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Gao Y, Gan X. A novel nomogram for the prediction of subsyndromal delirium in patients in intensive care units: A prospective, nested case-controlled study. Int J Nurs Stud 2024; 155:104767. [PMID: 38653158 DOI: 10.1016/j.ijnurstu.2024.104767] [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: 03/22/2023] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Subsyndromal delirium is a dynamic, recognizable condition commonly observed in intensive care unit (ICU) patients that can lead to poor patient prognosis, and its prompt recognition and management can prevent disease progression. However, no evidence-based predictive tool has been developed specifically to assess the occurrence of subsyndromal delirium in the ICU. OBJECTIVE To develop and validate a novel, simple and effective tool for estimating the risk of subsyndromal delirium among ICU patients. DESIGN A prospective, nested case-controlled study. DATA SOURCES A total of 731 patients were recruited from the central ICU of a tertiary hospital in southwestern China from August 2021 to November 2022. METHODS The least absolute shrinkage and selection operator was applied to screen potential features for univariate and multivariate logistic regression. A nomogram was constructed using the selected variables. The performance of the nomogram was evaluated by combining the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). RESULTS The prevalence of subsyndromal delirium among ICU patients was 23.06 %. Multiple logistic regression analysis revealed that the independent predictive factors for subsyndromal delirium among ICU patients were vision impairment, a history of falls, the use of restraint, blood transfusion, the use of antibiotics, surgery, the Caprini score, and the Braden score, all of which were used to construct the nomogram. The AUCs for the model were 0.710 (95 % CI, 0.654-0.766, P < 0.001) and 0.825 (95 % CI, 0.732-0.917, P < 0.001) in the training and validation cohorts, respectively, indicating that the model had high accuracy in distinguishing patients with and without subsyndromal delirium. The calibration curve of the nomogram showed good consistency between the predicted and actual probabilities. The DCA indicated that the nomogram has clinical application for patients in the ICU. CONCLUSIONS We developed an easy-to-use nomogram for identifying subsyndromal delirium in ICU patients with satisfactory predictive ability based on simple and easily accessible clinical features. The nomogram can identify ICU patients at high-risk for subsyndromal delirium and may be a useful subsyndromal delirium tool for current ICU physicians.
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Affiliation(s)
- Yan Gao
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; School of Nursing, Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; School of Nursing, Chongqing Medical University, Chongqing, China.
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Boncyk C, Rengel K, Stollings J, Marshall M, Feng X, Shotwell M, Pandharipande PP, Hughes CG. Recurrent delirium episodes within the intensive care unit: Incidence and associated factors. J Crit Care 2024; 79:154490. [PMID: 38000230 PMCID: PMC10842115 DOI: 10.1016/j.jcrc.2023.154490] [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: 03/27/2023] [Revised: 10/25/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE Describe the incidence and factors associated with recurrent delirium in the intensive care unit (ICU). MATERIALS AND METHODS Retrospective study of ICU patients diagnosed with delirium. Delirium clearance defined as 48 h of negative delirium assessments following initial episode and recurrent delirium as any positive delirium assessment following clearance. Multivariable logistic regression model assessed independent association of patient and hospital factors on development of recurrent delirium, adjusting for pre-defined covariates. RESULTS Among 8591 ICU admissions identified with delirium, 1067 (12.4%) had recurrent symptoms. Factors associated with increased odds of recurrent delirium were age (nonlinear; p = 0.02), shock (OR 1.45, 95% CI [1.20, 1.75]), admission to medical (OR 3.25, 95% CI [2.42, 4.37]), surgical (OR 3.00, 95% CI [2.21, 4.06]), or trauma (OR 2.17, 95% CI [1.58, 3.00]) ICU vs. cardiovascular ICU, increased duration of mechanical ventilation (OR 2.43, 95% CI [2.22, 2.65]), propofol use (OR 1.35, 95% CI [1.02, 1.80]), and antipsychotic medications (haloperidol OR 1.53, 95% CI [1.26, 1.86]; quetiapine OR 2.45, 95% CI [1.98, 3.02]; and olanzapine OR 1.54, 95% CI [1.25, 1.88]). CONCLUSIONS Over 10% of delirious ICU patients had recurrent symptoms. Factors associated with recurrence included age, duration of mechanical ventilation and medication exposure. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Christina Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America.
| | - Kimberly Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
| | - Joanna Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America; Department of Pharmaceutical Services, Vanderbilt University Medical Center, United States of America
| | - Matt Marshall
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, United States of America
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Pratik P Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
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Wang P, Xiao W. Development and Validation of Subsyndromal Delirium Prediction Model in Patients With Advanced Malignant Tumor: A Case-Control Study. Cancer Nurs 2023:00002820-990000000-00187. [PMID: 37962137 DOI: 10.1097/ncc.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Subsyndromal delirium (SSD) is a clinical manifestation between delirium and nondelirium. There is no established guideline for diagnosing SSD, with a few different tools used for diagnosis. OBJECTIVES To construct and verify the risk prediction model for subdelirium syndrome in patients with advanced malignant tumors and explore its application value in risk prediction. METHODS A total of 455 patients admitted to the Oncology Department in a tertiary grade A hospital in Hengyang City were recruited from December 2020 to May 2021. They were selected as the modeling group. The model was constructed by logistic regression. A total of 195 patients with advanced malignant tumors from June 2021 to July 2021 were selected to validate the developed model. RESULTS The predictors incorporated into the model were opioids (odds ratio [OR], 1.818), sleep disorders (OR, 1.783), daily living ability score (OR, 0.969), and pain (OR, 1.810). In the modeling group, the Hosmer-Lemeshow goodness-of-fit test was P = .113, the area under the receiver operating characteristic curve was 0.884, the sensitivity was 0.820, and the specificity was 0.893. In the validation group, the Hosmer-Lemeshow goodness-of-fit test P = .108, the area under the receiver operating characteristic curve was 0.843, the Yuden index was 0.670, the sensitivity was 0.804, and the specificity was 0.866. CONCLUSIONS This model has excellent precision in the risk prediction of subdelirium in patients with advanced malignant tumors. IMPLICATIONS FOR PRACTICE The model we developed has a guiding significance for specialized tumor nurses to care for patients with advanced malignant tumors and improve their quality of life.
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Affiliation(s)
- Pan Wang
- Author Affiliations: Departments of Medical Oncology (Ms Wang) and Gastroenterology (Mr Xiao), The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang
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Qian J, Shen X, Gao X, Sun Q. Grip Strength is a Predictor for Subsyndromal Delirium Among Older Adults Following Joint Replacement. Clin Interv Aging 2023; 18:1675-1685. [PMID: 37810954 PMCID: PMC10559797 DOI: 10.2147/cia.s423727] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Background Delirium is common in older patients during the postoperative period, increasing the number of adverse events, and grip strength is associated with delirium. Subsyndromal delirium (SSD) is a prostate of clinical delirium; nevertheless, the relationship between grip strength and SSD has not been elucidated. This study aimed to examine the association between grip strength and SSD in the elderly after arthroplasty. Methods A total of 181 patients were recruited from two Chinese hospitals. SSD and delirium were evaluated before the surgery and the first week after surgery using the confusion assessment method. The Mini-mental State Examination was used to assess patients' cognitive function, and their grip strength was evaluated with an electronic hand dynamometer before surgery. Logistic regression and ROC curve analysis were conducted to determine the odds ratio and predictive value of grip strength for SSD. Results The incidence of SSD and postoperative delirium (POD) was 41.44% and 14.36% for the elderly following arthroplasty respectively, and approximately 1/3 of SSD progressed into POD. Older age, declined cognitive function, fall history, and lower grip strength were risk factors for SSD (P<0.05). The area under the ROC curve of grip strength was 0.863 and 0.900 for males and females respectively, and the cut-off point of it was determined to be 22.050 kg for men and 18.050 kg for women. Conclusion SSD and POD are common among older people. Decreased grip strength, advanced age, lower cognitive function, and fall history were independent risk factors for SSD, and grip strength was a significant predictor for SSD in aged patients after the arthroplasty.
