Preventing postoperative delirium

Advanced Nursing Roles for People With Cognitive Impairment and Their Relatives in Acute Care Hospitals: A Systematic Review

AIM

To systematically review advanced nursing roles in caring for people with cognitive impairment and their relatives in acute care hospitals, focusing on describing roles and intervention components.

DESIGN

Systematic review.

METHODS

We included qualitative and quantitative studies on nurses in advanced roles caring for people with diagnosed or suspected cognitive impairment and their relatives, assessing outcomes at patient, staff and organisational levels. Nurses' advanced role profiles ranged from nurse-led interventions up to Advanced Practice Nurses. We employed the Mixed Methods Appraisal Tool for critical appraisal and conducted a synthesis without meta-analysis using a content analysis approach.

DATA SOURCES

MEDLINE, CINAHL, Cochrane Library, ALOIS, Web of Science and LIVIVO up to May 2024, along with forward and backward citation tracking.

RESULTS

We included 48 studies that described 39 distinct interventions. The majority of these studies employed a quasi-experimental design. Most interventions involved Advanced Practice Nurses (n = 23) and focused on people at risk of or experiencing delirium (n = 22). Nurses in advanced roles predominantly engaged in tasks related to direct clinical practice, as well as coaching and guidance for patients, relatives and colleagues. Their responsibilities also included leadership, collaboration and consultation on a regular basis. Activities related to research and ethical decision-making were infrequently reported.

CONCLUSION

Many areas of responsibility of nurses in advanced roles align with the needs of hospitalised people with cognitive impairment. Nurses in advanced roles increasingly take on diverse activities across all competence domains of Advanced Practice Nursing, with a focus on coaching and guidance, as well as clinical practice, while leadership, collaboration, research and ethical decision-making become more prominent as their formal training advances.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Our comprehensive description of advanced nursing roles in the care of people with cognitive impairment provides a foundation for developing and refining such roles in hospitals.

REPORTING METHOD

We followed the PRISMA guideline and SWiM guideline for reporting.

PATIENT OR PUBLIC CONTRIBUTION

This study did not include patient or public involvement in its design, conduct or reporting.

TRIAL REGISTRATION

Prospero number: CRD42021265157.

The Effect of Multidimensional Nursing Interventions on the Incidence of Delirium in Patients with COVID-19

Background

In patients with coronavirus disease 2019 (COVID-19), the incidence of delirium has been increased due to the nature of the disease and the specific protective protocols implemented to control the outbreak of this disease. The purpose of this study was to determine the effect of multidimensional nursing interventions on the incidence of delirium in patients with COVID-19.

Materials and Methods

A quasiexperimental study (preintervention, postintervention assessment) was conducted in168 patients (84 patients in each group) with COVID-19 admitted to the general wards of Hazrat Ali-Asghar Educational Hospital in Shiraz, Iran, between May and June 2021. At first, based on inclusion criteria, the control group was selected to prevent information transmission between the study groups. The control group was treated as usual, but the intervention group received a three-part intervention that included nurse-related, patient-related, and environment-related measures. A Demographic Information Form and the Richmond Agitation Sedation Score and the Intensive Care Delirium Screening Checklist were completed for each patient. The collected data were analyzed.

Results

25.30% of patients in the control group and 10.50% of patients in the intervention group experienced delirium (χ 2 = 5.72, p < 0.05). The results showed that the incidence of delirium was significantly lower in the intervention group. The mean number of days during which the patients experienced delirium was insignificantly lower in the intervention group (U = 2.56, p > 0.05). The mean length of hospital stay was also significantly lower in the control group (U = -2.41, p < 0.05).

Conclusions

The multidimensional nursing interventions effectively reduced the incidence of delirium in patients with COVID-19.

Sustained delirium reduction in an inpatient neuroscience unit

BACKGROUND

Delirium is described as acute brain dysfunction that often fluctuates throughout the day and is highly prevalent in hospitalized adults. Delirium negatively affects patient outcomes with consequences including decreased cognitive functioning and increased mortality and healthcare costs. Furthermore, neurological patients are at increased risk for developing delirium due to their underlying diagnoses.

PURPOSE

The purpose of this evidence-based practice project was to evaluate the long-term impact of nursing education and use of trained volunteers to prevent the development of delirium in an inpatient neuroscience unit.

IMPLEMENTATION PLAN

This was a pre-post designed evidence-based practice project to educate and prioritize nursing care interventions for delirium prevention compared to a delirium management framework. The interventions included delirium education for nurses and nursing assistants along with the development of a specialized volunteer program to implement non-pharmacological, multi-component delirium prevention interventions. Long-term sustainment and enculturation occurred over the subsequent year.

OUTCOMES

The baseline data collection period included 2520 patients. The intervention period included 4515 patients, with both groups being similar in age, race, gender, and length of stay. The total number of patients with a discharge diagnosis of delirium decreased from 29.2% to 19.8% (p < .001). Fewer patients in the intervention group were discharged to a skilled nursing facility (p < .001) and other post-acute facility (p = .008), along with more patients being discharged to home care (p < .001).

