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Daniels C, Rodríguez-Antigüedad J, Jentschke E, Kulisevsky J, Volkmann J. Cognitive disorders in advanced Parkinson's disease: challenges in the diagnosis of delirium. Neurol Res Pract 2024; 6:14. [PMID: 38481336 PMCID: PMC10938698 DOI: 10.1186/s42466-024-00309-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/15/2024] [Indexed: 03/17/2024] Open
Abstract
Parkinson's disease (PD) is a neurodegenerative condition that is frequently associated with cognitive disorders. These can arise directly from the primary disease, or be triggered by external factors in susceptible individuals due to PD or other predisposing factors. The cognitive disorders encompass PD-associated cognitive impairment (PD-CI), delirium, PD treatment-associated cognitive side effects, cognitive non-motor fluctuations, and PD-associated psychosis. Accurate diagnosis of delirium is crucial because it often stems from an underlying disease that may be severe and require specific treatment. However, overlapping molecular mechanisms are thought to be involved in both delirium and PD, leading to similar clinical symptoms. Additionally, there is a bidirectional interaction between delirium and PD-CI, resulting in frequent concurrent processes that further complicate diagnosis. No reliable biomarker is currently available for delirium, and the diagnosis is primarily based on clinical criteria. However, the screening tools validated for diagnosing delirium in the general population have not been specifically validated for PD. Our review addresses the current challenges in the diagnosis of these cognitive disorders and highlights existing gaps within this field.
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Affiliation(s)
- Christine Daniels
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Jon Rodríguez-Antigüedad
- Movement Disorders Unit, Sant Pau Hospital, Institut d'Investigacions Biomediques-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Elisabeth Jentschke
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Jaime Kulisevsky
- Movement Disorders Unit, Sant Pau Hospital, Institut d'Investigacions Biomediques-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Jens Volkmann
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
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Gerakios F, Yarnall AJ, Bate G, Wright L, Davis D, Stephan BCM, Robinson L, Brayne C, Stebbins G, Taylor JP, Burn DJ, Allan LM, Richardson SJ, Lawson RA. Delirium is more common and associated with worse outcomes in Parkinson's disease compared to older adult controls: results of two prospective longitudinal cohort studies. Age Ageing 2024; 53:afae046. [PMID: 38497236 PMCID: PMC10945294 DOI: 10.1093/ageing/afae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Inpatient prevalence of Parkinson's disease (PD) delirium varies widely across the literature. Delirium in general older populations is associated with adverse outcomes, such as increased mortality, dementia, and institutionalisation. However, to date there are no comprehensive prospective studies in PD delirium. This study aimed to determine delirium prevalence in hospitalised PD participants and the association with adverse outcomes, compared to a control group of older adults without PD. METHODS Participants were hospitalised inpatients from the 'Defining Delirium and its Impact in Parkinson's Disease' and the 'Delirium and Cognitive Impact in Dementia' studies comprising 121 PD participants and 199 older adult controls. Delirium was diagnosed prospectively using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Outcomes were determined by medical note reviews and/or home visits 12 months post hospital discharge. RESULTS Delirium was identified in 66.9% of PD participants compared to 38.7% of controls (p < 0.001). In PD participants only, delirium was associated with a significantly higher risk of mortality (HR = 3.3 (95% confidence interval [CI] = 1.3-8.6), p = 0.014) and institutionalisation (OR = 10.7 (95% CI = 2.1-54.6), p = 0.004) 12 months post-discharge, compared to older adult controls. However, delirium was associated with an increased risk of developing dementia 12 months post-discharge in both PD participants (OR = 6.1 (95% CI = 1.3-29.5), p = 0.024) and in controls (OR = 13.4 (95% CI = 2.5-72.6), p = 0.003). CONCLUSION Delirium is common in hospitalised PD patients, affecting two thirds of patients, and is associated with increased mortality, institutionalisation, and dementia. Further research is essential to understand how to accurately identify, prevent and manage delirium in people with PD who are in hospital.