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Affiliation(s)
- Jiawei Qian
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
| | - Xiulan Shen
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xin Gao
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Qiuhua Sun
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, People’s Republic of China
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Garrido M, Álvarez E, Salech F, Rojas V, Jara N, Farías JI, de la Vega DP, Tobar E. Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol. BMC Geriatr 2023; 23:472. [PMID: 37543590 PMCID: PMC10403832 DOI: 10.1186/s12877-023-04189-2] [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: 07/29/2022] [Accepted: 07/20/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Delirium is a clinical condition characterised by acute and fluctuating deterioration of the cognitive state, generally secondary to an acute pathology. Delirium is associated with negative outcomes in older adults, such as longer hospitalisations, higher mortality, and short and medium-term institutionalisation. Randomised clinical trials have shown that delirium is preventable through non-pharmacological prevention measures, decreasing its incidence by 30-50%. These interventions include promoting physical activity, facilitating the use of glasses and hearing aids, cognitive stimulation, and providing frequent reorientation of time and space, among others. These measures are currently seldom applied in hospitals in Chile and around the world for reasons including the heavy workload of clinical staff, the lack of trained personnel, and in general the absence of a systematic implementation processes. We developed a software called PREVEDEL, which includes non-pharmacological strategies such as cognitive stimulation, early mobilisation, orientation, and pain assessment. We propose a randomised clinical trial to evaluate whether cognitive stimulation guided by PREVEDEL software prevents delirium status (full/subsyndromal delirium) in hospitalised older adults. METHOD A randomised controlled trial, with parallel, multicentre groups. We will recruite patients 65 years or older who have been hospitalised for less than 48 h in the general ward or the intermediate care units of four hospitals in Santiago, Chile. The participants in the intervention group will use a tablet with cognitive stimulation software for delirium prevention for five continuous days versus the control group who will use the tablet without the software. We will evaluate the incidence, duration, density of delirium, subsyndromal delirium with the Confusion Assessment Method, cognitive with the Montreal Cognitive Assessment, and functional status with the Functional Independence Measure at discharge. Moreover, we will evaluate the adherence to prevention measures, as well as demographic variables of interest. DISCUSSION The use of cognitive PREVEDEL software could increase and improve the implementation of non-pharmacological prevention measures for delirium in hospitalised older adults, thus reducing its incidence and contributing to patients and health professionals. TRIAL REGISTRATION NCT05108207 ClinicalTrials.gov. Registered 4 November 2021.
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Affiliation(s)
- Maricel Garrido
- Departamento de Medicina, Servicio de Medicina Física y Rehabilitación, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Evelyn Álvarez
- Departamento de Terapia Ocupacional y Ciencia de La Ocupación, Facultad de Medicina, Universidad de Chile, Av. Independencia #1027, 8380453, Independencia-Santiago, Chile
- Centro de Estudios en Neurociencia Humana y Neuropsicología, Facultad de Psicología, Universidad Diego Portales, Vergara #275, 8320000, Santiago-Santiago, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Sección de Geriatría, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Centro de Gerociencia, Salud Mental y Metabolismo, GERO, Las Palmeras #3425, 7800003, Ñuñoa, Santiago, Chile
| | - Verónica Rojas
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- International Research Project for the Humanization of Intensive Care Units (HU-CI Project), Calle Cerceda #11, Collado -Villalba, 28400, Madrid, Spain
| | - Nicole Jara
- Departamento de Medicina, Servicio de Medicina Física y Rehabilitación, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - José Ignacio Farías
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Daniela Ponce de la Vega
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Eduardo Tobar
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile.
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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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Trzepacz PT, Lee HB. Have C-L Psychiatrists Abandoned Delirium Research? J Acad Consult Liaison Psychiatry 2022; 63:519-520. [DOI: 10.1016/j.jaclp.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Stroke, Seizures, Hallucinations and Postoperative Delirium as Neurological Complications after Cardiac Surgery and Percutaneous Valve Replacement. J Cardiovasc Dev Dis 2022; 9:jcdd9110365. [PMID: 36354764 PMCID: PMC9694228 DOI: 10.3390/jcdd9110365] [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: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Neurological complications such as acute ischemic stroke or postoperative delirium are frequent after cardiac surgery or percutaneous valve replacement. This study aimed to identify corresponding risk factors. (2) Methods: 297 patients with percutaneous valve replacement or cardiac surgery were postoperatively screened for neurological complications such as delirium, stroke, seizures and hallucinations twice daily for three days. Pre- and perioperative risk factors were evaluated in a multivariate model. (3) Results: Neurological complications occurred in 43.8% (n = 130) as composed of delirium (43.43%, n = 129), stroke (2.7%, n = 8), seizures (1.35%, n = 4) and real hallucinations (3.36%, n = 10). Multiple logistic regression revealed an association of neurological complications with lower Montreal Cognitive Assessment scores (Exp(B) 2.042; 95% CI, 1.183−3.525, p = 0.010), older age (Exp(B) 1.071; 95% CI, 1.036−1.107, p < 0.001), red blood cell transfusions until postoperative day 3 (Exp(B) 1.157; 95% CI, 1.030−1.300, p = 0.014), history of heart failure (Exp(B) 1.985; 95% CI, 1.130−3.487, p = 0.017) and increased CRP levels (Exp(B) 1.004; 95% CI, 1.000−1.008, p = 0.037). (4) Conclusions: Postoperative delirium remains a frequent complication after cardiac surgery, while stroke and seizures occur rarely. A preoperative risk profile including older age, history of heart failure and cognitive impairment was identified for a complicated postoperative course. However, the impact of an intense inflammatory response must not be neglected.
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Wirth R, Klimek CN, Lueg G, Pourhassan M, Danielzik LM, Krüger C, Trampisch US. Acute disease induced cognitive dysfunction in older patients - an unrecognized syndrome. BMC Geriatr 2022; 22:670. [PMID: 35971082 PMCID: PMC9377105 DOI: 10.1186/s12877-022-03323-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background It is unknown, how many older hospitalized patients experience cognitive changes independently from delirium. Methods In this retrospective study, cognitive function was assessed with the Montreal Cognitive Assessment on admission and discharge in 103 acute care geriatric hospital patients. Results Mean age was 80.8 ± 7.3 years. The total MoCA score on admission was 17.8 (±4.5) and at discharge 17.7 (±4.4). The mean difference of the total MoCA score was − 0.1 (±3.5). 12 (11.7%) patients suffered from delirium. 46 (44.7%) patients experienced significant changes of cognitive function <− 2 or > 2 MoCA points without delirium. There was no significant association between delirium during hospital stay and the prevalence and magnitude of changes in total MoCA score. Conclusion Cognitive changes frequently occur during acute disease of geriatric patients independently from delirium. We propose the term “acute disease induced cognitive dysfunction” (ADICD) for this entity. Trial registration German Clinical trial register (DRKS-ID: DRKS00025157 on 28.04.2021).
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Affiliation(s)
- Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Christiane Nicola Klimek
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Gero Lueg
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Maryam Pourhassan
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Louisa Maria Danielzik
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Caroline Krüger
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany
| | - Ulrike Sonja Trampisch
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, D- 44625, Herne, Germany.
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Klimiec-Moskal E, Slowik A, Dziedzic T. Delirium and subsyndromal delirium are associated with the long-term risk of death after ischaemic stroke. Aging Clin Exp Res 2022; 34:1459-1462. [PMID: 35015294 PMCID: PMC9151505 DOI: 10.1007/s40520-021-02071-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post-stroke delirium has a negative impact on functional outcome. We explored if there is any association between delirium, subsyndromal delirium and long-term mortality after ischaemic stroke and transient ischaemic attack. METHODS We included 564 patients with ischaemic stroke or transient ischaemic attack. We assessed symptoms of delirium during the first 7 days after admission. We used Cox proportional hazards models to analyse all-cause mortality during the first 5 years after stroke. RESULTS We diagnosed delirium in 23.4% and subsyndromal delirium in 10.3% of patients. During the follow-up, 72.7% of patients with delirium, 51.7% of patients with subsyndromal delirium and 22.7% of patients without delirious symptoms died (P < 0.001). Patients with subsyndromal delirium and delirium had higher risk of death in the multivariate analysis (HR 1.72, 95% CI 1.11-2.68, P = 0.016 and HR 3.30, 95% CI 2.29-4.76, P < 0.001, respectively). CONCLUSIONS Post-stroke delirium is associated with long-term mortality. Patients with subsyndromal delirium are at the intermediate risk of death.
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Affiliation(s)
- Elzbieta Klimiec-Moskal
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, ul. Botaniczna 3, 31-503, Kraków, Poland.
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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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Ojagbemi A, Bello T, Owolabi M, Baiyewu O. Cognitive, Functional, and Mortality Outcomes of Attenuated Delirium Syndrome in Stroke Survivors. J Geriatr Psychiatry Neurol 2021; 34:606-612. [PMID: 32757844 DOI: 10.1177/0891988720944234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES There is a knowledge gap on the prognostic significance of subsyndromes of delirium. We describe the association of poststroke attenuated delirium syndrome (ADS) with cognitive, functional, and mortality outcomes at 3 months. METHODS A longitudinal observational study in which repeated assessments for delirium symptoms were conducted in the first week of stroke using the confusion assessment method. Attenuated delirium syndrome was characterized in survivors who were free of the full delirium syndrome but had ≥2 core features of delirium. Baseline and follow-up assessments were conducted using the Mini-Mental State Examination (MMSE), 10-word list learning and delayed recall test, Animal naming test, and Barthel index. RESULTS Among 150 participants recruited consecutively over 2 years, ADS was present in 32 (21.3%). Of 121 who were free of the full delirium syndrome, 21 (17.4%) had died by 3 months. Those who survived were more likely to be receiving treatment for systemic hypertension (88.5%, P = .007). In analyses adjusting for the effect of age, economic status, and systemic hypertension, ADS in the first week of stroke predicted cognitive decline at 3 months ([mean difference (MD) in MMSE scores = -3.8, 95% CI = -7.0 to -0.7, P = .019]). However, ADS was not associated with greater decline in activities of daily life (MD = -0.4, 95% CI = -2.8 to 2.0) or significant odds ratio (OR) of mortality (OR = 2.3, 95% CI = 0.8-6.3). CONCLUSION Attenuated delirium syndrome may be an important marker of cognitive impairment at 3 months poststroke. Its detection may lead to identification of stroke survivors who are likely to benefit from evidence-based preventive interventions for poststroke cognitive decline.
