delirium misdiagnosis. METHOD A retrospective observational study was conducted at Alfred Hospital in Melbourne, collecting data from a record of all patients seen by CLP for a period of 5 months. Data was collected pertaining to putative factors underlying misdiagnosis. A Machine Learning-Logistic Regression classifier model was built, to classify cases of accurate delirium diagnosis vs. misdiagnosis. RESULTS Thirty five of 74 new cases referred were misdiagnosed. The proposed predictive algorithm achieved a mean Receiver Operating Characteristic (ROC) Area under the curve (AUC) of 79%, an average 72% classification accuracy, 77% sensitivity and 67% specificity. CONCLUSIONS Delirium is commonly misdiagnosed in hospital settings. Our findings support the potential application of Machine Leaning-logistic predictive classifier in health care settings.
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The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome. Geriatrics (Basel) 2019; 4:geriatrics4040057. [PMID: 31623269 PMCID: PMC6960557 DOI: 10.3390/geriatrics4040057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/04/2019] [Accepted: 10/05/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment). OBJECTIVES To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay. METHOD This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models. RESULTS The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67; OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009). CONCLUSION Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.
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Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia. Geriatrics (Basel) 2019; 4:geriatrics4030052. [PMID: 31514465 PMCID: PMC6787739 DOI: 10.3390/geriatrics4030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022] Open
Abstract
The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.
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Roijers JP, Hopmans CJ, Janssen TL, Mulder PGH, Buimer MG, Ho GH, de Groot HGW, Veen EJ, van der Laan L. The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation. Ann Vasc Surg 2019; 60:270-278.e2. [PMID: 31077770 DOI: 10.1016/j.avsg.2019.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed. METHODS An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model. RESULTS In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4). CONCLUSION Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.
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Affiliation(s)
- J P Roijers
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands.
| | - C J Hopmans
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - T L Janssen
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - P G H Mulder
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - M G Buimer
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - G H Ho
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - H G W de Groot
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - E J Veen
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - L van der Laan
- Department of Surgery, Amphia Hospital Breda, Breda, The Netherlands
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Dikken J, Bakker A, Hoogerduijn JG, Schuurmans MJ. Comparisons of Knowledge of Dutch Nursing Students and Hospital Nurses on Aging. J Contin Educ Nurs 2018; 49:84-90. [PMID: 29381172 DOI: 10.3928/00220124-20180116-08] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 11/13/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although there is a growing population of older adults admitted to hospitals, the literature demonstrates knowledge deficits of nurses regarding older patients. This study investigated knowledge levels of both nursing students and RNs about older hospitalized patients in relation to their educational level and work experience. METHOD First- and final-year vocational and bachelor nursing students, and associate degree and bachelor degree nurses working in the hospital setting with 0 to 5 years, 6 to 15 years, and more than 15 years of experience, have completed the Knowledge about Older Patients-Quiz (KOP-Q). The KOP-Q has a clearly described theoretical base finding its origin in knowledge regarding nursing care for older patients and shows good content and construct validity. RESULTS A substantial proportion of participants in all groups demonstrated insufficient knowledge about older patients. A difference in knowledge exists among nurses with different educational qualifications, and a link between years of experience and higher knowledge levels of nurses is found. CONCLUSION Throughout the nursing career, basic care topics in relation to care for older patients should play a key role in basic nursing education programs, as well as for continuing education programs provided in hospitals for nurses. J Contin Educ Nurs. 2018;49(2):84-90.
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Dixon M. Assessment and management of older patients with delirium in acute settings. Nurs Older People 2018; 30:35-42. [PMID: 29717845 DOI: 10.7748/nop.2018.e969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/09/2022]
Abstract
This article aims to assist nurses and nursing students to consider the presentation of delirium in older patients and the resulting assessment and nursing interventions required. It considers the three types of delirium: hyperactive, hypoactive and mixed. It also discusses potential causes of delirium. Older patients are at increased risk of delirium due to factors such as cognitive impairment, co-morbidities and acute illness. Nurses should be confident in the use of the 4AT score to assess patients with delirium. Use of the mnemonic PINCH ME is suggested to guide management of delirious patients in acute settings. Families of patients with delirium have emotional and other care needs and there are several ways in which nurses can meet them.
