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Porta G, Signorini F, Converso M, Cavalot G, Caramello V, Rossi C, Aprà F, Beltrame A, Boccuzzi A, Boverio R, Calci M, Castaldo E, Covella M, Cuppini P, Ghilardi GI, Mirante E, Noto P, Pierpaoli L, Parpaglia PP, Ricchiardi A, Zanetti M, Zatelli D, Nattino G, Bertolini G. The Fenice project to evaluate and improve the quality of healthcare in high-dependency care units: results after the first year. Intern Emerg Med 2024:10.1007/s11739-024-03640-5. [PMID: 38761333 DOI: 10.1007/s11739-024-03640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
High-Dependency care Units (HDUs) have been introduced worldwide as intermediate wards between Intensive Care Units (ICUs) and general wards. Performing a comparative assessment of the quality of care in HDU is challenging because there are no uniform standards and heterogeneity among centers is wide. The Fenice network promoted a prospective cohort study to assess the quality of care provided by HDUs in Italy. This work aims at describing the structural characteristics and admitted patients of Italian HDUs. All Italian HDUs affiliated to emergency departments were eligible to participate in the study. Participating centers reported detailed structural information and prospectively collected data on all admitted adult patients. Patients' data are presented overall and analyzed to evaluate the heterogeneity across the participating centers. A total of 12 HDUs participated in the study and enrolled 3670 patients. Patients were aged 68 years on average, had multiple comorbidities and were on major chronic therapies. Several admitted patients had at least one organ failure (39%). Mortality in HDU was 8.4%, raising to 16.6% in hospital. While most patients were transferred to general wards, a small proportion required ICU transfer (3.9%) and a large group was discharged directly home from the HDU (31%). The expertise of HDUs in managing complex and fragile patients is supported by both the available equipment and the characteristics of admitted patients. The limited proportion of patients transferred to ICUs supports the hypothesis of preventing of ICU admissions. The heterogeneity of HDU admissions requires further research to define meaningful patients' outcomes to be used by quality-of-care assessment programs.
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Affiliation(s)
- Giovanni Porta
- Department of Emergency Medicine, Santa Maria Delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Fabiola Signorini
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | | | - Giulia Cavalot
- High Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Valeria Caramello
- Department of Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Carlotta Rossi
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy.
| | - Franco Aprà
- High Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Angela Beltrame
- Pronto Soccorso E Medicina d'Urgenza, Ca Foncello ULSS9, Treviso, Italy
| | - Adriana Boccuzzi
- Department of Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Riccardo Boverio
- Department of Emergency Medicine, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Mario Calci
- Pronto Soccorso E Medicina d'Urgenza, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria Della Misericordia" Di Udine, Udine, Italy
| | | | | | | | - Giulia Irene Ghilardi
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | | | - Paola Noto
- Department of Emergency Medicine, Azienda Ospedaliero Universitario Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Lucia Pierpaoli
- Emergency Medicine, S. Maria Delle Croci Hospital, Ravenna, Italy
| | | | | | - Michele Zanetti
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Daniela Zatelli
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Giovanni Nattino
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Guido Bertolini
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
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Guo H, Li LH, Lv XH, Su FZ, Chen J, Xiao F, Shi M, Xie YB. Association Between Preoperative Sleep Disturbance and Postoperative Delirium in Elderly: A Retrospective Cohort Study. Nat Sci Sleep 2024; 16:389-400. [PMID: 38646462 PMCID: PMC11032121 DOI: 10.2147/nss.s452517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Postoperative sleep disturbance, characterized by diminished postoperative sleep quality, is a risk factor for postoperative delirium (POD); however, the association between pre-existing sleep disturbance and POD remains unclear. This study aimed to evaluate the association between preoperative sleep disturbance and POD in elderly patients after non-cardiac surgery. Patients and methods This retrospective cohort study was conducted at a single center and enrolled 489 elderly patients who underwent surgery between May 1, 2020, and March 31, 2021. Patients were divided into the sleep disorder (SD) and non-sleep disorder (NSD) groups according to the occurrence of one or more symptoms of insomnia within one month or sleep- Numerical Rating Scale (NRS)≥6 before surgery. The primary outcome was the incidence of POD. Propensity score matching analysis was performed between the two groups. Multiple logistic regression analysis was performed to identify the risk factors for POD. Results In both the unmatched cohort (16.0% vs 6.7%, P=0.003) and the matched cohort (17.0% vs 6.2%, P=0.023), the incidence of POD was higher in the SD group than in the NSD group. In addition, the postoperative sleep quality and the VAS score at postoperative 24 h were significantly lower in the SD group than in the NSD group. Multivariate logistic regression analysis indicated that age (Odds Ratio, 1.13 [95% CI: 1.04-1.23], P=0.003) and preoperative sleep disturbance (Odds Ratio, 3.03 [95% CI: 1.09-9.52], P=0.034) were independent risk factors for the development of POD. Conclusion The incidence of POD was higher in patients with pre-existing sleep disturbance than those without it. Whether improving sleep quality for preoperative sleep disturbance may help prevent POD remains to be determined.
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Affiliation(s)
- Hao Guo
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Li-Heng Li
- Department of Anesthesiology, The Guilin Municipal Hospital of Traditional Chinese Medicine, Guangxi, People’s Republic of China
| | - Xiao-Hong Lv
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Feng-Zhi Su
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jie Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Fei Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Min Shi
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yu-Bo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Infante S, Behn A, González M, Pintor L, Franco E, Araya P, Maldonado JR. Reliability and Validity of the Spanish Adaptation of the Stanford Proxy Test for Delirium in Two Clinical Spanish-Speaking Communities. J Acad Consult Liaison Psychiatry 2024; 65:136-147. [PMID: 37806639 DOI: 10.1016/j.jaclp.2023.09.004] [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] [Received: 09/21/2022] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies. OBJECTIVE It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method). METHODS The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other. RESULTS In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity. CONCLUSIONS The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version.
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Affiliation(s)
- Sanndy Infante
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile.
| | - Alex Behn
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile
| | - Matías González
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Health Service of Reloncaví, Puerto Montt, Chile
| | - Luis Pintor
- Department of Psychiatry, Hospital Clinic of Barcelona, Barcelona, Spain; School Medicine, University of Barcelona, Barcelona, Spain
| | - Eduardo Franco
- Research Department, Universidad Maria Auxiliadora, Lima, Peru
| | - Pablo Araya
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile
| | - José R Maldonado
- Division of Medical Psychiatry, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
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Jose S, Cyriac MC, Dhandapani M. Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence. Indian J Crit Care Med 2024; 28:111-119. [PMID: 38323249 PMCID: PMC10839928 DOI: 10.5005/jp-journals-10071-24626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/10/2023] [Indexed: 02/08/2024] Open
Abstract
Background Delirium, a prevalent condition among elderly individuals admitted to hospitals, particularly in intensive care settings, necessitates specialized medical intervention. The present study assessed the proficiency of nurses in the management of delirium and their subjective experience of stress while providing care for patients with delirium in emergency rooms and critical care units. Materials and methods The study adopted a quantitative descriptive approach, utilizing standardized self-reporting measures that assessed the nurses' expertise and perceived burden of care. A cohort of 86 nurses from a tertiary care hospital in North India participated in the study. Additionally, the impact of the web-based instructional module in enhancing the nurses' knowledge in delirium management was assessed by one group pretest-posttest quasi-experimental study. Findings The research revealed that nurses exhibited significant deficiencies in their knowledge, particularly in relation to the symptoms and causes of delirium. The most significant source of subjective stress was attributed to hyperactive delirium-associated behaviors, characterized by uncooperative and aggressive conduct. The utilization of the web-based instructional program significantly enhanced the comprehension of nurses about the management of delirium. Conclusion This study revealed a significant knowledge gap among nurses in delirium management and emphasizes the considerable subjective stress, particularly in dealing with hyperactive delirium-associated behaviors. The positive impact of the web-based instructional program underscores its potential as a valuable tool for enhancing nurses' knowledge and addressing these challenges in healthcare settings. How to cite this article Jose S, Cyriac MC, Dhandapani M. Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence. Indian J Crit Care Med 2024;28(2):111-119.
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Affiliation(s)
- Sinu Jose
- Postgraduate Institute of Medical Education and Research, PGIMER, Chandigarh, India
| | | | - Manju Dhandapani
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, PGIMER, Chandigarh, India
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Nagata C, Hata M, Miyazaki Y, Masuda H, Wada T, Kimura T, Fujii M, Sakurai Y, Matsubara Y, Yoshida K, Miyagawa S, Ikeda M, Ueno T. Development of postoperative delirium prediction models in patients undergoing cardiovascular surgery using machine learning algorithms. Sci Rep 2023; 13:21090. [PMID: 38036664 PMCID: PMC10689441 DOI: 10.1038/s41598-023-48418-5] [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: 05/23/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
Associations between delirium and postoperative adverse events in cardiovascular surgery have been reported and the preoperative identification of high-risk patients of delirium is needed to implement focused interventions. We aimed to develop and validate machine learning models to predict post-cardiovascular surgery delirium. Patients aged ≥ 40 years who underwent cardiovascular surgery at a single hospital were prospectively enrolled. Preoperative and intraoperative factors were assessed. Each patient was evaluated for postoperative delirium 7 days after surgery. We developed machine learning models using the Bernoulli naive Bayes, Support vector machine, Random forest, Extra-trees, and XGBoost algorithms. Stratified fivefold cross-validation was performed for each developed model. Of the 87 patients, 24 (27.6%) developed postoperative delirium. Age, use of psychotropic drugs, cognitive function (Mini-Cog < 4), index of activities of daily living (Barthel Index < 100), history of stroke or cerebral hemorrhage, and eGFR (estimated glomerular filtration rate) < 60 were selected to develop delirium prediction models. The Extra-trees model had the best area under the receiver operating characteristic curve (0.76 [standard deviation 0.11]; sensitivity: 0.63; specificity: 0.78). XGBoost showed the highest sensitivity (AUROC, 0.75 [0.07]; sensitivity: 0.67; specificity: 0.79). Machine learning algorithms could predict post-cardiovascular delirium using preoperative data.Trial registration: UMIN-CTR (ID; UMIN000049390).
