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Cho YE, Kim J, Vorn R, Cho H, Baek W, Park H, Yun S, Kim HS, Cashion AK, Gill J, Koo BN, Lee H. Extracellular Vesicle MicroRNAs as Predictive Biomarkers in Postoperative Delirium After Spine Surgery: Preliminary Study. J Gerontol A Biol Sci Med Sci 2024; 79:glae162. [PMID: 38970345 PMCID: PMC11398910 DOI: 10.1093/gerona/glae162] [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: 09/26/2023] [Indexed: 07/08/2024] Open
Abstract
Postoperative delirium (POD) can cause poor patient outcomes in older adults who undergo surgery. In this study, we tested plasma extracellular vesicle (EV) miRNAs obtained before the delirium event to find predictive POD biomarkers after spine surgery. We recruited patients who are more than 70 years old and have undergone spine surgery. Finally, POD patients (n = 31) were included, with no-POD patients matched in age, sex, medical history, and type of surgery (n = 31). Peripheral blood was collected from patients in the operating room after the operation was completed. EVs were isolated from plasma, and the 798 miRNA expression level from EVs was measured using a NanoString platform. Sixty-two patients were included in the study; all were Korean, 67.7% were females, and the median age was 75 years. Preoperative medical history was not statistically different between no-POD and POD patients except for hypertension and the American Society of Anesthesiologists physical status. From the miRNA profiling, we identified 142 significantly differentially expressed miRNAs in POD patients compared with no-POD patients, which are associated with psychological/neurological disorders. The top 10 differentially expressed miRNAs including miR-548ar-5p and miR-627-5p were all upregulated in POD patients and the results were validated using qRT-PCR from the independent sets of samples (n = 96). We demonstrated the potential of plasma EV-miRNAs as predictive biomarkers to identify the risk group of POD after spine surgery. It also provides opportunities for future studies investigating the role of EV-miRNAs in delirium pathology.
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Affiliation(s)
- Young-Eun Cho
- College of Nursing, The University of Iowa, Iowa City, Iowa, USA
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Rany Vorn
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Hyeonmi Cho
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Wonhee Baek
- College of Nursing, Gyeongsang National University, Jinju, Gyeongnam, Republic of Korea
| | - Hyunki Park
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Sijung Yun
- Predictiv Care, Inc, Sunnyvale, California, USA
| | - Hyung-Suk Kim
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Ann K Cashion
- College of Nursing, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jessica Gill
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyangkyu Lee
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
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Nitta Y, Sanuki T, Sugino S, Sugimoto M, Kido K. The impact of preoperative psychiatric intervention for postoperative delirium after major oral and maxillofacial surgery with free flap reconstruction. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:102026. [PMID: 39218156 DOI: 10.1016/j.jormas.2024.102026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 08/23/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe complication associated with various adverse outcomes, especially in older patients. Although the incidence and risk factors for POD have been explored in general surgery, they have not been fully elucidated. Early identification of high-risk patients and active preoperative intervention are considered essential for the prevention of POD. Recently, psychiatric consultation intervention have been shown to prevent delirium. This study investigated the effect of preoperative psychiatric interventions on preventing POD in our specific surgical context. MATERIALS AND METHODS This retrospective, single-center observational study included 86 patients who underwent major oral and maxillofacial surgery with free flap reconstruction between 2016 and 2023. The effect of psychiatric intervention were compared between patients with and without delirium. RESULTS Preoperative psychiatric intervention did not reduce the incidence of POD. The incidence of POD was 29.1 %. Univariate analyses showed no significant associations between POD and any clinical variables. CONCLUSION There was no difference in the incidence of POD between patients who received preoperative psychiatric intervention and those who did not, and further investigation is needed to determine the efficacy of preoperative psychiatric intervention in the prevention of POD.
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Affiliation(s)
- Yukie Nitta
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, Japan
| | - Shigekazu Sugino
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Masahiro Sugimoto
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Yamagata, 997-0052, Japan
| | - Kanta Kido
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
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Alhammadi E, Kuhlmann JM, Rana M, Frohnhofen H, Moellmann HL. Postoperative delirium in oral and maxillofacial surgery: a scoping review. Head Face Med 2024; 20:39. [PMID: 39044223 PMCID: PMC11265362 DOI: 10.1186/s13005-024-00439-9] [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: 05/07/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) in the oral and maxillofacial settings has gained more attention in recent decades. Due to advances in medical technology, treatment possibilities have expanded treatment for elderly and frail patients. This scoping review explores the correlation between POD and oral and maxillofacial surgery, summarizing screening and management protocols and identifying risk factors in this surgical field. METHODS This review follows the Scoping Review extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR). A comprehensive literature search was performed using multiple databases, focusing on articles published from 2002 to 2023 that discuss delirium in oral and maxillofacial surgery settings. The review was registered beforehand in the Open Science Framework ( https://osf.io/r2ebc ). RESULTS From the initial 644 articles, 68 met the inclusion criteria. These studies highlighted the significant heterogeneity in POD diagnosis methods. The review identifies multiple risk factors across the preoperative, intraoperative, and postoperative phases that influence the occurrence of POD. Significant and independent risk factors in multiple regression analysis were highlighted, creating a clinical prediction list for the occurrence of POD. CONCLUSION It is crucial to preoperatively identify patients at risk for POD and actively modify these risks throughout the patient's hospital stay. Implementing nonpharmacological preventive measures for at-risk patients is recommended to decrease the incidence of POD. Future research should focus on creating standardized specialty-specific protocols incorporating validated assessment tools and addressing the full spectrum of risk factors associated with POD.
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Affiliation(s)
- Eman Alhammadi
- Cranio-and-Maxillo Facial Surgery, University Hospital Düsseldorf, Moorenstraße 5, Düsseldorf, 40225, Germany.
- Dubai Health, Dubai, United Arab Emirates.
| | - Julian Max Kuhlmann
- Heinrich-Heine-Universität Düsseldorf, Universitätsstrasse 1, Düsseldorf, 40225, Germany
| | - Majeed Rana
- Cranio-and-Maxillo Facial Surgery, University Hospital Düsseldorf, Moorenstraße 5, Düsseldorf, 40225, Germany
| | - Helmut Frohnhofen
- Orthopedics and Trauma Surgery, University Hospital Düsseldorf, Moorenstraße 5, Düsseldorf, 40225, Germany
| | - Henriette Louise Moellmann
- Cranio-and-Maxillo Facial Surgery, University Hospital Düsseldorf, Moorenstraße 5, Düsseldorf, 40225, Germany.
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Sist L, Pezzolati M, Ugenti NV, Cedioli S, Messina R, Chiappinotto S, Rucci P, Palese A. Nurses prioritization processes to prevent delirium in patients at risk: Findings from a Q-Methodology study. Geriatr Nurs 2024; 58:59-68. [PMID: 38762972 DOI: 10.1016/j.gerinurse.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/22/2024] [Accepted: 05/06/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND This study aimed at (a) exploring how nurses prioritise interventions to prevent delirium among patients identified at risk and (b) describing the underlying prioritisation patterns according to nurses' individual characteristics. METHODS There was used the Q-methodology a research process following specific steps: (a) identifying the concourse, (b) the Q-sample, and (c) the population (P-set); (d) collecting data using the Q-sort table; (e) entering the data and performing the factor analysis; and (f) interpreting the factors identified. RESULTS There were involved 56 nurses working in medical, geriatric and log-term facilities (46; 82.2 %). The preventive intervention receiving the highest priority was 'Monitoring the vital parameters (heart rate, blood pressure, oxygen saturation)' (2.96 out of 4 as the highest priority; CI 95 %: 2.57, 3.36). Two priority patterns emerged among nurses (explained variance 44.78 %), one 'Clinical-oriented' (36.19 %) and one 'Family/caregiver-oriented' (8.60 %) representing 53 nurses out 56. CONCLUSION Alongside the overall tendency to prioritise some preventive interventions instead of others, the priorities are polarised in two main patterns expressing two main individual characteristics of nurses. Knowing the existence of individual patterns and their aggregation informs how to shape educational interventions.
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Affiliation(s)
- Luisa Sist
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Sviluppo Professionale e Implementazione della Ricerca nelle Professioni Sanitarie (SPIR), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | | | - Nikita Valentina Ugenti
- Sviluppo Professionale e Implementazione della Ricerca nelle Professioni Sanitarie (SPIR), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Rossella Messina
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Varpaei HA, Farhadi K, Mohammadi M, Khafaee Pour Khamseh A, Mokhtari T. Postoperative cognitive dysfunction: a concept analysis. Aging Clin Exp Res 2024; 36:133. [PMID: 38902462 PMCID: PMC11189971 DOI: 10.1007/s40520-024-02779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/17/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Post-operative cognitive dysfunction (POCD) is a concern for clinicians that often presents post-surgery where generalized anesthesia has been used. Its prevalence ranges from 36.6% in young adults to 42.4% in older individuals. Conceptual clarity for POCD is lacking in the currently body literature. Our two-fold purpose of this concept analysis was to (1) critically appraise the various definitions, while also providing the best definition, of POCD and (2) narratively synthesize the attributes, surrogate or related terms, antecedents (risk factors), and consequences of the concept. METHOD The reporting of our review was guided by the PRISMA statement and the 6-step evolutionary approach to concept analysis developed by Rodgers. Three databases, including Medline, CINAHL, and Web of Science, were searched to retrieve relevant literature on the concept of POCD. Two independent reviewers conducted abstract and full-text screening, data extraction, and appraisal. The review process yielded a final set of 86 eligible articles. RESULT POCD was defined with varying severities ranging from subtle-to-extensive cognitive changes (1) affecting single or multiple cognitive domains that manifest following major surgery (2), is transient and reversible, and (3) may last for several weeks to years. The consequences of POCD may include impaired quality of life, resulting from withdrawal from the labor force, increased patients' dependencies, cognitive decline, an elevated risk of dementia, rising healthcare costs, and eventual mortality. CONCLUSION This review resulted in a refined definition and comprehensive analysis of POCD that can be useful to both researchers and clinicians. Future research is needed to refine the operational definitions of POCD so that they better represent the defining attributes of the concept.
