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Saviano A, Zanza C, Longhitano Y, Ojetti V, Franceschi F, Bellou A, Voza A, Ceresa IF, Savioli G. Current Trends for Delirium Screening within the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1634. [PMID: 37763753 PMCID: PMC10537118 DOI: 10.3390/medicina59091634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/14/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
Abstract
Delirium is an acute neurological disorder that involves attention and cognition. It is associated with a high risk of morbidity and mortality among older people (>65 years old). In the context of the Emergency Department (ED), it is frequently experienced by patients but often not recognized. Literature studies have identified some screening instruments for an initial evaluation of delirium. Most of these tools have not been validated yet in the context of emergencies, but, in other settings, they were very useful for assessing and maximizing the recognition of this condition among older patients. We conducted a review of the literature, including randomized control trials, clinical and observational studies, and research studies published in recent years, confirming that most of the screening tools for delirium used in the intensive care unit (ICU) or the geriatric department have not been tested in the ED, and the ideal timing and form of the delirium assessment process for older adults have not been defined yet. The aim of our review is to summarize the updated evidence about the screening tools for delirium in the context of the ED, due to the fact that overcrowding of the ED and the stressful condition of emergency situations (that contribute to the onset of delirium) could expose older patients to a high risk of complications and mortality if delirium is not promptly recognized. In conclusion, we support the evidence that delirium is a current and real condition that emergency physicians have to face daily, and we are aware that more research is needed to explore this field in order to improve the overall outcomes of older patients admitted to the ED.
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Affiliation(s)
- Angela Saviano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy;
| | - Christian Zanza
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Yaroslava Longhitano
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Veronica Ojetti
- School of Medicine, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesco Franceschi
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Iride Francesca Ceresa
- Emergency Room and Internal Medicine, Istituti Clinici di Pavia e Vigevano, Gruppo San Donato, 27029 Milan, Italy
| | - Gabriele Savioli
- Department of Emergency Medicine, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Eeles E, Ward S, Teodorczuk A, Dissanayaka N, Burianová H. Consciousness and the rabbit holes of delirium. Med Hypotheses 2020; 144:110260. [PMID: 33254566 DOI: 10.1016/j.mehy.2020.110260] [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: 08/09/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/24/2022]
Abstract
Delirium is a common disorder in hospitalized older adults and the defining characteristic is a disturbance of consciousness. Unfortunately, there are currently no testable measures of consciousness as pertains to its disruption in delirium. Not surprisingly rates of recognition of delirium suffer. Arguably, a greater understanding of the quantum of consciousness may improve delirium diagnosis through better diagnostic tools. Candidate dimensions of consciousness derived from fields of psychology, psychiatry, and philosophy are discussed and relevance to delirium explored. Based upon existing literature in the field of consciousness we identify the pre-reflective state, experiential awareness, and functional networks as candidate sites that may be affected in delirium. Opportunities for clinical instrument development and how these tools can be tested are discussed. We conclude that consciousness content may not hold to a unitary measurement, but facets of its integrity that are impacted in delirium are open to further exploration. Disorders in pre-reflective status, experiential awareness, and functional networks may represent the measurable "rabbit holes" of consciousness disturbance.
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Affiliation(s)
- Eamonn Eeles
- Internal Medicine Service, The Prince Charles Hospital, Brisbane, QLD, Australia; School of Medicine, Northside Clinical School, The University of Queensland, The Prince Charles Hospital, QLD, Australia; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD.
