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Komninou MA, Egli S, Rossi A, Ernst J, Krauthammer M, Schuepbach RA, Delgado M, Bartussek J. Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study. Front Psychiatry 2024; 15:1347071. [PMID: 38559401 PMCID: PMC10979642 DOI: 10.3389/fpsyt.2024.1347071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients. Methods We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders. Results Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55). Discussion Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.
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Affiliation(s)
- Maria Angeliki Komninou
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Simon Egli
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Aurelio Rossi
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Sciences, University Hospital Zurich, Zurich, Switzerland
| | - Michael Krauthammer
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Reto A. Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Marcos Delgado
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department of Anesthesia and Intensive Care Medicine, Tiefenau Hospital, Insel Group. University of Bern, Bern, Switzerland
| | - Jan Bartussek
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
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Glynn K, McKenna F, Lally K, Grover S, Chakrabarti S, Mattoo SK, Avasthi A, Sharma A, Adamis D, Awan F, Dunne CP, McFarland J, Jabbar F, O’Connell H, Leonard M, Meagher DJ. Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study. J Geriatr Psychiatry Neurol 2024; 37:125-133. [PMID: 37566435 PMCID: PMC10802083 DOI: 10.1177/08919887231195232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K. Mattoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajita Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dimitrios Adamis
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
- Sligo Mental Health Services, Sligo, Ireland
| | - Fahad Awan
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Colum P. Dunne
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - John McFarland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Faiza Jabbar
- Psychiatry for Later Life Service, University College Hospital, Galway, Ireland
| | - Henry O’Connell
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - David J. Meagher
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
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Luo M, Wang D, Shi Y, Yi Q, Wang Z, Zhou B, Yang G, Chen J, Liang C, Wang H, Zeng X, Yang Y, Tan R, Xie Y, Chen J, Tang S, Huang J, Mei Z, Xiao Z. Risk factors of postoperative delirium following spine surgery: A meta-analysis of 50 cohort studies with 1.1 million participants. Heliyon 2024; 10:e24967. [PMID: 38322910 PMCID: PMC10844026 DOI: 10.1016/j.heliyon.2024.e24967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 12/11/2023] [Accepted: 01/17/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives Postoperative delirium (POD) is considered to be a common complication of spine surgery. Although many studies have reported the risk factors associated with POD, the results remain unclear. Therefore, we performed a meta-analysis to identify risk factors for POD among patients following spinal surgery. Methods We systematically searched the PubMed, Embase and the Cochrane Library for relevant articles published from 2006 to February 1, 2023 that reported risk factors associated with the incidence of POD among patients undergoing spinal surgery. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed, and random effects models were used to estimate pooled odds ratio (OR) estimates with 95 % confidence intervals (CIs) for each factor. The evidence from observational studies was classified according to Egger's P value, total sample size, and heterogeneity between studies. Results Of 11,329 citations screened, 50 cohort studies involving 1,182,719 participants met the inclusion criteria. High-quality evidence indicated that POD was associated with hypertension, diabetes mellitus, cardiovascular disease, pulmonary disease, older age (>65 years), patients experiencing substance use disorder (take drug ≥1 month), cerebrovascular disease, kidney disease, neurological disorder, parkinsonism, cervical surgery, surgical site infection, postoperative fever, postoperative urinary tract infection, and admission to the intensive care unit (ICU). Moderate-quality evidence indicated that POD was associated with depression, American Society of Anesthesiologists (ASA) fitness grade (>II), blood transfusion, abnormal potassium, electrolyte disorder, length of stay, inability to ambulate and intravenous fluid volume. Conclusions Conspicuous risk factors for POD were mainly patient- and surgery-related. These findings help clinicians identify high-risk patients with POD following spinal surgery and recognize the importance of early intervention.
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Affiliation(s)
- Mingjiang Luo
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Di Wang
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Yuxin Shi
- Department of Pediatric Dentistry, First Affiliated Hospital (Affiliated Stomatological Hospital) of Xinjiang Medical University, Urumqi 830054, China
| | - Qilong Yi
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zhongze Wang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Beijun Zhou
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Gaigai Yang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Juemiao Chen
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Can Liang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Haoyun Wang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Xin Zeng
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Yuxin Yang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Ridong Tan
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Yudie Xie
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Jiang Chen
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Siliang Tang
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Jinshan Huang
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zubing Mei
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
- Department of Anorectal Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Zhihong Xiao
- The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
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Demirtakan T, Cakmak F, Ipekci A, Akdeniz YS, Biberoglu S, Ikızceli I, Ozkan S. Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools. Am J Emerg Med 2024; 75:14-21. [PMID: 37897915 DOI: 10.1016/j.ajem.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.
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Affiliation(s)
- Turker Demirtakan
- Emergency Department, University of Health Science, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey.
| | - Fatih Cakmak
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Afsin Ipekci
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Yonca Senem Akdeniz
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Serap Biberoglu
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Ibrahim Ikızceli
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Seda Ozkan
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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McKay TB, Khawaja ZQ, Freedman IG, Turco I, Wiredu K, Colecchi T, Akeju O. Exploring the Pathophysiology of Delirium: An Overview of Biomarker Studies, Animal Models, and Tissue-Engineered Models. Anesth Analg 2023; 137:1186-1197. [PMID: 37851904 PMCID: PMC10840625 DOI: 10.1213/ane.0000000000006715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Delirium is an acute brain disorder associated with disorganized thinking, difficulty focusing, and confusion that commonly follows major surgery, severe infection, and illness. Older patients are at high risk for developing delirium during hospitalization, which may contribute to increased morbidity, longer hospitalization, and increased risk of institutionalization following discharge. The pathophysiology underlying delirium remains poorly studied. This review delves into the findings from biomarker studies and animal models, and highlights the potential for tissue-engineered models of the brain in studying this condition. The aim is to bring together the existing knowledge in the field and provide insight into the future direction of delirium research.
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Affiliation(s)
- Tina B. McKay
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Zain Q. Khawaja
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Isaac G. Freedman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Isabella Turco
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Kwame Wiredu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Talia Colecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Luu A, Bui NA, Adeola M, Bhakta S, Fuentes A, Agarwal K. Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients. J Am Geriatr Soc 2023; 71:3584-3594. [PMID: 37706219 DOI: 10.1111/jgs.18586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/19/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults. METHODS Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers. RESULTS A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden. CONCLUSIONS Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.
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Affiliation(s)
- Alan Luu
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
- Department of Pharmacy Practice, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nghi Andy Bui
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Mobolaji Adeola
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Sunny Bhakta
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Amaris Fuentes
- System Quality and Patient Safety, Houston Methodist, Houston, Texas, USA
| | - Kathryn Agarwal
- System Quality and Patient Safety, Houston Methodist, Houston, Texas, USA
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Ali MIM, Kalkman GA, Wijers CHW, Fleuren HWHA, Kramers C, de Wit HAJM. External validity of an automated delirium prediction model (DEMO) and comparison to the manual VMS-questions: a retrospective cohort study. Int J Clin Pharm 2023; 45:1128-1135. [PMID: 37713029 DOI: 10.1007/s11096-023-01641-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/23/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND It is estimated that one-third of delirium cases in hospitals could be prevented with appropriate interventions. In Dutch hospitals a manual instrument (VMS-questions) is used to identify patients at-risk for delirium. Delirium Model (DEMO) is an automated model which could support delirium prevention more efficiently. However, it has not been validated beyond the hospital it was developed in. AIM To externally validate the DEMO and compare its performance to the VMS-questions. METHOD A retrospective cohort study between July and December 2018 was conducted. Delirium cases were identified through a chart review, and the VMS-questions were extracted from the electronic health records. The DEMO was validated in patients ≥ 60 years, and a comparison with the VMS-questions was made in patients ≥ 70 years. RESULTS In total 1,345 admissions were included. The DEMO predicted 59 out of 75 delirium cases (sensitivity 0.79, 95% CI = 0.68-0.87; specificity 0.75, 95% CI = 0.72-0.77). Compared to the VMS-questions, the DEMO showed a lower specificity (0.64 vs. 0.72; p < 0.001) and a comparable sensitivity (0.83 vs. 0.80; p = 0.56). The VMS-questions were missing in 20% of admissions, in which the DEMO correctly predicted 10 of 12 delirium cases. CONCLUSION The DEMO showed acceptable performance for delirium prediction. Overall the DEMO predicted more delirium cases because the VMS-questions were missing in 20% of admissions. This study shows that automated instruments such as DEMO could play a key role in the efficient and timely deployment of measures to prevent delirium.