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Affiliation(s)
| | - Kousha Farhadi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Tahereh Mokhtari
- Department of Gynecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Liu C, Lv X, Meng L, Li J, Cao G. A Mendelian randomization-based study of the causal relationship between leisure sedentary behavior and delirium. J Affect Disord 2024; 355:50-56. [PMID: 38552912 DOI: 10.1016/j.jad.2024.03.158] [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: 08/12/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Delirium is an acute or subacute change in mental status caused by various factors. We evaluated the causal relationship between leisure sedentary behaviors (LSBs) and delirium. METHODS A two-sample Mendelian randomization (MR) study was performed to evaluate the causal relationship between sedentary behaviors (time spent watching television, time spent using computer, and time spent driving) and delirium. Statistical information for the associations between single nucleotide polymorphisms (SNPs) and the traits of interest was obtained from independent consortia that focused on European populations. The dataset for LSBs was acquired from genome-wide association studies (GWAS) comprising a substantial sample size: 437887 samples for time spent watching television, 360,895 for time spent using computer, and 310,555 for time spent driving. A GWAS with 1269 delirium cases and 209,487 controls was used to identify genetic variation underlying the time of LSBs. We used five complementary MR methods, including inverse variance weighted method (IVW), MR-Egger, weighted median, weighted mode, and simple mode. RESULTS Genetically predicted time spent watching television (odds ratio [OR]: 2.921, 95 % confidence interval [CI]: 1.381-6.179) demonstrated significant association with delirium (P = 0.005), whereas no significant associations were observed between time spent using computer (OR: 0.556, 95 % CI: 0.246-1.257, P = 0.158) and time spent driving (OR: 1.747, 95 % CI: 0.09-3. 40, P = 0.713) and delirium. Sensitivity analyses supported a causal interpretation, with limited evidence of significant bias from genetic pleiotropy. Moreover, our MR assumptions appeared to be upheld, enhancing the credibility of our conclusions. LIMITATIONS Larger sample sizes are needed to validate the findings of our study. CONCLUSION Time spent watching television is a significant risk factor for delirium. Reducing television time may be an important intervention for those at higher risk of delirium.
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Affiliation(s)
- Chuanzhen Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China; Shandong University, No. 27, South Shanda Road, Jinan 250100, Shandong, China; Pantheum Biotechnology Co., Ltd, Jinan 250012, Shandong, China
| | - Xin Lv
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China
| | - Lingwei Meng
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China
| | - Jianhua Li
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China.
| | - Guangqing Cao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, No. 107, West Wenhua Road, Jinan 250012, Shandong, China.
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Hui D, Cheng SY, Paiva CE. Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice. Cancers (Basel) 2024; 16:2045. [PMID: 38893163 PMCID: PMC11170992 DOI: 10.3390/cancers16112045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.
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Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Centre, Houston, TX 77030, USA
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei 10617, Taiwan;
| | - Carlos Eduardo Paiva
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos 1331, SP, Brazil;
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Penfold RS, Squires C, Angus A, Shenkin SD, Ibitoye T, Tieges Z, Neufeld KJ, Avelino-Silva TJ, Davis D, Anand A, Duckworth AD, Guthrie B, MacLullich AMJ. Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review. J Am Geriatr Soc 2024; 72:1508-1524. [PMID: 38241503 DOI: 10.1111/jgs.18751] [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: 07/06/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Multiple short delirium detection tools have been validated in research studies and implemented in routine care, but there has been little study of these tools in real-world conditions. This systematic review synthesized literature reporting completion rates and/or delirium positive score rates of detection tools in large clinical populations in general hospital settings. METHODS PROSPERO (CRD42022385166). Medline, Embase, PsycINFO, CINAHL, and gray literature were searched from 1980 to December 31, 2022. Included studies or audit reports used a validated delirium detection tool performed directly with the patient as part of routine care in large clinical populations (n ≥ 1000) within a general acute hospital setting. Narrative synthesis was performed. RESULTS Twenty-two research studies and four audit reports were included. Tools used alone or in combination were the Confusion Assessment Method (CAM), 4 'A's Test (4AT), Delirium Observation Screening Scale (DOSS), Brief CAM (bCAM), Nursing Delirium Screening Scale (NuDESC), and Intensive Care Delirium Screening Checklist (ICDSC). Populations and settings varied and tools were used at different stages and frequencies in the patient journey, including on admission only; inpatient, daily or more frequently; on admission and as inpatient; inpatient post-operatively. Tool completion rates ranged from 19% to 100%. Admission positive score rates ranged from: CAM 8%-51%; 4AT 13%-20%. Inpatient positive score rates ranged from: CAM 2%-20%, DOSS 6%-42%, and NuDESC 5-13%. Postoperative positive score rates were 21% and 28% (4AT). All but two studies had moderate-high risk of bias. CONCLUSIONS This systematic review of delirium detection tool implementation in large acute patient populations found clinically important variability in tool completion rates, and in delirium positive score rates relative to expected delirium prevalence. This study highlights a need for greater reporting and analysis of relevant healthcare systems data. This is vital to advance understanding of effective delirium detection in routine care.
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Affiliation(s)
- Rose S Penfold
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Susan D Shenkin
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Karin J Neufeld
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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Lauffer-Vogt SU, Hediger H, Lauener SK, Schubert M. [The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital]. Pflege 2024; 37:89-97. [PMID: 37997948 DOI: 10.1024/1012-5302/a000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital Abstract: Background: With a prevalence of 12-64%, delirium is a common complication in acute care, associated with negative outcomes such as increased mortality and prolonged length of stay. Many hospitals have guidelines to improve the delirium management. The Delirium Observation Screening Scale (DOS) Score is collected in the study hospital from all patients ≥ 70 years at each shift for at least 3 days. Delirium is diagnosed by a physician and coded according to ICD-10. Purpose: Evaluation of the delirium screening with the DOS according to internal guideline in terms of number of DOS assessments performed, prevalence of delirium (DOS score ≥ 3 points, CD-10 code delirium). Method: This retrospective quantitative single-centre longitudinal study used 2017 and 2018 data of 10046 cases. Statistical analysis methods were used to analyse prevalence of delirium and subgroup comparisons. Results: At least one DOS score was documented in 92% of cases aged ≥ 70-years (n = 5038). DOS implementation varied between 60% in the early, 49% in the late and 38% in the night shift. The prevalence of delirium was 12% according to DOS score ≥ 3 and 4% according to physician diagnosis of a delirium. Cases with a DOS score ≥ 3 were significantly older, more often female, had more comorbidities and were depressed. Conclusions: DOS is performed in most patients when indicated. The DOS implementation frequency varied depending on the shift.
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Affiliation(s)
- Stefan Urs Lauffer-Vogt
- Klinik für Plastische Chirurgie und Handchirurgie, Klinik für Traumatologie, Universitätsspital Zürich, Schweiz
| | - Hannele Hediger
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| | - Susanne Knüppel Lauener
- Abteilung für Praxisentwicklung und Forschung Pflege/MTT, Medizinische Direktion, Universitätsspital Basel, Schweiz
| | - Maria Schubert
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
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Park SJ, Oh AR, Lee JH, Yang K, Park J. Association of preoperative blood glucose level with delirium after non-cardiac surgery in diabetic patients. Korean J Anesthesiol 2024; 77:226-235. [PMID: 38171594 PMCID: PMC10982528 DOI: 10.4097/kja.23301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Hyperglycemia has shown a negative association with cognitive dysfunction. We analyzed patients with high preoperative blood glucose level and hemoglobin A1c (HbA1c) level to determine the prevalence of postoperative delirium. METHODS We reviewed a database of 23,532 patients with diabetes who underwent non-cardiac surgery. Acute hyperglycemia was defined as fasting blood glucose > 140 mg/dl or random glucose > 180 mg/dl within 24 h before surgery. Chronic hyperglycemia was defined as HbA1c level above 6.5% within three months before surgery. The incidence of delirium was compared according to the presence of acute and chronic hyperglycemia. RESULTS Of the 23,532 diabetic patients, 21,585 had available preoperative blood glucose level within 24 h before surgery, and 18,452 patients reported levels indicating acute hyperglycemia. Of the 8,927 patients with available HbA1c level within three months before surgery, 5,522 had levels indicating chronic hyperglycemia. After adjustment with inverse probability weighting, acute hyperglycemia was related to higher incidence of delirium (hazard ratio: 1.33, 95% CI [1.10,1.62], P = 0.004 for delirium) compared with controls without acute hyperglycemia. On the other hand, chronic hyperglycemia did not correlate with postoperative delirium. CONCLUSIONS Preoperative acute hyperglycemia was associated with postoperative delirium, whereas chronic hyperglycemia was not significantly associated with postoperative delirium. Irrespective of chronic hyperglycemia, acute glycemic control in surgical patients could be crucial for preventing postoperative delirium.
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Affiliation(s)
- Soo Jung Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Yogi TN, Puri S, Shah B, Nepal S, Mishra A. Point prevalence and clinical profile of patients with delirium admitted in internal medicine department at tertiary care centre in eastern Nepal: a descriptive cross-sectional study. Ann Med Surg (Lond) 2024; 86:1335-1340. [PMID: 38463110 PMCID: PMC10923295 DOI: 10.1097/ms9.0000000000001761] [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: 10/13/2023] [Accepted: 01/15/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction Delirium, marked by acute disturbances in consciousness and cognition, remains underdiagnosed despite its significant impact on morbidity and mortality. This study investigates the point prevalence and clinical profile of delirium in patients at an eastern Nepal tertiary care centre. Methods A 1-month descriptive cross-sectional study involved 152 Internal Medicine Department patients at BPKIHS, Dharan. Data, collected through face-to-face interviews and the Confusion Assessment Method (CAM), analyzed demographic details, clinical history, and laboratory findings. Ethical clearance and informed consent were obtained. Results Among 152 participants, 13.2% exhibited delirium, with notable risk factors identified. Elderly patients (≥65 years) and those with nasogastric tubes faced higher risks. Significant associations were found with cardiovascular diseases (P=0.002), central nervous system diseases (P=0.015), and alcoholism (P=0.003). Laboratory findings revealed correlations with elevated creatinine, hyperuremia, and abnormal aspartate aminotransferase levels. The study emphasizes key contributors to delirium, providing valuable insights for clinicians in identifying, preventing, and managing delirium in a hospital setting. Conclusions This study provides critical insights into delirium prevalence and profiles in Eastern Nepal. Identified risk factors underscore the importance of routine screenings and targeted interventions for at-risk populations. Study limitations, including sample size and single-centre focus, call for further research to validate findings and enhance our understanding of delirium's management across diverse healthcare settings. Overall, the study informs clinical practices and prompts broader exploration of delirium in healthcare contexts.