LINKING EVIDENCE TO ACTION

This evidence-based practice project demonstrates long-term sustained reduction of delirium in the neuroscience population. Despite the challenges during the COVID-19 pandemic, delirium prevention strategies were found to be effective in decreasing the rate at which patients develop delirium.

Association Between Preoperative Sleep Disturbance and Postoperative Delirium in Elderly: A Retrospective Cohort Study

Purpose

Postoperative sleep disturbance, characterized by diminished postoperative sleep quality, is a risk factor for postoperative delirium (POD); however, the association between pre-existing sleep disturbance and POD remains unclear. This study aimed to evaluate the association between preoperative sleep disturbance and POD in elderly patients after non-cardiac surgery.

Patients and methods

This retrospective cohort study was conducted at a single center and enrolled 489 elderly patients who underwent surgery between May 1, 2020, and March 31, 2021. Patients were divided into the sleep disorder (SD) and non-sleep disorder (NSD) groups according to the occurrence of one or more symptoms of insomnia within one month or sleep- Numerical Rating Scale (NRS)≥6 before surgery. The primary outcome was the incidence of POD. Propensity score matching analysis was performed between the two groups. Multiple logistic regression analysis was performed to identify the risk factors for POD.

Results

In both the unmatched cohort (16.0% vs 6.7%, P=0.003) and the matched cohort (17.0% vs 6.2%, P=0.023), the incidence of POD was higher in the SD group than in the NSD group. In addition, the postoperative sleep quality and the VAS score at postoperative 24 h were significantly lower in the SD group than in the NSD group. Multivariate logistic regression analysis indicated that age (Odds Ratio, 1.13 [95% CI: 1.04-1.23], P=0.003) and preoperative sleep disturbance (Odds Ratio, 3.03 [95% CI: 1.09-9.52], P=0.034) were independent risk factors for the development of POD.

Conclusion

The incidence of POD was higher in patients with pre-existing sleep disturbance than those without it. Whether improving sleep quality for preoperative sleep disturbance may help prevent POD remains to be determined.

Quality contract 'prevention of postoperative delirium in the care of elderly patients' study protocol: a non-randomised, pre-post, monocentric, prospective trial

INTRODUCTION

Postoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a 'quality contract' (QC) as a new instrument to improve healthcare in Germany. One of the four areas for improvement of in-patient care is the 'Prevention of POD in the care of elderly patients' (QC-POD), as a means to reduce the risk of developing POD and its complications.The Institute for Quality Assurance and Transparency in Health Care identified gaps in the in-patient care of elderly patients related to the prevention, screening and treatment of POD, as required by consensus-based and evidence-based delirium guidelines. This paper introduces the QC-POD protocol, which aims to implement these guidelines into the clinical routine. There is an urgent need for well-structured, standardised and interdisciplinary pathways that enable the reliable screening and treatment of POD. Along with effective preventive measures, these concepts have a considerable potential to improve the care of elderly patients.

METHODS AND ANALYSIS

The QC-POD study is a non-randomised, pre-post, monocentric, prospective trial with an interventional concept following a baseline control period. The QC-POD trial was initiated on 1 April 2020 between Charité-Universitätsmedizin Berlin and the German health insurance company BARMER and will end on 30 June 2023.

INCLUSION CRITERIA

patients 70 years of age or older that are scheduled for a surgical procedure requiring anaesthesia and insurance with the QC partner (BARMER). Exclusion criteria included patients with a language barrier, moribund patients and those unwilling or unable to provide informed consent. The QC-POD protocol provides perioperative intervention at least two times per day, with delirium screening and non-pharmacological preventive measures.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/054/20). The results will be published in a peer-reviewed scientific journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04355195.

The inter-relationship between delirium and dementia: the importance of delirium prevention

Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia.

In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk.

Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship.

Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline.

Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies.

Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier.

Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele.

Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.

Structured delirium management in the hospital—a randomized controlled trial

BACKGROUND

Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients.

METHODS

The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]).

RESULTS

The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02).

CONCLUSION

Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.

Individual Pharmacotherapy Management (IPM) - I: a group-matched retrospective controlled clinical study on prevention of complicating delirium in the elderly trauma patients and identification of associated factors

Background

Delirium is one of the most frequent complications in hospitalized elderly patients with additional costs such as prolongation of hospital stays and institutionalization, with risk of reduced functional recovery, long-term cognitive impairment, and increased morbidity and mortality. We analyzed the effect of individual pharmacotherapy management (IPM) in the University Hospital Halle in geriatric trauma patients on complicating delirium and aimed to identify associated factors.

Methods

In a retrospective controlled clinical study of 404 hospitalized trauma patients ≥70 years we compared the IPM intervention group (IG) with a control group (CG) before IPM implementation. Delirium was recorded from the hospital discharge letter. The medication review and data records included baseline data, all medications, diagnoses, electrocardiogram (ECG), laboratory and vital parameters during hospitalization. The IPM internist and the senior trauma physician guaranteed personnel and structural continuity in the implementation of the interdisciplinary patient rounds.