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Affiliation(s)
- Akin Ojagbemi
- Department of Psychiatry, World Health Organization (WHO) Collaborating Centre for Research and Training in Mental health, Neuroscience, and Substance abuse, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Toyin Bello
- Department of Psychiatry, World Health Organization (WHO) Collaborating Centre for Research and Training in Mental health, Neuroscience, and Substance abuse, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Mayowa Owolabi
- Division of Neurology, Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olusegun Baiyewu
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Rawle MJ, McCue L, Sampson EL, Davis D, Vickerstaff V. Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study. Drugs Aging 2021; 38:233-242. [PMID: 33415708 PMCID: PMC7914229 DOI: 10.1007/s40266-020-00827-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population. OBJECTIVES Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients. METHODS We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality. RESULTS The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship. CONCLUSIONS ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.
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Affiliation(s)
- Mark James Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- Whipps Cross University Hospital, London, UK
| | - Laura McCue
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Research Department of Primary Care and Population Health, UCL, London, UK
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Subsyndromal Delirium in Cardiac Surgery Patients: Risk Factors and Outcomes of the Different Trajectories. J Cardiovasc Nurs 2021; 37:41-49. [PMID: 33657067 DOI: 10.1097/jcn.0000000000000793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subsyndromal delirium (SSD), a subthreshold form of delirium, is related to longer length of stay and increased mortality rates among older adults. Risk factors and outcomes of SSD in cardiac surgery patients are not fully understood. OBJECTIVE The aim of this study was to assess and describe the characteristics and outcomes related to trajectories of SSD and delirium in cardiac surgery patients. METHODS In this secondary analysis of a retrospective case-control (1:1) cohort study, SSD was defined as a score between 1 and 3 on the Intensive Care Delirium Screening Checklist paired with an absence of diagnosis of delirium on the day of assessment. Potential risk factors (eg, age) and outcomes (eg, mortality) were identified from existing literature. Patients were grouped into 4 trajectories: (1) without SSD or delirium, (2) SSD only, (3) both, and (4) delirium only. These trajectories were contrasted using analysis of variance or χ2 test. RESULTS Among the cohort of 346 patients, 110 patients did not present with SSD or delirium, 62 presented with only SSD, 69 presented with both, and 105 presented with only delirium. In comparison with patients without SSD or delirium, patients with SSD presented preoperative risk factors known for delirium (ie, older age, higher European System for Cardiac Operative Risk Evaluation II) but underwent less complicated surgical procedures, received fewer transfusions postoperatively, and had a lower positive fluid balance postoperatively than patients who presented with delirium. Patients with both SSD and delirium had worse outcomes in comparison with those with delirium only. CONCLUSION This study stresses the importance for healthcare professionals to identify SSD and prevent its progression to delirium.
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Abstract
OBJECTIVE Although age and pre-existent dementia are robust risk factors for developing delirium, evidence for patients older than 90 years is lacking. Therefore, this study assesses the delirium prevalence rates and sequelae in this age group. METHOD Based on a Diagnostic and Statistical Manual (DSM)-5, Delirium Observation screening scale (DOS), and Intensive Care Delirium Screening Checklist (ICDSC) construct, in this prospective cohort study, the prevalence rates and sequelae of delirium were determined in 428 patients older than 90 years by simple logistic regressions and corresponding odds ratios (ORs). RESULTS The overall prevalence delirium rate was 45.2%, with a wide range depending upon specialty: intermediate and intensive care services (83.1%), plastic surgery and palliative care (75%), neurology (72%), internal medicine (69%) vs. dermatology (26.5%), and angiology (14.5%). Delirium occurred irrespective of age and gender; however, pre-existent dementia was the strongest delirium predictor (OR 36.05). Delirious patients were less commonly admitted from home (OR 0.47) than from assisted living (OR 2.24), indicating functional impairment. These patients were more severely ill, as indicated by emergency (OR 3.25) vs. elective admission (OR 0.3), requirement for intensive care management (OR 2.12) and ventilation (OR 5.56-8.33). At discharge, one-third did not return home (OR 0.22) and almost half were transferred to assisted living (OR 2.63), or deceased (OR 47.76). SIGNIFICANCE OF RESULTS At age older than 90 years, the prevalence and sequelae of delirium are substantial. In particular, functional impairment and pre-existent dementia predicted delirium and subsequently, the loss of independence and death were imminent.
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Franco JG, Trzepacz PT, Sepúlveda E, Ocampo MV, Velásquez-Tirado JD, Zaraza DR, Restrepo C, Giraldo AM, Serna PA, Zuluaga A, López C. Delirium diagnostic tool-provisional (DDT-Pro) scores in delirium, subsyndromal delirium and no delirium. Gen Hosp Psychiatry 2020; 67:107-114. [PMID: 33091783 DOI: 10.1016/j.genhosppsych.2020.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate whether the Delirium Diagnostic Tool-Provisional (DDT-Pro), a 0-9 point scale with three items each representing symptoms from delirium's three core domains, differentiates subsyndromal delirium (SSD) from delirium and no delirium. METHODS We applied cluster analyses of DDT-Pro scores from 200 consecutive inpatients using three reference standards for delirium diagnosis to determine DDT-Pro cutoff values for delirium, SSD and no delirium groups. Clinical validators and DDT-Pro item scores were compared among groups. RESULTS DDT-Pro SSD range was 6-7 (n = 54), with no delirium having higher scores (n = 98) and delirium lower (n = 48). Dementia prevalence in the SSD group (40.7%) was intermediate between no delirium (20.4%) and delirium (66.7%). SSD and delirium groups were more affected than no delirium regarding medical comorbidities, hospital stay (no delirium <1 week, SSD and delirium >1 week) and mortality (SSD = 7.4%, delirium = 18.8%, no delirium = 1%). Values for motor subtypes, frontal lobe signs, and DRS-R98 in the SSD group were intermediate between no delirium and delirium, as well as for the DDT-Pro items (all p < 0.05). CONCLUSIONS All DDT-Pro items, which represent the three delirium core domains, are important for SSD diagnosis. Patients scoring in the SSD 6-7 range have significant clinical and prognostic features and deserve clinical attention.
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Affiliation(s)
- José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Esteban Sepúlveda
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain
| | - María V Ocampo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Juan D Velásquez-Tirado
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Daniel R Zaraza
- Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Cristóbal Restrepo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Alejandra M Giraldo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paola A Serna
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Adolfo Zuluaga
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carolina López
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
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Mathies F, Lange C, Mäurer A, Apostolova I, Klutmann S, Buchert R. Brain FDG PET for the Etiological Diagnosis of Clinically Uncertain Cognitive Impairment During Delirium in Remission. J Alzheimers Dis 2020; 77:1609-1622. [PMID: 32925050 DOI: 10.3233/jad-200530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Positron emission tomography (PET) of the brain with 2-[F-18]-fluoro-2-deoxy-D-glucose (FDG) is widely used for the etiological diagnosis of clinically uncertain cognitive impairment (CUCI). Acute full-blown delirium can cause reversible alterations of FDG uptake that mimic neurodegenerative disease. OBJECTIVE This study tested whether delirium in remission affects the performance of FDG PET for differentiation between neurodegenerative and non-neurodegenerative etiology of CUCI. METHODS The study included 88 patients (82.0±5.7 y) with newly detected CUCI during hospitalization in a geriatric unit. Twenty-seven (31%) of the patients were diagnosed with delirium during their current hospital stay, which, however, at time of enrollment was in remission so that delirium was not considered the primary cause of the CUCI. Cases were categorized as neurodegenerative or non-neurodegenerative etiology based on visual inspection of FDG PET. The diagnosis at clinical follow-up after ≥12 months served as ground truth to evaluate the diagnostic performance of FDG PET. RESULTS FDG PET was categorized as neurodegenerative in 51 (58%) of the patients. Follow-up after 16±3 months was obtained in 68 (77%) of the patients. The clinical follow-up diagnosis confirmed the FDG PET-based categorization in 60 patients (88%, 4 false negative and 4 false positive cases with respect to detection of neurodegeneration). The fraction of correct PET-based categorization did not differ between patients with delirium in remission and patients without delirium (86% versus 89%, p = 0.666). CONCLUSION Brain FDG PET is useful for the etiological diagnosis of CUCI in hospitalized geriatric patients, as well as in patients with delirium in remission.