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Affiliation(s)
- Florence Gerakios
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Gemma Bate
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Wright
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Blossom C M Stephan
- Institute of Mental Health, School of Medicine, Nottingham University, Nottingham, UK
- Dementia Centre of Excellence, EnAble Institute, Curtin University, Perth, Australia
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Carol Brayne
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Glenn Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - David J Burn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Louise M Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
| | - Sarah J Richardson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Rachael A Lawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
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Bai X, Zhang A, Zhou Q, Wang H. Causal relationships between delirium and Parkinson's disease: a bidirectional two-sample Mendelian randomization study. Eur J Med Res 2024; 29:111. [PMID: 38336737 PMCID: PMC10854158 DOI: 10.1186/s40001-024-01696-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Previous observational studies have suggested a notably elevated prevalence of delirium in individuals diagnosed with Parkinson's disease (PD), thereby implying a potential increased susceptibility to delirium among PD patients. However, it is imperative to acknowledge that observational studies inherently possess limitations, rendering it arduous to establish a definitive causal or reverse causal association between delirium and PD. METHODS To explore the relationship between delirium and PD, a bidirectional two-sample Mendelian randomization (MR) was conducted using summary statistics obtained from genome-wide association studies. The main analysis was performed using the inverse-variance weighted (IVW) method, with further analyses conducted using MR Egger, weighted median, and weighted mode to ensure accuracy of findings. Additionally, Cochran's Q statistics and MR Egger intercept were utilized to assess heterogeneity and horizontal pleiotropy, respectively. RESULTS According to the results obtained from the IVW model, no compelling evidence was found to support a potential causal association between delirium and PD (IVW: odds ratio [OR]: 0.996, 95% confidence interval CI 0.949-1.043, P = 0.845). Additionally, in the reverse direction, based on the results obtained from the IVW model, no significant evidence was found to support a causal association between PD and delirium (IVW: OR: 1.078, 95%CI 0.960-1.204, P = 0.225). A sensitivity analysis verified the reliability of the results. CONCLUSION According to the MR findings, a bidirectional causal relationship between delirium and PD is not observed. It is crucial to conduct further research in clinical practice to investigate the association between delirium and the risk of PD.
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Affiliation(s)
- Xiaoliang Bai
- Department of Pain Management, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Anna Zhang
- Department of Geriatrics, South Branch of The Second Hospital of Shandong University, Jinan, 250033, China
| | - Qingbo Zhou
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China.
| | - Hongli Wang
- Department of Pain Management, The Second Hospital of Shandong University, Jinan, 250033, China.
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Hewer C, Richfield E, Halton C, Alty J. Transdermal Rotigotine at End-of-Life for Parkinson's Disease: Association With Measures of Distress. J Pain Symptom Manage 2024; 67:e121-e128. [PMID: 37838081 DOI: 10.1016/j.jpainsymman.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND End-of-life (EOL) care for Parkinson's disease (PD) can be challenging when oral medications are no longer tolerated. MEASURES To assess EOL prescribing for people with PD (PWP), focusing on rotigotine dosing and proxy measures of distress: benzodiazepine and opioid use. INTERVENTION A retrospective audit of patient records from PWP who died between January 2019 and May 2022 at the Royal Hobart Hospital (RHH), Australia, was conducted. Data was systematically collated on demographics, symptoms, levodopa equivalent daily dose (LEDD) and rotigotine, oral morphine equivalent (OME) and benzodiazepine doses in the last 72 hours of life . OUTCOMES Pain (72%), respiratory secretions (66%) and agitation (66%) were the most documented EOL symptoms. 83% (n = 52) of PWP were eligible for rotigotine and, of those, 13% (n = 7) received the correct dose, 38% (n = 20) a lower dose, 12% (n = 6) a higher dose and 37% (n = 19) did not receive any. Rotigotine dose was positively associated with total (P = 0.016) and PRN (P = 0.037) benzodiazepine dose. LEDD was positively associated with total benzodiazepine (P = 0.018) and total OME dose (P = 0.046). Contraindicated dopamine antagonists were prescribed for 43% of PWP and administered in 31% of those cases. CONCLUSIONS Rotigotine dose and admission LEDD were both associated with proxy measures of distress in the last 72 hours of life. This suggests cautious use of rotigotine at EOL. LEDD may help identify patients at risk of distress. Rates of inappropriate prescribing and symptom prevalence were high, indicating a need for further staff education to optimize the care of PWP.