Results

There was a highly matched congruence between CG and IG in terms of age, gender, residency, BMI, most diagnoses, and injury patterns to compare the two groups. The total number of medications per patient was 11.1 ± 4.9 (CG) versus 10.4 ± 3.6 (IG). Our targeted IPM focus on 6 frontline aspects with reduction of antipsychotics, anticholinergic burden, benzodiazepines, serotonergic opioids, elimination of pharmacokinetic and pharmacodynamic drug interactions and overdosage reduced complicating delirium from 5% to almost zero at 0.5%. The association of IPM with a significant 10-fold reduction, OR = 0.09 [95% CI 0.01–0.7], in univariable regression, maintained of clinical relevance in multivariable regression OR = 0.1 [95% CI 0.01–1.1]. Factors most strongly associated with complicating delirium in univariable regression were cognitive dysfunction, nursing home residency, muscle relaxants, antiparkinsonian agents, xanthines, transient disorientation documented in the fall risk scale, antibiotic-requiring infections, antifungals, antipsychotics, and intensive care stay, the two latter maintaining significance in multivariable regression.

Conclusions

IPM is associated with a highly effective prevention of complicating delirium in the elderly trauma patients. For patient safety it should be integrated as an essential preventative contribution. The associated factors help identify patients at risk.

Related Factors and Treatment of Postoperative Delirium in Old Adult Patients: An Integrative Review

“Postoperative delirium” is defined as delirium occurring in the hospital up to one week after a procedure or before discharge (whichever occurs first) that meets the DSM-5 diagnostic criteria. Objectives: To describe the risk factors related to this pathology and identify effective non-pharmacological forms of treatment. An integrative review of the available literature was performed. The search results considered included all quantitative studies published between 2011 and 2019 in both English and Spanish. A total of 117 studies were selected. Advanced age was identified as the principal risk factor for postoperative delirium. Nursing interventions appear to be the key to preventing or reducing the seriousness of delirium after an anaesthetic episode. The aetiology of postoperative delirium remains unknown, and no treatment exists to eliminate this pathology. The role of nursing staff is fundamental in the prevention, diagnosis, and management of the pathology.

The Role of Perioperative Sleep Disturbance in Postoperative Neurocognitive Disorders

Postoperative neurocognitive disorder (PND) increases the length of hospital stay, mortality, and risk of long-term cognitive impairment. Perioperative sleep disturbance is prevalent and commonly ignored and may increase the risk of PND. However, the role of perioperative sleep disturbances in PND remains unclear. Nocturnal sleep plays an indispensable role in learning, memory, and maintenance of cerebral microenvironmental homeostasis. Hospitalized sleep disturbances also increase the incidence of postoperative delirium and cognitive dysfunction. This review summarizes the role of perioperative sleep disturbances in PND and elucidates the potential mechanisms underlying sleep-deprivation-mediated PND. Activated neuroinflammation and oxidative stress; impaired function of the blood-brain barrier and glymphatic pathway; decreased hippocampal brain-derived neurotrophic factor, adult neurogenesis, and sirtuin1 expression; and accumulated amyloid-beta proteins are associated with PND in individuals with perioperative sleep disorders. These findings suggest that the improvement of perioperative sleep might reduce the incidence of postoperative delirium and postoperative cognitive dysfunction. Future studies should further investigate the role of perioperative sleep disturbance in PND.

Usefulness of postoperative serum translocator protein as a predictive marker for delirium after breast cancer surgery in elderly women

Objective

Postoperative delirium (POD) has rarely been investigated in breast cancer patients. Herein, we assessed the association between serum levels of the inflammatory biomarker translocator protein (TP) and the occurrence of POD in breast cancer patients.

Methods

In this prospective, observational study, TP levels were detected in preoperative and postoperative serum samples from 152 elderly breast cancer patients, samples from 152 healthy elderly women, and samples from 152 elderly women with benign breast diseases. The relationship between serum TP levels and POD was investigated using multivariate analysis.

Results

TP levels in postoperative patient serum samples were significantly higher than in preoperative patient serum samples and serum from women in the two control groups. Postoperative serum TP levels were independently correlated with serum C-reactive protein levels and the occurrence of POD. Postoperative serum TP levels had a high discriminatory ability for POD under the receiver operating characteristic curve.

Conclusions

Increased postoperative serum TP levels are independently associated with the degree of inflammatory response and the risk of POD in elderly breast cancer patients, substantializing TP as an inflammatory biomarker that can efficiently discriminate POD after breast cancer surgery.

[Competence, creativity and communication: basics for quality improvement in traumatology : Reality and future challenges]

Interdisciplinary collaboration is one of the key factors for successful treatment of patients with complex injuries and diseases. Hence, several innovative concepts have been initiated to improve the treatment quality within the field of trauma surgery. The implementation of a ward pharmacist with the daily discussion of prescribed medications shows a reduction of side effects, costs for medicaments and the use of antibiotics. An interdisciplinary and multimodal delirium team was introduced and every patient over the age of 65 years was screened for the risk of perioperative and postoperative delirium, the medication was adjusted and expert advice was available in the case of acute delirium. Corresponding to the well-established tumor boards, an interdisciplinary musculoskeletal conference to decide on the treatment of complex interdisciplinary injuries of the musculoskeletal system should be established. The future challenges will include the digital connection of hospitals within the already existing trauma networks in order to provide rapid access to this interdisciplinary expertise also outside maximum care hospitals.