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Affiliation(s)
- Ma Ida Mohmaed Ali
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Gerard A Kalkman
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
| | | | - Hanneke W H A Fleuren
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Pharmacology-Toxicology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Hugo A J M de Wit
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Sarkies MN, Testa L, Carrigan A, Roberts N, Gray R, Sherrington C, Mitchell R, Close JCT, McDougall C, Sheehan K. Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis. Age Ageing 2023; 52:afad154. [PMID: 37596922 PMCID: PMC10439513 DOI: 10.1093/ageing/afad154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery. OBJECTIVE Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture. METHODS Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis. RESULTS Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements. CONCLUSIONS Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.
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Affiliation(s)
- Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney NSW 2006, Australia
| | - Luke Testa
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Ann Carrigan
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Natalie Roberts
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Rene Gray
- James Paget University Hospital Foundation Trust, Norfolk NR31, UK
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney NSW 2006, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney NSW 2006, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Jacqueline C T Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney NSW 2052, Australia
| | - Catherine McDougall
- The University of Queensland, Brisbane 4072, Australia
- The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane 4032, Australia
| | - Katie Sheehan
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London WC2R, UK
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10
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Brier LM, Chen S, Sherafati A, Bice AR, Lee JM, Culver JP. Transient disruption of functional connectivity and depression of neural fluctuations in a mouse model of acute septic encephalopathy. Cereb Cortex 2023; 33:3548-3561. [PMID: 35972424 PMCID: PMC10068285 DOI: 10.1093/cercor/bhac291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Septic encephalopathy leads to major and costly burdens for a large percentage of admitted hospital patients. Elderly patients are at an increased risk, especially those with dementia. Current treatments are aimed at sedation to combat mental status changes and are not aimed at the underlying cause of encephalopathy. Indeed, the underlying pathology linking together peripheral infection and altered neural function has not been established, largely because good, acutely accessible readouts of encephalopathy in animal models do not exist. Behavioral testing in animals lasts multiple days, outlasting the time frame of acute encephalopathy. Here, we propose optical fluorescent imaging of neural functional connectivity (FC) as a readout of encephalopathy in a mouse model of acute sepsis. Imaging and basic behavioral assessment were performed at baseline, Hr8, Hr24, and Hr72 following injection of either lipopolysaccharide or phosphate buffered saline. Neural FC strength decreased at Hr8 and returned to baseline by Hr72 in motor, somatosensory, parietal, and visual cortical regions. Additionally, neural fluctuations transiently declined at Hr8 and returned to baseline by Hr72. Both FC strength and fluctuation tone correlated with neuroscore indicating this imaging methodology is a sensitive and acute readout of encephalopathy.
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Affiliation(s)
- L M Brier
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - S Chen
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - A Sherafati
- Department of Physics, Washington University School of Arts and Science, St. Louis, MO 63110, USA
| | - A R Bice
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - J M Lee
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - J P Culver
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Physics, Washington University School of Arts and Science, St. Louis, MO 63110, USA
- Department of Biomedical Engineering, Washington University School of Engineering, St. Louis, MO 63110, USA
- Department of Electrical and Systems Engineering, Washington University School of Engineering, St. Louis, MO 63110, USA
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11
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Wiredu K, Aduse-Poku E, Shaefi S, Gerber SA. Proteomics for the Discovery of Clinical Delirium Biomarkers: A Systematic Review of Major Studies. Anesth Analg 2023; 136:422-432. [PMID: 36580411 DOI: 10.1213/ane.0000000000006246] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Delirium represents a significant health care burden, diagnosed in more than 2 million elderly Americans each year. In the surgical population, delirium remains the most common complication among elderly patients, and is associated with longer hospital stays, higher costs of care, increased mortality, and functional impairment. The pathomechanism of disease is poorly understood, with current diagnostic approaches somewhat subjective and arbitrary, and definitive diagnostic biomarkers are currently lacking. Despite the recent interest in delirium research, biomarker discovery for it remains new. Most attempts to discover biomarkers are targeted studies that seek to assess the involvement of one or more members of a focused panel of candidates in delirium. For a more unbiased, system-biology view, we searched literature from Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central, Web of Science, SCOPUS, and Dimensions between 2016 and 2021 for untargeted proteomic discovery studies for biomarkers of delirium conducted on human geriatric subjects. Two reviewers conducted an independent review of all search results and resolved discordance by consensus. From an overall search of 1172 publications, 8 peer-reviewed studies met our defined inclusion criteria. The 370 unique perioperative biomarkers identified in these reports are enriched in pathways involving activation of the immune system, inflammatory response, and the coagulation cascade. The most frequently identified biomarker was interleukin-6 (IL-6). By reviewing the distribution of protein biomarker candidates from these studies, we conclude that a panel of proteins, rather than a single biomarker, would allow for discriminating delirium cases from noncases. The paucity of hypothesis-generating studies in the peer-reviewed literature also suggests that a system-biology view of delirium pathomechanisms has yet to fully emerge.
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Affiliation(s)
- Kwame Wiredu
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire
| | | | - Shahzad Shaefi
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School/Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A Gerber
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire.,Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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12
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Cizginer S, Prohl EG, Monteiro JFG, Yildiz F, Jones RN, Schechter S, Patterson R, Klipfel A, Katlic MR, Daiello LA, Mujahid N, Neupane I, Cioffi WG, Ducharme M, Vrees MD, McNicoll L. Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs. J Am Geriatr Soc 2023; 71:1452-1461. [PMID: 36721263 DOI: 10.1111/jgs.18216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/27/2022] [Accepted: 11/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.
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Affiliation(s)
- Sevdenur Cizginer
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Eian G Prohl
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Ferhat Yildiz
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Richard N Jones
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven Schechter
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Robert Patterson
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Adam Klipfel
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | | | - Lori A Daiello
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nadia Mujahid
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Iva Neupane
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - William G Cioffi
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Maria Ducharme
- Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Matthew D Vrees
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Lynn McNicoll
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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13
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Chishi KV, Patel BC, Umrania RA, Sanghavi PR, Yadav VS, Raval LV. Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention. Indian J Palliat Care 2023; 29:82-88. [PMID: 36846279 PMCID: PMC9945345 DOI: 10.25259/ijpc_114_2022] [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] [Received: 05/23/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022] Open
Abstract
Objectives The assessment of prevalence of delirium in advanced cancer patients admitted in hospice centre and outcome after palliative intervention. The possible related risk factors for development of delirium. Material and Methods This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019 - July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion criteria (all patient admitted to hospice centre above 18 years, with advance cancer disease and on best supportive care) and exclusion criteria (Lack of informed consent, Inability to participate in study due to mentally retard or coma). The following information were collected: age, gender, address, type of cancer, comorbidities, history of substance abuse, history of (h/o) palliative chemotherapy or radiotherapy within last 3month, general condition, ESAS (Edmonton symptom assessment scale), ECOG (Eastern cooperative oncology group), PaP score (palliative prognostic score), medication including opioids, NSAIDs (Non-steroidal anti-inflammatory drugs), steroids, antibiotic, adjuvant analgesic, PPI (Proton pump inhibitor), anti-emetic etc. Delirium diagnosis was based on diagnostic criterion of DSM-IV text revised and MDAS. Results In our study we found prevalence of delirium was 31.29% in advanced cancer patients admitted to hospice centre. We found most common type of delirium is hypoactive (34.7%) and mixed subtype (34.7%) followed by hyperactive (30.4%) delirium. Resolution of delirium was higher among hyperactive delirium (78.57%) followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%) followed by mixed (43.75%) and hyperactive delirium (14.28%). Conclusion An identification and assessment of delirium is vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalization, expanded time on a ventilator, and by and large more prominent medical services costs. Clinicians should utilize one of a few approved delirium assessment tools to help evaluate and archive cognitive function. Prevention and recognizing the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium. The study results demonstrate that multi component delirium management or projects are generally proficient to lessen the prevalence and negative outcomes of delirium. It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.