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Affiliation(s)
- Franziska Mathies
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Lange
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anja Mäurer
- Evangelisches Geriatriezentrum Berlin, Berlin, Germany
| | - Ivayla Apostolova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Klutmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph Buchert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
BACKGROUND The general in-hospital mortality and interrelationship with delirium are vastly understudied. Therefore, this study aimed to assess the rates of in-hospital mortality and terminal delirium. METHOD In this prospective cohort study of 28,860 patients from 37 services including 718 in-hospital deaths, mortality rates and prevalence of terminal delirium were determined with simple logistic regressions and their respective odds ratios (ORs). RESULTS Although overall in-hospital mortality was low (2.5%), substantial variance between services became apparent: Across intensive care services the rate was 10.8% with a 5.8-fold increased risk, across medical services rates were 4.4% and 2.4-fold, whereas at the opposite end, across surgical services rates were 0.7% and 87% reduction, respectively. The highest in-hospital mortality rate occurred on the palliative care services (27.3%, OR 19.45). The general prevalence of terminal delirium was 90.7% and ranged from 83.2% to 100%. Only across intensive care services (98.1%, OR 7.48), specifically medical intensive care (98.1%, OR 7.48) and regular medical services (95.8%, OR 4.12) rates of terminal delirium were increased. In contrast, across medical services (86.4%, OR 0.32) and in particular oncology (73.9%, OR 0.25), pulmonology (72%, OR 0.31) and cardiology (63.2%, OR 0.4) rates were decreased. For the remaining services, rates of terminal delirium were the same. SIGNIFICANCE OF RESULTS Although in-hospital mortality was low, the interrelationship with delirium was vast: most patients were delirious at the end of life. The implications of terminal delirium merit further studies.
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Ojagbemi A, Bello T, Elugbadebo O, Owolabi M, Baiyewu O. Different Cognitive and Functional Outcomes in Attenuated and Full Delirium Syndromes Among Recent Stroke Survivors. J Stroke Cerebrovasc Dis 2020; 29:105251. [PMID: 33066941 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Very little is known about the outcomes of poststroke delirium in relation to its symptom spectrum. We investigated the 3-months cognitive and functional outcomes of attenuated (ADS) and full delirium syndromes in Nigerian survivors of first ever stroke. METHODS A prospective observational study with repeated assessments conducted in the first week of stroke using the confusion assessment method. Full delirium was diagnosed according to criteria in the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-V). ADS was characterised in survivors who were free of full, but had ≥two core features of, delirium. Baseline and follow-up assessments were conducted using the Mini-Mental state examination (MMSE), 10-words list learning and delayed recall test, Animal naming test and Barthel index. RESULTS Among 150 participants, ADS was present in 32 (21.3%), full delirium in 29 (19.3%). In linear regression analyses adjusting for age, economic status and systemic hypertension, ADS [(Mean difference (MD) = -3.8, 95% C.I = -7.0, -0.7)] and full delirium (MD = -5.6, 95% C.I = -9.0, -2.1) independently predicted poorer global cognitive functioning at follow-up. Significant declines in memory (MD = -1.9, 95% C.I = -2.8, 0.9), executive (MD = -2.2, 95% C.I = -4.1, -0.3) and physical functioning (MD = -2.8, 95% C.I = -5.5, -0.2), as well as a 4-fold increase in the independent odds (O.R) for dementia (O.R = 4.1, 95% C.I = 1.0,16.1) were also recorded in full, but not attenuated, delirium. CONCLUSION Attenuated and full delirium are associated with graded risk of poststroke cognitive decline. Reconsideration of poststroke delirium as a spectrum, rather than threshold-based categorical diagnosis will improve detection and prioritization of stroke survivors at increased risk of cognitive decline.
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Affiliation(s)
- Akin Ojagbemi
- World Health Organization (WHO) Collaborating centre for Research and Training in Mental health, Neuroscience, and Substance abuse, Department of Psychiatry, College of Medicine, University of Ibadan; Department of Psychiatry, College of Medicine University of Ibadan, Nigeria.
| | - Toyin Bello
- World Health Organization (WHO) Collaborating centre for Research and Training in Mental health, Neuroscience, and Substance abuse, Department of Psychiatry, College of Medicine, University of Ibadan
| | | | - Mayowa Owolabi
- Division of Neurology, Department of Medicine, College of Medicine University of Ibadan, Nigeria
| | - Olusegun Baiyewu
- Department of Psychiatry, College of Medicine University of Ibadan, Nigeria
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The prevalence rates and adversities of delirium: Too common and disadvantageous. Palliat Support Care 2020; 19:161-169. [DOI: 10.1017/s1478951520000632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectiveThe prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled studies. Therefore, this study assesses the prevalence rates and outcome of and odds ratios for managing services for delirium.MethodsIn this prospective cohort study, based on the Diagnostic and Statistical Manual (DSM) 5, the Delirium Observation Screening (DOS) scale, and the Intensive Care Delirium Screening Checklist (ICDSC) construct, 28,118 patients from 35 managing services were included, and the prevalence rates and adverse outcomes were determined by simple logistic regressions and their corresponding odds ratios (ORs).ResultsDelirious patients were older, admitted from institutions (OR 3.44–5.2), admitted as emergencies (OR 1.87), hospitalized twice longer, and discharged, transferred to institutions (OR 5.47–6.6) rather than home (OR 0.1), or deceased (OR 43.88). The rate of undiagnosed delirium was 84.2%. The highest prevalence rates were recorded in the intensive care units (47.1–84.2%, pooled 67.9%); in the majority of medical services, rates ranged from 20% to 40% (pooled 26.2%), except, at both ends, palliative care (55.9%), endocrinology (8%), and rheumatology (4.4%). Conversely, in surgery and its related services, prevalence rates were lower (pooled 13.1%), except for cardio- and neurosurgical services (53.3% and 46.4%); the lowest prevalence rate was recorded in obstetrics (2%).Significance of resultsDelirium remains underdiagnosed, and novel screening approaches are required. Furthermore, this study identified the impact of delirium on patients, determined the prevalence rates for 32 services, and elucidated the association between individual services and delirium.
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Gutierrez R, Egaña JI, Saez I, Reyes F, Briceño C, Venegas M, Lavado I, Penna A. Intraoperative Low Alpha Power in the Electroencephalogram Is Associated With Postoperative Subsyndromal Delirium. Front Syst Neurosci 2019; 13:56. [PMID: 31680886 PMCID: PMC6813625 DOI: 10.3389/fnsys.2019.00056] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative delirium (PD) and subsyndromal delirium (PSSD) are frequent complications in older patients associated with poor long-term outcome. It has been suggested that certain electroencephalogram features may be capable of identifying patients at risk during surgery. Thus, the goal of this study was to characterize intraoperative electroencephalographic markers to identify patients prone to develop PD or PSSD. Methods We conducted an exploratory observational study in older patients scheduled for elective major abdominal surgery. Intraoperative 16 channels electroencephalogram was recorded, and PD/PSSD were diagnosed after surgery with the confusion assessment method (CAM). The total power spectra and relative power of alpha band were calculated. Results PD was diagnosed in 2 patients (6.7%), and 11 patients (36.7%) developed PSSD. All of them (13 patients, PD/PSSD group) were compared with patients without any alterations in CAM (17 patients, control group). There were no detectable power spectrum differences before anesthesia between both groups of patients. However, PD/PSSD group in comparison with control group had a lower intraoperative absolute alpha power during anesthesia (4.4 ± 3.8 dB vs. 9.6 ± 3.2 dB, p = 0.0004) and a lower relative alpha power (0.09 ± 0.06 vs. 0.21 ± 0.08, p < 0.0001). These differences were independent of the anesthetic dose. Finally, relative alpha power had a good ability to identify patients with CAM alterations in the ROC analysis (area under the curve 0.90 (CI 0.78-1), p < 0.001). Discussion In conclusion, a low intraoperative alpha power is a novel electroencephalogram marker to identify patients who will develop alterations in CAM - i.e., with PD or PSSD - after surgery.
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Affiliation(s)
- Rodrigo Gutierrez
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Jose I Egaña
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Iván Saez
- Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Fernando Reyes
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile
| | - Constanza Briceño
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mariana Venegas
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Isidora Lavado
- Escuela de Medicina, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico, Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Facultad de Medicina, Hospital Clínico, Universidad de Chile, Santiago, Chile
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Denny DL, Lindseth GN. Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery. West J Nurs Res 2019; 42:165-176. [PMID: 31096866 DOI: 10.1177/0193945919849096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.
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Choutko-Joaquim S, Tacchini-Jacquier N, Pralong D'Alessio G, Verloo H. Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department. Dement Geriatr Cogn Dis Extra 2019; 9:236-249. [PMID: 31303870 PMCID: PMC6600030 DOI: 10.1159/000499707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/17/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium. AIM To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland. METHOD A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver. RESULTS The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference. CONCLUSION Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.