Glycation Increases the Risk of Microbial Traversal through an Endothelial Model of the Human Blood-Brain Barrier after Use of Anesthetics

The function of the human blood–brain barrier (BBB), consisting mainly of the basement membrane and microvascular endothelial cells, is to protect the brain and regulate its metabolism. Dysfunction of the BBB can lead to increased permeability, which can be linked with several pathologies, including meningitis, sepsis, and postoperative delirium. Advanced glycation end products (AGE) are non-enzymatic, posttranslational modifications of proteins, which can affect their function. Increased AGE levels are strongly associated with ageing and degenerative diseases including diabetes. Several studies demonstrated that the formation of AGE interfere with the function of the BBB and may change its permeability for soluble compounds. However, it is still unclear whether AGE can facilitate microbial traversal through the BBB and how small compounds including anesthetics modulate this process. Therefore, we developed a cellular model, which allows for the convenient testing of different factors and compounds with a direct correlation to bacterial traversal through the BBB. Our results demonstrate that both glycation and anesthetics interfere with the function of the BBB and promote microbial traversal. Importantly, we also show that the essential nutrient and antioxidant ascorbic acid, commonly known as vitamin C, can reduce the microbial traversal through the BBB and partly reverse the effects of AGE.

Psychopharmacological Treatment in Older People: Avoiding Drug Interactions and Polypharmacy

BACKGROUND

As the elderly population increases, so, too, does the number of multimorbid patients and the risk of polypharmacy. The consequences include drug interactions, undesired side effects of medication, health impairment, and the need for hospital- ization. 5-10% of hospital admissions among the elderly are attributable to undesired side effects of medication.

METHODS

This review is based on publications retrieved by a selective search in PubMed and the Cochrane Library that employed the search terms "drug interaction," "undesired side effect," "polypharmacy," "pharmacokinetics," and "pharmacody- namics."

RESULTS

Elderly patients are particularly at risk of polypharmacy, both because of the prevalence of multimorbidity in old age and because of physicians' uncritical implementation of guidelines. The more drugs a person takes, the greater the risk of drug interactions and undesired side effects. Age-associated changes in pharmacokinetics and pharmacodynamics elevate this risk as well. Physicians prescribing drugs for elderly patients need to know about the drugs' catabolic pathways, protein binding, and inductive and inhibitory effects on cytochrome P450 in order to avoid drug interactions and polypharmacy.

CONCLUSION

Multiple aids and instruments are available to ensure practical and reasonable drug monitoring, so that the risks of drug interactions and undesired side effects can be detected early and avoided.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

PURPOSE

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

PATIENTS AND METHODS

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

RESULTS

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

CONCLUSION

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

BACKGROUND

Older people represent a risk group for acquiring or further development of delirium during hospitalization, therefore requiring suitable nonpharmacological delirium interventions.

OBJECTIVE

This scoping review analyzed nonpharmacological intervention programs for older inpatients with or without cognitive decline on regular or acute geriatric wards to present the range of interventions.

METHODS

A systematic literature search was conducted using scientific databases. A total of 4652 records were screened by two independent reviewers, leaving 81 eligible articles for full-text screening and 25 studies were finally included. Inclusion criteria were older patients ≥65 years in regular or acute geriatric wards and nonpharmacological multicomponent interventions.

RESULTS

More than a half of the included studies (14, 56%) recruited patients with pre-existing cognitive decline as part of the study population and 12% focused exclusively on patients with cognitive decline. On average 11 intervention components were integrated in the programs and two programs included full coverage of all 18 identified components.

CONCLUSION

Only few programs were described for older inpatients and even fewer regarding pre-existing cognitive decline. The low numbers of interventions and data heterogeneity restricted the assessment of outcomes; however, delirium incidence, as reported by two thirds of the studies was reduced by nonpharmacological multicomponent interventions.

[Aspects of liaison psychiatry care of patients in a university pain clinic]

BACKGROUND

Owing to a rise of psychosomatic comorbidities, the treatment of psychological disorders, which may negatively impact prognosis and therapy, is increasingly becoming a focus of attention for pain outpatient clinics.

AIM

This study investigates and discusses the advantages of liaison psychiatric care in a university pain clinic.

METHODS

In this retrospective study, we investigated all patients who presented to an anaesthesiologically led pain clinic between January and June 2014. The psychiatric history was taken by the liaison psychiatrist of the pain clinic.

RESULTS

In the period investigated, 485 patients were treated as outpatients. A psychiatric diagnosis was present 351 patients (72.4%). The distribution of the diagnoses was comparable with that of a consultation service. Adaptation and affective disorders dominated. The patients were preferentially treated with new generation antidepressants.

CONCLUSION

The constant presence of a liaison psychiatrist allows for timely, specialised care of pain patients in terms of a multimodal therapeutic approach.