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Affiliation(s)
- Claire Hewer
- Pallitative Care Department (C.H., C.H.), Royal Hobart Hospital, Hobart, Tasmania, Australia; Palliative Care Department (C.H.), Christchurch Hospital, Christchurch, New Zealand.
| | - Edward Richfield
- North Bristol NHS Trust (E.R.), Southmead Hospital, Westbury-on-Trym, Bristol, UK; Honorary Lecturer (E.R.), University of Bristol, Bristol, UK
| | - Carmen Halton
- Pallitative Care Department (C.H., C.H.), Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jane Alty
- Wicking Dementia Research and Education Centre (J.A.), University of Tasmania, Hobart, Tasmania, Australia; Neurology Department (J.A.), Royal Hobart Hospital, Hobart, Tasmania, Australia
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Kadura S, Schneider RB. Moving beyond alerts: Electronic health record strategies to improve inpatient Parkinson's disease care. Parkinsonism Relat Disord 2023; 116:105819. [PMID: 37635057 DOI: 10.1016/j.parkreldis.2023.105819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Sullafa Kadura
- Department of Medicine, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Ruth B Schneider
- Department of Neurology, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA; Center for Health + Technology, University of Rochester, 265 Crittenden Blvd, Rochester, NY, 14642, USA.
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Cullinan RJ, Richardson SJ, Yarnall AJ, Burn DJ, Allan LM, Lawson RA. Documentation and diagnosis of delirium in Parkinson's disease. Acta Psychiatr Scand 2023; 147:527-535. [PMID: 35771186 PMCID: PMC10952625 DOI: 10.1111/acps.13470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/22/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the accuracy of documentation of the symptoms and diagnosis of delirium in medical notes of inpatients with Parkinson's disease (PD). METHODS The DETERMINE-PD pilot study assessed PD inpatients over 4-months. Delirium prevalence was classified prospectively using a standardized assessment at a single visit on the basis of Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) criteria. Incident delirium was diagnosed retrospectively using detailed clinical vignettes and validated consensus method. Inpatient medical notes and discharge summaries of those with delirium were reviewed for documentation of symptoms, diagnosis and follow-up. RESULTS Forty-four PD patients consented to take part in the study, accounting for 53 admissions. We identified 30 cases (56.6%) of delirium during the participants' stay in hospital. Of those with delirium identified by the research team, delirium symptoms were documented in the clinical notes of 72.3%; 37.9% had a delirium diagnosis documented. Older patients were more likely to have delirium (p = 0.027) and have this diagnosis documented (p = 0.034). Time from documentation of symptoms to diagnosis ranged from <24 h to 7 days (mean 1.6 ± 4.4 days). Hypoactive delirium was significantly less likely to have been identified and formally diagnosed (63% of not documented were hypoactive vs. 37% hyperactive, mixed or unclear, p = 0.016). Only 11.5% of discharge summaries included diagnosis of delirium. CONCLUSION Delirium in PD is common. Documentation of symptoms of delirium was common; however, fails to lead to a documentation of diagnosis in over half of admissions with delirium and was even less commonly communicated in the Primary Care discharge summaries. This highlights the need for increased education about delirium symptomatology and diagnosis in PD.