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Affiliation(s)
- Kikato V. Chishi
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Bhavna Chirag Patel
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Ravi A. Umrania
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Priti Rashmin Sanghavi
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Varun Shaileshbhai Yadav
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
| | - Lekha V. Raval
- Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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14
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Hildenbrand FF, Murray FR, von Känel R, Deibel AR, Schreiner P, Ernst J, Zipser CM, Böettger S. Predisposing and precipitating risk factors for delirium in gastroenterology and hepatology: Subgroup analysis of 718 patients from a hospital-wide prospective cohort study. Front Med (Lausanne) 2022; 9:1004407. [PMID: 36530904 PMCID: PMC9747774 DOI: 10.3389/fmed.2022.1004407] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/15/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS Delirium is the most common acute neuropsychiatric syndrome in hospitalized patients. Higher age and cognitive impairment are known predisposing risk factors in general hospital populations. However, the interrelation with precipitating gastrointestinal (GI) and hepato-pancreato-biliary (HPB) diseases remains to be determined. PATIENTS AND METHODS Prospective 1-year hospital-wide cohort study in 29'278 adults, subgroup analysis in 718 patients hospitalized with GI/HPB disease. Delirium based on routine admission screening and a DSM-5 based construct. Regression analyses used to evaluate clinical characteristics of delirious patients. RESULTS Delirium was detected in 24.8% (178/718). Age in delirious patients (median 62 years [IQR 21]) was not different to non-delirious (median 60 years [IQR 22]), p = 0.45). Dementia was the strongest predisposing factor for delirium (OR 66.16 [6.31-693.83], p < 0.001). Functional impairment, and at most, immobility increased odds for delirium (OR 7.78 [3.84-15.77], p < 0.001). Patients with delirium had higher in-hospital mortality rates (18%; OR 39.23 [11.85-129.93], p < 0.001). From GI and HPB conditions, cirrhosis predisposed to delirium (OR 2.11 [1.11-4.03], p = 0.023), while acute renal failure (OR 4.45 [1.61-12.26], p = 0.004) and liver disease (OR 2.22 [1.12-4.42], p = 0.023) were precipitators. Total costs were higher in patients with delirium (USD 30003 vs. 10977; p < 0.001). CONCLUSION Delirium in GI- and HPB-disease was not associated with higher age per se, but with cognitive and functional impairment. Delirium needs to be considered in younger adults with acute renal failure and/or liver disease. Clinicians should be aware about individual risk profiles, apply preventive and supportive strategies early, which may improve outcomes and lower costs.
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Affiliation(s)
- Florian F. Hildenbrand
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Fritz R. Murray
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
| | - Ansgar R. Deibel
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Science, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Carl M. Zipser
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
- Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Soenke Böettger
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
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15
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Association between multidimensional prognostic index (MPI) and pre-operative delirium in older patients with hip fracture. Sci Rep 2022; 12:16920. [PMID: 36209284 PMCID: PMC9547845 DOI: 10.1038/s41598-022-20734-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 09/19/2022] [Indexed: 12/29/2022] Open
Abstract
Pre-operative delirium may cause delay in surgical intervention in older patients hospitalized for hip fracture. Also it has been associated with higher risk of post-surgical complications and worst functional outcomes. Aim of this retrospective cohort study was to evaluate whether the multidimensional prognostic index (MPI) at hospital admission was associated with pre-operative delirium in older individuals with hip fracture who are deemed to require surgical intervention. Consecutive older patients (≥ 65 years) with hip fracture underwent a comprehensive geriatric assessment to calculate the MPI at hospital admission. According to previously established cut-offs, MPI was expressed in three grades, i.e. MPI-1 (low-risk), MPI-2 (moderate-risk) and MPI-3 (high risk of mortality). Pre-operative delirium was assessed using the four 'A's Test. Out of 244 older patients who underwent surgery for hip fracture, 104 subjects (43%) received a diagnosis of delirium. Overall, the incidence of delirium before surgery was significantly higher in patients with more severe MPI score at admission. Higher MPI grade (MPI-3) was independently associated with higher risk of pre-operative delirium (OR 2.45, CI 1.21-4.96). Therefore, the MPI at hospital admission might help in early identification of older patients with hip fracture at risk for pre-operative delirium.
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16
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Heinrich M, Woike JK, Spies CD, Wegwarth O. Forecasting Postoperative Delirium in Older Adult Patients with Fast-and-Frugal Decision Trees. J Clin Med 2022; 11:jcm11195629. [PMID: 36233496 PMCID: PMC9571735 DOI: 10.3390/jcm11195629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Postoperative delirium (POD) is associated with increased complication and mortality rates, particularly among older adult patients. However, guideline recommendations for POD detection and management are poorly implemented. Fast-and-frugal trees (FFTrees), which are simple prediction algorithms, may be useful in this context. We compared the capacity of simple FFTrees with two more complex models—namely, unconstrained classification trees (UDTs) and logistic regression (LogReg)—for the prediction of POD among older surgical patients in the perioperative setting. Models were trained and tested on the European BioCog project clinical dataset. Based on the entire dataset, two different FFTrees were developed for the pre-operative and postoperative settings. Within the pre-operative setting, FFTrees outperformed the more complex UDT algorithm with respect to predictive balanced accuracy, nearing the prediction level of the logistic regression. Within the postoperative setting, FFTrees outperformed both complex models. Applying the best-performing algorithms to the full datasets, we proposed an FFTree using four cues (Charlson Comorbidity Index (CCI), site of surgery, physical status and frailty status) for the pre-operative setting and an FFTree containing only three cues (duration of anesthesia, age and CCI) for the postoperative setting. Given that both FFTrees contained considerably fewer criteria, which can be easily memorized and applied by health professionals in daily routine, FFTrees could help identify patients requiring intensified POD screening.
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Affiliation(s)
- Maria Heinrich
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
- Berlin Institute of Health@Charité (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Jan K. Woike
- School of Psychology, University of Plymouth, Plymouth PL4 8AA, UK
- Max Planck Institute for Human Development, Center for Adaptive Rationality, 14195 Berlin, Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
| | - Odette Wegwarth
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
- Max Planck Institute for Human Development, Center for Adaptive Rationality, 14195 Berlin, Germany
- Heisenberg Chair for Medical Risk Literacy and Evidence-Based Decisions, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-531-056; Fax: +49-30-450-551-909
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17
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Franco JG, Molano JC, Rincón H, Tirado JDV, Cardeño C, Rodriguez LP, Lugo GFO, Miranda JB, Moreno MR. Consensus of the Liaison-Psychiatry Committee of the Colombian Psychiatric Association on the diagnosis and treatment of delirium in the context of the COVID-19 pandemic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2022; 51:245-255. [PMID: 36085127 PMCID: PMC9433347 DOI: 10.1016/j.rcpeng.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
The pandemic caused by the new coronavirus named SARS-CoV-2 poses unprecedented challenges in the health care. Among them is the increase in cases of delirium. The severe SARS-CoV-2 disease, COVID-19, has common vulnerabilities with delirium and produces alterations in organs such as the lungs or the brain, among others, which have the potential to trigger the mental disorder. In fact, delirium may be the first manifestation of the infection, before fever, general malaise, cough or respiratory disturbances. It is widely supported that delirium increases the morbidity and mortality in those who suffer from it during hospitalization, so it should be actively sought to carry out the relevant interventions. In the absence of evidence on the approach to delirium in the context of COVID-19, this consensus was developed on three fundamental aspects: diagnosis, non-pharmacological treatment and pharmacological treatment, in patients admitted to the general hospital. The document contains recommendations on the systematic use of diagnostic tools, when to hospitalize the patient with delirium, the application of non-pharmacological actions within the restrictions imposed by COVID-19, and the use of antipsychotics, taking into account the most relevant side effects and pharmacological interactions.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Hernán Rincón
- Hospital Universitario Fundación Valle del Lili, Cali, Colombia; Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
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18
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Weldingh NM, Mellingsæter MR, Hegna BW, Benth JS, Einvik G, Juliebø V, Thommessen B, Kirkevold M. Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a controlled clinical trial design. BMC Geriatr 2022; 22:266. [PMID: 35361136 PMCID: PMC8974092 DOI: 10.1186/s12877-022-02949-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards. Methods This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 ‘A’s Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR). Results Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote “dementia-friendly” care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality. Conclusions A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention. Trial registration The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021.