Malondialdehyde on postoperative day 1 predicts postoperative cognitive dysfunction in elderly patients after hip fracture surgery

Background: Postoperative cognitive dysfunction (POCD) is a great problem for anesthetized subjects and is associated with poor short- and long-term outcomes. We explored promising predictors for POCD in elderly patients after hip fracture surgery.Methods: Elderly subjects (aged ≥65 years) undergoing surgery for hip fracture were consecutively recruited. Neuropsychological assessments were performed 1 day preoperatively (baseline) and 7 days postoperatively, and POCD was defined using the 'Z scores' method. Clinical data and laboratory tests were compared between patients with and without POCD development. Binary univariate and multivariate logistic regression analyses were conducted for risk factor assessment. Receiver operating characteristic (ROC) curve analysis was performed to investigate the predictive value of malondialdehyde (MDA) on postoperative day 1 (POD1) for POCD.Results: A total of 198 patients were finally enrolled in the analysis and 51 patients exhibited POCD within 7 postoperative days, with an incidence rate of 25.8%. MDA expression on POD1 (OR: 1.12, 95%CI: 1.03-1.23, P=0.017) was the only independent risk factor for POCD according to the final multivariate logistic regression analysis. ROC curve analysis indicated that MDA on POD1 was a predictor for POCD, with an area under the curve (AUC) of 0.683 and 95%CI of 0.590-0.775 (P<0.001).Conclusions: In conclusion, we demonstrated that MDA on POD1 was an independent risk factor for POCD in elderly subjects undergoing hip fracture surgery.

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery.

Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used.

Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium.

Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.

Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis

Background

Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients.

Methods

PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach.

Results

One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, − 0.23 to 0.31; P = 0.78).

Conclusion

Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population.

Trial registration

PROSPERO CRD42018108739.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0735-5) contains supplementary material, which is available to authorized users.

Serum soluble fibrinogen-like protein 2 concentration predicts delirium after acute pancreatitis

OBJECTIVE

Inflammation can cause delirium. Soluble fibrinogen-like protein 2 (sFGL2) is a modulator of the immune response and more recently found to be a biomarker for brain injury. This study was designed to discover the predictive capability of serum sFGL2 concentrations for delirium after acute pancreatitis (AP).

MATERIALS AND METHODS

In this prospective, observational study, serum sFGL2 concentrations were quantified in 184 healthy controls and in 184 AP patients. Disease severity was assessed by Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score, and sequential organ failure assessment score. Delirium was recorded during hospital stay. Predictors of delirium were identified using multivariate analysis.

RESULTS

Serum sFGL2 concentrations were substantially higher in AP patients than in controls. Serum sFGL2 concentrations were intimately correlated with the preceding severity parameters. Serum sFGL2 and the aforementioned severity parameters were independent predictors for delirium. Under receiver operating characteristic curve, the discriminatory ability of serum sFGL2 was equivalent to those of the above-mentioned severity parameters. Moreover, serum sFGL2 dramatically improved the predictive value of the aforementioned severity parameters.

CONCLUSIONS

Elevation of serum sFGL2 concentrations is strongly associated with the AP severity and has the potential to distinguish delirium after AP.

Acute Confusional States in Hospital

BACKGROUND

Acute confusional state (delirium) is an acute disturbance of brain function. The incidence of such states varies according to the group of patients con- cerned: it ranges from 30% to 80% among patients in intensive care and from 5.1% to 52.2% among surgical patients, depending on the type of procedure. The earlier German term "Durchgangssyndrom" (usually rendered as "transitory psychotic syn- drome") tended to imply a self-limited and thus relatively harmless condition. In fact, however, delirium is associated with longer hospital stays, poorer treatment out- comes, and higher mortality. Approximately 25% of patients who have experienced an acute confusional state have residual cognitive deficits thereafter.

METHODS

This review is based on publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and in the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

Validated instruments are available for the reliable diagnosis of an acute confusional state, e.g., the Confusion Assessment Method for the ICU (CAM-ICU) for patients in intensive care and the 3D-CAM or CAM-S for patients on regular hospital wards. The prevention and treatment of this condition are achieved primarily by a nonpharmacological, multidimensional approach including early mobilization, reorientation, improvement of sleep, adequate pain relief, and the avoidance of polypharmacy. A meta-analysis has shown that these measures lower the incidence of delirium by 44%. The authors find no basis in the current literature for recommending prophylactic medication, although current data promisingly suggest that the incidence of delirium in surgical patients can be lowered by the perioperative administration of dexmedetomidine (odds ratio 0.35). The pharmaco- therapy of acute confusional states involves a careful choice of drug based on the clinical manifestations in the individual case.

CONCLUSION

The key elements of success in the treatment of acute confusional states in the hospital are adequate prevention, rapid diagnosis, the identification of precipitating factors, and the rapid initiation of both causally oriented and symptom- directed treatment.

The Perioperative Care of Older Patients

BACKGROUND

Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews.

RESULTS

The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is best initiated before hospital admission, e.g., correction of deficiency states, optimization of chronic drug treatment, and respiratory training. Another important component consists of pre-, intra-, and postoperative measures to prevent delirium, which can lower the frequency of this complication by 30-50%: these include orientation aids, avoidance of inappropriate drugs for elderly patients, adequate analgesia, early mobilization, short fasting times, and a perioperative nutrition plan. Preexisting cognitive impairment predisposes to postoperative delirium (odds ratios [OR] ranging from 2.5 to 4.5). Frailty is the most important predictor of the postoperative course (OR: 2.6-11). It follows that preoperative assessment of the patient's functional and cognitive status is essential.