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Affiliation(s)
- Martha Dixon
- Orthogeriatric care, Homerton University Hospital NHS Foundation Trust, London, England
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Noh G, Kwon I, Lee M, Ahn SH, Kim JL. Factor Analysis of Delirium in Elderly, Using the Korean Version of Delirium Rating Scale-Revised-98. Psychiatry Investig 2018; 15:484-489. [PMID: 29614850 PMCID: PMC5975997 DOI: 10.30773/pi.2017.10.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/06/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to identify the core symptoms of delirium, particularly in elderly people associated with major risk factors, using the Korean version of the Delirium Rating Scale-Revised-98. METHODS The study sample consisted of 200 patients (mean age: 72.7±3.9 years, male: 68.5%) who had been diagnosed with delirium. Exploratory factor analysis was used to investigate the factor structure, and confirmatory factor analysis was used to evaluate the goodness of fit of the results. RESULTS The results demonstrated three core domains of delirium in the elderly patients: 1) the cognitive domain (e.g., language, thought process, orientation, attention, long-term memory, and visuospatial ability); 2) the circadian domain (e.g., sleep-wake cycle and motor behavior); and 3) the short-term memory domain (short-term memory). These results were confirmed by confirmatory factor analysis. CONCLUSION The findings of this study suggest a theoretical domain structure for delirium in elderly patients.
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Affiliation(s)
- Gahye Noh
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Insun Kwon
- Department of Statistics, Chungnam National University Hospital, Clinical Trials Center, Daejeon, Republic of Korea
| | - Miji Lee
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - So Hyun Ahn
- 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.,Department of Psychiatry, School of Medicine, Chungnam National University, Daejeon, Republic of Korea
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Gutiérrez-Valencia M, Martínez-Velilla N. [Pharmacological prevention of delirium: A long way to go]. Rev Esp Geriatr Gerontol 2018; 53:185-187. [PMID: 29598970 DOI: 10.1016/j.regg.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022]
Affiliation(s)
| | - Nicolás Martínez-Velilla
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Navarra, España; IdiSNa, Instituto de Investigación Sanitaria de Navarra, Pamplona, Navarra, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, España
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Myint PK, Owen S, McCarthy K, Pearce L, Moug SJ, Stechman MJ, Hewitt J, Carter B. Is anemia associated with cognitive impairment and delirium among older acute surgical patients? Geriatr Gerontol Int 2018; 18:1025-1030. [PMID: 29498179 PMCID: PMC6099313 DOI: 10.1111/ggi.13293] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/12/2017] [Accepted: 01/24/2018] [Indexed: 12/31/2022]
Abstract
AIM The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients. METHODS Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only. RESULTS A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group. CONCLUSIONS There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.
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Affiliation(s)
- Phyo Kyaw Myint
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Department of Medicine for the Elderly, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Stephanie Owen
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Kathryn McCarthy
- Department of General Surgery, North Bristol NHS Trust, Bristol, UK
| | - Lyndsay Pearce
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Susan J Moug
- Department of General Surgery, Royal Alexandra Hospital, Paisley, Greater Glasgow, UK
| | - Michael J Stechman
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Johansson YA, Bergh I, Ericsson I, Sarenmalm EK. Delirium in older hospitalized patients-signs and actions: a retrospective patient record review. BMC Geriatr 2018; 18:43. [PMID: 29409468 PMCID: PMC5801894 DOI: 10.1186/s12877-018-0731-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/24/2018] [Indexed: 12/23/2022] Open
Abstract
Background Delirium is common in older hospitalized patients, and is associated with negative consequences for the patients, next of kin, healthcare professionals and healthcare costs. It is important to understand its clinical features, as almost 40% of all cases in hospitals may be preventable. Yet, delirium in hospitalized patients is often unrecognized and untreated. Few studies describe thoroughly how delirium manifests itself in older hospitalized patients and what actions healthcare professionals take in relation to these signs. Therefore, the aim of this study was to describe signs of delirium in older hospitalized patients and action taken by healthcare professionals, as reported in patient records. Methods Patient records from patients aged ≥65 (n = 286) were retrospectively reviewed for signs of delirium, which was found in 78 patient records (27%). Additionally, these records were reviewed for action taken by healthcare professionals in relation to the patients’ signs of delirium. The identified text was analyzed with qualitative content analysis in two steps. Results Healthcare professionals responded only in part to older hospitalized patients’ needs of care in relation to their signs of delirium. The patients displayed various signs of delirium that led to a reduced ability to participate in their own care and to keep themselves free from harm. Healthcare professionals met these signs with a variation of actions and the care was adapted, deficient and beyond the usual care. A systematic and holistic perspective in the care of older hospitalized patients with signs of delirium was missing. Conclusion Improved knowledge about delirium in hospitals is needed in order to reduce human suffering, healthcare utilization and costs. It is important to enable older hospitalized patients with signs of delirium to participate in their own care and to protect them from harm. Delirium has to be seen as a preventable adverse event in all hospitals units. To improve the prevention and management of older hospitalized patients with signs of delirium, person-centered care and patient safety may be important issues.