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Affiliation(s)
| | | | | | - Suraj Nepal
- Psychiatry, BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
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12
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Oh AR, Lee DY, Lee S, Lee JH, Yang K, Choi B, Park J. Association between Preoperative Glucose Dysregulation and Delirium after Non-Cardiac Surgery. J Clin Med 2024; 13:932. [PMID: 38398245 PMCID: PMC10889204 DOI: 10.3390/jcm13040932] [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: 12/15/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
This study aimed to investigate the association between glucose dysregulation and delirium after non-cardiac surgery. Among a total of 203,787 patients who underwent non-cardiac surgery between January 2011 and June 2019 at our institution, we selected 61,805 with available preoperative blood glucose levels within 24 h before surgery. Patients experiencing glucose dysregulation were divided into three groups: hyperglycemia, hypoglycemia, and both. We compared the incidence of postoperative delirium within 30 days after surgery between exposed and unexposed patients according to the type of glucose dysregulation. The overall incidence of hyperglycemia, hypoglycemia, and both was 5851 (9.5%), 1452 (2.3%), and 145 (0.2%), respectively. The rate of delirium per 100 person-months of the exposed group was higher than that of the unexposed group in all types of glucose dysregulation. After adjustment, the hazard ratios of glucose dysregulation in the development of delirium were 1.35 (95% CI, 1.18-1.56) in hyperglycemia, 1.36 (95% CI, 1.06-1.75) in hypoglycemia, and 3.14 (95% CI, 1.27-7.77) in both. The subgroup analysis showed that exposure to hypoglycemia or both to hypo- and hyperglycemia was not associated with delirium in diabetic patients, but hyperglycemia was consistently associated with postoperative delirium regardless of the presence of diabetes. Preoperative glucose dysregulation was associated with increased risk of delirium after non-cardiac surgery. Our findings may be helpful for preventing postoperative delirium, and further investigations are required to verify the association and mechanisms for the effect we observed.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Dong Yun Lee
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea
| | - Seunghwa Lee
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Kwangmo Yang
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Byungjin Choi
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea
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Poikajärvi S, Peltonen LM, Siirala E, Heimonen J, Moen H, Salanterä S, Junttila K. Exploring the Documentation of Delirium in Patients After Cardiac Surgery: A Retrospective Patient Record Study. Comput Inform Nurs 2024; 42:27-34. [PMID: 37278574 DOI: 10.1097/cin.0000000000001039] [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: 06/07/2023]
Abstract
Delirium is a common disorder for patients after cardiac surgery. Its manifestation and care can be examined through EHRs. The aim of this retrospective, comparative, and descriptive patient record study was to describe the documentation of delirium symptoms in the EHRs of patients who have undergone cardiac surgery and to explore how the documentation evolved between two periods (2005-2009 and 2015-2020). Randomly selected care episodes were annotated with a template, including delirium symptoms, treatment methods, and adverse events. The patients were then manually classified into two groups: nondelirious (n = 257) and possibly delirious (n = 172). The data were analyzed quantitatively and descriptively. According to the data, the documentation of symptoms such as disorientation, memory problems, motoric behavior, and disorganized thinking improved between periods. Yet, the key symptoms of delirium, inattention, and awareness were seldom documented. The professionals did not systematically document the possibility of delirium. Particularly, the way nurses recorded structural information did not facilitate an overall understanding of a patient's condition with respect to delirium. Information about delirium or proposed care was seldom documented in the discharge summaries. Advanced machine learning techniques can augment instruments that facilitate early detection, care planning, and transferring information to follow-up care.
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Affiliation(s)
- Satu Poikajärvi
- Author Affiliations: Faculty of Medicine, Department of Nursing Science, University of Turku (Prof Poikajärvi, Dr Peltonen, Prof Salanterä, and Dr Junttila); Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital (Prof Poikajärvi); Research Services, Turku University Hospital (Dr Siirala); Faculty of Technology, Department of Computing, University of Turku (Dr Heimonen); Department of Computer Science, School of Science, Aalto University (Dr Moen); Turku University Hospital (Prof Salanterä); Nursing Research Center, Helsinki University Hospital and University of Helsinki (Dr Junttila), Finland
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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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15
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Jiang LS, Lai L, Chen YJ, Liu K, Shen QH. Prophylactic effect of exogenous melatonin and melatonin receptor agonists on postoperative delirium in elderly patients: a systemic review and meta-analysis of randomized controlled trials. Aging Clin Exp Res 2023; 35:2323-2331. [PMID: 37776484 DOI: 10.1007/s40520-023-02564-y] [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: 04/27/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The prophylactic effect of exogenous melatonin and melatonin receptor agonists (MMRAs) on postoperative delirium (POD) in elderly patients remains controversial. OBJECTIVE This study aimed to assess the prophylactic effect of MMRAs on POD by conducting a systemic review and meta-analysis of randomized controlled trials (RCTs). METHODS We systematically searched four electronic databases including PubMed, Web of Science, Cochrane Library, and Embase for the eligible studies up to February 28, 2023. The Cochrane risk of bias tool was used for assessing the risk of bias in the included RCTs. The occurrence of POD was the primary outcome. The quality of evidence was evaluated by Grading of Recommendations Assessment, Development, and Evaluation. RESULTS A total of 11 RCTs comprising patients (MMRA group: 777 patients and placebo group: 781 patients) were included. The results of the meta-analysis showed that the MMRA group had a lower occurrence of POD than the placebo group (risk ratio = 0.70, 95% confidence interval: 0.51-0.97, P < 0.05, I2 = 59%). The subgroup analysis showed that melatonin significantly reduced the occurrence of POD (moderate-quality evidence), whereas ramelteon and tryptophan had no significant impact (moderate-quality evidence). CONCLUSION Existing evidence suggested that perioperative use of melatonin can prevent POD in elderly patients.
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Affiliation(s)
- Li-Shan Jiang
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Lan Lai
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Yan-Jun Chen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Ke Liu
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Qi-Hong Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China.
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Versloot J, Minotti SC, Amer S, Ali A, Ma J, Peters ML, Saab H, Tang T, Kerr J, Reid R. Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis. J Gen Intern Med 2023; 38:2936-2944. [PMID: 37429974 PMCID: PMC10593633 DOI: 10.1007/s11606-023-08238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/09/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Delirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality. OBJECTIVE To evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units. DESIGN A pre-post intervention study using retrospective chart abstraction and interrupted time series analysis. COHORT Patients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria. INTERVENTION The delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team. MEASUREMENT Delirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected. RESULT Our evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units. CONCLUSION A multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.
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Affiliation(s)
- Judith Versloot
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON Canada
| | - Simona C. Minotti
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Samia Amer
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | - Amna Ali
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | - Julia Ma
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | | | - Hana Saab
- Trillium Health Partners, Mississauga, ON Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Jason Kerr
- Trillium Health Partners, Mississauga, ON Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON Canada
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Sheikhalishahi S, Bhattacharyya A, Celi LA, Osmani V. An interpretable deep learning model for time-series electronic health records: Case study of delirium prediction in critical care. Artif Intell Med 2023; 144:102659. [PMID: 37783541 DOI: 10.1016/j.artmed.2023.102659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/19/2023] [Accepted: 09/04/2023] [Indexed: 10/04/2023]
Abstract
Deep Learning (DL) models have received increasing attention in the clinical setting, particularly in intensive care units (ICU). In this context, the interpretability of the outcomes estimated by the DL models is an essential step towards increasing adoption of DL models in clinical practice. To address this challenge, we propose an ante-hoc, interpretable neural network model. Our proposed model, named double self-attention architecture (DSA), uses two attention-based mechanisms, including self-attention and effective attention. It can capture the importance of input variables in general, as well as changes in importance along the time dimension for the outcome of interest. We evaluated our model using two real-world clinical datasets covering 22840 patients in predicting onset of delirium 12 h and 48 h in advance. Additionally, we compare the descriptive performance of our model with three post-hoc interpretable algorithms as well as with the opinion of clinicians based on the published literature and clinical experience. We find that our model covers the majority of the top-10 variables ranked by the other three post-hoc interpretable algorithms as well as the clinical opinion, with the advantage of taking into account both, the dependencies among variables as well as dependencies between varying time-steps. Finally, our results show that our model can improve descriptive performance without sacrificing predictive performance.
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Affiliation(s)
| | | | - Leo Anthony Celi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy; Information School, University of Sheffield, UK.
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Nakamura T, Yoshizawa T, Toya R, Terasawa M, Takahashi K, Kitazawa K, Suzuki K, Sasayama D, Washizuka S. Orexin receptor antagonists versus antipsychotics for the management of delirium in intensive care unit patients with cardiovascular disease: A retrospective observational study. Gen Hosp Psychiatry 2023; 84:96-101. [PMID: 37413718 DOI: 10.1016/j.genhosppsych.2023.06.019] [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: 01/13/2023] [Revised: 06/02/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Although antipsychotics are often used in the pharmacological treatment of delirium, recent reports suggest the efficacy of orexin receptor antagonists. This study investigated whether orexin receptor antagonists could be a possible treatment option for delirium. METHOD A nonblinded nonrandomized routine clinical treatment was performed. Patients treated in intensive care units (ICU) for cardiovascular disease and receiving psychiatric intervention were studied retrospectively. The scores from the Intensive Care Delirium Screening Checklist (ICDSC) were compared between patients treated with orexin receptor antagonists and those treated with antipsychotics. RESULTS The mean (standard deviation) ICDSC scores were 4.5 (1.8) at day -1 and 2.6 (2.6) at day 7 for orexin receptor antagonist group (n = 25) and 4.6 (2.4) at day -1 and 4.1 (2.2) at day 7 for antipsychotic group (n = 28). The orexin receptor antagonist group showed significantly lower ICDSC scores than the antipsychotic group (p = 0.021). CONCLUSION While precise efficacy cannot be determined from our retrospective, observational, and uncontrolled pilot study, this analysis encourages a future double-blind randomized placebo-controlled trial of orexin-antagonists for delirium treatment.