CONCLUZION

The evidence-based and guideline-consistent care of elderly patients requires not only close interdisciplinary, interprofessional, and cross-sectoral collaboration, but also the restructuring and optimization of habitual procedural pathways in the hospital. Elderly patients' special needs can only be met by a treatment concept in which the entire perioperative phase is considered as a single, coherent process.

Relation of postoperative serum S100A12 levels to delirium and cognitive dysfunction occurring after hip fracture surgery in elderly patients

OBJECTIVE

Brain injury is implicated in pathogenesis of postoperative delirium (POD) and cognitive dysfunction (POCD). S100A12 is involved in inflammatory process and is recently known as a biomarker for brain injury. Herein, we clarified whether serum S100A12 levels are related to POD and POCD after hip fracture surgery in elderly patients.

MATERIALS AND METHODS

In this prospective, observational study, we gauged S100A12 levels in preoperative and postoperative serum from 186 patients and serum from 186 controls. Patients were categorized according to the presence of POD and POCD.

RESULTS

Postoperative, but not preoperative serum S100A12 levels were significantly higher in patients than in controls. There was a positive and independent correlation between postoperative C-reactive protein and S100A12 levels (t = 8.797, p < 0.001). Postoperative S10012 levels and age were independently associated with the risk of developing POD (S100A12 levels: odds ratio [OR] = 1.166, 95% confidence interval [CI] = 1.045-2.087, p = 0.001; age: OR = 1.243, 95% CI = 1.073-1.419, p = 0.012) and POCD (S100A12: OR = 1.157, 95% CI = 1.030-1.986, p = 0.003; age: OR = 1.228, 95% CI = 1.054-1.387, p = 0.014). In terms of area under receiver operating characteristic curve, postoperative S100A12 levels had a higher predictive ability than age and their combination dramatically exceeded that of each one alone.

CONCLUSIONS

Postoperative elevated serum S100A12 levels have a strong relation to inflammation and are associated independently with the development of POD and POCD, substantializing serum S100A12 as a potential biomarker for predicting POD and POCD in elderly patients undergoing hip fracture surgery.

Postoperative Complications Associated With Spine Surgery in Patients Older Than 90 Years: A Multicenter Retrospective Study

STUDY DESIGN

A review of a prospective database.

OBJECTIVES

Surgery for elderly patients is increasing yearly due to aging of society and the desire for higher quality of life. The goal of the study was to examine perioperative complications in spine surgery in such patients.

METHODS

A multicenter study of surgical details and perioperative complications was performed in 35 patients aged older than 90 years who underwent spinal surgery, based on a review of a prospective database. The frequency and severity of complications were assessed, and the effects of patient-specific and surgical factors were examined. Major complications were defined as those that were life threatening, required reoperation in the perioperative period or left a permanent injury. Ambulatory function before and after surgery was also analyzed.

RESULTS

Perioperative complications occurred in 19 of the 35 cases (54%), and included 11 cases of postoperative delirium, most of which occurred after cervical spine surgery. There were 8 major complications (23%), including cerebral infarction (n = 3), coronary heart disease (n = 3), pulmonary embolism (n = 1), and angina (n = 1). Preoperative motor deficit, operative time, estimated blood loss, and instrumented fusion were significantly associated with major complications. An improved postoperative ambulatory status occurred in 61% of cases, with no change in 33%, and worsening in 2 cases (6%).

CONCLUSIONS

Timing of surgery before paralysis progression and reduced surgical invasiveness are important considerations in treatment of the very elderly. Improved outcomes can be obtained with better management of spine surgery for patients aged 90 years or older.

The Prevalence of Dementia and Cognitive Impairment in Hospitals

BACKGROUND

The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals.

METHODS

We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients' medical records.

RESULTS

1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases.

CONCLUSION

Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.

Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness

BACKGROUND

Delirium, defined as an acute disorder of attention and cognition with high morbidity and mortality, can be prevented by multicomponent nonpharmacological interventions. The Hospital Elder Life Program (HELP) is the original evidence-based approach targeted to delirium risk factors, which has been widely disseminated.

OBJECTIVE

To summarize the current state of the evidence regarding HELP and to highlight its effectiveness and cost savings.

METHODS

Systematic review of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1999 to 2017, using a combination of controlled vocabulary and keyword terms.

RESULTS

Of the 44 final articles included, 14 were included in the meta-analysis for effectiveness and 30 were included for examining cost savings, adherence and adaptations, role of volunteers, successes and barriers, and issues in sustainability. The results for delirium incidence, falls, length of stay, and institutionalization were pooled for meta-analyses. Overall, 14 studies demonstrated significant reductions in delirium incidence (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.37-0.59). The rate of falls was reduced by 42% among intervention patients in three comparative studies (OR 0.58, 95% CI 0.35-0.95). In nine studies on cost savings, the program saved $1600-$3800 (2018 U.S. dollars) per patient in hospital costs and over $16,000 (2018 U.S. dollars) per person-year in long-term care costs in the year following delirium. The systematic review revealed that programs were generally successful in adhering to or appropriately adapting HELP (n = 13 studies) and in finding the volunteer role to be valuable (n = 6 studies). Successes and barriers to implementation were examined in 6 studies, including ensuring effective clinician leadership, finding senior administrative champions, and shifting organizational culture. Sustainability factors were examined in 10 studies, including adapting to local circumstances, documenting positive impact and outcomes, and securing long-term funding.