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Affiliation(s)
- N M Weldingh
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B W Hegna
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway
| | - J Saltyte Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - G Einvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pulmonary Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - V Juliebø
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - M Kirkevold
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.,Faculty of Medicine, Department of Nursing Science, University of Oslo, Institute of Health and Society, Oslo, Norway
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19
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Urfer Dettwiler P, Zúñiga F, Bachnick S, Gehri B, de Jonghe JFM, Hasemann W. Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study. Eur Geriatr Med 2022; 13:917-931. [PMID: 35143027 PMCID: PMC9378321 DOI: 10.1007/s41999-022-00612-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
Aim The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard. Findings This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%. Message The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents. Purpose Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard. Methods This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult. Results 85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer. Conclusion The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.
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Affiliation(s)
- Pia Urfer Dettwiler
- Nursing Home Frenkenbündten, Gitterlistrasse 10, 4410, Liestal, Switzerland.,Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Stefanie Bachnick
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland
| | - Beatrice Gehri
- Institute of Nursing Science, University of Basel, Bernoullistrasse, 4056, Basel, Switzerland.,University Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Jos F M de Jonghe
- Private Practice, DC VerzuimDiagnostiek , Tesselschadestraat 4, 1054 ET, msterdam, The Netherlands
| | - Wolfgang Hasemann
- University Department of Geriatric Medicine FELIX PLATTER, Burgfelderstrasse 101, 4002, Basel, Switzerland.
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20
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Zhao H, Ying HL, Zhang C, Zhang S. Relative Hypoglycemia is Associated with Delirium in Critically Ill Patients with Diabetes: A Cohort Study. Diabetes Metab Syndr Obes 2022; 15:3339-3346. [PMID: 36341226 PMCID: PMC9628698 DOI: 10.2147/dmso.s369457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Critically ill patients with premorbid diabetes can suffer from relative hypoglycemia (RHG), falling below the normal blood glucose (BG) target. However, these events have not been well defined or studied. In the present study, we aimed to explore the incidence and clinical significance of RHG events in critically ill patients with diabetes. PATIENTS AND METHODS Patients with a history of diabetes who stayed in the intensive care unit (ICU) for more than three days with at least 12 BG recordings were retrospectively included in the study. A BG level > 30% below the estimated average according to patient hemoglobin A1c measured at admission was defined as a single RHG event. Outcomes were compared between patients with and those without RHG events. RESULTS In total, 113 patients were included in the final analysis. RHG was detected in 73 patients (64.6%). Those who experienced RHG events had a significantly higher incidence of ICU delirium. They also had a higher risk of 28-day mortality, but this was not statistically significant. However, patients with a higher frequency of RHG events did have a significantly higher risk of overall mortality (57.1% for more than four events vs 15.4% for three to four events, P=0.006 and 15.1% for one to two events, P=0.003). CONCLUSION In conclusion, RHG is a common finding in critically ill patients with diabetes and is associated with mortality and the occurrence of delirium.
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Affiliation(s)
- Hui Zhao
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Hua-Liang Ying
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Chao Zhang
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
- Correspondence: Chao Zhang; Shaohua Zhang, Intensive Care Unit (ICU), Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 1 Tong-yang Road, Taizhou, People’s Republic of China, Tel +8613757602063; +8615268325868, Email ;
| | - Shaohua Zhang
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
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21
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Oldham MA. Delirium disorder: Unity in diversity. Gen Hosp Psychiatry 2022; 74:32-38. [PMID: 34875568 DOI: 10.1016/j.genhosppsych.2021.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing them through the model of delirium disorder. METHOD This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets. RESULTS Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies. CONCLUSIONS Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
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22
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LaHue SC, Douglas VC. Approach to Altered Mental Status and Inpatient Delirium. Neurol Clin 2021; 40:45-57. [PMID: 34798974 DOI: 10.1016/j.ncl.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Altered mental status is a nonspecific diagnosis that encompasses a wide spectrum of disease and is frequently cited as a reason for both hospital admission and inpatient neurologic consultation. There are numerous etiologies of altered mental status, and so although many are facile with the workup of this potentially life-threatening entity, it can nevertheless be overwhelming. Our goal was to provide a practical framework embedded in a current, comprehensive review of the epidemiology, clinical evaluation, and management of undifferentiated altered mental status. We pay particular attention to the management of a critical yet underdiagnosed subtype of altered mental status: delirium.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA; Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
| | - Vanja C Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA; Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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23
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Heinrich M, Sieg M, Kruppa J, Nürnberg P, Schreier PH, Heilmann-Heimbach S, Hoffmann P, Nöthen MM, Janke J, Pischon T, Slooter AJC, Winterer G, Spies CD. Association between genetic variants of the cholinergic system and postoperative delirium and cognitive dysfunction in elderly patients. BMC Med Genomics 2021; 14:248. [PMID: 34674705 PMCID: PMC8529799 DOI: 10.1186/s12920-021-01071-1] [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] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are frequent and serious complications after surgery. We aim to investigate the association between genetic variants in cholinergic candidate genes according to the Kyoto encyclopedia of genes and genomes - pathway: cholinergic neurotransmission with the development of POD or POCD in elderly patients. Methods This analysis is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini-Mental-State-Examination score ≤ 23 points were excluded. POD was assessed up to seven days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. POCD was assessed three months after surgery with a neuropsychological test battery. Genotyping was performed on the Illumina Infinium Global Screening Array. Associations with POD and POCD were analyzed using logistic regression analysis, adjusted for age, comorbidities and duration of anesthesia (for POCD analysis additionally for education). Odds ratios (OR) refer to minor allele counts (0, 1, 2). Results 745 patients could be included in the POD analysis, and 452 in the POCD analysis. The rate of POD within this group was 20.8% (155 patients), and the rate of POCD was 10.2% (46 patients). In a candidate gene approach three genetic variants of the cholinergic genes CHRM2 and CHRM4 were associated with POD (OR [95% confidence interval], rs8191992: 0.61[0.46; 0.80]; rs8191992: 1.60[1.22; 2.09]; rs2067482: 1.64[1.10; 2.44]). No associations were found for POCD. Conclusions We found an association between genetic variants of CHRM2 and CHRM4 and POD. Further studies are needed to investigate whether disturbances in acetylcholine release and synaptic plasticity are involved in the development of POD. Trial registration: ClinicalTrials.gov: NCT02265263. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-021-01071-1.
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Affiliation(s)
- Maria Heinrich
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Miriam Sieg
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Nürnberg
- Institute of Genetics, University of Cologne, Cologne, Germany.,Atlas Biolabs GmbH, Berlin, Germany
| | - Peter H Schreier
- Institute of Genetics, University of Cologne, Cologne, Germany.,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Stefanie Heilmann-Heimbach
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Per Hoffmann
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany.,Human Genomics Research Group, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Markus M Nöthen
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Jürgen Janke
- MDC/BIH Biobank, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Tobias Pischon
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,MDC/BIH Biobank, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Molecular Epidemiology Research Group, Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Neurology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Georg Winterer
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC Experimental and Clinical Research Center, Lindenberger Weg 80, 13125, Berlin, Germany
| | - Claudia D Spies
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.
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Naharci MI, Tasci I. Delirium in a patient with Alzheimer's dementia following COVID-19 vaccination. Psychogeriatrics 2021; 21:846-847. [PMID: 34245485 PMCID: PMC8447320 DOI: 10.1111/psyg.12747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/04/2021] [Accepted: 06/29/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mehmet Ilkin Naharci
- Division of Geriatrics, University of Health Sciences, Gulhane Faculty of Medicine & Gulhane Training and Research Hospital, Ankara, Turkey
| | - Ilker Tasci
- Department of Internal Medicine, University of Health Sciences, Gulhane Faculty of Medicine & Gulhane Training and Research Hospital, Ankara, Turkey
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25
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Ocagli H, Bottigliengo D, Lorenzoni G, Azzolina D, Acar AS, Sorgato S, Stivanello L, Degan M, Gregori D. A Machine Learning Approach for Investigating Delirium as a Multifactorial Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137105. [PMID: 34281037 PMCID: PMC8297073 DOI: 10.3390/ijerph18137105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/12/2022]
Abstract
Delirium is a psycho-organic syndrome common in hospitalized patients, especially the elderly, and is associated with poor clinical outcomes. This study aims to identify the predictors that are mostly associated with the risk of delirium episodes using a machine learning technique (MLT). A random forest (RF) algorithm was used to evaluate the association between the subject’s characteristics and the 4AT (the 4 A’s test) score screening tool for delirium. RF algorithm was implemented using information based on demographic characteristics, comorbidities, drugs and procedures. Of the 78 patients enrolled in the study, 49 (63%) were at risk for delirium, 32 (41%) had at least one episode of delirium during the hospitalization (38% in orthopedics and 31% both in internal medicine and in the geriatric ward). The model explained 75.8% of the variability of the 4AT score with a root mean squared error of 3.29. Higher age, the presence of dementia, physical restraint, diabetes and a lower degree are the variables associated with an increase of the 4AT score. Random forest is a valid method for investigating the patients’ characteristics associated with delirium onset also in small case-series. The use of this model may allow for early detection of delirium onset to plan the proper adjustment in healthcare assistance.