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Affiliation(s)
- Toshinori Nakamura
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan.
| | - Tomonari Yoshizawa
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Risa Toya
- Department of Nursing, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Miho Terasawa
- Department of Pharmacy, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kazuhito Takahashi
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kasumi Kitazawa
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kazuhiro Suzuki
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Daimei Sasayama
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Shinsuke Washizuka
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
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Dodsworth BT, Reeve K, Falco L, Hueting T, Sadeghirad B, Mbuagbaw L, Goettel N, Schmutz Gelsomino N. Development and validation of an international preoperative risk assessment model for postoperative delirium. Age Ageing 2023; 52:7192246. [PMID: 37290122 DOI: 10.1093/ageing/afad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a frequent complication in older adults, characterised by disturbances in attention, awareness and cognition, and associated with prolonged hospitalisation, poor functional recovery, cognitive decline, long-term dementia and increased mortality. Early identification of patients at risk of POD can considerably aid prevention. METHODS We have developed a preoperative POD risk prediction algorithm using data from eight studies identified during a systematic review and providing individual-level data. Ten-fold cross-validation was used for predictor selection and internal validation of the final penalised logistic regression model. The external validation used data from university hospitals in Switzerland and Germany. RESULTS Development included 2,250 surgical (excluding cardiac and intracranial) patients 60 years of age or older, 444 of whom developed POD. The final model included age, body mass index, American Society of Anaesthesiologists (ASA) score, history of delirium, cognitive impairment, medications, optional C-reactive protein (CRP), surgical risk and whether the operation is a laparotomy/thoracotomy. At internal validation, the algorithm had an AUC of 0.80 (95% CI: 0.77-0.82) with CRP and 0.79 (95% CI: 0.77-0.82) without CRP. The external validation consisted of 359 patients, 87 of whom developed POD. The external validation yielded an AUC of 0.74 (95% CI: 0.68-0.80). CONCLUSIONS The algorithm is named PIPRA (Pre-Interventional Preventive Risk Assessment), has European conformity (ce) certification, is available at http://pipra.ch/ and is accepted for clinical use. It can be used to optimise patient care and prioritise interventions for vulnerable patients and presents an effective way to implement POD prevention strategies in clinical practice.
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Affiliation(s)
| | - Kelly Reeve
- Institute of Data Analysis and Process Design, Zurich University of Applied Sciences, Winterthur 8400, Switzerland
| | - Lisa Falco
- Zühlke Engineering AG, Zürcherstrasse 39J, Schlieren 8952, Switzerland
| | - Tom Hueting
- Evidencio, Irenesingel 19, Haaksbergen 7481 GJ, Netherlands
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Anesthesia, McMaster University, Hamilton ON L8S 4L8, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Anesthesia, McMaster University, Hamilton ON L8S 4L8, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON L8S 4L8, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé 12117, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town 7600, South Africa
| | - Nicolai Goettel
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville FL 32610, USA
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
| | - Nayeli Schmutz Gelsomino
- PIPRA AG, Zurich 8005, Switzerland
- Department of Anaesthesia, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland
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20
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Lee DY, Oh AR, Park J, Lee SH, Choi B, Yang K, Kim HY, Park RW. Machine learning-based prediction model for postoperative delirium in non-cardiac surgery. BMC Psychiatry 2023; 23:317. [PMID: 37143035 PMCID: PMC10161528 DOI: 10.1186/s12888-023-04768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Postoperative delirium is a common complication that is distressing. This study aimed to demonstrate a prediction model for delirium. METHODS Among 203,374undergoing non-cardiac surgery between January 2011 and June 2019 at Samsung Medical Center, 2,865 (1.4%) were diagnosed with postoperative delirium. After comparing performances of machine learning algorithms, we chose variables for a prediction model based on an extreme gradient boosting algorithm. Using the top five variables, we generated a prediction model for delirium and conducted an external validation. The Kaplan-Meier and Cox survival analyses were used to analyse the difference of delirium occurrence in patients classified as a prediction model. RESULTS The top five variables selected for the postoperative delirium prediction model were age, operation duration, physical status classification, male sex, and surgical risk. An optimal probability threshold in this model was estimated to be 0.02. The area under the receiver operating characteristic (AUROC) curve was 0.870 with a 95% confidence interval of 0.855-0.885, and the sensitivity and specificity of the model were 0.76 and 0.84, respectively. In an external validation, the AUROC was 0.867 (0.845-0.877). In the survival analysis, delirium occurred more frequently in the group of patients predicted as delirium using an internal validation dataset (p < 0.001). CONCLUSION Based on machine learning techniques, we analyzed a prediction model of delirium in patients who underwent non-cardiac surgery. Screening for delirium based on the prediction model could improve postoperative care. The working model is provided online and is available for further verification among other populations. TRIAL REGISTRATION KCT 0006363.
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Affiliation(s)
- Dong Yun Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, 206, World cup-ro, Yeongtong-gu, Suwon, Korea
- Department of Medical Sciences, Graduate School of Ajou University, Suwon, Republic of Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jungchan Park
- Department of Biomedical Informatics, Ajou University School of Medicine, 206, World cup-ro, Yeongtong-gu, Suwon, Korea.
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea.
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Byungjin Choi
- Department of Biomedical Informatics, Ajou University School of Medicine, 206, World cup-ro, Yeongtong-gu, Suwon, Korea
| | - Kwangmo Yang
- Department of Biomedical Informatics, Ajou University School of Medicine, 206, World cup-ro, Yeongtong-gu, Suwon, Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, 206, World cup-ro, Yeongtong-gu, Suwon, Korea.
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21
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Babine RL, Hyrkäs KE, Scott C, Wierman HR. Individuals Who Developed Delirium While Enrolled in the Hospital Elder Life Program: An Exploratory Study. J Gerontol Nurs 2023; 49:19-29. [PMID: 37126011 DOI: 10.3928/00989134-20230414-02] [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: 05/02/2023]
Abstract
Delirium prevention in hospitalized older adults is important due to delirium's high prevalence and negative impact on outcomes. Today, there are evidence-based programs with well-documented effectiveness aimed at preventing delirium, such as the Hospital Elder Life Program (HELP); however, approximately 4% to 5% of patients develop delirium regardless of implemented prevention interventions. It remains unknown why some patients develop delirium. The current retrospective exploratory chart review analyzed 98 records for clinical risk factors and outcomes of patients who developed delirium while enrolled in the HELP. On admission, immobility (86.7%) was the most common risk factor. Patients developed delirium approximately 70 hours after admission. Average length of stay was 8 days. Approximately one half (44.9%) of patients died within 1 year. Immobility (97.7% vs. 77.8%, p = 0.005) and renal disease (52.3% vs. 24.1%, p = 0.008) were more often found in patients who died. This study identifies risk factors that seem to require heightened attention during hospitalization to prevent the negative outcomes associated with delirium in older adults. [Journal of Gerontological Nursing, 49(5), 19-29.].
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22
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Amonoo HL, Markovitz NH, Johnson PC, Kwok A, Dale C, Deary EC, Daskalakis E, Choe JJ, Yamin N, Gothoskar M, Cronin KG, Fernandez-Robles C, Pirl WF, Chen YB, Cutler C, Lindvall C, El-Jawahri A. Delirium and Healthcare Utilization in Patients Undergoing Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:334.e1-334.e7. [PMID: 36736782 PMCID: PMC10149603 DOI: 10.1016/j.jtct.2023.01.028] [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: 11/21/2022] [Revised: 01/04/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
Delirium, a common neuropsychiatric syndrome among hospitalized patients, has been associated with significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). Although delirium is often reversible with prompt diagnosis and appropriate management, timely screening of hospitalized patients, including HSCT recipients at risk for delirium, is lacking. The association between delirium symptoms and healthcare utilization among HSCT recipients is also limited. We conducted a retrospective analysis of 502 hospitalized patients admitted for allogeneic or autologous HSCT at 2 tertiary care hospitals between April 2016 and April 2021. We used Natural Language Processing (NLP) to identify patients with delirium symptoms, as defined by an NLP-assisted chart review of the electronic health record (EHR). We used multivariable regression models to examine the associations between delirium symptoms, clinical outcomes, and healthcare utilization, adjusting for patient-, disease-, and transplantation-related factors. Overall, 44.4% (124 of 279) of patients undergoing allogeneic HSCT and 39.0% (87 of 223) of those undergoing autologous HSCT were identified as having delirium symptoms during their index hospitalization. Two-thirds (139 of 211) of the patients with delirium symptoms were prescribed treatment with antipsychotic medications. Among allogeneic HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 7.960; P < .001), fewer days alive and out of the hospital (β = -23.669; P < .001), and more intensive care unit admissions (odds ratio, 2.854; P = .002). In autologous HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 2.204; P < .001). NLP-assisted EHR review is a feasible approach to identifying hospitalized patients, including HSCT recipients at risk for delirium. Because delirium symptoms are negatively associated with health care utilization during and after HSCT, our findings underscore the need to efficiently identify patients hospitalized for HSCT who are at risk of delirium to improve their outcomes. © 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Hermioni L Amonoo
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Netana H Markovitz
- Harvard Medical School, Boston, Massachusetts; Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - P Connor Johnson
- Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ciara Dale
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emma C Deary
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Joanna J Choe
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nikka Yamin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Maanasi Gothoskar
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Katherine G Cronin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Carlos Fernandez-Robles
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - William F Pirl
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Yi-Bin Chen
- Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Corey Cutler
- Harvard Medical School, Boston, Massachusetts; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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23
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Kim SY, Jo HY, Na HS, Han SH, Do SH, Shin HJ. The Effect of Peripheral Nerve Block on Postoperative Delirium in Older Adults Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12072459. [PMID: 37048543 PMCID: PMC10095174 DOI: 10.3390/jcm12072459] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
This meta-analysis aimed to determine whether peripheral nerve blocks (PNB) reduce postoperative delirium (POD) in elderly patients undergoing hip surgery. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022328320). The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) on 26 April 2022. A total of 19 RCTs with 1977 participants were included. Perioperative PNB lowered the POD incidence on the third postoperative day (OR: 0.59, 95% CI [0.40 to 0.87], p = 0.007, I2 = 35%), in patients without underlying cognitive impairment (OR: 0.47, 95% CI [0.30 to 0.74], p = 0.001, I2 = 30%), and when a fascia iliaca compartment block (OR: 0.58, 95% CI [0.37 to 0.91], p = 0.02, I2 = 0%) or a femoral nerve block (OR: 0.33, 95% CI [0.11 to 0.99], p = 0.05, I2 = 66%) were performed. The pain score was also reduced (SMD: -0.83, 95% CI [-1.36 to -0.30], p = 0.002, I2 = 95%) after PNB. Perioperative PNB can lower the POD incidence and pain scores up to the third postoperative day. However, considering the wide variety of PNBs performed, more trials are needed to identify the effects of each PNB on POD.