CONCLUSION

The Hospital Elder Life Program is effective in reducing incidence of delirium and rate of falls, with a trend toward decreasing length of stay and preventing institutionalization. With ongoing efforts in continuous program improvement, implementation, adaptations, and sustainability, HELP has emerged as a reference standard model for improving the quality and effectiveness of hospital care for older persons worldwide.

[Does multimorbidity in older psychiatric patients lead to higher transfer rates between psychiatric and somatic departments?]

OBJECTIVE

Multimorbidity is an increasing challenge in geriatric medicine, also in psychiatric patients. The question arises where an adequate treatment should be carried out.

METHODS

This exploratory study was part of the Gerontopsychiatry study Berlin (Gepsy-B), an investigation of all admissions of older inpatients (>65 years) to a psychiatric hospital within 3 years. A total of 1266 admissions to a hospital in Berlin could be analyzed.

RESULTS

Of the patients primarily admitted to the psychiatric department, 17.4% had to be transferred to a somatic department with a preponderance of patients with higher multimorbidity (11.7 ± 3.7 vs. 9.9 ± 3.8 somatic diagnoses, U‑test p < 0.001). Of the patients 19.7% were transferred from somatic departments to the psychiatric department mainly due to delirium. They were also often multimorbid (mean number of somatic diagnoses: 11.7 + 3.7 vs. 10.3 + 3.8, U‑test p < 0.001).

CONCLUSION

Multimorbidity results in more frequent transfer of older patients in hospital.

[Traumatology in the elderly : Multimodal prevention of delirium and use of augmentation techniques]

Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]

BACKGROUND

Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study.

METHODS

From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments.

RESULTS

A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives.

DISCUSSION

The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.

Complications Associated With Spine Surgery in Patients Aged 80 Years or Older: Japan Association of Spine Surgeons with Ambition (JASA) Multicenter Study

STUDY DESIGN

Retrospective study of registry data.

OBJECTIVES

Aging of society and recent advances in surgical techniques and general anesthesia have increased the demand for spinal surgery in elderly patients. Many complications have been described in elderly patients, but a multicenter study of perioperative complications in spinal surgery in patients aged 80 years or older has not been reported. Therefore, the goal of the study was to analyze complications associated with spine surgery in patients aged 80 years or older with cervical, thoracic, or lumbar lesions.

METHODS

A multicenter study was performed in patients aged 80 years or older who underwent 262 spinal surgeries at 35 facilities. The frequency and severity of complications were examined for perioperative complications, including intraoperative and postoperative complications, and for major postoperative complications that were potentially life threatening, required reoperation in the perioperative period, or left a permanent injury.

RESULTS

Perioperative complications occurred in 75 of the 262 surgeries (29%) and 33 were major complications (13%). In multivariate logistic regression, age over 85 years (hazard ratio [HR] = 1.007, P = 0.025) and estimated blood loss ≥500 g (HR = 3.076, P = .004) were significantly associated with perioperative complications, and an operative time ≥180 min (HR = 2.78, P = .007) was significantly associated with major complications.

CONCLUSIONS

Elderly patients aged 80 years or older with comorbidities are at higher risk for complications. Increased surgical invasion, and particularly a long operative time, can cause serious complications that may be life threatening. Therefore, careful decisions are required with regard to the surgical indication and procedure in elderly patients.

Delirium in Older Persons: Advances in Diagnosis and Treatment

Importance

Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.

Objective

To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence Review

Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Findings

Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and Relevance

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

Serum galectin-3 levels and delirium among postpartum intensive care unit women

OBJECTIVE

Inflammation correlates with delirium. Galectin-3 is a proinflammatory protein. This study aimed to determine relation of serum galectin-3 levels to delirium of postpartum intensive care unit (ICU) women.

MATERIALS AND METHODS

In this prospective observational study, serum galectin-3, S100B, and C-reactive protein levels of 412 postpartum ICU women and 412 healthy women were measured. Delirium and Acute Physiology and Chronic Health Care Evaluation II (APCHCE II) scores were recorded.

RESULTS

Serum levels of galectin-3, S100B, and C-reactive protein were significantly elevated in the postpartum women than in the healthy women. Galectin-3 levels were highly associated with APCHCE II scores and S100B and C-reactive protein levels. Galectin-3, C-reactive protein, and S100B levels and APCHCE II scores were identified as independent predictors for delirium. Area under the curve (AUC) of serum galectin-3 levels was similar to that of S100B levels, and significantly exceeded those of C-reactive protein levels and APCHCE II scores. Moreover, galectin-3 significantly improved the AUCs of APCHCE II scores, S100B levels, and C-reactive protein levels.

CONCLUSIONS

Galectin-3, involved in inflammatory process underlying delirium-related brain injury, might be a potential biomarker to predict delirium of postpartum ICU women.