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Affiliation(s)
- Honoria Ocagli
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Daniele Bottigliengo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64B, 44121 Ferrara, Italy
| | - Aslihan S. Acar
- Department of Actuarial Sciences, Hacettepe University, Ankara 06800, Turkey;
| | - Silvia Sorgato
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Lucia Stivanello
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Mario Degan
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
- Correspondence: ; Tel.: +39-049-827-5384
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26
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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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Heinrich M, Nottbrock A, Borchers F, Mörgeli R, Kruppa J, Winterer G, Slooter AJC, Spies C. Preoperative medication use and development of postoperative delirium and cognitive dysfunction. Clin Transl Sci 2021; 14:1830-1840. [PMID: 33934508 PMCID: PMC8504833 DOI: 10.1111/cts.13031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 11/30/2022] Open
Abstract
Postoperative delirium (POD) and postoperative (neuro‐)cognitive disorder (POCD) are frequent and serious complications after operations. We aim to investigate the association between pre‐operative polypharmacy and potentially inappropriate medications and the development of POD/POCD in elderly patients. This investigation is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini‐Mental State Examination score less than or equal to 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method (for the intensive care unit [ICU]), and a patient chart review. POCD was assessed 3 months after surgery with a neuropsychological test battery. Pre‐operative long‐term medication was evaluated in terms of polypharmacy (≥5 agents) and potentially inappropriate medication (defined by the PRISCUS and European list of potentially inappropriate medications [EU(7)‐PIM] lists), and associations with POD and POCD were analyzed using logistic regression analysis. Eight hundred thirty‐seven participants were included for analysis of POD and 562 participants for POCD. Of these, 165 patients (19.7%) fulfilled the criteria of POD and 60 (10.7%) for POCD. After adjusting for confounders, pre‐operative polypharmacy and intake of potentially inappropriate medications could not be shown to be associated with the development of POD nor POCD. We found no associations between pre‐operative polypharmacy and potentially inappropriate medications and development of POD and POCD. Future studies should focus on the evaluation of drug interactions to determine whether patients benefit from a pre‐operative adjustment.
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Affiliation(s)
- Maria Heinrich
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Nottbrock
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jochen Kruppa
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Winterer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.,Experimental and Clinical Research Center (ECRC), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Maeker É, Maeker-Poquet B. [Delirium, a possible typical presentation of COVID-19 in the elderly]. SOINS. GÉRONTOLOGIE 2021; 26:10-15. [PMID: 34083008 DOI: 10.1016/j.sger.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
COVID-19 has hit the entire world since late 2019 and is starting to be medically better known. Its clinical presentation is atypical in the elderly. Acute confusion is a sometimes unrecognized warning sign. It is also an element of severity of COVID-19. This viral infection should be systematically investigated for any confusional syndrome in the elderly population.
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Affiliation(s)
- Éric Maeker
- Court séjour gériatrique, unité Covid, centre hospitalier de Calais, 1601 boulevard des Justes, 62100 Calais, France.
| | - Bérengère Maeker-Poquet
- Court séjour gériatrique, unité Covid, centre hospitalier de Calais, 1601 boulevard des Justes, 62100 Calais, France
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Reimann F, Rinner T, Lindner A, Kofler M, Ianosi BA, Schiefecker AJ, Beer R, Schmutzhard E, Pfausler B, Helbok R, Rass V. Hyperactive delirium in patients after non-traumatic subarachnoid hemorrhage. J Crit Care 2021; 64:45-52. [PMID: 33794466 DOI: 10.1016/j.jcrc.2021.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/18/2021] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Hyperactive delirium is common after subarachnoid hemorrhage (SAH). We aimed to identify risk factors for delirium and to evaluate its impact on outcome. METHODS We collected daily Richmond Agitation Sedation Scale (RASS) and Intensive Care Delirium Screening Checklist (ICDSC) scores in 276 SAH patients. Hyperactive delirium was defined as ICDSC ≥4 when RASS was >0. We investigated risk factors for delirium and its association with 3-month functional outcome using generalized linear models. RESULTS Patients were 56 (IQR 47-67) years old and had a Hunt&Hess (H&H) grade of 3 (IQR 1-5). Sixty-five patients (24%) developed hyperactive delirium 6 (IQR 3-16) days after SAH. In multivariable analysis, mechanical ventilation>48 h (adjOR = 4.46; 95%-CI = 1.89-10.56; p = 0.001), the detection of an aneurysm (adjOR = 4.38; 95%-CI = 1.48-12.97; p = 0.008), a lower H&H grade (adjOR = 0.63; 95%-CI = 0.48-0.83; p = 0.001) and a pre-treated psychiatric disorder (adjOR = 3.17; 95%-CI = 1.14-8.83; p = 0.027) were associated with the development of delirium. Overall, delirium was not associated with worse outcome (p = 0.119). Interestingly, patients with delirium more often had a modified Rankin Scale Score (mRS) of 1-3 (77%) compared to an mRS of 0 (14%) or 4-6 (9%). CONCLUSION Our data indicate that hyperactive delirium is common after SAH patients and requires a certain degree of brain connectivity based ono the highest prevalence found in SAH patients with intermediate outcomes.
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Affiliation(s)
- Fabian Reimann
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Thomas Rinner
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Anna Lindner
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Mario Kofler
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; Institute of Medical Informatics, UMIT: University for Health Sciences, Biomedical Informatics and Mechatronics, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060 Hall i.T, Austria
| | - Alois Josef Schiefecker
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ronny Beer
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Verena Rass
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Toto S, Hefner G, Hahn M, Hiemke C, Roll SC, Wolff J, Klimke A. Current use of anticholinergic medications in a large naturalistic sample of psychiatric patients. J Neural Transm (Vienna) 2021; 128:263-272. [PMID: 33439364 DOI: 10.1007/s00702-020-02298-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/27/2020] [Indexed: 12/19/2022]
Abstract
Due to the high number of psychotropic drugs with anticholinergic potential, patients taking psychotropic drugs are at high risk for anticholinergic adverse drug reactions (ADRs). The aim of this study was to analyze the prevalence and type of pharmacodynamic anticholinergic drug-drug interactions in psychiatric patients. The retrospective longitudinal analysis used data from a large pharmacovigilance study conducted in ten German psychiatric hospitals. Anticholinergic burden of drugs was defined as "strong" or "moderate" based on current literature. Number and type of anticholinergic drugs were assessed. In total, 27,396 patient cases (45.6% female) with a mean age of 47.3 ± 18.3 years were included. 17.4% (n = 4760) of patients were ≥ 64 years. 35.4% of the patients received between one and four anticholinergic drugs simultaneously. A combination of drugs with anticholinergic potential was detected in 1738 cases (6.3%). Most prescribed drugs were promethazine (n = 2996), olanzapine (n = 2561), biperiden (n = 1074), and doxepin (n = 963). Patients receiving anticholinergic combinations were younger (45.7 vs. 47.4 years, p < 0.01) and had a longer inpatient stay (median 18 vs. 26.5 days, p < 0.001). The prevalence of anticholinergic drug use in psychiatry is high. Further efforts need to focus on reducing the rate of anticholinergics and inappropriate medication especially in the elderly. Anticholinergic ADRs can be prevented by avoiding high-risk drug combinations. Replacing tricyclic antidepressants and first-generation antihistamines with drugs with lower anticholinergic potential and avoiding biperiden could reduce 59.3% of anticholinergic drug application.
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Affiliation(s)
- Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany.
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Martina Hahn
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Sibylle C Roll
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Jan Wolff
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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Garcez FB, Avelino-Silva TJ, Castro REVD, Inouye SK. Delirium in older adults. GERIATRICS, GERONTOLOGY AND AGING 2021. [DOI: 10.53886/gga.e0210032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.