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Affiliation(s)
- Chie Nagata
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Masahiro Hata
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuki Miyazaki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirotada Masuda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tamiki Wada
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tasuku Kimura
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Makoto Fujii
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yasushi Sakurai
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Yasuko Matsubara
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Kiyoshi Yoshida
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Vlisides PE, Li D, Maywood M, Zierau M, Lapointe AP, Brooks J, McKinney AM, Leis AM, Mentz G, Mashour GA. Electroencephalographic Biomarkers, Cerebral Oximetry, and Postoperative Cognitive Function in Adult Noncardiac Surgical Patients: A Prospective Cohort Study. Anesthesiology 2023; 139:568-579. [PMID: 37364282 PMCID: PMC10592490 DOI: 10.1097/aln.0000000000004664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND Perioperative neurocognitive disorders are a major public health issue, although there are no validated neurophysiologic biomarkers that predict cognitive function after surgery. This study tested the hypothesis that preoperative posterior electroencephalographic alpha power, alpha frontal-parietal connectivity, and cerebral oximetry would each correlate with postoperative neurocognitive function. METHODS This was a single-center, prospective, observational study of adult (older than 18 yr) male and female noncardiac surgery patients. Whole-scalp, 16-channel electroencephalography and cerebral oximetry were recorded in the preoperative, intraoperative, and immediate postoperative settings. The primary outcome was the mean postoperative T-score of three National Institutes of Health Toolbox Cognition tests-Flanker Inhibitory Control and Attention, List Sorting Working Memory, and Pattern Comparison Processing Speed. These tests were obtained at preoperative baseline and on the first two postoperative mornings. The lowest average score from the first two postoperative days was used for the primary analysis. Delirium was a secondary outcome (via 3-min Confusion Assessment Method) measured in the postanesthesia care unit and twice daily for the first 3 postoperative days. Last, patient-reported outcomes related to cognition and overall well-being were collected 3 months postdischarge. RESULTS Sixty-four participants were recruited with a median (interquartile range) age of 59 (48 to 66) yr. After adjustment for baseline cognitive function scores, no significant partial correlation (ρ) was detected between postoperative cognition scores and preoperative relative posterior alpha power (%; ρ = -0.03, P = 0.854), alpha frontal-parietal connectivity (via weight phase lag index; ρ = -0.10, P = 0.570, respectively), or preoperative cerebral oximetry (%; ρ = 0.21, P = 0.246). Only intraoperative frontal-parietal theta connectivity was associated with postoperative delirium (F[1,6,291] = 4.53, P = 0.034). No electroencephalographic or oximetry biomarkers were associated with cognitive or functional outcomes 3 months postdischarge. CONCLUSIONS Preoperative posterior alpha power, frontal-parietal connectivity, and cerebral oximetry were not associated with cognitive function after noncardiac surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
| | - Duan Li
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Michael Maywood
- Department of Ophthalmology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Mackenzie Zierau
- College of Health Professions, University of Detroit Mercy, Detroit, MI USA
| | - Andrew P. Lapointe
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joseph Brooks
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, MI USA
| | - Amy M. McKinney
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - Aleda M. Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
| | - George A. Mashour
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, MI USA
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [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: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Yu M, Mi J, Zhang C, Chen H, Luo X. Knowledge, attitude and practice regarding hypoactive delirium among ICU nurses: A nationwide cross-sectional study. Nurse Educ Pract 2023; 72:103749. [PMID: 37660518 DOI: 10.1016/j.nepr.2023.103749] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
AIMS AND OBJECTIVES This study aimed to assess the knowledge, attitude and practice (KAP) of intensive care unit (ICU) nurses in patients with hypoactive delirium in China. BACKGROUND The presentation of hypoactive delirium is not obvious and tends to be ignored. However, it has a high incidence and can cause critical impairment. Although nurses are the primary caregivers of patients, the evidence of the current status of KAP of hypoactive delirium among ICU nurses is insufficient in China. DESIGN The study participants were 2835 ICU nurses from 201 hospitals in 69 cities from 31 provinces in China. METHODS The current status of KAP of hypoactive delirium among ICU nurses was determined using a self-reported structured questionnaire, including 52 questions covering general personal information; three dimensions of KAP; and relevant issues. Descriptive analyses of the sample distribution were reported as percentages and medians. The factors were detected using univariate and multivariate analyses. To guide the reporting of the research, a STROBE checklist of cross-sectional studies was used. RESULTS Of the 3101 returned questionnaires, 2835 were analyzed. Approximately 64. 94 % and 53. 30 % of them were identified with a positive attitude and appropriate practice, respectively, whereas only 1. 48 % showed a good level of knowledge. The regression analysis showed that age, years of working in the ICU, educational background, professional title, caring for patients with delirium, attending training on hypoactive delirium and hospital grading were significantly associated with their KAP status(P<005). CONCLUSIONS Hypoactive delirium is an ignored entity by nursing professionals, with no definite nursing procedure. This study shows that receiving relevant training is a factor affecting KAP status, indicating that training should be strengthened. Additionally, appropriate screening and nursing procedures should be developed to standardize the behavior of ICU nurses and improve the quality of care. RELEVANCE TO CLINICAL PRACTICE ICU nurses have poor knowledge of hypoactive delirium and related training should be strengthened, especially for middle-aged nurses. Screening and nursing procedures should be set up, which is critical to promote nursing practice. NO PATIENT OR PUBLIC CONTRIBUTION None.
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Affiliation(s)
- Mengting Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Mi
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Chuanlin Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Luo
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Sri-iesaranusorn P, Sadahiro R, Murakami S, Wada S, Shimizu K, Yoshida T, Aoki K, Uezono Y, Matsuoka H, Ikeda K, Yoshimoto J. Data-driven categorization of postoperative delirium symptoms using unsupervised machine learning. Front Psychiatry 2023; 14:1205605. [PMID: 37441147 PMCID: PMC10333495 DOI: 10.3389/fpsyt.2023.1205605] [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: 04/14/2023] [Accepted: 06/08/2023] [Indexed: 07/15/2023] Open
Abstract
Background Phenotyping analysis that includes time course is useful for understanding the mechanisms and clinical management of postoperative delirium. However, postoperative delirium has not been fully phenotyped. Hypothesis-free categorization of heterogeneous symptoms may be useful for understanding the mechanisms underlying delirium, although evidence is currently lacking. Therefore, we aimed to explore the phenotypes of postoperative delirium following invasive cancer surgery using a data-driven approach with minimal prior knowledge. Methods We recruited patients who underwent elective invasive cancer resection. After surgery, participants completed 5 consecutive days of delirium assessments using the Delirium Rating Scale-Revised-98 (DRS-R-98) severity scale. We categorized 65 (13 questionnaire items/day × 5 days) dimensional DRS-R-98 scores using unsupervised machine learning (K-means clustering) to derive a small set of grouped features representing distinct symptoms across all participants. We then reapplied K-means clustering to this set of grouped features to delineate multiple clusters of delirium symptoms. Results Participants were 286 patients, of whom 91 developed delirium defined according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria. Following the first K-means clustering, we derived four grouped symptom features: (1) mixed motor, (2) cognitive and higher-order thinking domain with perceptual disturbance and thought content abnormalities, (3) acute and temporal response, and (4) sleep-wake cycle disturbance. Subsequent K-means clustering permitted classification of participants into seven subgroups: (i) cognitive and higher-order thinking domain dominant delirium, (ii) prolonged delirium, (iii) acute and brief delirium, (iv) subsyndromal delirium-enriched, (v) subsyndromal delirium-enriched with insomnia, (vi) insomnia, and (vii) fit. Conclusion We found that patients who have undergone invasive cancer resection can be delineated using unsupervised machine learning into three delirium clusters, two subsyndromal delirium clusters, and an insomnia cluster. Validation of clusters and research into the pathophysiology underlying each cluster will help to elucidate the mechanisms of postoperative delirium after invasive cancer surgery.
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Affiliation(s)
| | - Ryoichi Sadahiro
- Department of Immune Medicine, National Cancer Center Research Institute, Tokyo, Japan
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Syo Murakami
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Saho Wada
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
- Department of Neuropsychiatry, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan
| | - Ken Shimizu
- Department of Psycho-Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Teruhiko Yoshida
- Department of Clinical Genomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Kazunori Aoki
- Department of Immune Medicine, National Cancer Center Research Institute, Tokyo, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazushi Ikeda
- Division of Information Science, Nara Institute of Science and Technology, Nara, Japan
| | - Junichiro Yoshimoto
- Division of Information Science, Nara Institute of Science and Technology, Nara, Japan
- Department of Biomedical Data Science, Fujita Health University School of Medicine, Aichi, Japan
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Viderman D, Nabidollayeva F, Aubakirova M, Yessimova D, Badenes R, Abdildin Y. Postoperative Delirium and Cognitive Dysfunction after General and Regional Anesthesia: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12103549. [PMID: 37240655 DOI: 10.3390/jcm12103549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Background: Perioperative disorders of neurocognitive function are a set of heterogeneous conditions, which include transient post-operative delirium (POD) and more prolonged post-operative cognitive dysfunction (POCD). Since the number of annually performed surgical procedures is growing, we should identify which type of anesthesia is safer for preserving neurocognitive function. The purpose of this study was to compare the effect of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing surgical procedures under general anesthesia and regional anesthesia. Material and methods: We searched for randomized controlled studies, which studied post-operative cognitive outcomes after general and regional anesthesia in the adult patient population. Results: Thirteen articles with 3633 patients: the RA group consisted of 1823 patients, and the GA group of 1810 patients, who were selected for meta-analysis. The overall effect of the model shows no difference between these two groups in terms of risk for post-operative delirium. The result is insensitive to the exclusion of any study. There was no difference between RA and GA in terms of post-operative cognitive dysfunction. Conclusions: There was no statistically significant difference between GA and RA in the incidence of POD. There was no statistically significant difference in the incidence of POCD per-protocol analysis, psychomotor/attention tests (preoperative/baseline, post-operative), memory tests (postoperatively, follow up), mini-mental state examination score 24 h postoperatively, post-operative reaction time three months postoperatively, controlled oral word association test, and digit copying test. There were no differences in the incidence of POCD in general and regional anesthesia at one week postoperatively, three months postoperatively, or total events (one week or three months). The incidence of post-operative mortality also did not differ between two groups.
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Affiliation(s)
- Dmitriy Viderman
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
| | - Fatima Nabidollayeva
- School of Engineering and Digital Sciences, Nazarbayev University, 53 Kabanbay Batyr Ave., Astana 010000, Kazakhstan
| | - Mina Aubakirova
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
| | - Dinara Yessimova
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Kerei and Zhanibek Khandar Str. 5/1, Astana 010000, Kazakhstan
| | - Rafael Badenes
- Department of Anaesthesiology and Intensive Care, Hospital Clínico Universitario de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Yerkin Abdildin
- School of Engineering and Digital Sciences, Nazarbayev University, 53 Kabanbay Batyr Ave., Astana 010000, Kazakhstan
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Barra BJ, Barahona M, Varela LF, Calvo P, Bastidas A, Carreño J, Pintor L. A Cross-Sectional, Retrospective, and Comparative Study between Delirium and Non-Delirium Psychiatric Disorders in a Psychogeriatric Inpatient Population Referred to Consultation-Liaison Psychiatry Unit. Medicina (B Aires) 2023; 59:medicina59040693. [PMID: 37109651 PMCID: PMC10141533 DOI: 10.3390/medicina59040693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background and objectives: Delirium is the most prevalent psychiatric disorder in inpatient older people. Its presence is associated with higher rates of institutionalization, functional disability and mortality. This study aims to evaluate delirium in a hospitalized psychogeriatric population, focusing on which factors predict the appearance of delirium, the impact it generates and the diagnostic concordance between non-psychiatric physicians and psychiatrists. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to general hospital and referred from different services to the consultation-liaison psychiatry (CLP) unit. Logistic regression was performed using delirium as the dependent variable. To estimate the concordance of the diagnoses, the Kappa coefficient was used. To assess the impact of delirium, an ordinal regression, Wilcoxon median test and Fisher’s test were performed. Results: Delirium is associated with a higher number of visits, OR 3.04 (95% CI 2.38–3.88), longer length of stay and mortality, OR 2.07 (95% CI, 1.05 to 4.10). The model to predict delirium shows that being >75 years old has an OR of 2.1 (95% CI, 1.59–2.79), physical disability has an OR of 1.66 (95% CI, 1.25–2.20), history of delirium has an OR of 10.56 (95% CI, 5.26–21.18) and no use of benzodiazepines has an OR of 4.24 (95% CI, 2.92–6.14). The concordance between the referring physician’s psychiatric diagnosis and the psychiatrist CLP unit showed a kappa of 0.30. When analysing depression and delirium, the concordance showed Kappa = 0.46. Conclusions: Delirium is a highly prevalent psychiatric disorder, but it is still underdiagnosed, with low diagnostic concordance between non-psychiatric doctors and psychiatrists from CLP units. There are multiple risk factors associated with the appearance of delirium, which must be managed to reduce its appearance.
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Affiliation(s)
- Bernardo J. Barra
- Department of Psychiatry, Hospital Clinic i Provincial of Barcelona, University of Barcelona, 08036 Barcelona, Spain (L.P.)