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Affiliation(s)
- Rachel J. Cullinan
- CNTW NHS TrustNewcastle upon TyneUK
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Sarah J. Richardson
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
- Faculty of Medical Sciences, NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastleUK
| | - Alison J. Yarnall
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
- Faculty of Medical Sciences, NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastleUK
- Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUK
| | - David J. Burn
- Faculty of Medical Sciences, Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Louise M. Allan
- Centre for Research in Ageing and Cognitive HealthUniversity of ExeterExeterUK
| | - Rachael A. Lawson
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
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Sousa-Fraguas MC, Rodríguez-Fuentes G, Conejo NM. Frailty and cognitive impairment in Parkinson’s disease: a systematic review. Neurol Sci 2022; 43:6693-6706. [PMID: 36056182 DOI: 10.1007/s10072-022-06347-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Frailty can lead to increased vulnerability in older people and patients with Parkinson's disease (pwPD) and worsen their health conditions. These patients can also develop cognitive function impairment. The objective is to analyze whether there is a relationship between frailty and cognitive impairment in pwPD, and to find out which instruments to use for its evaluation. METHODS Publications were searched in PubMed, Medline, Web of Science, Cinalh, Cochrane Library, Embase, Phycinfo, and Scopus. The results were measured with the instruments that are used to assess frailty and cognitive impairment, and analyze their relationship. RESULTS Two hundred seventy-one articles were identified, of which 12 met the inclusion criteria. All studies assessed frailty and cognitive function in pwPD. Five studies analyzed the relationship between frailty and cognitive impairment. The most used instruments were the Fried scale followed by the Clinical Frailty Scale (CFS) for frailty. Cognitive impairment was mostly evaluated with the Mini-Mental State Examination and the Montreal Cognitive Assessment. The prevalence data ranged from 20.2 to 51.5% with the Fried scale and from 35.6 to 83.9% with the CFS. Cognitive impairment was present in 15 to 45.2% of the pwPD. CONCLUSION Analysis of the included studies shows a relationship between frailty and cognitive impairment in pwPD. There was significant variability in the application of the scales used, which influences the prevalence data. More observational and experimental studies are needed to provide more evidence on this association and to determine which is the optimal tool to identify frailty in pwPD using multidimensional scales.
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Kim N, Kim TH, Oh JK, Lim J, Lee KU, Kim SW. Analysis of the Incidence and Risk Factors of Postoperative Delirium in Patients With Degenerative Cervical Myelopathy. Neurospine 2022; 19:323-333. [PMID: 35577342 PMCID: PMC9260543 DOI: 10.14245/ns.2142778.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Objective The purpose of this study is to analyze various risk factors that can cause postoperative delirium (POD) in degenerative cervical myelopathy (DCM) patients, which may affect normal recovery and outcomes after surgery, and to help deal with them in advance and to take a medical approach.
Methods A total of 148 patients aged 60 years or older who underwent laminoplasty or anterior cervical discectomy and fusion (ACDF) for DCM from 2008 to 2015 were included in this study. Incidence and multiple risk factors for development of POD were analyzed.
Results POD occurred in 24 patients (16.2%). Among the 148 patients, 78 received laminoplasty, of whom 19 patients (24%) experienced delirium; the other 70 patients underwent ACDF, of whom 5 patients (7.1%) experienced delirium. History of Parkinson disease (odds ratio [OR], 178.242; p = 0.015), potassium level (OR, 3.764; p = 0.031), and surgical approach of laminoplasty over ACDF (OR, 8.538; p = 0.008) were found to be significant risk factors in a multivariate analysis. Age (OR, 1.056; p = 0.04) and potassium level (OR, 3.217; p = 0.04) were significant risk factors in the laminoplasty group.
Conclusion The findings of this study suggest that the incidence and risk factors for POD may vary in patients with DCM. It is necessary to understand multiple factors that affect the development of POD.