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Affiliation(s)
| | | | | | - Henk Verloo
- School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Sion, Switzerland
- Consultant of Valais Hospital, Sion, Switzerland
- Scientific collaborator of the service of Old Age psychiatry, University Hospital Lausanne, Cery, Prilly, Switzerland
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Klimiec-Moskal E, Lis A, Pera J, Slowik A, Dziedzic T. Subsyndromal delirium is associated with poor functional outcome after ischaemic stroke. Eur J Neurol 2019; 26:927-934. [PMID: 30674083 DOI: 10.1111/ene.13912] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Subsyndromal delirium (SSD) refers to patients with delirious symptoms who do not meet the criteria for delirium. The aim was to determine the prognostic significance of SSD in stroke patients. METHODS In all, 564 patients with ischaemic stroke (median age 71 years, 50.5% female) were included. The Confusion Assessment Method was used to assess symptoms of delirium and the Diagnostic and Statistical Manual of Mental Disorders, 5th edn, criteria were used to diagnose delirium. SSD was defined as one or more core features of delirium without fulfilling diagnostic criteria. Functional outcome was assessed using the modified Rankin Scale at 3 and 12 months after stroke. RESULTS Delirium was diagnosed in 23.4% of patients and SSD in 10.3% of patients. SSD was associated with increased risk of poor functional outcome. The adjusted odds ratios (ORs) for unfavourable outcome at 3 and 12 months were 2.88 [95% confidence interval (CI) 1.43-5.79, P < 0.01] and 2.93 (95% CI 1.39-6.22, P < 0.01), respectively. In multivariate analysis, delirium was an independent predictor of poor functional outcome at 3 months (OR 6.41, 95% CI 3.36-12.21, P < 0.01) and 12 months (OR 6.11, 95% CI 3.05-12.27, P < 0.01) after stroke. Delirium was also independently associated with increased risk of death within 3 months (hazard ratio 3.68, 95% CI 1.69-8.02, P < 0.01) and 12 months (hazard ratio 3.76, 95% CI 2.05-6.90, P < 0.01). SSD was not associated with increased risk of death. CONCLUSIONS In SSD patients the risk of poor functional outcome after stroke is increased and intermediate between patients with and patients without delirium.
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Affiliation(s)
- E Klimiec-Moskal
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - A Lis
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - J Pera
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - A Slowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - T Dziedzic
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
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Yam K, Shea Y, Chan T, Chiu K, Luk JK, Chu L, Chan FH. Prevalence and risk factors of delirium and subsyndromal delirium in Chinese older adults. Geriatr Gerontol Int 2018; 18:1625-1628. [PMID: 30311332 DOI: 10.1111/ggi.13545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/29/2018] [Accepted: 09/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ka‐Keung Yam
- Department of MedicineQueen Mary Hospital Hong Kong, China
| | - Yat‐Fung Shea
- Department of MedicineQueen Mary Hospital Hong Kong, China
| | - Tuen‐Ching Chan
- Department of Medicine and GeriatricsTWGHs Fung Yiu King Hospital Hong Kong, China
| | - Ka‐Chun Chiu
- Department of MedicineQueen Mary Hospital Hong Kong, China
| | - James Ka‐Hei Luk
- Department of Medicine and GeriatricsTWGHs Fung Yiu King Hospital Hong Kong, China
| | - Leung‐Wing Chu
- Department of MedicineUniversity of Hong Kong Hong Kong, China
| | - Felix Hon‐Wai Chan
- Department of MedicineQueen Mary Hospital Hong Kong, China
- Department of Medicine and GeriatricsTWGHs Fung Yiu King Hospital Hong Kong, China
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Pendlebury ST. Delirium screening in older patients. Age Ageing 2018; 47:635-637. [PMID: 30010699 DOI: 10.1093/ageing/afy103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 01/23/2023] Open
Affiliation(s)
- Sarah T Pendlebury
- Departments of General (Internal) Medicine and Geratology, John Radcliffe hospital, Oxford, UK
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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Hwang H, Lee KM, Son KL, Jung D, Kim WH, Lee JY, Kong SH, Suh YS, Lee HJ, Yang HK, Hahm BJ. Incidence and risk factors of subsyndromal delirium after curative resection of gastric cancer. BMC Cancer 2018; 18:765. [PMID: 30053850 PMCID: PMC6062877 DOI: 10.1186/s12885-018-4681-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 07/19/2018] [Indexed: 02/06/2023] Open
Abstract
Background Subsyndromal delirium, a condition in which patients exhibit some, but not all, of the symptoms of delirium, can negatively affect the outcomes of patients with cancer. However, the incidence of subsyndromal delirium in patients with gastric cancer is unknown. Here, we investigated the incidence and risk factors of subsyndromal delirium after curative resection of gastric cancer. Methods We recruited consecutive patients with gastric cancer who were scheduled for curative resection at a tertiary hospital. Patients’ subsyndromal delirium symptoms were serially assessed preoperatively and 1, 2, 3, and 7 days postoperatively using the Delirium Rating Scale-Revised-98 (DRS-R-98). A DRS-R-98 score of 8–14 at any postoperative assessment was considered to indicate subsyndromal delirium. Sociodemographic and pre−/intra-operative clinical data were also assessed. Logistic regression analyses were used to determine the associated risk factors. Results Data were analysed from 163 out of 217 eligible patients. Postoperative delirium occurred in one patient (0.6%) and subsyndromal delirium occurred in 19 patients (11.7%). Age ≥ 70 years (odds ratio, [OR] 3.85; 95% confidence interval [CI], 1.36–10.92; p = 0.011) and education level ≤ 9 years (OR, 3.98; 95% CI, 1.39–11.41; p = 0.010) were independent risk factors of subsyndromal delirium after adjusting for preoperative cognitive function. Other pre−/intra-operative variables including anxiety/depression, poor sleep quality, and anaesthesia duration were not associated with subsyndromal delirium. Conclusions In contrast to the low incidence of delirium among patients undergoing curative resection of gastric cancer, a substantial proportion of such patients experienced subsyndromal delirium. Considering the prognostic implications, more careful detection and management of subsyndromal delirium may be warranted in patients with gastric cancer. Electronic supplementary material The online version of this article (10.1186/s12885-018-4681-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heesung Hwang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea.,Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Kwang-Min Lee
- Public Health and Medical Service, Seoul National University Hospital, Seoul, Korea.,Department of Psychiatry, Gyeonggi Provincial Medical Center Uijeongbu Hospital, Uijeongbu, Korea
| | - Kyung-Lak Son
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea.,Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Dooyoung Jung
- Department of Human Factors Engineering, Ulsan National Institute of Science and Technology, Ulsan, Korea
| | - Won-Hyoung Kim
- Department of Psychiatry, Inha University Hospital, Incheon, Korea
| | - Joo-Young Lee
- Department of Health Management, Armed Forces Medical Command, Seongnam, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Bong-Jin Hahm
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea. .,Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
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Attention, vigilance, and visuospatial function in hospitalized elderly medical patients: relationship to delirium syndromal status and motor subtype profile. Int Psychogeriatr 2018; 30:493-501. [PMID: 29249205 DOI: 10.1017/s1041610217002174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED ABSTRACTBackground:The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients. METHODS A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes. RESULTS A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories. CONCLUSIONS Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.
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Yamada C, Iwawaki Y, Harada K, Fukui M, Morimoto M, Yamanaka R. Frequency and risk factors for subsyndromal delirium in an intensive care unit. Intensive Crit Care Nurs 2018; 47:15-22. [PMID: 29606481 DOI: 10.1016/j.iccn.2018.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Delirium and subsyndromal delirium in critically ill patients are important determinants of long-term functional disability and cognitive impairment. However, few outcome studies on sub-syndromal delirium have been reported. Thus, this study aimed to evaluate the incidence of delirium and sub-syndromal delirium as well as the risk factors and progression to delirium. DESIGN A prospective cohort study. SETTING Six bed medical and surgical intensive care unit in Otsu Municipal Hospital in Japan. METHODS Delirium and sub syndromal delirium were evaluated using the Intensive Care Delirium Screening Checklist scores and the demographic data of the patients recorded. Statistical analyses were conducted using the Mann-Whitney U test and chi-square test for comparison. We also compared groups using multivariate analyses. RESULTS Of the 380 patients who were screened, 15.8% and 33.9% had delirium or sub syndromal delirium, respectively and 9.5% of patients progressed from a state of sub syndromal delirium to delirium. Older age, predisposing cognitive impairment, blood transfusion, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, low red blood cell count and high C-reactive protein levels were the risk factors highly associated with subsyndromal delirium symptoms. Older age, acute admission, steroid use, the utilisation of restraints and lower PaO2 were the determinants of progression to delirium. CONCLUSIONS A high incidence of sub syndromal delirium was observed in critically ill patients. Patient with sub syndromal delirium must be promptly identified and treated due to the risk of progression to delirium.