- Mental Health Service, Clínica Universidad de los Andes, Santiago 7591047, Chile
- Department of Psychiatry, Medicine School, Universidad Andrés Bello (UNAB), Santiago 8370146, Chile;
- Correspondence: ; Tel.: +56-9-9139-9020
| | - Maximiliano Barahona
- Department of Orthopaedic Surgery, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Luis F. Varela
- Department of Psychiatry, Medicine School, Universidad Andrés Bello (UNAB), Santiago 8370146, Chile;
| | - Pilar Calvo
- Medicine School, University of Chile, Santiago 8330015, Chile
| | - Anna Bastidas
- Department of Psychiatry, Hospital Clinic i Provincial of Barcelona, University of Barcelona, 08036 Barcelona, Spain (L.P.)
| | - Jorge Carreño
- Department of Psychiatry, Medicine School, Universidad de Santiago de Chile, Santiago 8380456, Chile
- Department of Psychiatry, Medicine School, Universidad Mayor, Santiago 8330015, Chile
| | - Luis Pintor
- Department of Psychiatry, Hospital Clinic i Provincial of Barcelona, University of Barcelona, 08036 Barcelona, Spain (L.P.)
- Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain
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12
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Zhou W, Bai X, Yang Y, Huang M, Zheng Q, Wu J, Wang R, Gan X. Revelations of delirium subtype research: A bibliometric analysis of publications in the past twenty years in the field. Asian J Psychiatr 2023; 83:103561. [PMID: 36989982 DOI: 10.1016/j.ajp.2023.103561] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/05/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Delirium is an acute confusion state that is common and costly. According to different clinical manifestations, delirium can be divided into three subtypes: hyperactive, hypoactive and mixed. Subtype research has become a necessary branch. However, it is difficult to record all the changes in subtype research. METHODS Publications on delirium subtypes in the Web of Science Core Collection (WOSCC) were identified and analyzed by visualization software VOSviewer and CiteSpace. RESULTS A total of 247 articles published from 1999 to 2022 were identified in the WOSCC, and the largest number of articles was published in 2021 (n = 33). The top three countries that contributed publications were the USA (n = 75), Ireland (n = 26), and the United Kingdom (n = 25), which communicated more often and focused on delirium subtypes earlier. Critical Care Medicine published the most articles regarding delirium subtypes, with 11 publications. Three instrument validation studies were cited most frequently. Six clusters were summarized, including descriptions of delirium among elderly people, delirium research, postoperative delirium, delirium motor subtype validation, critical delirium, and motor characteristics. The "postoperative delirium", "intensive care unit", and "cardiac surgery" keywords were seen in recent years. CONCLUSION Based on this bibliometric analysis of the publications in the last twenty years, a comprehensive analysis of the literature clarified the contributions, changes, and evolution regarding delirium subtypes. This research can provide medical staff and researchers with revelations into future directions of delirium subtype advancements.
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Affiliation(s)
- Wen Zhou
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Xue Bai
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yun Yang
- Department of Geriatrics, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Miao Huang
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Qiulan Zheng
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Jiaqian Wu
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Rui Wang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China; Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Occurrence of Postoperative Delirium and the Use of Different Assessment Tools. Geriatrics (Basel) 2023; 8:geriatrics8010011. [PMID: 36648916 PMCID: PMC9844299 DOI: 10.3390/geriatrics8010011] [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: 11/11/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
(1) Background: Postoperative delirium (POD) poses a high risk of worsening outcomes for patients and is also a burden for hospitals. The leading guidelines recommend standardized POD assessment and prevention. The aim of this subgroup analysis of the PRe-Operative Prediction of Postoperative DElirium by Appropriate SCreening (PROPDESC) trial was to compare different delirium assessments and to analyse the frequency of POD on five postoperative days. (2) Methods: This prospective observational trial enrolled 1097 patients in a university hospital from 2018 until 2019. The following POD assessment tools were used for five consecutive days: Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method for normal ward (CAM), 4 A's Test (4AT) and Delirium Observation Screening (DOS) scale. (3) Results: In a 5-day visit interval, most new POD developments occurred on the first and second postoperative day. A clear recommendation for a specific POD assessment tool based on our results cannot be given. (4) Conclusions: According to guidelines, a POD assessment should take place on the first five postoperative days, but of these, the first two are those of highest POD occurrence. The POD assessment tool used should at best include direct patient questioning and aspects of patient observation.
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Muzzana C, Mantovan F, Huber MK, Trevisani K, Niederbacher S, Kugler A, Ausserhofer D. Delirium in elderly postoperative patients: A prospective cohort study. Nurs Open 2022; 9:2461-2472. [PMID: 35716398 PMCID: PMC9374408 DOI: 10.1002/nop2.1263] [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: 09/22/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN Prospective cohort study. METHODS Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.
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Affiliation(s)
- Chiara Muzzana
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | - Franco Mantovan
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy.,Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
| | | | - Katia Trevisani
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | | | - Alexander Kugler
- Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
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15
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Delirium in Nursing Home Residents: A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10081544. [PMID: 36011202 PMCID: PMC9407867 DOI: 10.3390/healthcare10081544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Delirium is an important component of the geriatric syndromes and has been recognized to negatively influence the prognosis of older people in hospital and in a post-acute setting. About 2–5% of older people world-wide live in nursing homes and are characterized by functional impairment, cognitive decline, dementia, comorbidities, and polypharmacotherapy, all factors which influence the development of delirium. However, in this setting, delirium remains often understudied. Therefore, in this narrative review, we aimed to describe the latest evidence regarding delirium screening tools, epidemiology characteristics, outcomes, risk factors, and preventions strategies in nursing homes.
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16
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Li T, Dong T, Cui Y, Meng X, Dai Z. Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2022; 9:937293. [PMID: 35959124 PMCID: PMC9360531 DOI: 10.3389/fsurg.2022.937293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 12/21/2022] Open
Abstract
Objective Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD. Methods Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model. Results Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63). Conclusions There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Tiantian Dong
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiangrui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
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Mack L, Zonsius MC, Newman M, Emery-Tiburcio EE. Recognizing and Acting on Mentation Concerns. Am J Nurs 2022; 122:50-55. [PMID: 35447655 DOI: 10.1097/01.naj.0000830764.74949.fd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article is the fourth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.
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Affiliation(s)
- Laurin Mack
- Laurin Mack is an assistant professor and Erin E. Emery-Tiburcio is an associate professor in the Department of Psychiatry and Behavioral Sciences at Rush University Medical Center in Chicago, where Mary C. Zonsius is an associate professor in the College of Nursing and Michelle Newman is a program manager in the Department of Social Work and Community Health. Contact author: Erin E. Emery-Tiburcio, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Kim B, Cho J, Park JY, Kim HE, Oh J. Delirium and Anxiety Outcomes Related to Visiting Policy Changes in the Intensive Care Unit During the COVID-19 Pandemic. Front Aging Neurosci 2022; 14:845105. [PMID: 35309896 PMCID: PMC8926309 DOI: 10.3389/fnagi.2022.845105] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the effect of intensive care unit (ICU) visit on the incidence of delirium, delirium subtype, and anxiety level in ICU patients. Methods Trained psychiatrists and nurses evaluated ICU patients for delirium, delirium subtypes, and anxiety. Propensity score matching (PSM) was used to retrospectively analyze the data. Then, we compared the differences in the incidence of delirium, delirium subtypes, and anxiety level before and after the ICU visit ban. Logistic regression was conducted to identify the risk factors for delirium subtypes and high anxiety levels. Results After PSM, there was no statistically significant difference in the incidence of delirium between the non-visiting and restrictive visiting groups (non-visiting 27.4% versus restrictive visiting 30.9%, p = 0.162). The proportion of hyperactive and mixed subtypes was higher in the non-visiting than in the restrictive visiting group (non-visiting 35.3 and 30.1% versus restrictive visiting 27.7 and 20.1%, p = 0.002). The anxiety level was higher in the non-visiting than in the restrictive visiting group (state-trait anxiety inventory score: non-visiting 53.46 ± 4.58 versus restrictive visiting 52.22 ± 6.50, p = 0.009). Patients who stayed in the ICU during the visit ban were more likely to have hyperactive (p = 0.005) and mixed subtype (p = 0.001) than those who did not. Moreover, patients who stayed in the ICU during the visit ban were more likely to experience high anxiety levels than those who did not (p < 0.001). Conclusion Prohibition of ICU visits during COVID-19 pandemic did not affect the incidence of delirium during COVID-19 but could change the delirium subtype and raise anxiety level. Moreover, visiting prohibition was a risk factor for non-hypoactive delirium subtype and high anxiety levels. Therefore, ICU visits are important in dealing with delirium subtypes and anxiety in ICU patients.
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Affiliation(s)
- Bomi Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jooyoung Oh
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Jooyoung Oh,
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Kirfel A, Guttenthaler V, Mayr A, Coburn M, Menzenbach J, Wittmann M. Postoperative delirium is an independent factor influencing the length of stay of elderly patients in the intensive care unit and in hospital. J Anesth 2022; 36:341-348. [PMID: 35182209 PMCID: PMC9156481 DOI: 10.1007/s00540-022-03049-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/05/2022] [Indexed: 12/19/2022]
Abstract
Purpose Postoperative delirium (POD) is an often unrecognized adverse event in older people after surgery. The aim of this subgroup analysis of the PRe-Operative Prediction of postoperative DElirium by appropriate SCreening (PROPDESC) trial in patients aged 70 years and older was to identify preoperative risk factors and the impact of POD on length of stay (LOS) in intensive care unit (ICU) and hospital. Methods Of the total 1097 patients recruited at a German university hospital (from September 2018 to October 2019) in the PROPDESC prospective observational study, 588 patients aged 70 years and older (mean age 77.2 ± 4.7 years) were included for subgroup analysis. The primary endpoint POD was considered positive if one of the following tests were positive on any of the five postoperative visit days: Confusion Assessment Method for ICU (CAM-ICU), Confusion Assessment Method (CAM), 4'A's (4AT) and Delirium Observation Scale (DOS). Trained doctoral students carried out these visitations and additionally the nursing staff were interviewed for completion of the DOS. To evaluate the independent effect of POD on LOS in ICU and in hospital, a multi-variable linear regression analysis was performed. Results The POD incidence was 25.9%. The results of our model showed POD as an independent predictor for a prolonged LOS in ICU (36%; 95% CI 4–78%; < 0.001) and in hospital (22%; 95% CI 4–43%; < 0.001). Conclusion POD has an independent impact on LOS in ICU and in hospital. Based on the effect of POD for the elderly, a standardized risk screening is required. Trail registration German Registry for Clinical Studies: DRKS00015715.
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Affiliation(s)
- Andrea Kirfel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Vera Guttenthaler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Andreas Mayr
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jan Menzenbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Boord MS, Davis DHJ, Psaltis PJ, Coussens SW, Feuerriegel D, Garrido MI, Bourke A, Keage HAD. DelIrium VULnerability in GEriatrics (DIVULGE) study: a protocol for a prospective observational study of electroencephalogram associations with incident postoperative delirium. BMJ Neurol Open 2021; 3:e000199. [PMID: 34964043 PMCID: PMC8653776 DOI: 10.1136/bmjno-2021-000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/07/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Delirium is a neurocognitive disorder common in older adults in acute care settings. Those who develop delirium are at an increased risk of dementia, cognitive decline and death. Electroencephalography (EEG) during delirium in older adults is characterised by slowing and reduced functional connectivity, but markers of vulnerability are poorly described. We aim to identify EEG spectral power and event-related potential (ERP) markers of incident delirium in older adults to understand neural mechanisms of delirium vulnerability. Characterising delirium vulnerability will provide substantial theoretical advances and outcomes have the potential to be translated into delirium risk assessment tools. METHODS AND ANALYSIS We will record EEG in 90 participants over 65 years of age prior to elective coronary artery bypass grafting (CABG) or transcatheter aortic valve implantation (TAVI). We will record 4-minutes of resting state (eyes open and eyes closed) and a 5-minute frequency auditory oddball paradigm. Outcome measures will include frequency band power, 1/f offset and slope, and ERP amplitude measures. Participants will undergo cognitive and EEG testing before their elective procedures and daily postoperative delirium assessments. Group allocation will be done retrospectively by linking preoperative EEG data according to postoperative delirium status (presence, severity, duration and subtype). ETHICS AND DISSEMINATION This study is approved by the Human Research Ethics Committee of the Royal Adelaide Hospital, Central Adelaide Local Health Network and the University of South Australia Human Ethics Committee. Findings will be disseminated through peer-reviewed journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12618001114235 and ACTRN12618000799257.