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Affiliation(s)
- Yvonne A Johansson
- Skaraborg Hospital, Skövde, Sweden. .,Jönköping University, Jönköping, Sweden.
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Constaín GA, Ocampo Saldarriaga MV, Velásquez Tirado JD, Rodríguez-Gázquez MDLÁ, Betancur Morales LM, Rico Escobar JJ, Castilla Agudelo GA, Maya Osorno AF. Persistent Delirium in Elderly patients Three Months After Hospital Discharge from a University Clinic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2018; 47:37-45. [PMID: 29428120 DOI: 10.1016/j.rcp.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/29/2016] [Accepted: 10/31/2016] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of the study was to determine the prevalence and characteristics of patients with persistent delirium (PD) at three months after hospital discharge. METHODOLOGY Longitudinal descriptive study to assess the prevalence and characteristics of in-patients aged 65 years and older in the Clinica Universitaria Bolivariana who met DSM-5 criteria for delirium at admission, at discharge, and at a 3-month follow up assessment. Socio-demographic features were determined, and CGI-S and DRS-R98 scales used. RESULTS A total of 30 patients were evaluated between April and October 2013, but 6 did not fulfil the inclusion criteria. The study included 24 patients, with 9 (37.5%) dying during hospitalisation. Of the 15 surviving patients, five (20.8% of the total sample) had their delirium resolved at discharge, and ten (41.6% of the sample) continued with symptoms. These established the PD group, of whom five of them (20.8%) had full PD, and the other five (20.8%) sub-syndromal PD (SSPD). At the final assessment, only two patients (8.3%) continued with full PD, and another two (8.3%) with SSPD. Among the PD group, 30% had a full delirium at admission (prevalence), and 70% developed full delirium during hospitalization (incidence). CONCLUSIONS A significant number of patients did not recover from delirium at leaving hospital, and remained symptomatic three months after discharge. The study findings suggest a course of gradual improvement of delirium, with a persistence of symptoms over time in 40% of the patients, which would have implications for the clinical practice.
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Affiliation(s)
- Gustavo A Constaín
- Grupo de Investigación de Psiquiatría de Enlace, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
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Youn YC, Shin HW, Choi BS, Kim S, Lee JY, Ha YC. Rivastigmine patch reduces the incidence of postoperative delirium in older patients with cognitive impairment. Int J Geriatr Psychiatry 2017; 32:1079-1084. [PMID: 27561376 DOI: 10.1002/gps.4569] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To date, data regarding the efficacy of acetylcholinesterase inhibitors in preventing postoperative delirium (POD) are inconsistent and conflicting. Older individuals with cognitive dysfunction are thought to show POD more frequently. Our aim was to study the effectiveness of rivastigmine prophylaxis on the incidence, severity, and risk factors for POD in older patients with cognitive impairment undergoing hip fracture surgery. METHODS Of 62 older patients with cognitive impairment about to undergo surgery after a hip fracture, 31 were randomly assigned to receive a rivastigmine patch from 3 days before to 7 days after the operation (Group I), and the other 31 did not receive a rivastigmine patch (Group II). The two groups were compared with regard to incidence and severity of delirium on postoperative days 2 or 3 and 7. Multivariate logistic regression analysis was performed to assess factors associated with POD. RESULTS Postoperative delirium occurred in five Group I patients and 14 Group II patients (p = 0.013). The mean severity of delirium in the two groups as determined by the Delirium Rating Scale was 2.2 and 6.2 respectively (p = 0.033). The odds ratio for POD was 0.259 (95% CI: 0.074-0.905, p = 0.034) after adjusting for American Society of Anesthesiologists score (p = 0.058), age (p = 0.203), and gender (p = 0.560). There were no rivastigmine-related perioperative complications. CONCLUSION Perioperative rivastigmine patch application could reduce the occurrence of POD in older patients with low cognitive status. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Young Chul Youn
- Department of Neurology, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Hae-Won Shin
- Department of Neurology, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Byung-Sun Choi
- Department of Preventive Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - SangYun Kim
- Department of Neurology, Seoul National University College of Medicine & Seoul National University Bundang Hospital, Seoul, South Korea
| | - Jung-Yeop Lee
- Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
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Abstract
OBJECTIVE Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium. METHODS The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment. RESULTS The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12-0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62-0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20-9.33; p=0.020), after controlling for age and medication. CONCLUSION Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.