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Affiliation(s)
- Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Ha Young Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sung-Hee Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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24
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Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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Zitikyte G, Roy DC, Tran A, Fernando SM, Rosenberg E, Kanji S, Engels PT, Wells GA, Vaillancourt C. Pharmacologic Interventions to Prevent Delirium in Trauma Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2023; 5:e0875. [PMID: 36937896 PMCID: PMC10019141 DOI: 10.1097/cce.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
To compare the relative efficacy of pharmacologic interventions in the prevention of delirium in ICU trauma patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Registry of Clinical Trials from database inception until June 7, 2022. We included randomized controlled trials comparing pharmacologic interventions in critically ill trauma patients. STUDY SELECTION Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. DATA EXTRACTION Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for network analysis were followed. Random-effects models were fit using a Bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) for dichotomous outcomes and mean differences for continuous outcomes, each with 95% credible intervals. Treatment rankings were estimated for each outcome in the form of surface under the cumulative ranking curve values. DATA SYNTHESIS A total 3,541 citations were screened; six randomized clinical trials (n = 382 patients) were included. Compared with combined propofol-dexmedetomidine, there may be no difference in delirium prevalence with dexmedetomidine (HR 1.44, 95% CI 0.39-6.94), propofol (HR 2.38, 95% CI 0.68-11.36), nor haloperidol (HR 3.38, 95% CI 0.65-21.79); compared with dexmedetomidine alone, there may be no effect with propofol (HR 1.66, 95% CI 0.79-3.69) nor haloperidol (HR 2.30, 95% CI 0.88-6.61). CONCLUSIONS The results of this network meta-analysis suggest that there is no difference found between pharmacologic interventions on delirium occurrence, length of ICU stay, length of hospital stay, or mortality, in trauma ICU patients.
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Affiliation(s)
- Gabriele Zitikyte
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Danielle C Roy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - George A Wells
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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26
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In Situ Simulation Training for Frailty. Geriatrics (Basel) 2023; 8:geriatrics8010026. [PMID: 36826368 PMCID: PMC9957163 DOI: 10.3390/geriatrics8010026] [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: 11/01/2022] [Revised: 02/11/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND People living with frailty account for a significant proportion of hospital inpatients and are at increased risk of adverse events during admission. The understanding of frailty remains variable among hospital staff, and there is a need for effective frailty training across multidisciplinary teams. Simulation is known to be advantageous for improving human factor skills in multidisciplinary teams. In situ simulation can increase accessibility and promote ward team learning, but its effectiveness with respect to frailty has not been explored. METHOD A single-centre, multi-fidelity, inter-professional in situ frailty simulation programme was developed. One-hour sessions were delivered weekly using frailty-based clinical scenarios. Mixed-method evaluation was used, with data collected pre- and post-session for comparison. RESULTS In total, 86 multidisciplinary participants attended 19 sessions. There were significant improvements in self-efficacy rating across 10 of 12 human factor domains and in all frailty domains (p < 0.05). The common learning themes were situational awareness, communication and teamwork. Participants commented on the value of learning within ward teams and having the opportunity to debrief. CONCLUSION In situ simulation can improve the self-efficacy of clinical and human factor skills related to frailty. The results are limited by the nature of self-reporting methods, and further studies assessing behavioural change and clinical outcomes are warranted.
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Blättler N, Schaffert B, Schubert M. [Evaluation of the implementation of non-pharmacological measures for the prevention and treatment of delirium: A retrospective cohort study]. Pflege 2023. [PMID: 36749189 DOI: 10.1024/1012-5302/a000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Evaluation of the implementation of non-pharmacological measures for the prevention and treatment of delirium: A retrospective cohort study Abstract. Background: Delirium is burdensome for the affected patients, their relatives, hospital staff and the health care system. Preventing delirium with targeted multicomponent interventions is therefore essential. Aim: To investigate the implementation of defined non-pharmacological, preventive, and supportive measures in patients with an increased risk of delirium and/or delirium by the hospital's directions. Methods: In this observational study, routine data from 175 hospitalized patients were included. Data on delirium prevention, treatment and presence of delirium were extracted from the patient records and analyzed using appropriate statistical methods. Group comparisons were made between the medical/surgical clinic and the delirium/no delirium group. Results: Of the 175 patients, 31 had delirium. For delirium prevention, measures to improve oxygen supply, excretion, pain and mobility were most frequently implemented and measures such as improving cognition and communication were least frequently implemented. In the case of delirium, measures to modify risk factors, ensure safety, as well as prophylaxis were applied most frequently. Between the two clinics and between the delirium/no delirium group significant differences in the frequency of these measures were shown. Conclusion: The differences in frequency of implementation provide preliminary evidence that clinic-specific delirium prevention, early detection, and treatment may be needed.
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Affiliation(s)
- Nadia Blättler
- Institut für Pflege, Departement Gesundheit, ZHAW Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| | - Bianca Schaffert
- Institut für Pflege, Departement Gesundheit, ZHAW Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| | - Maria Schubert
- Institut für Pflege, Departement Gesundheit, ZHAW Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
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Ceolin C, Papa MV, De Rui M, Devita M, Sergi G, Coin A. Micronutrient Deficiency and Its Potential Role in Delirium Onset in Older Adults: A Systematic Review. J Nutr Health Aging 2023; 27:785-790. [PMID: 37754219 DOI: 10.1007/s12603-023-1976-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/26/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND OBJECTIVES One of the pathogenetic hypotheses of delirium is the "neuroinflammatory theory" with consequent neurotoxicity of brain connectivity networks. Micronutrients may play a significant role in the prevention of neuroinflammation. This systematic review addresses the role of micronutrients in the development of delirium in older populations. METHODS The EBSCO, Cochrane, PubMed, and Web of Science databases were searched for articles on delirium and micronutrients. The methodological quality of the studies included in the review was evaluated with the Newcastle-Ottawa Scales for observational studies and for case-control studies. RESULTS 1326 papers were identified from the searches, 7 of which met the inclusion criteria (see section 2.3). All the papers included were written in English. Delirium was predominantly secondary to post-operative dysfunction or acute medical conditions. By altering the production of neurotransmitters resulting in an imbalance, and by reducing their immunomodulatory role with a consequent increase in inflammatory oxidative stress, micronutrient deficiency seems to be associated with an increased incidence of delirium. CONCLUSIONS This review supports the existence of an association between micronutrient deficiency (i.e. cobalamin, thiamine, and vitamin D) and an increased incidence of delirium, with a greater prevalence in hospitalized patients.
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Affiliation(s)
- C Ceolin
- Chiara Ceolin, MD, Department of Medicine (DIMED), Geriatrics Division, University of Padua, via Giustiniani 2, 35128 Padua, Italy. E-mail:
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29
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Spiller TR, Tufan E, Petry H, Böttger S, Fuchs S, Duek O, Ben-Zion Z, Korem N, Harpaz-Rotem I, von Känel R, Ernst J. Delirium screening in an acute care setting with a machine learning classifier based on routinely collected nursing data: A model development study. J Psychiatr Res 2022; 156:194-199. [PMID: 36252349 DOI: 10.1016/j.jpsychires.2022.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 12/12/2022]
Abstract
Delirium screening in acute care settings is a resource intensive process with frequent deviations from screening protocols. A predictive model relying only on daily collected nursing data for delirium screening could expand the populations covered by such screening programs. Here, we present the results of the development and validation of a series of machine-learning based delirium prediction models. For this purpose, we used data of all patients 18 years or older which were hospitalized for more than a day between January 1, 2014, and December 31, 2018, at a single tertiary teaching hospital in Zurich, Switzerland. A total of 48,840 patients met inclusion criteria. 18,873 (38.6%) were excluded due to missing data. Mean age (SD) of the included 29,967 patients was 71.1 (12.2) years and 12,231 (40.8%) were women. Delirium was assessed with the Delirium Observation Scale (DOS) with a total score of 3 or greater indicating that a patient is at risk for delirium. Additional measures included structured data collected for nursing process planning and demographic characteristics. The performance of the machine learning models was assessed using the area under the receiver operating characteristic curve (AUC). The training set consisted of 21,147 patients (mean age 71.1 (12.1) years; 8,630 (40.8%) women|) including 233,024 observations with 16,167 (6.9%) positive DOS screens. The test set comprised 8,820 patients (median age 71.1 (12.4) years; 3,601 (40.8%) women) with 91,026 observations with 5,445 (6.0%) positive DOS screens. Overall, the gradient boosting machine model performed best with an AUC of 0.933 (95% CI, 0.929 - 0.936). In conclusion, machine learning models based only on structured nursing data can reliably predict patients at risk for delirium in an acute care setting. Prediction models, using existing data collection processes, could reduce the resources required for delirium screening procedures in clinical practice.
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Affiliation(s)
- Tobias R Spiller
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - Ege Tufan
- German Institute for Literature, Leipzig University, Leipzig, Germany
| | - Heidi Petry
- University of Zurich (UZH), Zurich, Switzerland; Center of Clinical Nursing Science, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Sönke Böttger
- University of Zurich (UZH), Zurich, Switzerland; Department of Gastroenterology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland; Psychiatric University Hospital Zurich (PUK), Zurich, Switzerland
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ziv Ben-Zion
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Nachshon Korem
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ilan Harpaz-Rotem
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, USA; Department of Psychology, Yale University, New Haven, CT, USA
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), Zurich, Switzerland; University of Zurich (UZH), Zurich, Switzerland
| | - Jutta Ernst
- University of Zurich (UZH), Zurich, Switzerland; Center of Clinical Nursing Science, University Hospital Zurich (USZ), Zurich, Switzerland
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30
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Dave MG, Chudyk AM, Oravec N, Kent DE, Duhamel TA, Schultz AS, Arora RC. Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations. JTCVS OPEN 2022; 12:306-314. [PMID: 36590723 PMCID: PMC9801247 DOI: 10.1016/j.xjon.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 01/04/2023]
Abstract
Objective In 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective. Methods Using a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities. Results Seven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively. Conclusions Exploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.