| | - S Ward
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD; Redcliffe Hospital, Redcliffe, QLD, Australia
| | - A Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia; Metro North Mental Health, The Prince Charles Hospital, Brisbane, Australia
| | - N Dissanayaka
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, QLD; Department of Neurology, Royal Brisbane & Women's Hospital, Herston, Brisbane, QLD, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, QLD, Australia
| | - H Burianová
- Department of Psychology, Bournemouth University, Fern Barrow, Poole, Dorset UK
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Delirium Management: Anything’s Possible. Can J Aging 2020; 39:89-97. [DOI: 10.1017/s0714980819000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
RÉSUMÉLe délirium est un problème de santé majeur aux conséquences potentiellement graves. Malheureusement, la prise en charge de ce trouble est souvent sous-optimale. Nous considérons que les lacunes dans les soins offerts aux patients avec délirium sont liées aux particularités de cette condition, qui affecte la perception du « soi » de la personne qui en souffre. Cette atteinte entraîne un comportement hors de contrôle chez la personne avec délirium et l’expose à une déshumanisation mécaniste. Une solution consisterait à favoriser une vision élargie du « soi », inspirée de la philosophie et des sciences cognitives récentes, afin d’aider les cliniciens dans la compréhension du comportement pathologique en tant que manifestation de la perturbation de la pensée. Une approche centrée sur l’éthique des soins, intégrant un nouveau cadre pour la relation patient-soignant, est proposée. Considérées dans leur ensemble, les propositions novatrices émises pourraient faciliter l’élaboration d’un cadre de pratiques et de relations plus attentionnées et plus efficaces pour le traitement du délirium.
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Fleischmann R, Traenkner S, Kraft A, Schmidt S, Schreiber SJ, Brandt SA. Delirium is associated with frequency band specific dysconnectivity in intrinsic connectivity networks: preliminary evidence from a large retrospective pilot case-control study. Pilot Feasibility Stud 2019; 5:2. [PMID: 30631448 PMCID: PMC6322230 DOI: 10.1186/s40814-018-0388-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Pathophysiological concepts in delirium are not sufficient to define objective biomarkers suited to improve clinical approaches. Advances in neuroimaging have revalued electroencephalography (EEG) as a tool to assess oscillatory network activity in neuropsychiatric disease. Yet, research in the field is limited to small populations and largely confined to postoperative delirium, which impedes generalizability of findings and planning of prospective studies in other populations. This study aimed to assess effect sizes of connectivity measures in a large mixed population to demonstrate that there are measurable EEG differences between delirium and control patients. Methods This retrospective pilot study investigated EEG measures as biomarkers in delirium using a case-control design including patients diagnosed with delirium (DSM-5 criteria) and age-/gender-matched controls drawn from a database of 9980 patients (n = 129 and 414, respectively). Assessors were not blinded for groups. Power spectra and connectivity estimates, using the weighted phase log index, of continuous EEG data were compared between conditions. Alterations of information flow through nodes of intrinsic connectivity networks (ICN; default mode, salience, and executive control network) were evaluated in source space using betweenness centrality. This was done frequency specific and network nodes were defined by the multimodal human cerebral cortex parcellation based on human connectome project data. Results Delirium and control patients exhibited distinct EEG power, connectivity, and network characteristics (F(72,540) = 70.3, p < .001; F(493,1079) = 2.69, p < .001; and F(718,2159) = 1.14, p = .007, respectively). Connectivity analyses revealed global alpha and regional beta band disconnectivity that was accompanied by theta band hyperconnectivity in delirious patients. Source and network analyses yielded that these changes are not specific to single intrinsic connectivity networks but affect multiple nodes of networks engaged in level of consciousness, attention, working memory, executive control, and salience detection. Effect sizes were medium to strong in this mixed population of delirious patients. Conclusions We quantified effect sizes for EEG connectivity and network analyses to be expected in delirium. This study implicates that theta band hyperconnectivity and alpha band disconnectivity may be essential mechanisms in the pathophysiology of delirium. Upcoming prospective studies will build upon these results and evaluate the clinical utility of identified EEG measures as therapeutic and prognostic biomarkers. Electronic supplementary material The online version of this article (10.1186/s40814-018-0388-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert Fleischmann
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany.,2Department of Neurology, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Steffi Traenkner