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Grandahl MG, Nielsen SE, Koerner EA, Schultz HH, Arnfred SM. Prevalence of delirium among patients at a cancer ward: Clinical risk factors and prediction by bedside cognitive tests. Nord J Psychiatry 2016; 70:413-7. [PMID: 26882016 DOI: 10.3109/08039488.2016.1141982] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Delirium is a frequent psychiatric complication to cancer, but rarely recognized by oncologists. Aims 1. To estimate the prevalence of delirium among inpatients admitted at an oncological cancer ward 2. To investigate whether simple clinical factors predict delirium 3. To examine the value of cognitive testing in the assessment of delirium. Methods On five different days, we interviewed and assessed patients admitted to a Danish cancer ward. The World Health Organization International Classification of Diseases Version 10, WHO ICD-10 Diagnostic System and the Confusion Assessment Method (CAM) were used for diagnostic categorization. Clinical information was gathered from medical records and all patients were tested with Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test. Results 81 cancer patients were assessed and 33% were diagnosed with delirium. All delirious participants were CAM positive. Poor performance on the cognitive tests was associated with delirium. Medical records describing CNS metastases, benzodiazepine or morphine treatment were associated with delirium. Conclusions Delirium is prevalent among cancer inpatients. The Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test can be used as screening tools for delirium among inpatients with cancer, but even in synergy, they lack specificity. Combining cognitive testing and attention to nurses' records might improve detection, yet further studies are needed to create a more detailed patient profile for the detection of delirium.
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Affiliation(s)
| | - Svend Erik Nielsen
- b Department of Oncology and Palliation, North Zealand Hospital , Hilleroed, Denmar
| | | | - Helga Holm Schultz
- d Department of Cardiology, Nephrology and Endocrinology, North Zealand Hospital , Hilleroed, Denmark
| | - Sidse Marie Arnfred
- e Psychiatric Hospital Slagelse, Region Zealand, University of Copenhagen , Denmark
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Prinka, Sharma A. Comparative Study of Delirium in Emergency and Consultation Liaison- A Tertiary Care Hospital Based Study in Northern India. J Clin Diagn Res 2016; 10:VC01-VC05. [PMID: 27656535 DOI: 10.7860/jcdr/2016/20267.8260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/10/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Delirium is an acute and often fluctuating disturbance in level of consciousness and thought process (cognition) that develops over a short period of time and is a significant change from previous level of functioning. Its prevalence increases with age, complexity of medical co- morbidities and number of medications prescribed. AIM To compare the cause and severity of delirium in patients in emergency and consultation liaison psychiatry group. MATERIALS AND METHODS A cross-sectional, tertiary care hospital based study was conducted on the patients who presented with delirium from emergency department (50) and consultation-liaison psychiatry groups (50), over a period of one year. The diagnosis was made on the basis of DSM- 5 criteria. The Delirium Rating Scale (DRS-R-98) was applied to know the severity of delirium, cognitive and non-cognitive symptoms of delirium in patients. The results were subjected to appropriate statistical analysis. RESULTS In emergency group, 42% patients had metabolic abnormalities, while in consultation-liaison, 38% patients had hyponatremia and hypokalemia and the difference was found to be statistically non-significant (p>0.05). In emergency group, 21(42%) patients were diagnosed as delirium due to other medical condition, followed by 13 (26%) and 8(16%) patients, who were diagnosed as delirium due to multiple aetiologies and substance intoxication each respectively. In only 33(66%) cases in consultation liaison group patients had delirium secondary to other medical conditions. As per DRS-R98 Scale, mean severity score was found to be statistically significant (p<0.05) in consultation liaison group as compared to emergency department group (p> 0.05). CONCLUSION Delirium is multifactorial aetiological disease, with variable but preventable outcome. Approach should be aimed at finding the treatable causes to reduce morbidity and mortality.
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Affiliation(s)
- Prinka
- Student, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital , Faridkot, Punjab, India
| | - Arvind Sharma
- Professor and Head, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital , Faridkot, Punjab, India
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Abstract
Delirium is a common, disabling medical condition that is associated with numerous adverse outcomes. A number of inter-related factors, including pre-existing cognitive impairment, usually contribute to the development of delirium in a particular susceptible individual. Non-pharmacological approaches to prevention typically target multiple risk factors in a systematic manner (multicomponent interventions). There is generally good evidence that multicomponent interventions reduce the incidence of delirium in hospital populations but there are limited data in people with dementia and those living in the community. It is likely that there is a differential effect of specific interventions in those with cognitive impairment (e.g. people with dementia may respond better to simpler, more pragmatic interventions rather than complex procedures) but this cannot be determined from the existing data. Targeted interventions focussed on hydration, medication rationalization and sleep promotion may also be effective in reducing the incidence of delirium, as well as the active involvement of family members in the care of the elderly hospitalized patient. Hospitalization itself is a potential risk factor for delirium and promising data are emerging of the benefits of home-based care as an alternative to hospitalization but this is restricted to specific sub-populations of patients and is reliant on these services being available.