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Affiliation(s)
- Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, South Australia, Australia
| | | | - Peter J Psaltis
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Scott W Coussens
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, South Australia, Australia
| | - Daniel Feuerriegel
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Marta I Garrido
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Alice Bourke
- Aged Care, Rehabilitation and Palliative Care (Medical), Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, South Australia, Australia
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21
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Postoperative delirium after cardiac surgery of elderly patients as an independent risk factor for prolonged length of stay in intensive care unit and in hospital. Aging Clin Exp Res 2021; 33:3047-3056. [PMID: 33813686 PMCID: PMC8595147 DOI: 10.1007/s40520-021-01842-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/19/2021] [Indexed: 12/20/2022]
Abstract
Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.
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22
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Son CS, Kang WS, Lee JH, Moon KJ. Machine Learning to Identify Psychomotor Behaviors of Delirium for Patients in Long-Term Care Facility. IEEE J Biomed Health Inform 2021; 26:1802-1814. [PMID: 34596563 DOI: 10.1109/jbhi.2021.3116967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study aimed to develop accurate and explainable machine learning models for three psychomotor behaviors of delirium for hospitalized adult patients. A prospective pilot study was conducted with 33 participants admitted to a long-term care facility between August 10 and 25, 2020. During the pilot study, we collected 560 cases that included 33 clinical variables and the survey items from the short confusion assessment method (S-CAM), and developed a mobile-based application. Multiple machine learning algorithms, including four rule-mining algorithms (C4.5, CBA, MCAR, and LEM2) and four other statistical learning algorithms (LR, ANNs, SVMs with three kernel functions, and random forest), were validated by paired Wilcoxon signed-rank tests on both macro-averaged F1 and weighted average F1-measures during the 10-times stratified 2-fold cross-validation. The LEM2 algorithm achieved the best prediction performance (macro-averaged F1-measure of 49.35%; weighted average F1-measure of 96.55%), correctly identifying adult patients at delirium risk. In the pairwise comparison between predictive powers observed from independent models, the LEM2 model showed a medium or large effect size between 0.4925 and 0.8766 when compared with LR, ANN, SVM with RBF, and MCAR models. We have confirmed that acute consciousness in S-CAM assessment is closely associated with different predictors for screening three psychomotor behaviors of delirium: 1) education level, dementia type or its level, sleep disorder, dehydration, and infection in mixed-type delirium; 2) gender, education level, dementia type, dehydration, bedsores, and foley catheter in hyperactive delirium; and 3) pain, sleep disorder, and haloperidol use in hypoactive delirium.
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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24
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Postoperative Delirium in Patients After Brain Tumor Surgery. World Neurosurg 2021; 155:e472-e479. [PMID: 34455093 DOI: 10.1016/j.wneu.2021.08.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium. METHODS Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05. RESULTS Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536). CONCLUSIONS Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.
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Tan H, Zhou L, Wu S, Dong Q, Yang L, Xu J, Zhao S, Wang X, Yang H. Subjective strain of care experienced by pulmonary and critical care medical nurses when caring for patients with delirium: a cross-sectional study. BMC Health Serv Res 2021; 21:808. [PMID: 34384433 PMCID: PMC8361859 DOI: 10.1186/s12913-021-06860-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Delirium, a disorder of consciousness, often occurs for a period of time during hospitalisation. It is characterised by a disturbance of attention or awareness. Hyperactive delirium may lead to accidental removal of medical equipment, while hypoactive delirium may inhibit patients from participating in nursing interventions, medical treatment, and physical therapy. However, there are limited relevant studies of the strain of care of nurses in China when caring for patients with delirium. This study, thus, aimed to investigate the subjective level of the strain of care experienced by pulmonary and critical care nurses when caring for patients with delirium. Methods This was a descriptive, cross-sectional study. A survey was conducted with 100 nurses in the Chinese pulmonary and critical care medical (PCCM) department in 2018. The Strain of Care for Delirium Index (SCDI) was used to measure nurses’ strain of care. Participants were instructed to rate the degree of perceived difficulty in managing patients who displayed the behaviours listed in the SCDI, on a scale from 1 (quite easy) to 4 (very difficult). The mean ± standard deviation (SD) scores of the ranked difficulty scores were calculated. Results In our sample, 47 % of the nurses had received delirium-related training previously. The three wards with the highest strain of care scores when caring for patients with delirium were the chronic obstructive pulmonary disease ward (3.29 ± 0.72), interstitial lung disease ward (3.11 ± 1.31), and respiratory intensive care unit (3.02 ± 0.78). The three types of patient behaviours associated with the highest degree of nursing strain of care were being uncooperative and difficult to manage (3.37 ± 0.84), pulling out tubes and tearing out dressings (3.33 ± 0.98), and irritability (3.22 ± 0.95). Conclusions This study is the first to focus on nurses’ subjective strain of care when caring for patients with delirium in PCCM departments in China. The findings suggest the need to pay more attention to the working status of Chinese nurses. Further trials with large samples assessing relevant outcomes of patients with delirium are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06860-z.
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Affiliation(s)
- Hongyi Tan
- Pulmonary and Critical Care Medicine Department, Huizhou Central People's Hospital, Guangdong Medical University, No. 41, Eling Road, HuiCheng District, Guangdong, 516001, Huizhou, People's Republic of China
| | - Lihua Zhou
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Shuang Wu
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Qiyu Dong
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Liu Yang
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Jiao Xu
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Sue Zhao
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China
| | - Xiaoshan Wang
- Pulmonary and Critical Care Medicine Department, Huizhou Central People's Hospital, Guangdong Medical University, No. 41, Eling Road, HuiCheng District, Guangdong, 516001, Huizhou, People's Republic of China.
| | - Hongzhong Yang
- Pulmonary and Critical Care Medicine Department, Changsha Central Hospital, University of South China, No. 161, Lushan South Road, Yuhua District, Hunan, 410001, Changsha, People's Republic of China.
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Punko D, Hogan C, Quinn D, Kontos N. C-L Case Conference: A 73-Year-Old Man With "Altered Mental Status" and Agitation. J Acad Consult Liaison Psychiatry 2021; 62:485-492. [PMID: 34256179 DOI: 10.1016/j.jaclp.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Diana Punko
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Charlotte Hogan
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Davin Quinn
- Division of Behavioral Health Consultation and Integration, Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM
| | - Nicholas Kontos
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Rengel KF, Hayhurst CJ, Jackson JC, Boncyk CS, Patel MB, Brummel NE, Shi Y, Shotwell MS, Ely EW, Pandharipande PP, Hughes CG. Motoric Subtypes of Delirium and Long-Term Functional and Mental Health Outcomes in Adults After Critical Illness. Crit Care Med 2021; 49:e521-e532. [PMID: 33729717 PMCID: PMC8634774 DOI: 10.1097/ccm.0000000000004920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Adult ICU survivors that experience delirium are at high risk for developing new functional disabilities and mental health disorders. We sought to determine if individual motoric subtypes of delirium are associated with worse disability, depression, and/or post-traumatic stress disorder in ICU survivors. DESIGN Secondary analysis of a prospective multicenter cohort study. SETTING Academic, community, and Veteran Affairs hospitals. PATIENTS Adult ICU survivors of respiratory failure and/or shock. INTERVENTIONS We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation and Sedation Scale daily during hospitalization. We classified delirium as hypoactive (Richmond Agitation and Sedation Scale ≤ 0) or hyperactive (Richmond Agitation and Sedation Scale > 0). At 3- and 12-month postdischarge, we assessed for dependence in activities of daily living and instrumental activities of daily living, symptoms of depression, and symptoms of post-traumatic stress disorder. Adjusting for baseline and inhospital covariates, multivariable regression examined the association of exposure to delirium motoric subtype and long-term outcomes. MEASUREMENTS AND MAIN RESULTS In our cohort of 556 adults with a median age of 62 years, hypoactive delirium was more common than hyperactive (68.9% vs 16.8%). Dependence on the activities of daily living was present in 37% at 3 months and 31% at 12 months, whereas dependence on instrumental activities of daily living was present in 63% at 3 months and 56% at 12 months. At both time points, depression and post-traumatic stress disorder rates were constant at 36% and 5%, respectively. Each additional day of hypoactive delirium was associated with higher instrumental activities of daily living dependence at 3 months only (0.24 points [95% CI, 0.07-0.41; p = 0.006]). There were no associations between the motoric delirium subtype and activities of daily living dependence, depression, or post-traumatic stress disorder. CONCLUSIONS Longer duration of hypoactive delirium, but not hyperactive, was associated with a minimal increase in early instrumental activities of daily living dependence scores in adult survivors of critical illness. Motoric delirium subtype was neither associated with early or late activities of daily living functional dependence or mental health outcomes, nor late instrumental activities of daily living functional dependence.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Surgery, Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Departments of Neurosurgery, and Hearing & Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Internal Medicine, Division of Pulmonary, Allery, Critical Care, and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
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Glynn K, McKenna F, Lally K, O'Donnell M, Grover S, Chakrabarti S, Avasthi A, Mattoo SK, Sharma A, Gosh A, Shah R, Hickey D, Fitzgerald J, Davis B, O'Regan N, Adamis D, Williams O, Awan F, Dunne C, Cullen W, McInerney S, McFarland J, Jabbar F, O'Connell H, Trzepacz PT, Leonard M, Meagher D. How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients. BMJ Open 2021; 11:e041214. [PMID: 33853791 PMCID: PMC8054089 DOI: 10.1136/bmjopen-2020-041214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN Cross-sectional study. SETTING International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Muireann O'Donnell
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Sandeep Grover
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajit Avasthi
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K Mattoo
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Gosh
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ruchita Shah
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David Hickey
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - James Fitzgerald
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Brid Davis
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - Olugbenja Williams
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Fahad Awan
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - C Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - John McFarland
- Clare Mental Health Services, Ennis General Hospital, Clare, Ireland
| | | | | | - Paula T Trzepacz
- Lilly Research Laboratories, Indianapolis, Indiana, USA
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - David Meagher
- Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Davies N. Preventing, identifying and managing delirium in nursing homes and acute settings. Nurs Older People 2021; 33:33-42. [PMID: 33655732 DOI: 10.7748/nop.2021.e1259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 11/09/2022]
Abstract
Older people, particularly those in nursing homes, are vulnerable to delirium, which is a condition characterised by confusion. This article outlines the risk factors, prevention, identification and management of delirium in older people in nursing homes and acute settings. It uses a case study approach to encourage nurses to consider the challenges faced in these settings and how they could address delirium. The article also details the multicomponent interventions that can be used for prevention, as well as the available delirium assessment tools, with a focus on selecting tools based on the person's health status and the healthcare setting.