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Affiliation(s)
- Mudra G. Dave
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Anna M. Chudyk
- St Boniface Research Centre, Health Services & Structural Determinants of Health Research, Winnipeg, Manitoba, Canada
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojša Oravec
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David E. Kent
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, Alberchtsen Research Centre, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Annette S.H. Schultz
- St Boniface Research Centre, Health Services & Structural Determinants of Health Research, Winnipeg, Manitoba, Canada
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C. Arora
- Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, Alberchtsen Research Centre, St Boniface Hospital, Winnipeg, Manitoba, Canada
- Section of Cardiac Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Poikajärvi S, Rauta S, Salanterä S, Junttila K. Delirium in a surgical context from a nursing perspective: A hybrid concept analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100103. [PMID: 38745600 PMCID: PMC11080469 DOI: 10.1016/j.ijnsa.2022.100103] [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: 12/10/2021] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022] Open
Abstract
Background The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed. Objective The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective. Design The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases. Settings Surgical wards, surgical intensive care units, and post-anaesthesia care units. Data sources A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase. Participants Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase. Methods In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported. Results The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care. Conclusions In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
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Affiliation(s)
- Satu Poikajärvi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Satu Rauta
- Department of Perioperative, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Salanterä
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
| | - Kristiina Junttila
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Nursing Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Hildenbrand FF, Murray FR, von Känel R, Deibel AR, Schreiner P, Ernst J, Zipser CM, Böettger S. Predisposing and precipitating risk factors for delirium in gastroenterology and hepatology: Subgroup analysis of 718 patients from a hospital-wide prospective cohort study. Front Med (Lausanne) 2022; 9:1004407. [PMID: 36530904 PMCID: PMC9747774 DOI: 10.3389/fmed.2022.1004407] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/15/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS Delirium is the most common acute neuropsychiatric syndrome in hospitalized patients. Higher age and cognitive impairment are known predisposing risk factors in general hospital populations. However, the interrelation with precipitating gastrointestinal (GI) and hepato-pancreato-biliary (HPB) diseases remains to be determined. PATIENTS AND METHODS Prospective 1-year hospital-wide cohort study in 29'278 adults, subgroup analysis in 718 patients hospitalized with GI/HPB disease. Delirium based on routine admission screening and a DSM-5 based construct. Regression analyses used to evaluate clinical characteristics of delirious patients. RESULTS Delirium was detected in 24.8% (178/718). Age in delirious patients (median 62 years [IQR 21]) was not different to non-delirious (median 60 years [IQR 22]), p = 0.45). Dementia was the strongest predisposing factor for delirium (OR 66.16 [6.31-693.83], p < 0.001). Functional impairment, and at most, immobility increased odds for delirium (OR 7.78 [3.84-15.77], p < 0.001). Patients with delirium had higher in-hospital mortality rates (18%; OR 39.23 [11.85-129.93], p < 0.001). From GI and HPB conditions, cirrhosis predisposed to delirium (OR 2.11 [1.11-4.03], p = 0.023), while acute renal failure (OR 4.45 [1.61-12.26], p = 0.004) and liver disease (OR 2.22 [1.12-4.42], p = 0.023) were precipitators. Total costs were higher in patients with delirium (USD 30003 vs. 10977; p < 0.001). CONCLUSION Delirium in GI- and HPB-disease was not associated with higher age per se, but with cognitive and functional impairment. Delirium needs to be considered in younger adults with acute renal failure and/or liver disease. Clinicians should be aware about individual risk profiles, apply preventive and supportive strategies early, which may improve outcomes and lower costs.
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Affiliation(s)
- Florian F. Hildenbrand
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Fritz R. Murray
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
| | - Ansgar R. Deibel
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Science, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Carl M. Zipser
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
- Department of Neurology and Neurophysiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Soenke Böettger
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Zurich, Switzerland
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Hoch J, Bauer JM, Bizer M, Arnold C, Benzinger P. Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatr 2022; 22:879. [PMCID: PMC9675220 DOI: 10.1186/s12877-022-03573-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium. Methods The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models. Results The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants. Conclusions Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03573-8.
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Affiliation(s)
- Jonas Hoch
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jürgen M. Bauer
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.7700.00000 0001 2190 4373Network Aging Research (NAR), Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
| | - Martin Bizer
- grid.5253.10000 0001 0328 4908Department of Internal Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Christine Arnold
- grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Petra Benzinger
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.200773.10000 0000 9807 4884Institute of Health and Generations, University of Applied Sciences Kempten, Bahnhofstrasse 61, 87435 Kempten, Germany
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Moura LM, Zafar S, Benson NM, Festa N, Price M, Donahue MA, Normand SL, Newhouse JP, Blacker D, Hsu J. Identifying Medicare Beneficiaries With Delirium. Med Care 2022; 60:852-859. [PMID: 36043702 PMCID: PMC9588515 DOI: 10.1097/mlr.0000000000001767] [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: 01/28/2023]
Abstract
BACKGROUND Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes. METHODS Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV). RESULTS Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV- calibration-in-the-large <0.001, CV-slope 0.94, and CV-area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84-0.91)]. CONCLUSIONS A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.
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Affiliation(s)
- Lidia M.V.R. Moura
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole M. Benson
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - Natalia Festa
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary Price
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria A. Donahue
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Deborah Blacker
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Desrochers RM, Lynch LJ, Gates JD, Ricaurte D, Wade JT, Dicks RS, Keating JJ. Outcomes in Post-operative Delirium Following Bowel Resection: A Single Center Retrospective Review. J Surg Res 2022; 280:163-168. [PMID: 35973340 DOI: 10.1016/j.jss.2022.07.009] [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: 01/05/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Delirium is associated with adverse post-operative outcomes, long-term cognitive dysfunction, and prolonged hospitalization. Risk factors for its development include longer surgical duration, increased operative complexity and invasiveness, and medical comorbidities. This study aims to further evaluate the incidence of delirium and its impact on outcomes among patients undergoing both elective and emergency bowel resections. METHODS This is a retrospective cohort study using an institutional patient registry. All patients undergoing bowel resection over a 3.5-year period were included. The study measured the incidence of post-operative delirium via the nursing confusion assessment method. This incidence was then compared to patient age, emergency versus elective admission, length of stay, mortality, discharge disposition, and hospital cost. RESULTS A total of 1934 patients were included with an overall delirium incidence of 8.8%. Compared to patients without delirium, patients with delirium were more likely to have undergone emergency surgery, be greater than 70 y of age, have a longer length of stay, be discharged to a skilled nursing facility, and have a more expensive hospitalization. In addition, the overall mortality was 14% in patients experiencing delirium versus 0.1% in those that did not. Importantly, when broken down between elective and emergency groups, the mortality of those experiencing delirium was similar (11 versus 13%). CONCLUSIONS The development of delirium following bowel resection is an important risk factor for worsened outcomes and mortality. Although the incidence of delirium is higher in the emergency surgery population, the development of delirium in the elective population infers a similar risk of mortality.
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Affiliation(s)
| | - Lindsay J Lynch
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | | | - Daniel Ricaurte
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | - Jason T Wade
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | - Robert S Dicks
- Department of Geriatrics, Hartford Hospital, Hartford, Connecticut
| | - Jane J Keating
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
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Development of a Delirium Risk Predication Model among ICU Patients in Oman. Anesthesiol Res Pract 2022; 2022:1449277. [PMID: 35959195 PMCID: PMC9357679 DOI: 10.1155/2022/1449277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
Background Delirium is a common disorder among patients admitted to intensive care units. Identification of the predicators of delirium is very important to improve the patient's quality of life. Methods This study was conducted in a prospective observational design to build a predictive model for delirium among ICU patients in Oman. A sample of 153 adult ICU patients from two main hospitals participated in the study. The Intensive Care Delirium Screening Checklist (ICDSC) was used to assess the participants for delirium twice daily. Result The results showed that the incidence of delirium was 26.1%. Multiple logistic regression analysis showed that sepsis (odds ratio (OR) = 9.77; 95% confidence interval (CI) = 1.91–49.92; P < 0.006), metabolic acidosis (odds ratio (OR) = 3.45; 95% confidence interval [CI] = 1.18–10.09; P=0.024), nasogastric tube use (odds ratio (OR) 9.74; 95% confidence interval (CI) = 3.48–27.30; P ≤ 0.001), and APACHEII score (OR = 1.22; 95% CI = 1.09–1.37; P ≤ 0.001) were predictors of delirium among ICU patients in Oman (R2=0.519, adjusted R2=0.519, P ≤ 0.001). Conclusion To prevent delirium in Omani hospitals, it is necessary to work on correcting those predictors and identifying other factors that had effects on delirium development. Designing of a prediction model may help on early delirium detection and implementation of preventative measures.
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Gaudet JG, Kull C, Eskenazi ML, Diaper J, Maillard J, Mollard F, Marti C, Marcantonio ER, Courvoisier DS, Walder B. Three-Minute Diagnostic Assessment for Delirium using the Confusion Assessment Method (3D-CAM): French translation and cultural adaptation. Can J Anaesth 2022; 69:726-735. [PMID: 35338453 PMCID: PMC9132814 DOI: 10.1007/s12630-022-02232-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The routine use of validated diagnostic instruments is key to identifying delirious patients early and expediting care. The 3-Minute Diagnostic Assessment for Delirium using the Confusion Assessment Method (3D-CAM) instrument is a brief, easy to use, sensitive, and specific delirium assessment tool for hospitalized patients. We aimed to translate the original English version into French, and then adapt it to older high-risk patients. METHODS Translation and adaptation of the questionnaire were guided by an expert committee and the 3D-CAM instrument developer. During the translation phase, we achieved semantic and conceptual equivalence of the instrument by conducting forward and backward translations. During the adaptation phase, we assessed the face validity, clarity of wording, and ease of use of the translated questionnaire by administering it to 30 patients and their caregivers in peri-interventional and medical intermediate care units. During both phases, we used qualitative (goal and adequacy of the questionnaire) and quantitative (Sperber score, clarity score) criteria. RESULTS Translation: four items were judged inadequate and were revised until all reached a Sperber score of < 3/7. Face validity: 91% of patients thought the questionnaire was designed to assess memory, thoughts, or reasoning. Clarity: eight items required adjustments until all scored ≥ 9/10 for clarity. Ease of use: all bedside caregivers reported that the questionnaire was easy to complete after receiving brief instructions. CONCLUSIONS We produced a culturally adapted French version of the 3D-CAM instrument that is well understood and well-received by older high-risk patients and their caregivers.
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Affiliation(s)
- John G Gaudet
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Corey Kull
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Marc L Eskenazi
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Julien Maillard
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Florence Mollard
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Christophe Marti
- Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Bernhard Walder
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Division of Anesthesiology, Geneva University Hospital, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.
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Applicability of the interventions recommended for patients at risk or with delirium in medical and post-acute settings: a systematic review and a Nominal Group Technique study. Aging Clin Exp Res 2022; 34:1781-1791. [PMID: 35451735 DOI: 10.1007/s40520-022-02127-7] [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: 02/08/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is a common condition during hospitalisation that should be prevented and treated. Several recommendations have been established to date, whereas few studies have investigated their applicability in daily practice for medical and post-acute settings. AIM The aim of this research exercise was to emerge the applicability of the interventions recommended by studies in the daily care of patients at risk or with delirium cared in medical and post-acute settings. METHODS The study was organised in three phases. A systematic literature review according to Centre for Reviews and Dissemination was conducted (January-February 2021). Cochrane Library, Pubmed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Psychological Information Database, and the Joanna Briggs Institute databases were searched. Primary and secondary studies were evaluated in their methodological quality with the Standard Quality Assessment Criteria, the Critical Appraisal Skills Programme, and the Appraisal of Guidelines for Research & Evaluation. Then, the interventions identified were assessed in their applicability using the Nominal Group Technique who ranked their judgement on a four-point Likert scale from 1 (totally inapplicable) to 4 (totally applicable). Qualitative feedbacks were also considered, and a validation of the final list was performed by the Nominal Group. RESULTS A total of 12 studies were included producing a list of 96 interventions categorised into four macro-areas (prevention, non-pharmacological, communication and pharmacological management). The Nominal Group identified 51 interventions (average score > 3.5) as applicable in medical and post-acute settings. Then, through a process of re-reading, and revising according to the comments provided by the Nominal Group, a list of 35 interventions out of the initial 96 were judged as applicable. CONCLUSION Applicability should be assessed with experts in the field to understand the involved factors. One-third of interventions have been judged as applicable in the Italian context; the nurses' expertise, the work environment features, and the time required for each intervention in a high workload setting may prevent the full applicability of the interventions recommended by the literature.