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Travica N, Ried K, Hudson I, Pipingas A, Scholey A, Sali A. The effects of surgery on plasma vitamin C concentrations and cognitive function: a protocol for a prospective, observational study. Nutr Health 2020; 27:283-292. [PMID: 33356889 DOI: 10.1177/0260106020982343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Post-operative cognitive function has recently become an area of focus for researchers. The most commonly reported perioperative neurocognitive disorders include delirium and longer-lasting post-operative cognitive dysfunctions. The contributing pathophysiology to these complications remains unclear. A number of studies have systematically revealed a significant post-operative plasma vitamin C depletion. Recent insights have also exhibited a link between plasma vitamin C and numerous biological roles in brain function, with deficiencies potentially compromising cognitive function. AIM The present prospective, observational study will investigate whether there is a possible link between post-operative plasma vitamin C depletion and cognitive dysfunction. METHODS The cohort will consist of surgical patients, between the ages of 65 and 85 years, undergoing hip replacement surgery or a control group not exposed to surgical trauma. Participants will have their plasma vitamin C concentrations tested alongside a battery of computer-based cognitive assessments and paper and pen based cognitive tests. Further assessments will include dietary nutritional intake, serum vitamin B12 concentrations, cardiovascular biomarkers, wound healing, sleep quality, pain, mood and inflammatory cytokines. Participants will be tested at baseline (1-2 weeks prior to surgery) and subsequent testing sessions will be performed within 1 week, 4-6 weeks, 3 months and 6 months following surgery. CONCLUSIONS Findings from this observational study will provide insight into whether there is a concomitant depletion in post-operative plasma vitamin C concentrations and cognition function. Extrapolated results may prompt future, extensive randomized controlled trials to assess whether vitamin C supplementation can alleviate or even prevent post-operative cognitive complications.
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Affiliation(s)
- Nikolaj Travica
- Centre for Human Psychopharmacology, 3783Swinburne University of Technology, Australia.,296252The National Institute of Integrative Medicine, Australia
| | - Karin Ried
- 296252The National Institute of Integrative Medicine, Australia.,University of Adelaide, Australia.,Torrens University, Australia
| | - Irene Hudson
- Centre for Human Psychopharmacology, 3783Swinburne University of Technology, Australia.,Department of Mathematical Sciences, 5376Royal Melbourne Institute of Technology (RMIT), Australia.,School of Mathematical and Physical Science, University of Newcastle, Australia
| | - Andrew Pipingas
- Centre for Human Psychopharmacology, 3783Swinburne University of Technology, Australia
| | - Andrew Scholey
- Centre for Human Psychopharmacology, 3783Swinburne University of Technology, Australia
| | - Avni Sali
- 296252The National Institute of Integrative Medicine, Australia
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Franco JG, Molano JC, Rincón H, Velasquez Tirado JD, Cardeño C, Patarroyo Rodriguez L, Oviedo Lugo GF, Bernal Miranda J, Rojas Moreno M. Consensus of the Liaison-Psychiatry Committee of the Colombian Psychiatric Association on the Diagnosis and Treatment of Delirium in the Context of the COVID-19 Pandemic. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 51:S0034-7450(20)30118-9. [PMID: 33735042 PMCID: PMC7709601 DOI: 10.1016/j.rcp.2020.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/14/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
The pandemic caused by the new coronavirus named SARS-CoV-2 poses unprecedented challenges in the health care. Among them is the increase in cases of delirium. The severe SARS-CoV-2 disease, COVID-19, has common vulnerabilities with delirium and produces alterations in organs such as the lungs or the brain, among others, which have the potential to trigger the mental disorder. In fact, delirium may be the first manifestation of the infection, before fever, general malaise, cough or respiratory disturbances. It is widely supported that delirium increases the morbidity and mortality in those who suffer from it during hospitalization, so it should be actively sought to carry out the relevant interventions. In the absence of evidence on the approach to delirium in the context of COVID-19, this consensus was developed on three fundamental aspects: diagnosis, non-pharmacological treatment and pharmacological treatment, in patients admitted to the general hospital. The document contains recommendations on the systematic use of diagnostic tools, when to hospitalize the patient with delirium, the application of non-pharmacological actions within the restrictions imposed by COVID-19, and the use of antipsychotics, taking into account the most relevant side effects and pharmacological interactions.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Hernán Rincón
- Hospital Universitario Fundación Valle del Lili, Cali, Colombia; Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
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35
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Prevalence and management of delirium in intensive care units in the Netherlands: An observational multicentre study. Intensive Crit Care Nurs 2020; 61:102925. [DOI: 10.1016/j.iccn.2020.102925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 01/06/2023]
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Morandi A, Inzitari M, Udina C, Gual N, Mota M, Tassistro E, Andreano A, Cherubini A, Gentile S, Mossello E, Marengoni A, Olivé A, Riba F, Ruiz D, de Jaime E, Bellelli G. Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study. J Am Med Dir Assoc 2020; 22:1162-1167.e3. [PMID: 33160873 DOI: 10.1016/j.jamda.2020.09.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/16/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. DESIGN Cross-sectional study nested in the 2017 "Delirium Day" project. SETTING AND PARTICIPANTS Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. METHODS Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). RESULTS A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). CONCLUSIONS AND IMPLICATIONS Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy; REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain.
| | - Marco Inzitari
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Udina
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Neus Gual
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Miriam Mota
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Anita Andreano
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA Ancona, Italy
| | - Simona Gentile
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Enrico Mossello
- University of Florence, Carreggi University Hospital, Florence, Italy
| | - Alessandra Marengoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Anna Olivé
- Hospital Mare de Déu de la Mercè, Barcelona, Spain
| | - Francesc Riba
- Hospital de la Santa Creu, Jesus-Tortors, Tarragona, Spain
| | - Domingo Ruiz
- Fundació Althaia, Manresa, Spain; Universitat de Vic-Universitat Central de Catalunya, Barcelona, Spain
| | - Elisabet de Jaime
- Geriatrics Department, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Giuseppe Bellelli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy; Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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Delirium Superimposed on Dementia in Perioperative Period and Intensive Care. J Clin Med 2020; 9:jcm9103279. [PMID: 33066174 PMCID: PMC7601948 DOI: 10.3390/jcm9103279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022] Open
Abstract
Delirium is a life-threatening condition, the causes of which are still not fully understood. It may develop in patients with pre-existing dementia. Delirium superimposed on dementia (DSD) can go completely unnoticed with routine examination. It may happen in the perioperative period and in the critical care setting, especially in the ageing population. Difficulties in diagnosing and lack of specific pharmacological and non-pharmacological treatment make DSD a seriously growing problem. Patient-oriented, multidirectional preventive measures should be applied to reduce the risk of DSD. For this reason, anesthesiologists and intensive care specialists should be aware of this interesting condition in their everyday clinical practice.
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Chen J, Yu J, Zhang A. Delirium risk prediction models for intensive care unit patients: A systematic review. Intensive Crit Care Nurs 2020; 60:102880. [PMID: 32684355 DOI: 10.1016/j.iccn.2020.102880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 04/08/2020] [Accepted: 04/18/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To systematically review the delirium risk prediction models for intensive care unit (ICU) patients. METHODS A systematic review was conducted. The Cochrane Library, PubMed, Ovid and Web of Science were searched to collect studies on delirium risk prediction models for ICU patients from database establishment to 31 March 2019. Two reviewers independently screened the literature according to the pre-determined inclusion and exclusion criteria, extracted the data and evaluated the risk of bias of the included studies using the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) checklist. A descriptive analysis was used to describe and summarise the data. RESULTS A total of six models were included. All studies reported the area under the receiver operating characteristic curve (AUROC) of the prediction models in the derivation and (or) validation datasets as over 0.7 (from 0.75 to 0.9). Five models reported calibration metrics. Decreased cognitive reserve and the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score were the most commonly reported predisposing and precipitating factors, respectively, of ICU delirium among all models. The small sample size, lack of external validation and the absence of or unreported blinding method increased the risk of bias. CONCLUSION According to the discrimination and calibration statistics reported in the original studies, six prediction models may have moderate power in predicting ICU delirium. However, this finding should be interpreted with caution due to the risk of bias in the included studies. More clinical studies should be carried out to validate whether these tools have satisfactory predictive performance in delirium risk prediction for ICU patients.