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Affiliation(s)
- Chikayo Yamada
- Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Emergency and Intensive Care Medicine, Otsu Municipal Hospital, Otsu, Shiga, Japan.
| | - Yoko Iwawaki
- Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Kiyomi Harada
- Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michihiko Fukui
- Department of Emergency and Intensive Care Medicine, Otsu Municipal Hospital, Otsu, Shiga, Japan
| | - Masafumi Morimoto
- Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryuya Yamanaka
- Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Laboratory of Molecular Target Therapy for Cancer, Graduate School for Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Pasinska P, Kowalska K, Klimiec E, Szyper-Maciejowska A, Wilk A, Klimkowicz-Mrowiec A. Frequency and predictors of post-stroke delirium in PRospective Observational POLIsh Study (PROPOLIS). J Neurol 2018; 265:863-870. [DOI: 10.1007/s00415-018-8782-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 02/06/2023]
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Shen YZ, Peng K, Zhang J, Meng XW, Ji FH. Effects of Haloperidol on Delirium in Adult Patients: A Systematic Review and Meta-Analysis. Med Princ Pract 2018; 27. [PMID: 29518791 PMCID: PMC6062716 DOI: 10.1159/000488243] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to investigate whether or not the use of haloperidol could reduce the incidence of delirium in adult patients. SUBJECTS AND METHODS PubMed, Embase, the Cochrane Library, Elsevier, Wiley, and Ovid were searched for randomized controlled trials and prospective interventional cohort studies that compared haloperidol with placebo for delirium prophylaxis or with second generation antipsychotics for delirium treatment. The primary end point was the incidence and severity of delirium. After reviewing 272 relevant articles, 10 studies with 1,861 patients were finally included (haloperidol vs. placebo in 8 studies [n = 1,734], and haloperidol vs. second-generation antipsychotics in 2 studies [n = 127]). Revman 5.3 was used for the data analysis. RESULTS Compared with placebo, a high dose of prophylactic haloperidol (≥5 mg/day) may help reduce the incidence of delirium in surgical patients (risk ratio 0.50, 95% CI 0.32, 0.79). There were no differences in the duration of delirium, QTc interval prolongation, extrapyramidal symptoms, intensive care unit stay, hospital stay, or mortality between the haloperidol and placebo groups. For delirium treatment, haloperidol exhibited similar effects as the second-generation antipsychotics. CONCLUSIONS In this study, the limited available data revealed that prophylaxis haloperidol at a dose of ≥5 mg/day might help reduce delirium in adult surgical patients. Further outcome studies with larger sample sizes are required to confirm these findings.
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Affiliation(s)
| | | | | | | | - Fu-hai Ji
- *Fu-hai Ji, MD, Department of Anesthesiology, First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu 215006 (China), E-Mail
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Are Melatonin and its Agonist the Natural Solution for Prevention of Delirium in Critically Ill Patients? A Review of Current Studies. Jundishapur J Nat Pharm Prod 2017. [DOI: 10.5812/jjnpp.64305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
OBJECTIVE Our objective was to examine the accuracy of non-psychiatrist assessments of psychiatric problems in cancer patients. METHOD We conducted a retrospective chart review of cancer patients who were admitted and referred to the consultation-liaison (C-L) team between January of 2011 and December of 2012. The agreement between non-psychiatrist assessments and final diagnoses by attending C-L psychiatrists was estimated for every category of referral assessment using codes from the International Classification of Mental and Behavioral Disorders (10th revision). The data were obtained from the consultation records of 240 cancer inpatients who were referred to the C-L service at a tertiary care center in Tokyo. RESULTS The agreement ratio between referring oncologists and psychiatrists differed according to the evaluation categories. The degrees of agreement for the categories of "delirious," "depressive," "dyssomnia," "anxious," "demented," "psychotic," and "other" were 0.87, 0.43, 0.51, 0.50, 0.27, 0.55, and 0.57, respectively. The agreement for all patients was 0.65. Significant differences were observed among seven categories (chi-squared value = 42.454 at p < 0.001 and df = 6). The analysis of means for proportions showed that the degree of agreement for the "delirious" category was significantly higher and that that for the "depressive" category was lower than that for all patients, while for the "demented" category it was close to the lower decision limit but barely significant. One half of the 20 cases who were referred as depressive were diagnosed with delirium, with one quarter of those having continuously impaired consciousness. Some 7 of the 11 cases who were referred as demented were diagnosed as having delirium. SIGNIFICANCE OF RESULTS The accuracy of non-psychiatrist assessments for psychiatric problems in cancer patients differs by presumed diagnosis. Oncologists should consider unrecognized delirium in cancer inpatients who appear depressed or demented.
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Abstract
Integrating mental and physical healthcare is difficult to achieve because of professional and organisational barriers. Psychiatrists recognise the problems resulting from fragmentation of services and want continuity of care for patients, but commissioning and service structures perpetuate these problems. One way forward may be to follow the syndromic model employed by geriatricians as a means of avoiding over-emphasis on diagnosis above the pragmatics of implementing multi-component, coordinated care. Commissioners need to be made aware of the overlap and complementarity of skills possessed by old age psychiatry and geriatric medicine to create joint services for people vulnerable to dementia and delirium. A re-forged alliance between the two specialties will be necessary to turn integrated care for frail, elderly people from rhetoric into reality.
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Delirium in the intensive care setting: A reevaluation of the validity of the CAM-ICU and ICDSC versus the DSM-IV-TR in determining a diagnosis of delirium as part of the daily clinical routine. Palliat Support Care 2017; 15:675-683. [PMID: 28173895 DOI: 10.1017/s1478951516001176] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the intensive care setting, delirium is a common occurrence that comes with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their validity and psychometric properties, however, remain controversial. METHOD In this prospective cohort study, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM-IV-TR in the diagnosis of delirium with respect to their validity and psychometric properties. RESULTS Out of some 289 patients, 210 with matching CAM-ICU, ICDSC, and DSM-IV-TR diagnoses were included. Between the scales, the prevalence of delirium ranged from 23.3% with the CAM-ICU, to 30.5% with the ICDSC, to 43.8% with the DSM-IV-TR criteria. The CAM-ICU showed only moderate concurrent validity (Cohen's κ = 0.44) and sensitivity (50%), but high specificity (95%). The ICDSC also reached moderate agreement (Cohen's κ = 0.60) and sensitivity (63%) while being very specific (95%). Between the CAM-ICU and the ICDSC, the concurrent validity was again only moderate (Cohen's κ = 0.56); however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively). SIGNIFICANCE OF RESULTS In the daily clinical routine, neither the CAM-ICU nor the ICDSC, common tools used in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity; nor did they outperform the DSM-IV-TR diagnostic criteria with respect to sensitivity or positive prediction, but they were very specific. Thus, the non-prediction by the CAM-ICU or ICDSC did not refute the presence of delirium. Between the CAM-ICU and ICDSC, the ICDSC proved to be the more accurate instrument.
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[Treatment with psychotropic agents in patients with dementia and delirium : Gap between guideline recommendations and treatment practice]. Z Gerontol Geriatr 2017; 50:106-114. [PMID: 28124100 DOI: 10.1007/s00391-016-1176-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Psychiatric symptoms in dementia and delirium are associated with a substantially reduced quality of life of patients and their families and often challenging for professionals. Pharmacoepidemiological surveys have shown that, in particular, patients living in nursing homes receive prescriptions of psychotropic agents in significant higher frequency than recommended by current guidelines. This article focuses on a critical appraisal of this gap from the point of view of German healthcare services. MATERIAL AND METHODS Narrative review with special reference to the German dementia guideline from 2016 and recently published practice guidelines for delirium in old age in German and English language. RESULTS The indications for use of psychotropic agents, especially antipsychotics, are defined narrowly in the German dementia guideline. According to this guideline for several psychopathological symptoms evidence based recommendations cannot be given, currently. For delirium several practice guidelines related to different treatment settings have been published recently. Comparable to the German dementia guideline they recommend general medical interventions and nonpharmacological treatment as first line measures and the use of psychotropic agents only under certain conditions. These guidelines differ to some extent regarding the strength of recommendation for psychopharmacological treatment. CONCLUSION The guidelines discussed here advocate well-founded a cautious prescription of psychotropic agents in patients with dementia and delirium. This contrasts to everyday practice which is characterized by significantly higher prescription rates. This gap may explained partially by a lack of evidence-based recommendations regarding certain psychopathological symptoms. Most notably, however, epidemiological data disclose an unacceptable rate of hazardous overtreatment with psychotropic agents, especially in long-term care of persons with dementia. In this situation counteractive measures by consequent implementation of the principles of good clinical practice in geriatrics are required urgently.