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Huang HW, Zhang XK, Li HY, Wang YG, Jing B, Chen Y, Patel MB, Ely EW, Liu YO, Zhou JX, Lin S, Zhang GB. Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium. Front Aging Neurosci 2022; 14:822984. [PMID: 35493935 PMCID: PMC9045131 DOI: 10.3389/fnagi.2022.822984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The brain compensation mechanism in postoperative delirium (POD) has not been reported. We uncovered the mechanism by exploring the association between POD and glioma grades, and the relationship between preoperative brain structural and functional compensation with POD in patients with frontal glioma. Methods A total of 335 adult patients with glioma were included. The multivariable analysis examined the association between tumor grade and POD. Then, 20 patients with left frontal lobe glioma who had presurgical structural and functional MRI data and Montreal Cognitive Assessment (MoCA) in this cohort were analyzed. We measured the gray matter volume (GMV) and functional connectivity (FC) in patients with (n = 8) and without (n = 12) POD and healthy controls (HCs, n = 29) to detect the correlation between the structural and functional alteration and POD. Results The incidence of POD was 37.3%. Multivariable regression revealed that high-grade glioma had approximately six times the odds of POD. Neuroimaging data showed that compared with HC, the patients with left frontal lobe glioma showed significantly increased GMV of the right dorsal lateral prefrontal cortex (DLPFC) in the non-POD group and decreased GMV of right DLPFC in the POD group, and the POD group exhibited significantly decreased FC of right DLPFC, and the non-POD group showed the increasing tendency. Partial correlation analysis showed that GMV in contralesional DLPFC were positively correlated with preoperative neurocognition, and the GMV and FC in contralesional DLPFC were negatively correlated with POD. Conclusions Our findings suggested that insufficient compensation for injured brain regions involving cognition might be more vulnerable to suffering from POD.
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Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Kang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Hao-Yi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yong-Gang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Bin Jing
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - You Chen
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, United States
- Department of Electrical Engineering & Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Mayur B. Patel
- Section of Surgical Sciences, Department of Surgery and Neurosurgery, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ya-Ou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
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Bhattacharyya A, Sheikhalishahi S, Torbic H, Yeung W, Wang T, Birst J, Duggal A, Celi LA, Osmani V. Delirium prediction in the ICU: designing a screening tool for preventive interventions. JAMIA Open 2022; 5:ooac048. [PMID: 35702626 PMCID: PMC9185728 DOI: 10.1093/jamiaopen/ooac048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/05/2022] [Accepted: 05/24/2022] [Indexed: 01/16/2023] Open
Abstract
Introduction Delirium occurrence is common and preventive strategies are resource intensive. Screening tools can prioritize patients at risk. Using machine learning, we can capture time and treatment effects that pose a challenge to delirium prediction. We aim to develop a delirium prediction model that can be used as a screening tool. Methods From the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care version III (MIMIC-III) database, patients with one or more Confusion Assessment Method-Intensive Care Unit (CAM-ICU) values and intensive care unit (ICU) length of stay greater than 24 h were included in our study. We validated our model using 21 quantitative clinical parameters and assessed performance across a range of observation and prediction windows, using different thresholds and applied interpretation techniques. We evaluate our models based on stratified repeated cross-validation using 3 algorithms, namely Logistic Regression, Random Forest, and Bidirectional Long Short-Term Memory (BiLSTM). BiLSTM represents an evolution from recurrent neural network-based Long Short-Term Memory, and with a backward input, preserves information from both past and future. Model performance is measured using Area Under Receiver Operating Characteristic, Area Under Precision Recall Curve, Recall, Precision (Positive Predictive Value), and Negative Predictive Value metrics. Results We evaluated our results on 16 546 patients (47% female) and 6294 patients (44% female) from eICU-CRD and MIMIC-III databases, respectively. Performance was best in BiLSTM models where, precision and recall changed from 37.52% (95% confidence interval [CI], 36.00%–39.05%) to 17.45 (95% CI, 15.83%–19.08%) and 86.1% (95% CI, 82.49%–89.71%) to 75.58% (95% CI, 68.33%–82.83%), respectively as prediction window increased from 12 to 96 h. After optimizing for higher recall, precision and recall changed from 26.96% (95% CI, 24.99%–28.94%) to 11.34% (95% CI, 10.71%–11.98%) and 93.73% (95% CI, 93.1%–94.37%) to 92.57% (95% CI, 88.19%–96.95%), respectively. Comparable results were obtained in the MIMIC-III cohort. Conclusions Our model performed comparably to contemporary models using fewer variables. Using techniques like sliding windows, modification of threshold to augment recall and feature ranking for interpretability, we addressed shortcomings of current models.
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Affiliation(s)
- Anirban Bhattacharyya
- Corresponding Author: Anirban Bhattacharyya, MD, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA;
| | | | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wesley Yeung
- National University of Singapore, Singapore, Singapore
| | - Tiffany Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jennifer Birst
- Physical and Occupational Therapy, Mayo Clinic, Jacksonville, Florida, USA
| | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy
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van Lieshout C, Schuit E, Hermes C, Kerrigan M, Frederix GWJ. Hospitalisation costs and health related quality of life in delirious patients: a scoping review. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 169:28-38. [PMID: 35288063 DOI: 10.1016/j.zefq.2022.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Delirium is a common condition of a global disturbance of cognition, triggered by underlying diseases. The objective of this study is to review the current evidence in the literature on direct healthcare costs and health-related quality of life (HRQOL) associated with delirium. METHODS A systematic search was conducted in PubMed and Embase for relevant studies published between January 1, 2010 and November 4, 2021. Studies for inclusion reported estimates on healthcare costs or HRQOL, adjusted for relevant confounding factors. RESULTS Fourteen studies on healthcare costs and eleven studies on HRQOL were included. Delirium resulted in (adjusted) increased costs ranging from $1,532 to $22,269 depending on included cost categories, the country and the type of hospital department. Increased length of stay for delirious patients ranged from 2.5 days to 10.4 days and had the largest contribution to overall, direct incremental costs. Heterogeneity was observed in HRQOL outcomes. CONCLUSION The analysis indicates that the presence of a delirium episode may lead to increased costs of hospitalisation. Changes in HRQOL due to delirium are not well demonstrated and more research is needed to determine the effect of delirium on HRQOL.
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Affiliation(s)
- Chris van Lieshout
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands.
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands
| | - Carsten Hermes
- CCRN, Business economist (IHK), Co-founder of the German Delirium Network e.V., Bonn, Germany
| | | | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, The Health Care Innovation Centre (THINC.) University Medical Center Utrecht, The Netherlands
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Krämer J, Nolte K, Zupanc L, Schnitker S, Roos A, Göpel C, Cid JS, Eichler K, Hooven TVD, Hempel G, Pavenstädt HJ, Klaas C, Gosheger G, Raschke MJ, Wiendl H, Duning T. Structured delirium management in the hospital—a randomized controlled trial. DEUTSCHES ÄRZTEBLATT INTERNATIONAL 2022; 119:188-194. [PMID: 35197189 PMCID: PMC9229581 DOI: 10.3238/arztebl.m2022.0131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/04/2021] [Accepted: 02/01/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients. METHODS The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]). RESULTS The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02). CONCLUSION Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.
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Halhouli O, Zhang Q, Aldridge GM. Caring for patients with cognitive dysfunction, fluctuations and dementia caused by Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2022; 269:407-434. [PMID: 35248204 DOI: 10.1016/bs.pbr.2022.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cognitive dysfunction is one of the most prevalent non-motor symptoms in patients with Parkinson's disease (PD). While it tends to worsen in the later stages of disease, it can occur at any time, with 15-20% of patients exhibiting cognitive deficits at diagnosis (Aarsland et al., 2010; Goldman and Sieg, 2020). The characteristic features of cognitive dysfunction include impairment in executive function, visuospatial abilities, and attention, which vary in severity from subtle impairment to overt dementia (Martinez-Horta and Kulisevsky, 2019). To complicate matters, cognitive dysfunction is prone to fluctuate in PD patients, impacting diagnosis and the ability to assess progression and decision-making capacity. The diagnosis of cognitive impairment or dementia has a huge impact on patient independence, quality of life, life expectancy and caregiver burden (Corallo et al., 2017; Lawson et al., 2016; Leroi et al., 2012). It is therefore essential that physicians caring for patients with PD provide education, screening and treatment for this aspect of the disease. In this chapter, we provide a practical guide for the assessment and management of various degrees of cognitive dysfunction in patients with PD by approaching the disease at different stages. We address risk factors for cognitive dysfunction, prevention strategies prior to making the diagnosis, available tools for screening. Lastly, we review aspects of care, management and considerations, including decision-making capacity, that occur after the patient has been diagnosed with cognitive dysfunction or dementia.
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Affiliation(s)
- Oday Halhouli
- University of Iowa, Department of Neurology, Iowa City, IA, United States
| | - Qiang Zhang
- University of Iowa, Department of Neurology, Iowa City, IA, United States
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Ishii K, Kuroda K, Tokura C, Michida M, Sugimoto K, Sato T, Ishikawa T, Hagioka S, Manabe N, Kurasako T, Goto T, Kimura M, Sunami K, Inoue K, Tsukiji T, Yasukawa T, Nogami S, Tsukioki M, Okabe D, Tanino M, Morimatsu H. Current status of delirium assessment tools in the intensive care unit: a prospective multicenter observational survey. Sci Rep 2022; 12:2185. [PMID: 35140285 PMCID: PMC8828828 DOI: 10.1038/s41598-022-06106-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 01/01/2023] Open
Abstract
Delirium is a critical challenge in the intensive care unit (ICU) or high care unit (HCU) setting and is associated with poor outcomes. There is not much literature on how many patients in this setting are assessed for delirium and what tools are used. This study investigated the status of delirium assessment tools of patients in the ICU/HCU. We conducted a multicenter prospective observational study among 20 institutions. Data for patients who were admitted to and discharged from the ICU/HCU during a 1-month study period were collected from each institution using a survey sheet. The primary outcome was the usage rate of delirium assessment tools on an institution- and patient-basis. Secondary outcomes were the delirium prevalence assessed by each institution’s assessment tool, comparison of delirium prevalence between delirium assessment tools, delirium prevalence at the end of ICH/HCU stay, and the relationship between potential factors related to delirium and the development of delirium. Result showed that 95% of institutions used the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU) to assess delirium in their ICU/HCU, and the remaining one used another assessment scale. The usage rate (at least once during the ICU/HCU stay) of the ICDSC and the CAM-ICU among individual patients were 64.5% and 25.1%, and only 8.2% of enrolled patients were not assessed by any delirium assessment tool. The prevalence of delirium during ICU/HCU stay was 17.9%, and the prevalence of delirium at the end of the ICU/HCU stay was 5.9%. In conclusion, all institutions used delirium assessment tools in the ICU/HCU, and most patients received delirium assessment. The prevalence of delirium was 17.9%, and two-thirds of patients had recovered at discharge from ICU/HCU. Trial registration number: UMIN000037834.