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Affiliation(s)
- Namhoo Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Tae-Hwan Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Keun Oh
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jeongsup Lim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kang Uk Lee
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Seok Woo Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
- Corresponding Author Seok Woo Kim Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170beon-gil, Dongann-gu, Anyang 14068, Korea
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Lawson RA, Richardson SJ, Kershaw D, Davis D, Stephan BCM, Robinson L, Brayne C, Barnes L, Burn DJ, Yarnall AJ, Taylor JP, Parker S, Allan LM. Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson's Disease, Dementia, and Older Adults. J Parkinsons Dis 2022; 12:655-665. [PMID: 34842195 DOI: 10.3233/jpd-212849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal. OBJECTIVE To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson's disease (PD) and dementia. METHODS Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria. RESULTS On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS (AUC=0.90 and 0.84, respectively, p < 0.001 for both). CONCLUSION Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.
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Affiliation(s)
- Rachael A Lawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah J Richardson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Daisy Kershaw
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Blossom C M Stephan
- Institute of Mental Health, School of Medicine, Nottingham University, Nottingham, UK
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Carol Brayne
- Cambridge Public Health, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Linda Barnes
- Cambridge Public Health, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - David J Burn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Faculty of Medical Sciences, Newcastle University, UK
| | - Stuart Parker
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Louise M Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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Green S, Perrott SL, McCleary A, Sleeman I, Maple-Grødem J, Counsell CE, Macleod AD. First delirium episode in Parkinson's disease and parkinsonism: incidence, predictors, and outcomes. NPJ Parkinsons Dis 2021; 7:92. [PMID: 34635668 PMCID: PMC8505483 DOI: 10.1038/s41531-021-00234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 09/13/2021] [Indexed: 11/09/2022]
Abstract
To define the incidence, predictors and prognosis of the first hospital delirium episode in Parkinson’s disease (PD) and atypical parkinsonism (AP), we identified the first hospital episode of delirium after diagnosis in the Parkinsonism Incidence in North-East Scotland (PINE) study, a prospective community-based incidence cohort of parkinsonism, using chart-based criteria to define delirium. Of 296 patients (189=PD, 107=AP [dementia with Lewy bodies, progressive supranuclear palsy, multiple system atrophy, vascular parkinsonism]), 152 developed delirium (PD = 98, AP = 54). Incidence of first hospital delirium episode per 100 person years was 8.1 (95% confidence interval [CI] 6.6–9.9) in PD and 18.5 (95% CI 13.9–24.7) in AP. Independent predictors of delirium were atypical parkinsonism (Hazard ratio [HR] vs PD = 2.83 [95% CI 1.60–5.03], age in PD but not in AP (HR for 10-year increase 2.29 [95% CI 1.74–3.02]), baseline MMSE (HR = 0.94 [95% CI 0.89–0.99]), APOE ε4 in PD (HR 2.16 [95% CI 1.15–4.08]), and MAPT H1/H1 in PD (HR 2.08 [95% CI 1.08–4.00]). Hazards of dementia and death after delirium vs before delirium were increased (dementia: HR = 6.93 [95% CI 4.18–11.48] in parkinsonism; death: HR = 3.76 [95% CI 2.65–5.35] in PD, 1.59 [95% CI 1.04–2.42] in AP). Delirium is a common non-motor feature of PD and AP and is associated with increased hazards of dementia and mortality. Whether interventions for early identification and treatment improve outcomes requires investigation.