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Affiliation(s)
- Nicola Davies
- Health Psychology Consultancy Ltd, Stoke-on-Trent, England
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30
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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31
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 373] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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32
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Deng Y, Wang R, Li S, Zhu X, Wang T, Wu J, Zhang J. Methylene blue reduces incidence of early postoperative cognitive disorders in elderly patients undergoing major non-cardiac surgery: An open-label randomized controlled clinical trial. J Clin Anesth 2020; 68:110108. [PMID: 33091706 DOI: 10.1016/j.jclinane.2020.110108] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE The purpose of the present study was to investigate whether methylene blue (MB) could reduce the incidences of postoperative delirium (POD) and early postoperative cognitive dysfunction (POCD) in elderly patients undergoing major non-cardiac surgery. DESIGN Prospective, randomized, open-label clinical trial. SETTING University-affiliated hospital. PATIENTS Two hundred and forty-eight elderly patients scheduled for non-cardiac surgery. INTERVENTIONS Elderly patients undergoing non-cardiac major surgery were randomly assigned to MB group (n = 124), who receiving intravenous infusion of 2 mg/kg MB within 60 min immediately after anesthetic induction, or control group (n = 124), who receiving equal volume saline in the same way. MEASUREMENTS All patients were evaluated with delirium and neuropsychological batteries before and after surgery, as well as perioperative adverse events. Two plasma biomarkers superoxide dismutase (SOD) and homocysteine (HCY) were measured pre- and post-operatively. MAIN RESULTS There were total 39 cases(15.7%)experienced POD. The incidence of POD in MB group was significantly less than that in control group (7.3% vs. 24.2%, OR = 0.24, 95%CI: 0.11-0.53, p < 0.001). The incidence of early POCD at postoperative 7th day in MB group was also less than that in control group (16.1% vs. 40.2%, OR = 0.30, 95% CI: 0.16-0.57, p < 0.001). The adverse events were comparable in both groups. In addition, there was no significant correlation between POD/POCD and levels of SOD or HCY. CONCLUSION We conclude that intraoperative intravenous 2 mg/kg MB could significantly reduce the incidences of POD and early POCD in elderly surgical patients, while not remarkably increase incidence of perioperative adverse events, suggesting MB may be clinically effective and safe for prevention of early postoperative neurocognitive disorders.
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Affiliation(s)
- Yixu Deng
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai 200032, PR China
| | - Ruijing Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Shitong Li
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Xiao Zhu
- Department of Psychiatry, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Tingting Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Jianjun Wu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Jun Zhang
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University,Shanghai 200032, PR China.
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33
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Hamiko M, Charitos EI, Velten M, Hilbert T, Putensen C, Treede H, Duerr GD. Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia. Thorac Cardiovasc Surg 2020; 70:549-557. [PMID: 32886926 PMCID: PMC9556161 DOI: 10.1055/s-0040-1715891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background
Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).
Materials and Method
s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (
n
= 188) and nonmannitol (
n
= 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at
p
< 0.05.
Results
Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%;
p
= 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours;
p
= 0.021), higher reintubation rate (11.3 vs. 2.7%;
p
= 0.009), ICU readmission (12.7 vs. 4.8%;
p
= 0.026), prolonged ICU (112 vs. 70 hours;
p
= 0.040), and hospital stay (17.8 vs. 12.6 days;
p
< 0.001), leading to higher expenses (19,349 € vs. 16,606 €,
p
< 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7;
p
< 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89;
p
= 0.02).
Conclusion
Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Efstratios I Charitos
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Markus Velten
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Tobias Hilbert
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Hendrik Treede
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
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34
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Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
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35
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Rosgen BK, Krewulak KD, Stelfox HT, Ely EW, Davidson JE, Fiest KM. The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review. Age Ageing 2020; 49:549-557. [PMID: 32342978 PMCID: PMC7331098 DOI: 10.1093/ageing/afaa053] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 01/23/2020] [Accepted: 03/13/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND delirium is an acute state of confusion that affects >20% of hospitalised patients. Recent literature indicates that more severe delirium may lead to worse patient outcomes and health system outcomes, such as increased mortality, cognitive impairment and length of stay (LOS). METHODS using systematic review methodology, we summarised associations between delirium severity and patient or health system outcomes in hospitalised adults. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus databases with no restrictions, from inception to 25 October 2018. We included original observational research conducted in hospitalised adults that reported on associations between delirium severity and patient or health system outcomes. Quality of included articles was assessed using the Newcastle-Ottawa Scale. The level of evidence was quantified based on the consistency of findings and quality of studies reporting on each outcome. RESULTS we included 20 articles evaluating associations that reported: mortality (n = 11), cognitive ability (n = 3), functional ability (n = 3), patient distress (n = 1), quality of life (n = 1), hospital LOS (n = 4), intensive care unit (ICU) LOS (n = 2) and discharge home (n = 2). There was strong-level evidence that delirium severity was associated with increased ICU LOS and a lower proportion of patients discharged home. There was inconclusive evidence for associations between delirium severity and mortality, hospital LOS, functional ability, cognitive ability, patient distress and quality of life. CONCLUSION delirium severity is associated with increased ICU LOS and a lower proportion of patients discharged home. Delirium severity may be a useful adjunct to existing delirium screening to determine the burden to health care system resources.
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Affiliation(s)
- Brianna K Rosgen
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - E Wesley Ely
- Department of Internal Medicine, Center for Health Services Research and Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, and the Tennessee Valley VA GRECC, Nashville, TN, USA
| | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
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36
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Canet E, Amjad S, Robbins R, Lewis J, Matalanis M, Jones D, Bellomo R. Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients. Intern Med J 2020; 49:1496-1504. [PMID: 30887670 DOI: 10.1111/imj.14287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/24/2019] [Accepted: 03/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is common in hospitalised patients but its epidemiology remains poorly characterised. AIMS To test the hypothesis that patient demographics, clinical phenotype, management and outcomes of patient with delirium in hospital ward patients differ from intensive care unit (ICU) patients. METHODS Retrospective cohort of patients admitted to an Australian university-affiliated hospital between March 2013 and April 2017 and coded for delirium at discharge using the International Classification of Diseases System, 10th revision, criteria. RESULTS Among 61 032 hospitalised patients, 2864 (4.7%) were coded for delirium. From these, we studied a random sample of 100 ward patients and 100 ICU patients. Ward patients were older (median age: 84 vs 65 years; P < 0.0001), more likely to have dementia (38% vs 2% for ICU patients; P < 0.0001) and less likely to have had surgery (24% vs 62%; P < 0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P < 0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, P < 0.0001). On multivariable analysis, age and dementia predicted persistent delirium, while surgery predicted recovery. CONCLUSIONS Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by dementia and is less likely to recover at hospital discharge. Therefore, delirium prevention, detection and goals of care should be adapted to the environment in which it occurs.
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Affiliation(s)
- Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Sobia Amjad
- School of Computing and Information Systems, The University of Melbourne, Melbourne, Victoria, Australia
| | - Raymond Robbins
- Business Intelligence Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Jane Lewis
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
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37
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Morandi A, Zambon A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Marengoni A, Bellelli G, Rispoli V, Malara A, Spadea F, Di Cello S, Ceravolo F, Fabiano F, Chiaradia G, Gabriele A, Lenino P, Andrea T, Settembrini V, Capomolla D, Citrino A, Scriva A, Bruno I, Secchi R, De Martino E, Muccinelli R, Lupi G, Paonessa P, Fabbri A, Passuti MT, Castellari S, Po A, Gaggioli G, Varesi M, Moneti P, Capurso S, Latini V, Ghidotti S, Riccardelli F, Macchi M, Rigo R, Claudio P, Angelo B, Flavio C, Benedetta B, Boffelli S, Cassinadri A, Franzoni S, Spazzini E, Andretto D, Tonini G, Andreani L, Coralli M, Balotta A, Cancelliere R, Ballardini G, Simoncelli M, Mancini A, Strazzacapa M, Fabio S, De Filippi F, Giudice C, Dentizzi C, Azzini M, Cazzadori M, Mastroeni V, Bertassello P, Claudia Benati HS, Nesta E, Tobaldini C, Guerini F, Elena T, Mombelloni P, Fontanini F, Gabriella L, Pizzorni C, Oliverio M, Del Grosso LL, Giavedoni C, Bidoli G, Mazzei B, Corsonello A, Fusco S, Vena S, De Vuono T, Maiuri G, Luca FF, Andrea A, Giovanni S, Rossella N, Castegnaro E, De Rosa S, Sechi RB, Benvenuti E, Del Lungo I, Giardini S, Giulietti C, Mauro DB, Eleonora B, Roberto F, Paolo B, DuranteMangoni E, Testoni M, Fabio DS, Loredana S, Valeria S, Fabiano M, Annabella DG, Salvatore DC, Martina P, Greco A, Grazia D, Daniele S, Gianluca R, Renzo G, Sergio M, Morena B, Vitali M, Marina P, Paolo DC, Irene F, Cristina S, Alessandra F, Orlandini F, La Regina M, Desirée A, Mirella F, Marco F, Mario B, Paola P, Giuliana B, Riccardo B, Michela T, Eleonora C, Padulo F, Cristina M, Dario R, Giancarla M, Guido R, Elena M, Prete C, Marileda N, Federica S, Igor B, Nicole B, Elena R, Paolillo C, Riccardi A, Claudia B, Barbara R, Francesca M, Silvia V, Chiara C, Ilaria DL, Oliver B, Mauro C, Eleonora M, Giuseppe P, Rosaria T, Maria C, Davide D, Stefania C, Marco C, Massimo P, Bertoletti E, Luca S, Martina DF, Paola V, Lia S, Sandro C, Valentina DS, Erminia B, Paola C, Romina R, Minisola S, D'Amico F, Luciano C, Pasquale A, Ilaria L, Francesca C, Guglielmo S, Marco E, Sara R, Paola A, Claudio A, Francesco R, Caronzolo F, Alessandro C, Simona M, Lara F, Paola R, Simonetta C, Antonella C, Generoso U, Fernando G, Giuliano C, Emanuela S, Grippa A, Mariolina S, Alessandro D, Chiara P, Giulia L, Alessandro G, Famularo S, Sandini M, Pinotti E, Gianotti L, Antonella B, Lombardo G, Giulia P, Sante G, Rossi A, Rubele S, Sant S, Marco V, Danila C, Fabio R, Bandirali MP, Nicoletta C, Pipicella T, Laura B, Paolo T, Luciano T, Leonello A, Margherita S, Stefania DN, Pierluigi DS, Laura R, Fabiana T, Giovanna C, Antonino S, Antonino A, Felice C, Giuseppe B, Danilo F, Giovanna DB, Francesco L, Salini