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Scholtens RM, van Munster BC, Adamis D, de Jonghe A, Meagher DJ, de Rooij SEJA. Variability of Delirium Motor Subtype Scale-Defined Delirium Motor Subtypes in Elderly Adults with Hip Fracture: A Longitudinal Study. J Am Geriatr Soc 2016; 65:e45-e50. [DOI: 10.1111/jgs.14582] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rikie M. Scholtens
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Barbara C. van Munster
- Department of Geriatrics; Gelre Hospitals; Apeldoorn The Netherlands
- University Center for Geriatric Medicine; University Medical Center Groningen; Groningen the Netherlands
| | - Dimitrios Adamis
- Sligo Mental Health Services; Ballytivnan Sligo Ireland
- Research and Academic Institute of Athens; Athens Greece
- Cognitive Impairment Research Group; Centre for Interventions in Infection; Inflammation and Immunity; Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | | | - David J. Meagher
- Cognitive Impairment Research Group; Centre for Interventions in Infection; Inflammation and Immunity; Graduate Entry Medical School; University of Limerick; Limerick Ireland
- Department of Psychiatry; University Hospital Limerick; Limerick Ireland
| | - Sophia E. J. A. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
- University Center for Geriatric Medicine; University Medical Center Groningen; Groningen the Netherlands
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Sepulveda E, Leonard M, Franco JG, Adamis D, McCarthy G, Dunne C, Trzepacz PT, Gaviria AM, de Pablo J, Vilella E, Meagher DJ. Subsyndromal delirium compared with delirium, dementia, and subjects without delirium or dementia in elderly general hospital admissions and nursing home residents. ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2016; 7:1-10. [PMID: 28116342 PMCID: PMC5233793 DOI: 10.1016/j.dadm.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction Subsyndromal delirium (SSD) complicates diagnosis of delirium and dementia, although there is little research comparing their symptom profiles. Methods Cross-sectional study of 400 elderly patients' admission to a general hospital or nursing home diagnosed with delirium, SSD, dementia, or no-delirium/no-dementia (NDND). Symptom profiles were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Results Twenty percent patients had delirium, 19.3% had SSD, 29.8% had dementia-only, and 31% had NDND. Eighty-one percent of subsyndromal and 76% of delirium groups had comorbid dementia. DRS-R98 scores showed ascending severity from NDND < dementia-only < SSD < delirium. DRS-R98 scores for items evaluating the three core symptom domains (cognitive, higher-order thinking, and circadian) distinguished SSD from delirium and both from nondelirium groups. DRS-R98 profiles were essentially the same in delirium and SSD subgroups with or without dementia, although total scale scores were generally higher when in comorbid subgroups. Discussion SSD shared characteristic core domain symptoms with delirium, which distinguished each from nondelirium groups, although severity was intermediate in the subsyndromal group. Delirium core symptoms overshadowed the dementia phenotype when comorbid. Milder disturbances of delirium core domain symptoms are highly suggestive of SSD.
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Affiliation(s)
- Esteban Sepulveda
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain
| | - Maeve Leonard
- University of Limerick Graduate Entry Medical School, Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland
| | - Jose G Franco
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain; Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Dimitrios Adamis
- Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Research and Academic Institute of Athens, Athens, Greece; Sligo-Leitrim Mental Health Services, Sligo, Ireland
| | | | - Colum Dunne
- University of Limerick Graduate Entry Medical School, Limerick, Ireland
| | - Paula T Trzepacz
- Indiana University School of Medicine, Indianapolis, IN, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Ana M Gaviria
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain; Universidad de San Buenaventura, Faculty of Psychology, Medellín, Colombia
| | - Joan de Pablo
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain
| | - Elisabet Vilella
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Tarragona, Spain
| | - David J Meagher
- University of Limerick Graduate Entry Medical School, Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
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Fukata S, Kawabata Y, Fujishiro K, Kitagawa Y, Kuroiwa K, Akiyama H, Takemura M, Ando M, Hattori H. Haloperidol prophylaxis for preventing aggravation of postoperative delirium in elderly patients: a randomized, open-label prospective trial. Surg Today 2016; 47:815-826. [DOI: 10.1007/s00595-016-1441-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022]
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Abstract
Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).
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Jackson TA, MacLullich AMJ, Gladman JRF, Lord JM, Sheehan B. Undiagnosed long-term cognitive impairment in acutely hospitalised older medical patients with delirium: a prospective cohort study. Age Ageing 2016; 45:493-9. [PMID: 27076525 DOI: 10.1093/ageing/afw064] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 02/03/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND delirium and dementia are common in the general hospital, being present in nearly 50% of older unselected admissions to hospital. Cognitive impairment is a risk factor for delirium, but the prevalence of previously undiagnosed cognitive impairment (dementia or mild cognitive impairment) in patients with delirium is unknown. METHODS we performed a prospective cohort study of people over 70 years admitted to hospital with delirium to establish the prevalence of previously unrecognised prior cognitive impairment. Delirium was diagnosed at baseline using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Mild cognitive impairment and dementia were diagnosed 3 months following recruitment in survivors using the International Working Group on Mild Cognitive Impairment criteria and DSM-IV criteria, respectively. RESULTS delirium was identified in 17.9% of older patients, and 82 participants with delirium were assessed at 3 months: 5 (6%) had persistent delirium, 14 (17%) had mild cognitive impairment and 47 (57%) had dementia. In 17 participants with prior dementia and 14 with prior mild cognitive impairment, the diagnosis had been unrecognised, amounting to 31/82 (38%) of all patients with delirium having some form of previously undiagnosed cognitive impairment. CONCLUSION given that over 1/3 of older patients with delirium were found to have a previously undiagnosed cognitive impairment, the development and evaluation of services to follow-up and manage patients with delirium are warranted.
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Affiliation(s)
- Thomas A Jackson
- Institute of Inflammation and Ageing, Centre for Translational Inflammation Research, Queen Elizabeth Hospital Mindelsohn Way, University of Birmingham, Birmingham B15 2WD, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, F1424, Royal Infirmary of Edinburgh 51, Little France Crescent, University of Edinburgh, Edinburgh EH16 4SA, UK
| | - John R F Gladman
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Bart Sheehan
- Psychological Medicine, Oxford University Hospitals, John Radcliffe Hospital, Oxford, UK
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Hall RJ, Watne LO, Idland AV, Raeder J, Frihagen F, MacLullich AMJ, Staff AC, Wyller TB, Fekkes D. Cerebrospinal fluid levels of neopterin are elevated in delirium after hip fracture. J Neuroinflammation 2016; 13:170. [PMID: 27357281 PMCID: PMC4928278 DOI: 10.1186/s12974-016-0636-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The inflammatory cell product neopterin is elevated in serum before and during delirium. This suggests a role for disordered cell-mediated immunity or oxidative stress. Cerebrospinal fluid (CSF) neopterin levels reflect brain neopterin levels more closely than serum levels. Here we hypothesized that CSF neopterin levels would be higher in delirium. METHODS In this prospective cohort study, 139 elderly patients with acute hip fracture were recruited in Oslo and Edinburgh. Delirium was diagnosed with the confusion assessment method performed daily pre-operatively and on the first 5 days post-operatively. Paired CSF and blood samples were collected at the onset of spinal anaesthesia. Neopterin levels were measured using high-performance liquid chromatography. RESULTS Sixty-four (46 %) of 139 hip fracture patients developed delirium perioperatively. CSF neopterin levels were higher in delirium compared to controls (median 29.6 vs 24.7 nmol/mL, p = 0.003), with highest levels in patients who developed delirium post-operatively. Serum neopterin levels were also higher in delirium (median 37.0 vs 27.1 nmol/mL, p = 0.003). CSF neopterin remained significantly associated with delirium after controlling for relevant risk factors. Higher neopterin levels were associated with poorer outcomes (death or new institutionalization) 1 year after surgery (p = 0.02 for CSF and p = 0.03 for serum). CONCLUSIONS This study is the first to examine neopterin in CSF from patients with delirium. Our findings suggest potential roles for activation of cell-mediated immune responses or oxidative stress in the delirium process. High levels of serum or CSF neopterin in hip fracture patients may also be useful in predicting poor outcomes.
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Affiliation(s)
- Roanna J. Hall
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ane-Victoria Idland
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Raeder
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- />Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alasdair M. J. MacLullich
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Anne Cathrine Staff
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Durk Fekkes
- />Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Abstract
BACKGROUND There are high rates of cognitive problems and organic and functional psychiatric disorders in patients admitted to general hospital wards, which may necessitate the use of psychotropic medications. There is evidence of over-prescription of medications such as antipsychotics and antidepressants in community settings such as residential care. However, the prevalence of psychotropic use in general hospitals is unknown. METHODS A point prevalence study of the use of psychotropic medications in an acute general hospital was conducted by auditing medication charts for type, dose, indication, and other clinical processes associated with their use. RESULTS The files of 197 patients were audited, 139 (70%) were aged 65 years and over. Eighty-nine (45%) of patients were prescribed a psychotropic, with 35 (17.7%) antidepressants; 21 (11%) antipsychotics; 19 (10%) benzodiazepines; six (3%) mood stabilizer; five (2%) cholinesterase inhibitors; one (0.5%) anti-parkinsonian medication, and one (1%) patient on zolpidem and another patient melatonin (1%). Most prescriptions (72%) were in people 65 years and over and 27 (20%) of indications were found to be off label prescribing. There were deficits in the documentation of indications for the use of psychotropic medications and follow up arrangements. CONCLUSIONS Rates of benzodiazepines use were less than that reported incomparable settings. Concerns regarding off label prescribing, under-dosing, and lack of adequate documentation of indications and follow-up instructions were raised. Given the potential adverse effects of psychotropic medication, improved governance, and education regarding their use is required.