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Affiliation(s)
- Andrew H Ford
- Western Australian Centre for Health & Ageing (M573), Harry Perkins Institute of Medical Research, University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
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Corradi JP, Chhabra J, Mather JF, Waszynski CM, Dicks RS. Analysis of multi-dimensional contemporaneous EHR data to refine delirium assessments. Comput Biol Med 2016; 75:267-74. [PMID: 27340924 DOI: 10.1016/j.compbiomed.2016.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 12/16/2022]
Abstract
Delirium is a potentially lethal condition of altered mental status, attention, and level of consciousness with an acute onset and fluctuating course. Its causes are multi-factorial, and its pathophysiology is not well understood; therefore clinical focus has been on prevention strategies and early detection. One patient evaluation technique in routine use is the Confusion Assessment Method (CAM): a relatively simple test resulting in 'positive', 'negative' or 'unable-to-assess' (UTA) ratings. Hartford Hospital nursing staff use the CAM regularly on all non-critical care units, and a high frequency of UTA was observed after reviewing several years of records. In addition, patients with UTA ratings displayed poor outcomes such as in-hospital mortality, longer lengths of stay, and discharge to acute and long term care facilities. We sought to better understand the use of UTA, especially outside of critical care environments, in order to improve delirium detection throughout the hospital. An unsupervised clustering approach was used with additional, concurrent assessment data available in the EHR to categorize patient visits with UTA CAMs. The results yielded insights into the most common situations in which the UTA rating was used (e.g. impaired verbal communication, dementia), suggesting potentially inappropriate ratings that could be refined with further evaluation and remedied with updated clinical training. Analysis of the patient clusters also suggested that unrecognized delirium may contribute to the poor outcomes associated with the use of UTA. This method of using temporally related high dimensional EHR data to illuminate a dynamic medical condition could have wider applicability.
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Affiliation(s)
- John P Corradi
- Research Department, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 USA.
| | - Jyoti Chhabra
- Research Department, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 USA
| | - Jeffrey F Mather
- Research Department, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 USA
| | - Christine M Waszynski
- Division of Geriatric Medicine, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 USA
| | - Robert S Dicks
- Division of Geriatric Medicine, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102 USA
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The Impact of Frailty on Mortality, Length of Stay and Re-hospitalisation in Older Patients with Atrial Fibrillation. Heart Lung Circ 2016; 25:551-7. [DOI: 10.1016/j.hlc.2015.12.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/09/2015] [Accepted: 12/06/2015] [Indexed: 01/08/2023]
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Tampi RR, Tampi DJ, Ghori AK. Acetylcholinesterase Inhibitors for Delirium in Older Adults. Am J Alzheimers Dis Other Demen 2016; 31:305-10. [PMID: 26646113 PMCID: PMC10852606 DOI: 10.1177/1533317515619034] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this systematic review is to identify published randomized controlled trials (RCTs) that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). METHODS A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO, and Cochrane collaboration databases for RCTs in any language that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). Also, bibliographic databases of the published articles were searched for additional studies. RESULTS A total of 7 RCTs that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years) were identified. In 5 of the 7 studies, there was no benefit for the acetylcholinesterase inhibitor in either the prevention or the management of delirium. In one study, there was a trend toward benefit for the active drug group on the incidence of delirium and the length of hospital stay, but both outcomes did not attain statistical significance. One study found a longer duration of delirium and a longer length of hospital stay in the active drug group when compared to the placebo group. The acetylcholinesterase inhibitors were well tolerated in 4 of the 7 studies. In 1 study, the mortality rate was found to be almost 3 times higher in the group receiving haloperidol and rivastigmine when compared to the group receiving haloperidol and placebo. CONCLUSION Current evidence does not suggest efficacy of acetylcholinesterase inhibitors for the prevention or management of delirium in older adults.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, MetroHealth, Cleveland, OH, USA
| | - Deena J Tampi
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