S, Angela BM, De Filippi F, Giorgetta C, Francesco C, Giovanni G, Paola C, Gerardo B, Silvio R, Letizia S, Sabrina P, Davide B, Rosaria RM, Maria DA, Raffaele P, Valeria PG, Palmieri VO, Palasciano G, Belfiore A, Portincasa P, Carlo S, Vincenzo S, Alessia D, Valiani V, Carolina B, Tiziana C, Daniela L, Giuseppe M, Francesca C, Giordano C, Roberto S, Paola T, Ugo P, Federica R, Giacomo P, Castellano M, Anna G, Domenico C, Elisa C, Federica C, Antonietta CM, Luigi M, Fabio L, Salvatore B, Giuseppe M, Gelosa G, Viviana AT, Piras V, Giorgio B, Andrea C, Alessandra B, Coen D, Magliola R, Milanesio D, Muzzulini CL, Paolo F, Marinella T, Sofia CM, Marta B, March A, Siano P, Capo G, Napoletano R, Cecilia P, Mancini C, Del Buono C, De Bartolomeo G, Addolorata M, Carmen C, Roberto C, Nitti MT, Giovanni VA, Moschettini G, Franco M, Daniela R, D'Amico G, Mirella P, Endrizzi C, Trotta L, Ciarambino T, Orazio Z, Felici A, Emanuela T, Marta S, Thomas F, Giacomo T, Ignazio DF, Andrea B, Giuseppe O, Emanuela F, Serena A, Elena D, Pavan S, Anna C, Serena B, Erika N, Roberto S, Elena S, Manuela P, Francesca A, Angelo T, Piazzani F, Lunelli A, Dimori S, Margotta A, Soglia T, Postacchini D, Brunelli R, Santini S, Francavilla M, Macchiati I, Sorvillo F, Giuli C, Mecocci P, Longo A, Perticone F, Addesi D, Rosa PC, Bencardino G, Falbo T, Grillo N, Marco F, Mirella F, Fantò F, Isaia G, Pezzilli S, Bergamo D, Furno E, Rrodhe S, Lucarini S, Dijk B, Dall'Acqua F, Cappelletto F, Calvani D, Becheri D, Giuseppe M, Costanza M, Vito A, Francesca B, Magherini L, Novella M, Franca B, Lucia Gambardella PM, Valente C, Ilaria B, Alice F, Bo M, Porrino P, Ceci G, Giuliana B, Michela T, Eleonora C, Ettore E, Camellini C, Servello A, Grassi A, Rozzini R, Tironi S, Grassi MG, Troisi E, Carlo C, Simona Gabriella DS, Flaminia F, Federica R, Beatrice P, Sofia T, Gabutto A, Quazzo L, Rosatello A, Suraci D, Tagliabue B, Perrone C, Ferrara L, Castagna A, Tremolada ML, Giuseppe C, Stefano B, Davide O, Piano S, Serviddio G, Lo Buglio A, Gurrera T, Merlo V, Rovai C, Cotroneo AM, Carlucci R, Abbaldo A, Monzani F, Qasem AA, Bini G, Tafuto S, Galli G, Bruni AC, Mancuso G, Mancuso G, Calipari D, Giuseppe Massimiliano DL, Bernardini B, Corsini C, Michele C, Sara DF, Cagnin A, Fragiacomo F, Pompanin S, Piero A, Marco C, Zurlo A, Guerra G, Pala M, Menozzi L, Gatti CD, Magon S, Roberto M, Alfredo DG, Fabio F, Ruana T, Elisa M, Benedetta B, Christian M, Marco P, Massimo G, Di Francesco V, Faccioli S, Pellizzari L, Giorgia F, Barbagallo G, Lunardelli ML, Martini E, Ferrari E, Macchiarulo M, Corneli M, Bacci M, Battaglia G, Anastasio L, Lo Storto MS, Seresin C, Simonato M, Loreggian M, Cestonaro F, Durando M, Latella R, Mazzoleni M, Russo G, Ponte M, Valchera A, Salustri G, Petritola D, Costa A, Sinforiani E, Cotta MR, Piano S, Pizio RN, Cester A, Formilan M, Pietro B, Carbone P, Cazzaniga I, Appollonio I, Cereda D, Stabile A, Xhani R, Acampora R, Tremolizzo L, Federico P, Antonio C, Valerio P, Cesare B, Zhirajr M, Giovanni V, Maria A, Mariaelena S, Bottacchi E, Bucciantini E, Di Giovanni M, Franchi F, Lucchetti L, Mariani C, Grande G, Rapazzini P, Marco M, Romanelli G, Marengoni A, Franco N, Alessio M, Stefano B, Nicola L, Laura P, Nazario P, Carlo C, Chiara G, Soccorso P, Andrea S, Luca B, Francesca S, Roberto A, Marco F, Anna C, Francesco C, Anna C, Fugazza L, Guerrini C, De Paduanis G, Iallonardo L, Palumbo P, Zuliani G, Ortolani B, Capatti E, Soavi C, Bianchi L, Francesconi D, Miselli A, Gloria B, Tommaso R, Chiara P, Agata MM, Marco D, Luca M, Gianluca G, Suardi T, Mazzone A, Zaccarini C, Manuela R, Mirra G, Muti E, Bottura R, Gianpaolo M, Secreto P, Bisio E, Cecchettani M, Naldi T, Pallavicino A, Pugliese M, Iozzo RC, Grassi G, Michele B, Raffaella D, Fosca QT, Giorgio GC, Giovanni P, Ernesto C, Soccorso P, Mannironi A, Giorli E, Oberti S, Fierro B, Piccoli T, Giacalone F, Mandas A, Serchisu L, Costaggiu D, Pinna E, Orrù F, Mannai M, Cordioli Z, Pelizzari L, Turcato E, Arduini P, Cacace C, Chiloiro R, Cimino R, Ruberto C, Giovanni R, Pietro G, Laura G, Alberto C, Pietro G, Carmen R, Santo PD, Andriolli A, Burattin G, Rossi L, Andreolli Antonino CG, Giuseppe C, Tezza F, Maddalena P, Laura S, Crippa P, Aloisio P, Di Monda T, Malighetti A, Galbassini G, Salutis D, Ivaldi C, Russo AM, Bennati E, Pino E, Zavarise G, Pesci A, Suigo G, Faverio P, Andrea G, Sabrina P, Zanasi M, Moniello G, Rostagno C, Cartei A, Polidori G, Ungar A, Melis MR, Martellini E, Enrico M, Monica T, Antonella G, Giovanna L, Migliorini M, Caramelli F, Battiston B, Berardino M, Cavallo S, Alessandro M, Anna S, Lombardi B, D'Ippolito P, Furini A, Villani D, Clara R, Guarneri M, Paolucci S, Bassi A, Coiro P, De Angelis D, Morone G, Venturiero V, Palleschi L, Raganato P, Di Niro G, Rosa CA, Loredana B, Imoscopi A, Isaia G, Tibaldi V, Bottignole G G, Calvi E, Clementi C, Zanocchi M, Agosta L, Nortarelli A, Provenzano G, Mari D, Romano FY, Rosini F, Mansi M, Rossi S, Geriatria AR, Inzaghi L, Bonini G, Rossi P, Potena A, Lichii M, Candiani T, Grimaldi W, Bertani E, Alessandra P, Calogero P, Pinto D, Bernardi R, Nicolino F, Galetti C, Gianstefani A, Giulia C, Lorenzo M, Odetti P, Monacelli F, Prefumo M, Fiammetta M, Canepa M, Minaglia C, Paolisso G, Rizzo MR, Prestano R, Dalise AM, Barra D, Bosco LD, Asprinio V, Dallape L, Perina E, Incalzi RA, Bartoli IR, Pluderi A, Maina A, Pecoraro E, Sciarra M, Prudente A, Paola M, Francesca M, Manuel V, Luisella C, Maria PL, Tina S, Benini L, Levato F, Mhiuta V, Alius F, Davidoaia D, Giardini V, Garancini M, Bellamoli C, Terranova L, Bozzini C, Tosoni P, Provoli E, Cascone L, Dioli A, Ferrarin G, Gabutto A, Bucci A, Bua G, Fenu S, Bianchi G, Casella S, Romano V, Maurizio P, Mascherona I, Belotti G, Cavaliere S, Cuni E, Merciuc N, Oberti R, Veneziani S, Capoferri E, De Bernardi E, Colombo K, Bravi M, Nicoletta N, D'Arcangelo P, Montenegro N, Galli G, Montanari R, Lamanna P, Gasperini B, Isabella M, Stefania D, Gaia A, Filippo C, Palamà C, Di Emidio C, Scarpini E, Arighi A, Fumagalli G, Basilico P, De Amicis Margherita M, Marta M, Diletta M, D'Amico F, Granata A, Rostagno C, Ranalli C, Cammilli A, Cavallini MC, Tricca M, Natella D, Gabbani L, Tesi F, Martella L, Gurrera T, Imbrici R, Guerrini G, Scotuzzi AM, Sozzi F, Valenti L, Chiarello A, Monia M, Pilotto A, Prete C, Senesi B, Meta AC, Pendenza E, Monzani F, Pasqualetti G, Polini A, Tognini S, Ballino E, Cherubini A, Dell'Aquila G, Gasparrini PM, Marotti E, Migale M, Scrimieri A, Falsetti L, Salvi A, Toigo G, Ceschia G, Rosso A, Tongiorgi C, Scarpa C, Maurizio P, De Dominicis L, Pucci E, Renzi S, Cartechini E, Tomassini PF, Del Gobbo M, Ugenti F, Romeo P, Nardelli A, Lauretani F, Visioli S, Montanari I, Ermini F, Giordano A, Pigato G, Simeone E, Barbujani M, Giampieri M, Amoruso R, Piccinini M, Ferrari C, Gambetti C, Sfrappini M, Semeraro L, Striuli R, Mariani C, Pelliccioni G, Marinelli D, Fabi K, Rossi T, Pesallaccia M, Sabbatini D, Gobbi B, Cerqua R, Tagliani G, Schlauser E, Caser L, Caramello E, Sandigliano F, Rosso G, Ferrari A, Bendini C, Luisa DM, Casella M, Prampolini R, Scevola M, Vitale E, Roberto B, Carlo F, Sergio F, Alberto S, Daniela Z, Giulia B, Serena G, Michele B, Maugeri D, Sorace R, Anzaldi M, De Gesu R, Morrone G, Davolio F, Fabbo A, Palmieri M, Barbagallo G, Zoli M, Forti P, Pirazzoli L, Fabbri E, Terenzi L, Bergolari F, Wenter C, Ruffini I, Insam M, Abraham E, Kirchlechner C, Cucinotta D, Antonino L, Basile G, Grazia AM, Parise P, Boccali A, Amici S, Gambacorta M, Ferrari A, Lasagni A, Lovati R, Giovinazzo F, Kimak E, Zappa P, Medici F, Lo Castro M, Mauro F, De Luca A, Sancesario G, Martorana A, Scaricamazza B, Toniolo S, Di Lorenzo F, Liguori C, Lasco A, Basile G, Vita N, Giomi M, Dimori S, Forte F, Padovani A, Rozzini L, Ceraso A, Salvatore C, Padovani A, Cottino M, Vitali S, Marelli E, Tripi G, Miceli S, Urso G, Grioni G, Vezzadini G, Misaggi G, Forlani C, Avanzi S, Serena S, Claudia C, Marilena V, Alberto L, Diego G, Alessandro G, Iemolo F, Giordano A, Sanzaro E, D'Asta G, Proietto M, Carnemolla A, Razza G, Spadaro D, Bertolotti M, Mussi C, Neviani F, Roberto C, Valentina G, Linda M, Francesca V, Tarozzi A, Balestri F, Monica T, Mannarino G, Tesi F, Bigolari M, Natale A, Grassi S, Bottaro C, Stefanelli S, Bovone U, Tortorolo U, Quadri R, Leone G, Ponzetto M, Frasson P, Annoni G, Bellelli G, Bruni A, Confalonieri R, Corsi M, Moretti D, Teruzzi F, Umidi S, Mazzola P, Perego S, Persico I, Olivieri G, Bonfanti A, Hajnalka S, Galeazzi M, Massariello F, Anzuini A, Caffarra P, Barocco F, Spallazzi M, Paolo CG, Simonetta M, Andrea A, Chioatto P, Bortolamei S, Soattin L, Ruotolo G, Beneamino B, Pietro G, Giuseppe B, Carmen R, Castagna A, Bertazzoli M, Rota E, Adobati A, Scarpa A, Granziera S, Zuccher P, Fabbro AD, Zara D, Lo Nigro A, Franchetti L, Toniolo M, Marcuzzo C, Piano S, Rollone M, Guerriero F, Sgarlata C, Massè A, Berardino M, Cavallo S, Anna S, Zatti G, Piatti M, Graci J, Benati G, Boschi F, Biondi M, Fiumi N, Erika T, Locatelli SM, Mauri S, Beretta M, Margheritis L, Desideri G, Liberatore E, Carucci AC, Bonino P, Caput M, Antonietti MP, Polistena G, De la Pierre F, Mari M, Massignani P, Tombesi F, Selvaggio F, Verbo B, Bodoni P, Marchionni N, Mossello E, Cavallini MC, Sabatini T, Mussio E, Magni E, Bianchetti A, Crucitti A, Titoldini G, Cossu B, Fascendini S, Licini C, Tomasoni A, Calderazzo M, Daniela T, Valentina L, Ferrari A, Prampolini R, Melotti RM, Lilli A, Buda S, Adversi M, Noro G, Turco R, Ubezio MC, Mantovani AR, Viola MC, Serrati C, Pretta S, Infante M, Gentile S, Morandi A, D'Ambrosio V, Mazzanti P, Brambilla C, Sportelli S, Platto C, Faraci B, Quattrocchi D, Pernigotti LM, Pisu C, Sicuro F, Oliverio M, Del Grosso LL, Zagnoni P, Ghiglia S, Mosca M, Corazzin I, Deola M, Biagini CA, Bencini F, Cantini C, Tonon E, Pierinelli S, Onofrj M, Thomas A, Filomena B, Bonanni L, Gabriella C, Comi G, Magnani G, Santangelo R, Mazzeo S, Giuseppe M, Francesca C, Giordano C, Roberto S, Barbieri C, Giroldi L, Davolio F, Bandini F, Masina M, Malservisi S, Cicognani A, Ricca L, Ricca L, Piccininni M, Ferrari C, Gambetti C, Tassinari T, Brogi D, Sugo A, Alessandra F, Sonia M, Valerio V, Andrea UC, Enrico C, Vera RF, Assunta S, Gianmaria Z, Mauro P, Pietro B, Roberto M, Salvatore C, Barone A, Razzano M, Giuseppe I, Angela B, Francesco S, Valeria D, Federico G, Lucia P, Antonella V, Elisabetta DC, Cristina R, Nadia C, Maria S, Luciano A, Chiara C, Bini P, Pignata M, Enrico B, Maria V, Giovanni C, Giorgio C, Andrea T, Marco M, Anna C, Piera R, Alberto Z, Ceccon A, Magrin L, Marin S, Barbara S, Marco M, Laura G, Matteo M, Marco P, Caterina PM, Carla R, Federica G, Clara T, Melania C, Giampaolo B, Stefano G, Valeria G, Lucia M, Giovambattista D, Ester L, Cecilia CA, Maurizio T, Alessandra F, Vera RF, Nadia B, Grillo A, Arenare F, Tonino M, David K, Giorgio VP, Ubaldo B, Vincenzo S, Stefano M, Marino F, Busonera Flavio MT, Paolo A, Monica M, Francesco B. Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia. J Am Med Dir Assoc 2020; 21:486-492.e7. [DOI: 10.1016/j.jamda.2020.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022]
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Tobar E, Alvarez E. DELIRIUM EN EL ADULTO MAYOR HOSPITALIZADO. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Grealish L, Todd JA, Krug M, Teodorczuk A. Education for delirium prevention: Knowing, meaning and doing. Nurse Educ Pract 2019; 40:102622. [DOI: 10.1016/j.nepr.2019.102622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 05/28/2019] [Accepted: 08/31/2019] [Indexed: 11/27/2022]