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Antje Kraft
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Sein Schmidt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Stephan J Schreiber
- 3Department of Neurology, Asklepios Fachklinikum Brandenburg, 14772 Brandenburg an der Havel, Brandenburg Germany
| | - Stephan A Brandt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
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Eeles E, Teodorczuk A, Mitleton-Kelly E. Reconceptualizing delirium as a disorder of complex system failure. Med Hypotheses 2018; 118:121-126. [PMID: 30037597 DOI: 10.1016/j.mehy.2018.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/19/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
Delirium is conceptually elusive and falls outside of conventional biomedical models. Positivist theoretical paradigms of single linear causality are therefore insufficient to provide mechanistic enlightenment. Delirium does, however, share parallels with features of failure within a complex system. Lessons from complex system theory provide important potential healthcare dividends with respect to delirium. The brain is complex and exhibits emergence, a feature of consciousness, which is crucially impacted in delirium. Volatility, non-linear relationships and multiple point failures are cardinal features of complex system failure, thence delirium. An alternative emphasis away from end of chain analysis and oversimplification of cause and an attempt to avoid introduction of new forms of failure in a responsive healthcare environment are lessons from complex system theory. Insights from complex systems provide potentially important mechanistic underpinnings and new lines of research enquiry for delirium. Not least, a fuller understanding of delirium from a complex system viewpoint may help transform management and outcomes in one of the biggest challenges of acute healthcare.
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Affiliation(s)
- E Eeles
- 4th Floor, Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia; The Northside Clinical Unit, The Prince Charles Hospital, The University of Queensland, Brisbane 4032, Australia.
| | - A Teodorczuk
- School of Medicine, Griffiths University, Gold Coast Campus, Queensland 4222, Australia; The Northside Clinical Unit, The Prince Charles Hospital, The University of Queensland, Brisbane 4032, Australia
| | - E Mitleton-Kelly
- LSE Complexity Research Group, London School of Economics and Political Science, Houghton St, London WC2A 2AE, UK
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Mutch WAC, El-Gabalawy RM, Graham MR. Postoperative Delirium, Learning, and Anesthetic Neurotoxicity: Some Perspectives and Directions. Front Neurol 2018; 9:177. [PMID: 29615969 PMCID: PMC5869196 DOI: 10.3389/fneur.2018.00177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/07/2018] [Indexed: 01/04/2023] Open
Abstract
Evidence of anesthetic neurotoxicity is unequivocal when studied in animal models. These findings have translated poorly to the clinical domain when equated to postoperative delirium (POD) in adults and postoperative cognitive dysfunction (POCD) in either children or the elderly. In this perspective, we examine various reasons for the differences between animal modeling of neurotoxicity and the clinical situation of POD and POCD and make suggestions as to potential directions for ongoing research. We hypothesize that the animal anesthetic neurotoxicity models are limited, in part, due to failed scaling correction of physiological time. We posit that important insights into POCD in children and adults may be gleaned from studies in adults examining alterations in perioperative management designed to limit POD. In this way, POD may be more useful as the proxy for POCD rather than neuronal dropout or behavioral abnormalities that have been used in animal models but which may not be proxies for the human condition. We argue that it is time to move beyond animal models of neurotoxicity to directly examine these problems in well-conducted clinical trials with comprehensive preoperative neuropsychometric and psychiatric testing, high fidelity intraoperative monitoring of physiological parameters during the anesthetic course and postoperative assessment of subthreshold and full classification of POD. In this manner, we can “model ourselves” to better understand these important and poorly understood conditions.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Renée M El-Gabalawy
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Health Psychology, University of Manitoba, Winnipeg, MB, Canada
| | - M Ruth Graham
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
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Haggstrom L, Welschinger R, Caplan GA. Functional neuroimaging offers insights into delirium pathophysiology: A systematic review. Australas J Ageing 2017; 36:186-192. [DOI: 10.1111/ajag.12417] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Lucy Haggstrom
- University of New South Wales; Sydney New South Wales Australia
| | - Robert Welschinger
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
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