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Risk factors and clinical aspects of delirium in elderly hospitalized patients in Iran. Aging Clin Exp Res 2016; 28:313-9. [PMID: 26194422 DOI: 10.1007/s40520-015-0400-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/12/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recognition of the risk factors of delirium has been clearly advantageous in preventing and managing it as it occurs. AIMS The main aims of this study were to investigate the occurrence of delirium and identify the associated risk factors in a sample of hospitalized elderly in Southwestern Iran. METHODS A cross-sectional, hospital-based study was performed on a total of 200 elderly patients, admitted to a general hospital for various health reasons. Data were gathered over a 3-month period of time in 2010. Abbreviated Mental Test score (AMTs) used for delirium detection in post-admission days 1, 3, and 5, followed by clinical diagnostic confirmation according to the DSM-IV-TR criteria for delirium. Information regarding physical, cognitive, emotional, and functional states of the participants was collected, too. RESULTS Delirium developed in 22 % of the participants. The demographic characteristics of the patients with delirium indicated that they were typically single, older men who lived alone and had a lower level of education and poorer functional status. Among other variables, the following were significantly associated with delirium: hemoglobin ≤12 (P < 0.001); Blood urea nitrogen/creatinine ratio ≥1/20 (P < 0.005); and positive C-reactive protein (P = 0.022); depressive symptoms (P < 0.001), and previous cognitive decline (P < 0.001). Patients with more than six different categories of medications were at high risk for delirium as well. CONCLUSIONS Delirium is a serious and common problem in people over 60 years of age who are admitted to hospitals. Understanding risk factors and clinical aspects of delirium in elderly hospitalized patients will provide us with a better delirium management strategy.
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Moyo P, Huang TY, Simoni-Wastila L, Harrington D. Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents. J Appl Gerontol 2016; 37:228-255. [PMID: 27006431 DOI: 10.1177/0733464816633859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States. METHOD Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). RESULTS There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity. CONCLUSION This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.
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Shulman RW, Kalra S, Jiang JZ. Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses. BMC Geriatr 2016; 16:44. [PMID: 26879927 PMCID: PMC4754883 DOI: 10.1186/s12877-016-0217-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 02/03/2016] [Indexed: 12/21/2022] Open
Abstract
Background Delirium is a common condition in hospitalized seniors that nonetheless often goes undetected by nurses or is delayed in being detected which negatively impacts quality of care and outcomes. We sought to develop a new screening tool for delirium, The Sour Seven Questionnaire, a 7-item questionnaire suitable to be completed from informal or untrained caregiver observation. The study aimed to develop the scoring criteria for a positive delirium screen and assess concurrent validity of the questionnaire against a geriatric psychiatrist’s assessment. Methods A pilot study of 80 hospitalized seniors over age 65 recruited from three units (2 medical, 1 orthopedic). Participants were assessed using the Confusion Assessment Method (CAM) with a brief cognitive screen and the Sour Seven Questionnaire posed to the appointed informal caregiver (family member) or untrained nurse for up-to 7 days. Subjects testing positive on the CAM and a random sample of negatively CAM screened subjects were assessed by the geriatric psychiatrist. Results From 80 participants, 21 screened positive for delirium on the CAM. 18 of the 21 CAM positive screens were diagnosed to have delirium by the geriatric psychiatrist, and 17 of the 18 randomly assigned negative CAM screens were confirmed as not having delirium. From the questionnaires on these 39 participants, weighted scoring for each of the 7 questions of the Sour Seven Questionnaire was developed based on their relative risks for correctly predicting delirium when compared to the geriatric psychiatrist’s clinical assessment. Total scoring of the questionnaire resulted in the following positive predictive values for delirium: 89 % with a total score of 4 (sensitivity 89.5 %, specificity 90 %), and 100 % with a total score of 9 (sensitivity 63.2 %, specificity 100 %). Comparison between scoring on questionnaires posed to informal caregivers versus untrained nurses showed no differences. Conclusion A weighted score of 4 in the Sour Seven Questionnaire has concurrent validity as a screening tool for delirium and a score of 9 is diagnostic for delirium. The Sour Seven Questionnaire is the first screening tool for delirium shown to be suitable for use by informal caregivers and untrained nurses in hospitalized seniors. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0217-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard W Shulman
- Trillium Health Partners, Queensway Health Centre, 150 Sherway Drive, 4th floor, Toronto, ON, M9C 1A5, Canada. .,Faculty of Medicine, Department of Psychiatry, Division of Geriatric Psychiatry, University of Toronto, Toronto, Canada. .,Mississauga Academy of Medicine, University of Toronto, Mississauga, Canada.
| | - Saurabh Kalra
- Mississauga Academy of Medicine, University of Toronto, Mississauga, Canada.