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Liveris A, Stein DM. Delirium in the Elderly Surgical Patient. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-00288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Evensen S, Saltvedt I, Lydersen S, Wyller TB, Taraldsen K, Sletvold O. Delirium motor subtypes and prognosis in hospitalized geriatric patients - A prospective observational study. J Psychosom Res 2019; 122:24-28. [PMID: 31126407 DOI: 10.1016/j.jpsychores.2019.04.020] [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] [Received: 03/29/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Delirium is common and associated with poor outcomes. Hypoactive motor subtype may predict worse outcome than no-subtype, hyperactive and mixed delirium, but uncertainty remains due to heterogeneity of results and subtyping tools. Other prognostic aspects across delirium motor subtypes are understudied. We investigated differences in one-year mortality, length of stay and institutionalization at discharge and after one year, across delirium motor subtypes in geriatric patients. METHODS We conducted a prospective observational study, included 311 patients ≥75 years acutely admitted to a geriatric ward, diagnosed delirium using Diagnostic and Statistical Manual of Mental Disorder (5th ed.) criteria and used the Delirium Motor Subtype Scale for subtyping. Differences in mortality across subtypes were investigated using Cox proportional-hazard regression analyses, unadjusted and adjusted for age, comorbidity and delirium severity. We investigated differences in length of stay and institutionalization using the Kruskal-Wallis test and Pearson's chi-squared test with subsequent Hommel-adjusted pairwise comparisons. RESULTS Ninety-three patients (30%) had delirium; 12 (13%) had no-subtype, 27 (29%) hyperactive, 30 (32%) hypoactive and 24 (26%) mixed delirium. There were no group differences regarding mortality (p = .61) or length of stay (p = .32). Analyses indicated group differences regarding discharge to an institution (p = .028), but pairwise comparisons showed no differences (smallest p = .071, no-subtype 45% vs hypoactive 85%). There were no group differences in institutionalization after one year (p = .26). CONCLUSION There were no significant differences in one-year mortality, length of stay or institutionalization across delirium motor subtypes in geriatric patients, although the study may indicate better prognosis in the no-subtype group.
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Affiliation(s)
- Sigurd Evensen
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Norway; Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway.
| | - Ingvild Saltvedt
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Norway; Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway.
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Kristin Taraldsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway.
| | - Olav Sletvold
- Department of Geriatrics, St. Olavs Hospital, Trondheim University Hospital, Norway; Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway.
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Home-based Cognitive Prehabilitation in Older Surgical Patients: A Feasibility Study. J Neurosurg Anesthesiol 2019; 31:212-217. [PMID: 30557230 DOI: 10.1097/ana.0000000000000569] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cognitive training is beneficial in various clinical settings, although its perioperative feasibility and impact remain unknown. The objective of this pilot study was to determine the feasibility of home-based cognitive prehabilitation before major surgery in older adults. MATERIALS AND METHODS Sixty-one patients were enrolled, randomized, and allocated to either a home-based preoperative cognitive training regimen or no training before surgery. Outcomes included postoperative delirium incidence (primary outcome; assessed with the 3D-Confusion Assessment Method), perioperative cognitive function based on NIH Toolbox measures, hospital length of stay, and physical therapy session participation. Reasons for declining enrollment were reported, as were reasons for opting out of the training program. RESULTS Postoperative delirium incidence was 6 of 23 (26%) in the prehabilitation group compared with 5 of 29 (17%) in the control group (P=0.507). There were no significant differences between groups in NIH Toolbox cognitive function scoring, hospital length of stay, or physical therapy participation rates. Study feasibility data were also collected and reported. The most common reasons for declining enrollment were lack of computer access (n=19), time commitment (n=9), and feeling overwhelmed (n=9). In the training group, only 5 of 29 (17%) included patients were able to complete the prescribed 7 days of training, and 14 of 29 (48%) opted out of training once home. Most common reasons were feeling overwhelmed (n=4) and computer difficulties (n=3). CONCLUSIONS Short-term, home-based cognitive training before surgery is unlikely to be feasible for many older patients. Barriers to training include feeling overwhelmed, technical issues with training, and preoperative time commitment.
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Štubljar D, Štefin M, Tacar MP, Cerović O, Grosek Š. Prolonged hospitalization is a risk factor for delirium onset: one-day prevalence study in Slovenian INTENSIVE CARE UNITS. Acta Clin Croat 2019; 58:265-273. [PMID: 31819322 PMCID: PMC6884389 DOI: 10.20471/acc.2019.58.02.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Delirium is a clinical syndrome often underestimated in the intensive care units (ICU). The aim of this study was to determine the prevalence and factors that influence the onset of delirium. A questionnaire was sent to intensivists in Slovenian ICUs, who estimated the prevalence of delirious patients. The questionnaire consisted of demographic data, type of ICU, diagnosis, reason for admission to the ICU, type of anesthesia and surgery, clinical condition, type of supportive therapy, presence of delirium, data on discharge, transfers between departments or patient outcome on day 30. Patient consciousness was assessed by the Richmond Agitation-Sedation Scale (RASS) and the presence of delirium by the validated delirium-screening Confusion Assessment Method for the ICU (CAM-ICU). Replies received from intensivists included data on 103 patients. According to RASS ≥-3, the prevalence of delirium was 9.5% (7 out of 74 patients). There was no difference in the prevalence of delirium between surgical and medical ICU patients (p=0.388). Delirious patients had longer hospital stay (p=0.002) and ICU stay (p=0.032) compared to patients without delirium. All delirious patients survived until day 30, whereas 19 patients without delirium died (p=0.092). Logistic regression analysis dismissed any association of delirium with patient mortality (p=0.998). Age, gender, anesthesia, mechanical ventilation, and type of surgical procedure could not be evaluated as risk factors for delirium. In Slovenian ICUs, a lower proportion of delirium was observed, as reported from similar studies. Risk factors such as gender, age, mechanical ventilation, sedation, anesthesia, or department could not predict delirium. However, prolonged hospitalization of ICU patients could predict the onset of delirium, but the presence of delirium did not increase patient mortality.
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Affiliation(s)
| | - Maruša Štefin
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Marija Pia Tacar
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ognjen Cerović
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Štefan Grosek
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Abstract
Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Consciousness Science, University of Michigan Medical School,, Ann Arbor, MI, USA
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, USA
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Woodhouse R, Burton JK, Rana N, Pang YL, Lister JE, Siddiqi N. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database Syst Rev 2019; 4:CD009537. [PMID: 31012953 PMCID: PMC6478111 DOI: 10.1002/14651858.cd009537.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is a common and distressing mental disorder. It is often caused by a combination of stressor events in susceptible people, particularly older people living with frailty and dementia. Adults living in institutional long-term care (LTC) are at particularly high risk of delirium. An episode of delirium increases risks of admission to hospital, development or worsening of dementia and death. Multicomponent interventions can reduce the incidence of delirium by a third in the hospital setting. However, it is currently unclear whether interventions to prevent delirium in LTC are effective. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in older people in institutional long-term care settings. SEARCH METHODS We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group (CDCIG) 's Specialised Register of dementia trials (dementia.cochrane.org/our-trials-register), to 27 February 2019. The search was sufficiently sensitive to identify all studies relating to delirium. We ran additional separate searches in the Cochrane Central Register of Controlled Trials (CENTRAL), major healthcare databases, trial registers and grey literature sources to ensure that the search was comprehensive. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single and multicomponent, non-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes were prevalence, incidence and severity of delirium; and mortality. Secondary outcomes included falls, hospital admissions and other adverse events; cognitive function; new diagnoses of dementia; activities of daily living; quality of life; and cost-related outcomes. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes, hazard ratios (HR) for time-to-event outcomes and mean difference (MD) for continuous outcomes. For each outcome, we assessed the overall certainty of the evidence using GRADE methods. MAIN RESULTS We included three trials with 3851 participants. All three were cluster-RCTs. Two of the trials were of complex, single-component, non-pharmacological interventions and one trial was a feasibility trial of a complex, multicomponent, non-pharmacological intervention. Risk of bias ratings were mixed across the three trials. Due to the heterogeneous nature of the interventions, we did not combine the results statistically, but produced a narrative summary.It was not possible to determine the effect of a hydration-based intervention on delirium incidence (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00; 1 study, 98 participants; very low-certainty evidence downgraded for risk of bias and very serious imprecision). This study did not assess delirium prevalence, severity or mortality.The introduction of a computerised system to identify medications that may contribute to delirium risk and trigger a medication review was probably associated with a reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51; 1 study, 7311 participant-months; moderate-certainty evidence downgraded for risk of bias) but probably had little or no effect on mortality (HR 0.88, CI 0.66 to 1.17; 1 study, 9412 participant-months; moderate-certainty evidence downgraded for imprecision), hospital admissions (HR 0.89, CI 0.72 to 1.10; 1 study, 7599 participant-months; moderate-certainty evidence downgraded for imprecision) or falls (HR 1.03, CI 0.92 to 1.15; 1 study, 2275 participant-months; low-certainty evidence downgraded for imprecision and risk of bias). Delirium prevalence and severity were not assessed.In the enhanced educational intervention study, aimed at changing practice to address key delirium risk factors, it was not possible to determine the effect of the intervention on delirium incidence (RR 0.62, 95% CI 0.16 to 2.39; 1 study, 137 resident months; very low-certainty evidence downgraded for risk of bias and serious imprecision) or delirium prevalence (RR 0.57, 95% CI 0.15 to 2.19; 1 study, 160 participants; very low-certainty evidence downgraded for risk of bias and serious imprecision). There was probably little or no effect on mortality (RR 0.82, CI 0.50 to 1.34; 1 study, 215 participants; moderate-certainty evidence downgraded for imprecision). The intervention was probably associated with a reduction in hospital admissions (RR 0.67, CI 0.57 to 0.79; 1 study, 494 participants; moderate-certainty evidence downgraded due to indirectness). AUTHORS' CONCLUSIONS Our review identified limited evidence on interventions for preventing delirium in older people in LTC. A software-based intervention to identify medications that could contribute to delirium risk and trigger a pharmacist-led medication review, probably reduces incidence of delirium in older people in institutional LTC. This is based on one large RCT in the US and may not be practical in other countries or settings which do not have comparable information technology services available in care homes. In the educational intervention aimed at identifying risk factors for delirium and developing bespoke solutions within care homes, it was not possible to determine the effect of the intervention on delirium incidence, prevalence or mortality. This evidence is based on a small feasibility trial. Our review identified three ongoing trials of multicomponent delirium prevention interventions. We identified no trials of pharmacological agents. Future trials of multicomponent non-pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence-based care for this vulnerable group.