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Affiliation(s)
- Kenzo Ishii
- Department of Anesthesiology, Intensive Care Unit, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan. .,Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Kosuke Kuroda
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Chika Tokura
- Department of Anesthesia, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Masaaki Michida
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | | | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoki Ishikawa
- Department of Anesthesia, Okayama Red Cross General Hospital, Okayama, Japan
| | - Shingo Hagioka
- Department of Anesthesia, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | - Nobuki Manabe
- Department of Anesthesia, Saiseikai Imabari Hospital, Imabari, Ehime, Japan
| | - Toshiaki Kurasako
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Takashi Goto
- Department of Anesthesia, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masakazu Kimura
- Department of Anesthesia, Okayama City Hospital, Okayama, Japan
| | - Kazuharu Sunami
- Department of Internal Medicine, Okayama Kyoritsu Hospital, Okayama, Japan
| | - Kazuyoshi Inoue
- Department of Anesthesia, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Takashi Tsukiji
- Department of Anesthesia, Takasago Municipal Hospital, Takasago, Hyogo, Japan
| | - Takeshi Yasukawa
- Department of Anesthesia, Okayama Kyokuto Hospital, Okayama, Japan
| | - Satoshi Nogami
- Department of Anesthesia, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Mitsunori Tsukioki
- Department of Anesthesia, Onomichi Municipal Hospital, Onomichi, Hiroshima, Japan
| | - Daisuke Okabe
- Department of Anesthesia, Himeji St. Mary's Hospital, Himeji, Hyogo, Japan
| | - Masaaki Tanino
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School Hospital, Kurashiki, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System. J Am Med Dir Assoc 2022; 23:1322-1327.e2. [PMID: 35172165 PMCID: PMC9359928 DOI: 10.1016/j.jamda.2022.01.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services. DESIGN Pragmatic prospective cohort study of consecutive admissions to a large health care system. SETTING AND PARTICIPANTS A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014. METHODS Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI). RESULTS Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001). CONCLUSIONS AND IMPLICATIONS This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.
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Gale L, McGill K, Twaddell S, Whyte IM, Lewin TJ, Carter GL. Hospital-treated deliberate self-poisoning patients: Drug-induced delirium and clinical outcomes. Aust N Z J Psychiatry 2022; 56:154-163. [PMID: 33938265 DOI: 10.1177/00048674211009608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Drug-induced delirium has been attributed to opioid, benzodiazepine, antipsychotic, antihistaminic and anticholinergic drug groups at therapeutic doses. Delirium also occurs in hospital-treated self-poisoning (at supra-therapeutic doses), although the causative drug classes are not well established and co-ingestion is common. We tested the magnitude and direction of association of five major drug groups with incident cases of delirium. METHODS A retrospective longitudinal cohort (n = 5131) study was undertaken of deliberate and recreational/chronic misuse poisoning cases from a regional sentinel toxicology unit. We described ingestion and co-ingestion patterns and estimated the unadjusted and adjusted odds for developing a drug-induced delirium. We also estimated the odds of drug-induced delirium being associated with three outcomes: intensive care unit admission, general hospital length of stay and discharge to home. RESULTS Drug-induced delirium occurred in 3.9% of cases (n = 200). The unadjusted odds ratios for development of delirium were increased for anticholinergics 10.79 (5.43-21.48), antihistamines 6.10 (4.20-8.84) and antipsychotics 2.99 (2.20-4.06); non-significant for opioids 1.31 (95% confidence interval = [0.81, 2.13]); and reduced for benzodiazepines 0.37 (0.24-0.58); with little change after adjustment for age, gender and co-ingestion. Delirium was associated with intensive care unit admission, longer length of stay and discharge destination. CONCLUSION Drug-induced delirium was uncommon in this population. Co-ingestion was common but did not alter the risk. In contrast to drug-induced delirium at therapeutic doses in older populations, opioids were not associated with delirium and benzodiazepines were protective. Drug-induced delirium required increased clinical services. Clinical services should be funded and prepared to provide additional supportive care for these deliriogenic drug group ingestions.
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Affiliation(s)
- Lindsay Gale
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia
| | - Katie McGill
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Scott Twaddell
- Department of Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Ian M Whyte
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Terry J Lewin
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Gregory L Carter
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
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Swarbrick CJ, Partridge JSL. Evidence‐based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia 2022; 77 Suppl 1:92-101. [DOI: 10.1111/anae.15607] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 12/18/2022]
Affiliation(s)
- C. J. Swarbrick
- Department of Anaesthesia Royal Devon and Exeter Hospital Exeter UK
| | - J. S. L. Partridge
- Peri‐operative medicine for Older People undergoing Surgery Department of Ageing and Health Guy's and St Thomas' NHS Foundation Trust London UK
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Castro VM, Hart KL, Sacks CA, Murphy SN, Perlis RH, McCoy TH. Longitudinal validation of an electronic health record delirium prediction model applied at admission in COVID-19 patients. Gen Hosp Psychiatry 2022; 74:9-17. [PMID: 34798580 PMCID: PMC8562039 DOI: 10.1016/j.genhosppsych.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To validate a previously published machine learning model of delirium risk in hospitalized patients with coronavirus disease 2019 (COVID-19). METHOD Using data from six hospitals across two academic medical networks covering care occurring after initial model development, we calculated the predicted risk of delirium using a previously developed risk model applied to diagnostic, medication, laboratory, and other clinical features available in the electronic health record (EHR) at time of hospital admission. We evaluated the accuracy of these predictions against subsequent delirium diagnoses during that admission. RESULTS Of the 5102 patients in this cohort, 716 (14%) developed delirium. The model's risk predictions produced a c-index of 0.75 (95% CI, 0.73-0.77) with 27.7% of cases occurring in the top decile of predicted risk scores. Model calibration was diminished compared to the initial COVID-19 wave. CONCLUSION This EHR delirium risk prediction model, developed during the initial surge of COVID-19 patients, produced consistent discrimination over subsequent larger waves; however, with changing cohort composition and delirium occurrence rates, model calibration decreased. These results underscore the importance of calibration, and the challenge of developing risk models for clinical contexts where standard of care and clinical populations may shift.
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Affiliation(s)
- Victor M. Castro
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA
| | - Kamber L. Hart
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Chana A. Sacks
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114, USA
| | - Shawn N. Murphy
- Research Information Science and Computing, Mass General Brigham, 399 Revolution Drive, Somerville, MA 02145, USA,Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Roy H. Perlis
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA
| | - Thomas H. McCoy
- Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA,Corresponding author at: Simches Research Building, Massachusetts General Hospital, 185 Cambridge St, 6th Floor, Boston, MA 02114, USA
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Zhao H, Ying HL, Zhang C, Zhang S. Relative Hypoglycemia is Associated with Delirium in Critically Ill Patients with Diabetes: A Cohort Study. Diabetes Metab Syndr Obes 2022; 15:3339-3346. [PMID: 36341226 PMCID: PMC9628698 DOI: 10.2147/dmso.s369457] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Critically ill patients with premorbid diabetes can suffer from relative hypoglycemia (RHG), falling below the normal blood glucose (BG) target. However, these events have not been well defined or studied. In the present study, we aimed to explore the incidence and clinical significance of RHG events in critically ill patients with diabetes. PATIENTS AND METHODS Patients with a history of diabetes who stayed in the intensive care unit (ICU) for more than three days with at least 12 BG recordings were retrospectively included in the study. A BG level > 30% below the estimated average according to patient hemoglobin A1c measured at admission was defined as a single RHG event. Outcomes were compared between patients with and those without RHG events. RESULTS In total, 113 patients were included in the final analysis. RHG was detected in 73 patients (64.6%). Those who experienced RHG events had a significantly higher incidence of ICU delirium. They also had a higher risk of 28-day mortality, but this was not statistically significant. However, patients with a higher frequency of RHG events did have a significantly higher risk of overall mortality (57.1% for more than four events vs 15.4% for three to four events, P=0.006 and 15.1% for one to two events, P=0.003). CONCLUSION In conclusion, RHG is a common finding in critically ill patients with diabetes and is associated with mortality and the occurrence of delirium.
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Affiliation(s)
- Hui Zhao
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Hua-Liang Ying
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Chao Zhang
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
- Correspondence: Chao Zhang; Shaohua Zhang, Intensive Care Unit (ICU), Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 1 Tong-yang Road, Taizhou, People’s Republic of China, Tel +8613757602063; +8615268325868, Email ;
| | - Shaohua Zhang
- Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
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Marcantonio ER, Fick DM, Jung Y, Inouye SK, Boltz M, Leslie DL, Husser EK, Shrestha P, Moore A, Sulmonte K, Siuta J, Boustani M, Ngo LH. Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study. Ann Intern Med 2022; 175:65-73. [PMID: 34748377 PMCID: PMC8938856 DOI: 10.7326/m21-1687] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN Prospective cohort study. SETTING Large urban academic medical center and small rural community hospital. PARTICIPANTS 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION Two sites; limited diversity. CONCLUSION An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Edward R Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (E.R.M.)
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, and College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania (D.M.F.)
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Y.J.)
| | - Sharon K Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts (S.K.I.)
| | - Marie Boltz
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania (M.B., E.K.H., P.S.)
| | - Douglas L Leslie
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania (D.L.L.)
| | - Erica K Husser
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania (M.B., E.K.H., P.S.)
| | - Priyanka Shrestha
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania (M.B., E.K.H., P.S.)
| | - Amber Moore
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts (A.M.)
| | - Kimberlyann Sulmonte
- Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.S.)
| | - Jonathan Siuta
- Department of Medicine, Mount Nittany Medical Center, State College, Pennsylvania (J.S.)
| | - Malaz Boustani
- Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana (M.B.)
| | - Long H Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (L.H.N.)
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