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El Hussein M, Hirst S. Tracking the footsteps: a constructivist grounded theory of the clinical reasoning processes that registered nurses use to recognise delirium. J Clin Nurs 2016; 25:381-91. [PMID: 26818365 DOI: 10.1111/jocn.13058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To construct a grounded theory that explains the clinical reasoning processes that registered nurses use to recognise delirium while caring for older adults in acute care settings. BACKGROUND Delirium is often under-recognised in acute care settings; this may stem from underdeveloped clinical reasoning processes. Little is known about registered nurses' clinical reasoning processes in complex situations such as delirium recognition. DESIGN Seventeen registered nurses working in acute care settings were interviewed. Concurrent data collection and analysis, constant comparative analysis and theoretical sampling were conducted in 2013-2014. METHODS A grounded theory approach was used to analyse interview data about the clinical reasoning processes of registered nurse in acute hospital settings. RESULTS The core category that emerged from data was 'Tracking the footsteps'. This refers to the common clinical reasoning processes that registered nurses in this study used to recognise delirium in older adults in acute care settings. It depicted the process of continuously trying to catch the state of delirium in older adults. CONCLUSIONS Understanding the clinical reasoning processes that contribute to delirium under-recognition provides a strategy by which this problem can be brought to the forefront of awareness and intervention by registered nurses. RELEVANCE TO CLINICAL PRACTICE Registered nurses could draw from the various processes identified in this research to develop their clinical reasoning practice to enhance their effective assessment strategies. Delirium recognition by registered nurses will contribute to quality care to older adults.
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Affiliation(s)
- Mohamed El Hussein
- Faculty of Health & Community Studies, School of Nursing, Mount Royal University, Calgary, AB, Canada
| | - Sandra Hirst
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
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Ford AH, Flicker L, Passage J, Wibrow B, Anstey M, Edwards M, Almeida OP. The Healthy Heart-Mind trial: melatonin for prevention of delirium following cardiac surgery: study protocol for a randomized controlled trial. Trials 2016; 17:55. [PMID: 26822209 PMCID: PMC4730774 DOI: 10.1186/s13063-016-1163-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/07/2016] [Indexed: 12/16/2022] Open
Abstract
Background Delirium is a common occurrence in patients undergoing major cardiac surgery and is associated with a number of adverse consequences for the individual, their family and the health system. Current approaches to the prevention of delirium include identifying those at risk together with various non-pharmacological and pharmacological strategies, although the efficacy of these is often modest. Emerging evidence suggests that melatonin may be biologically implicated in the development of delirium and that melatonin supplementation may be beneficial in reducing the incidence of delirium in medical and surgical patients. We designed this trial to determine whether melatonin reduces the incidence of delirium following cardiac surgery compared with placebo. Methods/Design The Healthy Heart-Mind trial is a randomized, double-blind, placebo-controlled clinical trial of 3 mg melatonin or matching placebo administered on seven consecutive days for the prevention of delirium following cardiac surgery. We will recruit 210 adult participants, aged 50 and older, undergoing elective or semi-elective cardiac surgery with the primary outcome of interest for this study being the difference in the incidence of delirium between the groups within 7 days of surgery. Secondary outcomes of interest include the difference between groups in the severity and duration of delirious episodes, hospital length of stay and referrals to mental health services during admission. In addition, we will assess differences in depressive and anxiety symptoms, as well as cognitive performance, at discharge and 3 months after surgery. Discussion The results of this trial will clarify whether melatonin reduces the incidence of delirium following cardiac surgery. Trial registration The trial is registered with the Australian Clinical Trials Registry, trial number ACTRN12615000819527 (10 August 2015). Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1163-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew H Ford
- WA Centre for Health and Ageing, Centre for Medical Research, Harry Perkins Institute of Medical Research and School of Psychiatry and Clinical Neurosciences, University of Western Australia, Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.
| | - Leon Flicker
- WA Centre for Health and Ageing, Centre for Medical Research, Harry Perkins Institute of Medical Research and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
| | - Jurgen Passage
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Bradley Wibrow
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Matthew Anstey
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Mark Edwards
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia.
| | - Osvaldo P Almeida
- WA Centre for Health and Ageing, Centre for Medical Research, Harry Perkins Institute of Medical Research and School of Psychiatry and Clinical Neurosciences, University of Western Australia, Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.