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Sepulveda E, Franco JG, Trzepacz PT, Gaviria AM, Meagher DJ, Palma J, Viñuelas E, Grau I, Vilella E, de Pablo J. Delirium diagnosis defined by cluster analysis of symptoms versus diagnosis by DSM and ICD criteria: diagnostic accuracy study. BMC Psychiatry 2016; 16:167. [PMID: 27229307 PMCID: PMC4882791 DOI: 10.1186/s12888-016-0878-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 05/18/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Information on validity and reliability of delirium criteria is necessary for clinicians, researchers, and further developments of DSM or ICD. We compare four DSM and ICD delirium diagnostic criteria versions, which were developed by consensus of experts, with a phenomenology-based natural diagnosis delineated using cluster analysis of delirium features in a sample with a high prevalence of dementia. We also measured inter-rater reliability of each system when applied by two evaluators from distinct disciplines. METHODS Cross-sectional analysis of 200 consecutive patients admitted to a skilled nursing facility, independently assessed within 24-48 h after admission with the Delirium Rating Scale-Revised-98 (DRS-R98) and for DSM-III-R, DSM-IV, DSM-5, and ICD-10 criteria for delirium. Cluster analysis (CA) delineated natural delirium and nondelirium reference groups using DRS-R98 items and then diagnostic systems' performance were evaluated against the CA-defined groups using logistic regression and crosstabs for discriminant analysis (sensitivity, specificity, percentage of subjects correctly classified by each diagnostic system and their individual criteria, and performance for each system when excluding each individual criterion are reported). Kappa Index (K) was used to report inter-rater reliability for delirium diagnostic systems and their individual criteria. RESULTS 117 (58.5 %) patients had preexisting dementia according to the Informant Questionnaire on Cognitive Decline in the Elderly. CA delineated 49 delirium subjects and 151 nondelirium. Against these CA groups, delirium diagnosis accuracy was highest using DSM-III-R (87.5 %) followed closely by DSM-IV (86.0 %), ICD-10 (85.5 %) and DSM-5 (84.5 %). ICD-10 had the highest specificity (96.0 %) but lowest sensitivity (53.1 %). DSM-III-R had the best sensitivity (81.6 %) and the best sensitivity-specificity balance. DSM-5 had the highest inter-rater reliability (K =0.73) while DSM-III-R criteria were the least reliable. CONCLUSIONS Using our CA-defined, phenomenologically-based delirium designations as the reference standard, we found performance discordance among four diagnostic systems when tested in subjects where comorbid dementia was prevalent. The most complex diagnostic systems have higher accuracy and the newer DSM-5 have higher reliability. Our novel phenomenological approach to designing a delirium reference standard may be preferred to guide revisions of diagnostic systems in the future.
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Affiliation(s)
- Esteban Sepulveda
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
| | - José G. Franco
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain ,Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paula T. Trzepacz
- Indiana University School of Medicine, Indianapolis, IN USA ,Tufts University Medical Shool, Boston, MA USA
| | - Ana M. Gaviria
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain ,Universidad San Buenaventura, Faculty of Psychology, Medellín, Antioquia Colombia
| | - David J. Meagher
- Department of Psychiatry, University of Limerick School of Medicine, Limerick, Ireland ,School of Medicine, University College Dublin, Dublin, Ireland
| | - José Palma
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
| | - Eva Viñuelas
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
| | - Imma Grau
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
| | - Elisabet Vilella
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
| | - Joan de Pablo
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus Tarragona, Spain
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The effect of range of motion exercises on delirium prevention among patients aged 65 and over in intensive care units. Geriatr Nurs 2016; 37:180-5. [DOI: 10.1016/j.gerinurse.2015.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 12/07/2015] [Accepted: 12/14/2015] [Indexed: 12/25/2022]
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Piotrowicz K, Klich-Rączka A, Pac A, Zdzienicka A, Grodzicki T. The diurnal profile of melatonin during delirium in elderly patients--preliminary results. Exp Gerontol 2015; 72:45-9. [PMID: 26368540 DOI: 10.1016/j.exger.2015.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/31/2015] [Accepted: 09/07/2015] [Indexed: 11/25/2022]
Abstract
Delirium is an acute-onset syndrome that exacerbates patients' condition and significantly increases consequential morbidity and mortality. There is no comprehensive, cellular and tissue-level, pathophysiological theory. The melatonin hormone imbalance has been shown to be linked to circadian rhythms, sleep-wake cycle disturbances, and delirium incidence. There has been relatively little research about melatonin in delirium, and there has been no such study done in the group of elderly patients of a general medicine ward yet. The aim of our study was to compare melatonin hormone concentration in relation to the presence of delirium in elderly patients hospitalized in the general medicine ward. Blood samples were collected four times a day for two days (at 12:00, 18:00, 00:00 and 6:00), on the day when delirium was diagnosed and 72 h after the delirium resolution. Delirium was diagnosed with the Confusion Assessment Method and the criteria of the Diagnostic and Statistic Manual of Mental Disorders, 4th Revision. The mean age of 30 patients (73.3% women) was 86.5 ± 5.2 years. Delirium was diagnosed most often on the second and third day of hospitalization. A lot of predisposing and precipitating factors for delirium were identified. There was a significant difference in the melatonin hormone concentration measurement at 12:00 when patients had acute delirium and after its resolution [18.5 (13.8, 27.5) vs 12.9 (9.8, 17.8), p<0.01]. Different patterns of the melatonin hormone concentration were shown in analyses in the subgroups defined according to the patients' diagnosis of dementia. We found that the delirium recovery was, in fact, associated with the alteration of the daily profile of melatonin.
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Affiliation(s)
- Karolina Piotrowicz
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland.
| | - Alicja Klich-Rączka
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Pac
- Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Anna Zdzienicka
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland
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Shim J, DePalma G, Sands LP, Leung JM. Prognostic Significance of Postoperative Subsyndromal Delirium. PSYCHOSOMATICS 2015. [PMID: 26198571 DOI: 10.1016/j.psym.2015.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Whether postoperative subsyndromal delirium (SSD) is a separate syndrome from delirium and has clinical relevance is not well understood. OBJECTIVES We sought to investigate SSD in older surgical patients and to determine its prognostic significance. METHODS We performed a prospective cohort study of patients who were 65 years or older and were scheduled for noncardiac surgery. Postoperative delirium was determined using the Confusion Assessment Method. SSD was defined as the presence of at least one of the possible 10 symptoms of delirium, as defined by the Confusion Assessment Method, but not meeting the criteria for delirium. RESULTS The number of features of SSD on the first postoperative day was associated with the subsequent development of delirium on the next day, after controlling for other risk factors. When compared with a patient with no SSD features, a patient with 1 SSD feature was 1.07 times more likely to have delirium on the next day (95% CI: 0.42-2.53), with 2 features was 3.32 times more likely to have it (95% CI: 1.42-7.57), and with ≥ 2 features was 8.37 times more likely to have it (95% CI: 4.98-14.53). Furthermore, there was a significant relationship between the number of features of SSD and increased length of hospital stay and worsened functional status at 1 month after surgery. CONCLUSIONS SSD is prevalent in at-risk surgical patients and has prognostic significance. Only a single symptom of SSD was sufficient to cause a significant increase in hospital length of stay and further decline in functional status. These results suggest that monitoring for SSD is indicated in at-risk patients.
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Affiliation(s)
- Jewel Shim
- Psychiatry, University of California, San Francisco, CA
| | - Glen DePalma
- Statistics, Purdue University, San Francisco, CA
| | - Laura P Sands
- Center for Gerontology, Virginia Tech University, San Francisco, CA
| | - Jacqueline M Leung
- Anesthesia and Perioperative Care, University of California, San Francisco, CA.
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Breu A, Stransky M, Metterlein T, Werner T, Trabold B. Subsyndromal delirium after cardiac surgery. SCAND CARDIOVASC J 2015; 49:207-12. [DOI: 10.3109/14017431.2015.1041423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Recognizing acute delirium as part of your routine [RADAR]: a validation study. BMC Nurs 2015; 14:19. [PMID: 25844067 PMCID: PMC4384313 DOI: 10.1186/s12912-015-0070-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 03/18/2015] [Indexed: 11/15/2022] Open
Abstract
Background Although detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings. Methods This was a validation study conducted on three units of an acute care hospital (medical, cardiology and coronary care) and five units of a long-term care facility. A total of 142 patients and 51 residents aged 65 and over, with or without dementia, participated in the study and 139 nurses were recruited and trained to use the RADAR tool. Data on each patient/resident was collected over a 12-hour period. The nursing staff and researchers administered RADAR during the scheduled distribution of medication. Researchers used the Confusion Assessment Method to determine the presence of delirium symptoms. Delirium itself was defined as meeting the criteria for DMS-IV-TR delirium. Inter-rater reliability, convergent, and concurrent validity of RADAR were assessed. At study end, 103 (74%) members of the nursing staff completed the RADAR feasibility and acceptability questionnaire. Results Percentages of agreement between RADAR items that bedside nurses administered and those research assistants administered varied from 82% to 98%. When compared with DSM-IV-TR criterion-defined delirium, RADAR had a sensitivity of 73% and a specificity of 67%. Participating nursing staff took about seven seconds on average, to complete the tool and it was very well received (≥98%) overall. Conclusions The RADAR tool proved to be efficient, reliable, sensitive and very well accepted by nursing staff. Consequently, it becomes an appropriate new option for delirium screening among older adults, with or without cognitive impairment, in both hospitals and nursing homes. Further projects are currently underway to validate the RADAR among middle-aged adults, as well as in newer clinical settings; home care, emergency department, medical intensive care unit, and palliative care. Electronic supplementary material The online version of this article (doi:10.1186/s12912-015-0070-1) contains supplementary material, which is available to authorized users.
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