The Diagnosis and Treatment of Behavioral Disorders in Dementia

BACKGROUND

Behavioral disorders such as aggressiveness, agitation, delusions, disinhibition, affect lability, and apathy arise in more than 90% of patients with dementia. Behavioral disorders are a major challenge and the greatest stress factor in everyday life for nursing personnel and for family members caring for the patient.

METHODS

This review is based on relevant publications retrieved by a selective literature search in the PubMed, Cochrane Library, and German S3 guideline databases with the search terms "behavioral disorders," "non-cognitive disorders," and "challenging behavior," in conjunction with "dementia" and "behavioral and psychological symptoms of dementia."

RESULTS

Behavioral disorders regularly accompany dementing illness and have identifiable and treatable somatic and environment-related causes. They should be treated symptomatically, both with non-pharmacological measures and with drugs. Memory therapy (d = 0.47), ergotherapy (d = 0.72), music therapy (d = 0.62), and physical exercise (d = 0.68) are effective, as are antidementia drugs (galantamine: p = 0.04, donepezil: p = 0.01, rivastigmine: p = 0.02, memantine: p = 0.004). Risperidone is the drug of choice to combat agitation and aggressiveness (d = 0.33) as well as dementia and hallucinations (d = 0.5). Citalopram can be recommended for the treatment of depression in patients with dementia (p = 0.05).

CONCLUSION

Because of an improved evidence base, the latest version of the German S3 guideline on the diagnosis and treatment of dementia places greater emphasis on non-pharmacological treatments for behavioral disorders in dementia than it did in the past. The global efficacy of such treatments against behavioral disorders is well documented. Nonetheless, because of the heterogeneity of interventions and varying standards of assessment, the evidence for the utility of certain specific methods in the treatment of specific behavioral disorders is still limited. More research is needed in this area.

[Acute and long-term cognitive consequences of treatment on intensive care units]

BACKGROUND

Following treatment on the intensive care unit (ICU) patients often suffer from acute and long-term cognitive deficits. This is true for patients of all age groups but especially for elderly patients who have undergone surgery and develop postoperative delirium (POD) or postoperative cognitive decline (POCD). Both are associated with severe limitations in the quality of life and long-term outcome.

OBJECTIVE

Which acute and long-term cognitive effects develop in ICU survivors and how do they influence the outcome? How can POD and POCD be differentiated?

METHOD

A selective literature search was carried out.

RESULTS

Following surgery POCD can develop within days to weeks, may persist for weeks or months and can lead to problems in attentiveness even under conditions of inconspicuous consciousness. Remission is possible but may take up to more than 12 months. The POD is a phenomenon characterized by disturbances of consciousness and problems in attention, beginning acutely hours and days postoperatively, can persist for days to weeks and remission can be expected within a few days. While POD often has an organic cause, such as an infection, the pathogenesis of POCD has not been sufficiently elucidated.

DISCUSSION

Both POD and particularly POCD can lead to a deterioration of cognition following ICU treatment. As efficient treatment still has to be developed preventive methods, such as preoperative screening for risk factors, thorough planning of operative and anesthetic techniques and compensation of risk factors as well as providing assistance to patients, e. g. by a trained nurse should be implemented in the clinical routine more often than is presently the case.

[Nursing workload indices TISS-10, TISS-28, and NEMS : Higher workload with agitation and delirium is not reflected]

BACKGROUND

Financial resources for the treatment of ICU patients requiring high nursing workload are allocated within the German diagnostic-related groups (DRG) system in part through the Therapeutic Intervention Scoring System-10 (TISS-10). TISS-10, however, has never been validated. This study evaluated whether delirium and agitation in ICU were reflected by TISS-10, and also by the established workload indices TISS-28 and Nine Equivalents of Nursing Manpower (NEMS). Secondary aims were if indices correlated, and what effects delirium and agitation had on financial balances.

MATERIALS AND METHODS

Analyses were performed retrospectively in 521 datasets from 152 patients. Nursing workload was assessed with TISS-28, TISS-10, and NEMS, delirium with the Confusion Assessment Method for Intensive Care Units (CAM-ICU), and vigilance with the Richmond Agitation-Sedation Scale (RASS). Revenues were retrieved from the institution's patient data management system, and costs calculated with the Budget Calculation Tool 2007 provided by the German Society of Anaesthesiologists.

RESULTS

Delirium was found in 36.2 % of patients (n = 55). TISS-28, TISS-10, and NEMS were not higher in patients with delirium, if corrected for mechanical ventilation. TISS-28, TISS-10, and NEMS were significantly higher in deeply sedated and comatose patients (RASS ≤ - 3, p < 0.001), but not in agitated (RASS ≥ 1) and lightly sedated patients (RASS - 1/- 2). TISS-10 and TISS-28 had a linear correlation (r (2)  = 0.864). Median financial balances were negative, but much more pronounced in patients with delirium that without (- 3174 € with delirium vs. - 1721 € without delirium, p = 0.0147).

CONCLUSION

The standard workload-scores (TISS-10, TISS-28, NEMS) do not reflect higher daily workload associated with patients with delirium and agitation.