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Affiliation(s)
- Junshan Chen
- Department of Intensive Care Unit, The Jinling Hospital Affiliated Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, PR China
| | - Jintian Yu
- Department of Intensive Care Unit, The Jinling Hospital Affiliated Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, PR China
| | - Aiqin Zhang
- Department of Professional Training of Clinical Nursing, the Jinling Hospital Affiliated Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, PR China.
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Gravante F, Giannarelli D, Pucci A, Gagliardi AM, Mitello L, Montagna A, Latina R. Prevalence and risk factors of delirium in the intensive care unit: An observational study. Nurs Crit Care 2020; 26:156-165. [PMID: 32633010 DOI: 10.1111/nicc.12526] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/25/2020] [Accepted: 06/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several risk factors, such as age, alcohol abuse, dementia, and severe illness, can contribute to the development of delirium. However, limited information is available in the literature regarding the risk of delirium among surgical, trauma, neurological, and medical intensive care patients. AIM To describe the prevalence of risk factors associated with delirium in intensive care units. DESIGN This study used an observational design. METHODS We enrolled 165 patients hospitalized in two intensive care units in Italy. Patients were first evaluated using the Prediction of Delirium model and were subsequently evaluated using the Intensive Care Delirium Screening Checklist; evaluation lasted a maximum of 5 days for each admitted patient after sedation. A logistic regression model was used to identify the prevalence and risk factors of delirium. RESULTS The average age of the patients was 57.6 (SD = 18.3) years, and the patients were predominantly male (65.0%). The majority of patients had been subjected to trauma (38.8%); 37.6% had undergone general surgical interventions, and 23.6% had undergone medical interventions. Delirium occurred in 55.8% of the 165 patients. The risk of delirium was independently associated with coma (odds ratio = 10.6; 95% confidence interval, 3.08-39.9) and the Acute Physiology and Chronic Health Evaluation II score (odds ratio = 4.27; 95% confidence interval, 1.58-11.53). CONCLUSIONS This study confirmed that coma and the Acute Physiology and Chronic Health Evaluation II score were non-modifiable risk factors for delirium. Further studies could categorize the different types of coma. Proper delirium management could limit the impact on the recovery of these patients, their autonomy, and their reintegration into the social and professional world. RELEVANCE TO CLINICAL PRACTICE Delirium increases intensive care unit and hospital length of stay. Early identification and risk factor assessment by critical care nurses are considered the key factors in the treatment of delirium.
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Affiliation(s)
- Francesco Gravante
- Department of Anesthesiology, Intensive Care Unit Local Health Authority of Caserta, Caserta, Italy
| | - Diana Giannarelli
- Biostatistical Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Antonello Pucci
- Department of Health Profession, Intensive Care Unit AO S. Camillo-Forlanini Hospital, Rome, Italy
| | - Anna Maria Gagliardi
- Maternal Neonatal Department, Delivery Room Burlo Garofolo Scientific Institute for Health (IRCCS), Trieste, Italy
| | - Lucia Mitello
- Department of Health Profession, School of Nursing and Midwifery AO S. Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
| | - Attilio Montagna
- Department of Health Profession, Intensive Care Unit AO S. Camillo-Forlanini Hospital, Rome, Italy
| | - Roberto Latina
- Department of Health Profession, School of Nursing and Midwifery AO S. Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
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Activity-based occupational therapy intervention for delirium superimposed on dementia in nursing home setting: a feasibility study. Aging Clin Exp Res 2020; 32:827-833. [PMID: 31768877 DOI: 10.1007/s40520-019-01422-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Multi-component interventions can reduce delirium incidence. Occupational therapy (OT) has been effective in the management of dementia. We designed a real-world feasibility study of an OT intervention in the management of delirium superimposed on dementia (DSD). METHODS We included a convenient sample of 22 patients older than 65 years of age with delirium and moderate dementia admitted to a nursing home (NH). The OT procedures were standardized according to the level of agitation or sedation of the patient and based on a structured OT evaluation. The Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution. RESULTS The mean age was 86.45 ± 6.46 years. The first daily treatment was delivered in the entire sample, while the second was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6. The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min. The mean time of the first treatment varied day 1 through day 6 from 14.8 ± 8.5 to 20 ± 0 min, while the second treatment from 3.9 ± 6.7 to 20.1 ± 0 min. The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution. CONCLUSIONS This is the first study to report the feasibility of an OT intervention for the management of DSD in a NH setting. The results are important to support future trials on delirium management in a setting often understudied and underrepresented.
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Vreeswijk R, Kalisvaart I, Maier AB, Kalisvaart KJ. Development and validation of the delirium risk assessment score (DRAS). Eur Geriatr Med 2020; 11:307-314. [PMID: 32297197 DOI: 10.1007/s41999-019-00287-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/27/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Development and validation of a delirium risk assessment score. Predisposing risk factors for delirium were used, which are easily assessed at hospital admission without additional clinical or laboratory testing. METHODS A systematic literature search identified ten risk factors: acute admission, alcohol use > 4 units/day, cognitive impairment, ADL impairment, age > 75 years, earlier delirium, hearing/vision problems, number of medication ≥ 5, number of morbidities > 2 and male. The DRAS was developed in a mixed patient population (N = 842) by the use of univariate and multivariate analyses and -2 log-likelihood calculation to weigh the risk factors. Based on the sensitivity and specificity, a cutoff score was calculated. The validation was performed in 3 cohorts (N = 408, N = 186, N = 365). In cohort 3, the DRAS was compared (AUC, sensitivity and specificity) to 3 instruments (Inouye, Kalisvaart, VMS rules). RESULTS The delirium incidence was 31.8%, 20.3%, 15.6% and 15.1%. All risk factors were independently predictive for delirium, except male. The multivariate analyses excluded morbidities. The final DRAS consists of 8 items; acute admission, cognitive impairment, alcohol use (3 points), ADLimpairment/mobilityproblems (2 points), higher age, earlier delirium, hearing/vision problems, and medication (1 point). The total score is 15 points and at a cut-of score of 5 or higher the patient is at risk of developing a delirium. The cutoff was at 5 or more points, AUC: 0.76 (95% CI 0.72-0.79), sensitivity 0.77, specificity 0.60. Validation cohorts AUC was 0.75 (95% CI 0.96-0.81), 0.76 (95% CI 0.70-0.83) and 0.78 (95% CI 0.70-0.87), sensitivity 0.71, 0.67 and 0.89 and specificity 0.70, 0.72 and 0.60. The comparison revealed the highest AUC for the DRAS. CONCLUSION Based on an admission interview, the delirium risk can be easily evaluated using the DRAS shortlist score of predisposing risk factors for delirium in older inpatients.
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Affiliation(s)
- Ralph Vreeswijk
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - Imke Kalisvaart
- Health Care Inspectorate (IGJ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Kees J Kalisvaart
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands
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Gual N, García-Salmones M, Brítez L, Crespo N, Udina C, Pérez LM, Inzitari M. The role of physical exercise and rehabilitation in delirium. Eur Geriatr Med 2020; 11:83-93. [PMID: 32297245 PMCID: PMC7224129 DOI: 10.1007/s41999-020-00290-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/15/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research. METHODS In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other. RESULTS This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function. CONCLUSION The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.