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Affiliation(s)
- Rebecca Woodhouse
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkUKYork YO10 5DD
| | - Jennifer K Burton
- University of GlasgowAcademic Geriatric Medicine, Institute of Cardiovascular and Medical SciencesNew Lister Building, Glasgow Royal InfirmaryGlasgowUKG4 0SF
| | - Namrata Rana
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkUKYork YO10 5DD
| | - Yan Ling Pang
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkUKYork YO10 5DD
| | - Jennie E Lister
- University of YorkDepartment of Health SciencesSeebohm Rowntree BuildingHeslingtonYorkUKYO10 5DD
| | - Najma Siddiqi
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkUKYork YO10 5DD
- Bradford District Care NHS Foundation TrustGeneral Adult PsychiatryVictoria RoadSaltaireBradfordWest YorkshireUKBD18 3LD
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van Montfort SJT, van Dellen E, Stam CJ, Ahmad AH, Mentink LJ, Kraan CW, Zalesky A, Slooter AJC. Brain network disintegration as a final common pathway for delirium: a systematic review and qualitative meta-analysis. NEUROIMAGE-CLINICAL 2019; 23:101809. [PMID: 30981940 PMCID: PMC6461601 DOI: 10.1016/j.nicl.2019.101809] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/25/2019] [Accepted: 03/31/2019] [Indexed: 01/05/2023]
Abstract
Delirium is an acute neuropsychiatric syndrome characterized by altered levels of attention and awareness with cognitive deficits. It is most prevalent in elderly hospitalized patients and related to poor outcomes. Predisposing risk factors, such as older age, determine the baseline vulnerability for delirium, while precipitating factors, such as use of sedatives, trigger the syndrome. Risk factors are heterogeneous and the underlying biological mechanisms leading to vulnerability for delirium are poorly understood. We tested the hypothesis that delirium and its risk factors are associated with consistent brain network changes. We performed a systematic review and qualitative meta-analysis and included 126 brain network publications on delirium and its risk factors. Findings were evaluated after an assessment of methodological quality, providing N=99 studies of good or excellent quality on predisposing risk factors, N=10 on precipitation risk factors and N=7 on delirium. Delirium was consistently associated with functional network disruptions, including lower EEG connectivity strength and decreased fMRI network integration. Risk factors for delirium were associated with lower structural connectivity strength and less efficient structural network organization. Decreased connectivity strength and efficiency appear to characterize structural brain networks of patients at risk for delirium, possibly impairing the functional network, while functional network disintegration seems to be a final common pathway for the syndrome. Delirium is consistently associated with functional network impairments. Risk factors are associated with lower structural connectivity strength. Risk factors are associated with a less efficient structural network organization. Structural impairments make the functional network more vulnerable to deterioration. Functional network disintegration seems to be a final common pathway for delirium.
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Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | - E van Dellen
- Department of Psychiatry and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Melbourne Neuropsychiatry Center, Department of Psychiatry, Level 3, Alan Gilbert Building, 161 Barry Street, Carlton South, 3053 Victoria, University of Melbourne and Melbourne Health, Australia
| | - C J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - A H Ahmad
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands
| | - L J Mentink
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - C W Kraan
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - A Zalesky
- Melbourne Neuropsychiatry Center, Department of Psychiatry, Level 3, Alan Gilbert Building, 161 Barry Street, Carlton South, 3053 Victoria, University of Melbourne and Melbourne Health, Australia
| | - A J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Evensen S, Saltvedt I, Lydersen S, Wyller TB, Taraldsen K, Sletvold O. Environmental factors and risk of delirium in geriatric patients: an observational study. BMC Geriatr 2018; 18:282. [PMID: 30442109 PMCID: PMC6238358 DOI: 10.1186/s12877-018-0977-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/06/2018] [Indexed: 11/22/2022] Open
Abstract
Background Patients with delirium have increased risk of death, dementia and institutionalization, and prognosis differs between delirium motor subtypes. A few studies have identified associations between environmental factors like room-transfers and time spent in the emergency department (ED) and delirium, but no studies have investigated if environmental factors may influence delirium motor subtypes. We wanted to explore if potentially stressful events like ward-transfers, arriving ED at nighttime, time spent in ED and nigthttime investigations were associated with development of delirium (incident delirium) and delirium motor subtypes. Methods We used the DSM-5 criteria to diagnose delirium and the Delirium Motor Subtype Scale for motor subtyping. We defined hyperactive and mixed delirium as delirium with hyperactive symptoms, and hypoactive and no-subtype delirium as delirium without hyperactive symptoms. We registered ward-transfers, time of arrival in ED, time spent in ED and nighttime investigations (8 p.m. to 8 a.m.), and calculated Global Deterioration Scale (GDS) and Cumulative Illness Rating Scale (CIRS) to adjust for cognitive impairment and comorbidity. We used logistic regression analyses with incident delirium and delirium with hyperactive symptoms as outcome variables, and ward-transfers, arriving ED at nighttime, time spent in ED and nighttime investigations as exposure variables, adjusting for age, GDS and CIRS in the analyses for incident delirium. Results We included 254 patients, mean age 86.1 years (SD 5.2), 49 (19.3%) had incident delirium, 22 with and 27 without hyperactive symptoms. There was a significant association between nighttime investigations and incident delirium in both the unadjusted (odds ratio (OR) 2.22, 95% confidence interval (CI) 1.17 to 4.22, p = 0.015) and the multiadjusted model (OR 2.61, CI 1.26 to 5.40, p = 0.010). There were no associations between any other exposure variables and incident delirium. No exposure variables were associated with delirium motor subtypes. Conclusions Nighttime investigations were associated with incident delirium, even after adjusting for age, cognitive impairment and comorbidity. We cannot out rule that the medical condition leading to nighttime investigations is the true delirium-trigger, so geriatric patients must still receive emergency investigations at nighttime. Hospital environment in broad sense may be a target for delirium prevention.
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Affiliation(s)
- Sigurd Evensen
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway.
| | - Ingvild Saltvedt
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin Taraldsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
| | - Olav Sletvold
- Department of Geriatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
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Impact of psychotic symptoms on clinical outcomes in delirium. PLoS One 2018; 13:e0200538. [PMID: 30005081 PMCID: PMC6044533 DOI: 10.1371/journal.pone.0200538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 06/28/2018] [Indexed: 11/19/2022] Open
Abstract
Delirium is an acute disturbance in attention and awareness in response to one or more physiological stressors that is closely related to poor clinical outcomes. The aim of this study is to investigate whether delirium patients with psychotic symptoms (PS) would have unique clinical characteristics and outcomes. A retrospective chart review was performed on the patients with delirium due to general medical conditions to assess clinical characteristics and outcomes. All patients were assessed by Delirium Rating Scale-revised-98 and classified as having PS when scored two or more on at least one of the psychotic symptom items (perceptual disturbances, delusions, and thought process abnormalities). Of 233 patients with delirium, 116 (49.8%) manifested PS. Patients with PS were younger, more likely to use antipsychotics to manage delirium, and had more hyperactive motor subtype than patients without PS. Logistic regression analysis showed that odds ratio of psychotic symptoms for having in-hospital mortality was 0.27 (95% CI = 0.08-0.94) after controlling age, sex, disease severity, comorbidity, number of medications, etiologies, motor subtypes, delirium severity and use of antipsychotics. The present study demonstrated that PS of delirium was associated with unique clinical characteristics and may affect the clinical course in a psychiatry-referral sample.
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Lopes R, Pereira BD. Delirium and Psychotic Symptoms Associated with Hyperglycemia in a Patient with Poorly controlled Type 2 Diabetes Mellitus. INNOVATIONS IN CLINICAL NEUROSCIENCE 2018; 15:30-33. [PMID: 30013817 PMCID: PMC6040722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Delirium, acute confusional states, and secondary psychosis have been associated with several medical conditions, including endocrine disorders. In the context of diabetes mellitus (DM), it has been mostly related to hypoglycemia and rarely occurs in association with hyperglycemia, outside of the context of a hyperglycemic hyperosmolar state or diabetic ketoacidosis. Here, we describe a case of delirium and psychotic symptoms associated with hyperglycemia in a patient with poorly controlled Type 2 DM as an attempt to alert clinicians to this rare association. We also review the pathophysiological mechanisms that might lead to the onset of delirium in the context of hyperglycemia.
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Affiliation(s)
- Rui Lopes
- Dr. Lopes is with the Faculty of Medicine at the University of Porto in Porto, Portugal
- Dr. Pereira is with the Department of Endocrinology and Nutrition at the Hospital do Divino Espírito Santo de Ponta Delgada in Azores, Portugal, and the Pre-clinical Section of the Medicine Course, Faculty of Sciences and Technology, at the University of Azores in Ponta Delgada, Portugal
| | - Bernardo Dias Pereira
- Dr. Lopes is with the Faculty of Medicine at the University of Porto in Porto, Portugal
- Dr. Pereira is with the Department of Endocrinology and Nutrition at the Hospital do Divino Espírito Santo de Ponta Delgada in Azores, Portugal, and the Pre-clinical Section of the Medicine Course, Faculty of Sciences and Technology, at the University of Azores in Ponta Delgada, Portugal
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50
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Antoine V, Courtial M, de Wazieres B, Di Castri A, Duvjnak S, Geronimi L, Labarias C, Le Guillou C, Martin-Allier A, Matelot D, Moitrelle C, Santoni F, Solinas G, Viala M. [Cognitive decline in geriatric oncology: Trends, evaluation and treatment]. Bull Cancer 2018; 105:720-734. [PMID: 29773225 DOI: 10.1016/j.bulcan.2018.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/13/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022]
Abstract
Cancer prevalence increases with aging. Prevalent or incident neurocognitive disorders are frequent in geriatric oncology. Cognitive decline associated with cancer increases the risk of under or over-cancer treatment and makes therapeutic decisions complex. In this context, we present tools to optimize cognitive impairment screening, identification of underlying mechanisms and specific treatments. Geriatric specialists intervention can help global care, social services utilization and patient's orientation when ambulatory cares become difficult.
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Affiliation(s)
- V Antoine
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France.
| | - M Courtial
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - B de Wazieres
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - A Di Castri
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - S Duvjnak
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - L Geronimi
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - C Labarias
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - C Le Guillou
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - A Martin-Allier
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - D Matelot
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - C Moitrelle
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - F Santoni
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - G Solinas
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
| | - M Viala
- CHU de Caremeau, pôle de gérontologie, place Robert-Debré, 30000 Nîmes, France
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