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Odiari EA, Sekhon N, Han JY, David EH. Stabilizing and Managing Patients with Altered Mental Status and Delirium. Emerg Med Clin North Am 2015; 33:753-64. [DOI: 10.1016/j.emc.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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van Eijsden WA, Raats JW, Mulder PG, van der Laan L. New aspects of delirium in elderly patients with critical limb ischemia. Clin Interv Aging 2015; 10:1537-46. [PMID: 26451094 PMCID: PMC4592029 DOI: 10.2147/cia.s87383] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objective The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality. Methods All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery. Results We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11–52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07–42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P<0.001). Conclusion Delirium is a common adverse event in patients with critical limb ischemia undergoing surgery with devastating outcome in the long term. Most patients developed delirium preoperatively, which indicates the need for early recognition and preventive strategies in the preoperative period. This study identified undernourishment and diabetes mellitus as independent risk factors for delirium.
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Affiliation(s)
| | - Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
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Current Concepts in the Diagnosis, Pathophysiology, and Treatment of Delirium: A European Perspective. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0142-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Current Factors of Fragility and Delirium in Vascular Surgery. Ann Vasc Surg 2015; 29:968-76. [DOI: 10.1016/j.avsg.2015.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/02/2015] [Accepted: 01/05/2015] [Indexed: 11/19/2022]
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Pharmacological interventions for preventing delirium in the elderly. Maturitas 2015; 81:287-92. [DOI: 10.1016/j.maturitas.2015.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/30/2015] [Indexed: 01/26/2023]
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Kirino E. Use of aripiprazole for delirium in the elderly: a short review. Psychogeriatrics 2015; 15:75-84. [PMID: 25514894 DOI: 10.1111/psyg.12088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 09/04/2014] [Accepted: 09/08/2014] [Indexed: 01/21/2023]
Abstract
The effects and tolerability of antipsychotics in delirium treatment remain controversial. Compared to other antipsychotics, aripiprazole differs in pharmacological activity because it exerts its effect as a dopamine D2 partial agonist. The guidelines of the American Psychiatric Association rank aripiprazole highly among antipsychotics with regard to safety, and this drug is likely to be useful for delirium treatment. Here, we reviewed the efficacy and safety of aripiprazole for delirium. The results of our literature review on the efficacy and safety of delirium treatments suggest that aripiprazole is an effective treatment option for delirium in the elderly. Aripiprazole is as effective as other antipsychotics in improving delirium symptoms, and it is safer because it is less likely to cause extrapyramidal symptoms, excessive sedation, and weight gain. However, these findings are based on only a few clinical studies of elderly patients with delirium. Therefore, further investigations are necessary.
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Affiliation(s)
- Eiji Kirino
- Department of Psychiatry, Juntendo University School of Medicine, Shizuoka, Japan; Department of Psychiatry, Juntendo University Shizuoka Hospital, Shizuoka, Japan; Juntendo Institute of Mental Health, Shizuoka, Japan
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Chakraborti D, Tampi DJ, Tampi RR. Melatonin and melatonin agonist for delirium in the elderly patients. Am J Alzheimers Dis Other Demen 2015; 30:119-29. [PMID: 24946785 PMCID: PMC10852672 DOI: 10.1177/1533317514539379] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
The objective of this review is to summarize the available data on the use of melatonin and melatonin agonist for the prevention and management of delirium in the elderly patients from randomized controlled trials (RCTs). A systematic search of 5 major databases PubMed, MEDLINE, PsychINFO, Embase, and Cochrane Library was conducted. This search yielded a total of 2 RCTs for melatonin. One study compared melatonin to midazolam, clonidine, and control groups for the prevention and management of delirium in individuals who were pre- and posthip post-hip arthroplasty. The other study compared melatonin to placebo for the prevention of delirium in older adults admitted to an inpatient internal medicine service. Data from these 2 studies indicate that melatonin may have some benefit in the prevention and management of delirium in older adults. However, there is no evidence that melatonin reduces the severity of delirium or has any effect on behaviors or functions in these individuals. Melatonin was well tolerated in these 2 studies. The search for a melatonin agonist for delirium in the elderly patients yielded 1 study of ramelteon. In this study, ramelteon was found to be beneficial in preventing delirium in medically ill individuals when compared to placebo. Ramelteon was well tolerated in this study.
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Affiliation(s)
- Dwaipayan Chakraborti
- The Division of Gerontology, Geriatrics and Palliative Care, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Deena J Tampi
- Behavioral Health Service, Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Rajesh R Tampi
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA Adult Psychiatry Residency, Regional Academic Health Center, Harlingen, TX, USA
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