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Affiliation(s)
- N Gual
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain. .,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M García-Salmones
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - L Brítez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - N Crespo
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain
| | - C Udina
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L M Pérez
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - M Inzitari
- Parc Sanitari Pere Virgili, Carrer d'Esteve Terradas 30, 08023, Barcelona, Spain.,REFiT Barcelona Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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Pasinska P, Kowalska K, Klimiec E, Wilk A, Szyper-Maciejowska A, Dziedzic T, Klimkowicz-Mrowiec A. Poststroke Delirium Clinical Motor Subtypes: The PRospective Observational POLIsh Study (PROPOLIS). J Neuropsychiatry Clin Neurosci 2019; 31:104-111. [PMID: 30404531 DOI: 10.1176/appi.neuropsych.18040073] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although delirium is the most common neurobehavioral complication after stroke, its motor subtypes-hypoactive, hyperactive, mixed, and none-as well as their risk factors are not well characterized. Motor subtypes influence recognition and prognosis of delirium in hospitalized patients. METHODS The aim of this prospective study was to assess the frequency of poststroke delirium subtypes and to describe their predictive models. Consecutive patients with stroke were screened for delirium with the Confusion Assessment Method for the Intensive Care Unit. Delirium was diagnosed according to DSM-5 criteria, and subtypes were classified with the Delirium Motor Subtype Scale-4. Baseline demographic characteristics, biochemistry, stroke-related data, medications, neurological deficits, and premorbid cognitive and functional impairments were assessed. RESULTS Out of 750 patients (mean age, 71.75 years [SD=13.13]), 203 (27.07%) had delirium: 85 (11.34%) were hypoactive, 77 (10.27%) were mixed hypoactive-hyperactive, 31 (4.13%) were hyperactive, and 10 (1.33%) had an unspecified type. Cognitive impairment at the time of hospital admission and spatial neglect, among other factors, were identified as the best predictors for all motor delirium subtypes. CONCLUSIONS Screening for poststroke delirium is important because the hypoactive subtype bears the worst prognosis and is misdiagnosed the most compared with other subtypes. All identified factors for the predictive models of delirium subtypes are routinely assessed during hospital admission. Their occurrence in patients with stroke should alert the treating physician to the high risk for a particular delirium subtype.
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Affiliation(s)
- Paulina Pasinska
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Katarzyna Kowalska
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Elzbieta Klimiec
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Aleksander Wilk
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Aleksandra Szyper-Maciejowska
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Tomasz Dziedzic
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
| | - Aleksandra Klimkowicz-Mrowiec
- From the Department of Neurology, School of Medicine, Jagiellonian University, Krakow, Poland (PP, KK, EK, AW, AS-M, TD, AK-M)
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Abstract
PURPOSE Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia. METHODS This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD. RESULTS There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia. CONCLUSIONS It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.
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Lee SJ, Jung SH, Lee SU, Lim JY, Yoon KS, Lee SY. Postoperative delirium after hip surgery is a potential risk factor for incident dementia: A systematic review and meta-analysis of prospective studies. Arch Gerontol Geriatr 2019; 87:103977. [PMID: 31751902 DOI: 10.1016/j.archger.2019.103977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although a few trials have explored the relationship between postoperative delirium (POD) and incident dementia in patients with hip surgery, the numbers of participants in each study are relatively small. Thus, we performed a meta-analysis to examine whether POD after hip surgery is a risk factor for incident dementia. METHODS Six prospective cohort studies investigating the development of incident dementia in patients with POD after hip surgery were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- and random- effect models. RESULTS POD significantly increased the risk of incident dementia and cognitive decline (overall odds ratio [ORs] = 8.957; 95 % confidence interval [CI], 5.444-14.737; P < 0.001 in fixed-effects model; overall ORs = 8.962; 95 % CI, 5.344-15.029; P < 0.001 in random-effects model). A publication bias was not evident in this study. CONCLUSIONS Our meta-analysis revealed that POD after hip surgery is a risk factor for incident dementia. Early identification of cognitive function should be needed after surgery and appropriate prevention and treatment for dementia will be required, especially in cases with POD.
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Affiliation(s)
- Soong Joon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Shi-Uk Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kang-Sup Yoon
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.
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Moazam C, Hirst J, Mesarwi P, Atayee RS. Ketamine: When Delirium and Desperation Call for a Hero. J Pain Palliat Care Pharmacother 2019; 33:120-124. [DOI: 10.1080/15360288.2019.1686099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Postoperative Delirium is Associated with Negative Outcomes and Long-Term Mortality in Elderly Koreans: A Retrospective Observational Study. ACTA ACUST UNITED AC 2019; 55:medicina55100618. [PMID: 31547219 PMCID: PMC6843516 DOI: 10.3390/medicina55100618] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 01/31/2023]
Abstract
Background and objectives: Delirium is an acute state that causes confusion and occurs frequently after surgery in elderly patients. Delirium is also related to various clinical complications. With increasing numbers of surgeries performed on elderly Koreans, the number of cases of delirium and associated complications will likely rise. The purpose of the present study was to determine whether postoperative delirium in elderly Korean patients negatively influenced other clinical outcomes and their long-term mortality. Materials and Methods: The medical records of 1016 elderly patients (65 years or older) who underwent major abdominal surgery from January 2014 to December 2016 were retrospectively investigated. To determine long-term mortality, patients were followed for up to 12 months post-operation. Results: Delirium occurred in 194 patients (18.3%). Postoperative delirium was significantly associated with the length of hospital stay (B = 2.72), length of ICU stay (B = 18.78), adverse medical events (OR = 2.26, CI = 1.45–3.52), reoperation (OR = 5.50, CI = 1.66–18.22), ICU readmission (OR = 14.10, CI = 2.97–66.90), medical costs (B = 2473.85), discharge to somewhere other than the patient’s home (OR = 6.01, CI = 3.35–10.76), hospital readmission (OR = 2.73, CI = 1.45–5.14), in-hospital mortality (OR = 3.34, CI = 1.21–9.19), three-month mortality (HR = 3.22, CI = 1.27–8.14), six-month mortality (HR = 2.85, CI = 1.28–6.36), and 12-month mortality (HR = 2.19, CI = 1.10–4.32). Conclusions: Postoperative delirium in elderly Korean patients was associated with negative clinical outcomes and mortality. For rapid recovery and increased survival rates in surgical patients, effective delirium-prevention care and active delirium treatments are necessary.
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Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study. PLoS One 2019; 14:e0218152. [PMID: 31194798 PMCID: PMC6564537 DOI: 10.1371/journal.pone.0218152] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients. Methods A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients’ physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality. Result A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes. Conclusion Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation. Trial registration Dutch Trial Registration, NTR5932.
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Abstract
Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 311 Oxford House, Nashville, TN 37232, USA.
| | - Joe Suyama
- Department of Emergency Medicine, Magee-Womens Hospital of UPMC, University of Pittsburgh School of Medicine, 3600 Forbes Tower, Pittsburgh, PA 15213, USA
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LaHue SC, Douglas VC, Kuo T, Conell CA, Liu VX, Josephson SA, Angel C, Brooks KB. Association between Inpatient Delirium and Hospital Readmission in Patients ≥ 65 Years of Age: A Retrospective Cohort Study. J Hosp Med 2019; 14:201-206. [PMID: 30933669 PMCID: PMC6628723 DOI: 10.12788/jhm.3130] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 11/20/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delirium affects more than seven million hospitalized adults in the United States annually. However, its impact on postdischarge healthcare utilization remains unclear. OBJECTIVE To determine the association between delirium and 30-day hospital readmission. DESIGN A retrospective cohort study. SETTING A general community medical and surgical hospital. PATIENTS All adults who were at least 65 years old, without a history of delirium or alcohol-related delirium, and were hospitalized from September 2010 to March 2015. MEASUREMENTS The patients deemed at risk for or displaying symptoms of delirium were screened by nurses using the Confusion Assessment Method with a followup by a staff psychiatrist for a subset of screen-positive patients. Patients with delirium confirmed by a staff psychiatrist were compared with those without delirium. The primary outcome was the 30-day readmission rate. The secondary outcomes included emergency department (ED) visits 30 days postdischarge, mortality during hospitalization and 30 days postdischarge, and discharge location. RESULTS The cohort included 718 delirious patients and 7,927 nondelirious patients. Using an unweighted multivariable logistic regression, delirium was determined to be significantly associated with the increased odds of readmission within 30 days of discharge (odds ratio (OR): 2.60; 95% CI, 1.96-3.44; P < .0001). Delirium was also significantly (P < .0001) associated with ED visits within 30 days postdischarge (OR: 2.18; 95% CI: 1.77-2.69) and discharge to a facility (OR: 2.52; 95% CI: 2.09-3.01). CONCLUSIONS Delirium is a significant predictor of hospital readmission, ED visits, and discharge to a location other than home. Delirious patients should be targeted to reduce postdischarge healthcare utilization.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
- Corresponding Author: Sara Catherine LaHue, MD; E-mail: ; Telephone: 415-476-1489
| | - Vanja C. Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
| | - Teresa Kuo
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Carol A Conell
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Vincent X Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - S Andrew Josephson
- Department of Neurology, School of Medicine, University of California, San Francisco, California
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, California
| | - Clay Angel
- Department of Hospital Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Kristen B Brooks
- Department of Psychiatry, Kaiser Permanente San Rafael Medical Center, San Rafael, California
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