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Affiliation(s)
- Samantha Green
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Sarah L Perrott
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Isobel Sleeman
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jodi Maple-Grødem
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, Stavanger, Norway.,Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Carl E Counsell
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Angus D Macleod
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
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McMillan JM, Michalchuk Q, Goodarzi Z. Frailty in Parkinson's disease: A systematic review and meta-analysis. Clin Park Relat Disord 2021; 4:100095. [PMID: 34316672 PMCID: PMC8299963 DOI: 10.1016/j.prdoa.2021.100095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Frailty and Parkinson's disease (PD) are common conditions that increase with age. Independently, frailty and PD lead to increased morbidity and mortality for patients. Few studies report on frailty in patients with PD. We performed a systematic review and meta-analysis of the prevalence, associations and outcomes of frailty in persons with PD. METHODS We searched four electronic databases and grey literature from inception to May 19, 2020, for articles which reported the prevalence, associations and outcomes of frailty in persons with PD. RESULTS One-thousand and sixty-three citations were identified, of which 127 articles were reviewed. Thirty studies were included. Twenty-eight studies were observational and the settings varied including 25 community and 5 inpatient studies.The most common frailty screening measures were the frailty phenotype and clinical frailty scale. The prevalence of frailty in PD using the FP was 0.38 (0.24-0.55) with I2 = 92.6% (p < 0.01). Frailty was associated with recurrent falls, cognitive impairment, dementia, orthostatic hypotension, fatigue, hallucinations, nursing home placement, dependency in activities of daily living and in-patient mortality. PD disease duration, motor impairment, non-tremor dominant PD (postural instability/gait difficulty dominant phenotype) and total daily levodopa dose were associated with frailty. CONCLUSION Frailty is common in PD. There is no agreed upon tool for identifying frailty, however, the importance of its identification is apparent given the high prevalence and the association between frailty and adverse outcomes in persons with PD. Future studies are required to guide clinicians in how best to identify and manage frail patients with PD.
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Affiliation(s)
- Jacqueline M. McMillan
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | | | - Zahra Goodarzi
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Chuen VL, Chan ACH, Ma J, Alibhai SMH, Chau V. The frequency and quality of delirium documentation in discharge summaries. BMC Geriatr 2021; 21:307. [PMID: 33980170 PMCID: PMC8117503 DOI: 10.1186/s12877-021-02245-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. METHODS This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary. RESULTS We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). CONCLUSIONS The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.
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Affiliation(s)
- Victoria L Chuen
- Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.,Faculty of Medicine, McMaster University, Ontario, Hamilton, Canada
| | - Adrian C H Chan
- Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.,Faculty of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- Division of General Internal Medicine and Geriatrics, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Ontario, Toronto, Canada
| | - Vicky Chau
- Division of General Internal Medicine and Geriatrics, Department of Medicine, University Health Network, Toronto, Ontario, Canada. .,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Ontario, Toronto, Canada.
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Abstract
Patients with Parkinson's disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.
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Lawson RA, Richardson SJ, Yarnall AJ, Burn DJ, Allan LM. Identifying delirium in Parkinson disease: A pilot study. Int J Geriatr Psychiatry 2020; 35:547-552. [PMID: 31994774 PMCID: PMC7186820 DOI: 10.1002/gps.5270] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/21/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION People with Parkinson disease (PD) may be at increased risk of delirium and associated adverse outcomes. Delirium is an acute neuropsychiatric syndrome defined by confusion and inattention and is common in older adults. Previous studies may have underestimated the prevalence of delirium in PD because of overlapping symptoms, lack of awareness, and poorly defined criteria. We aimed to identify the prevalence and incidence of delirium in inpatients with PD. MEASUREMENTS Participants were inpatients with PD admitted over a 4-month period. Delirium prevalence was classified using a standardised assessment at a single visit on the basis of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) criteria. To capture remaining time in hospital, incident delirium was diagnosed using detailed clinical vignettes and a validated consensus method. RESULTS Forty-four PD patients consented to take part in the study, accounting for 53 admissions. Delirium prevalence was 34.0% (n = 18); reviewing participants over the duration of their hospital stay identified 30 (56.6%) incident delirium cases. The admitting team screened 24.5% for delirium, and delirium was documented in eight (14.8%) patients' medical notes. Patients with delirium were significantly older, had higher frailty scores, and had a longer hospital stay (P < .05 for all). CONCLUSIONS Delirium is common in PD inpatients at admission and incidence increases during hospital stay, but delirium is commonly missed. Our results highlight the importance of screening for delirium throughout patients' stay in hospital. Future studies should consider frequent evaluation over the duration of hospital stay to identify emergent delirium during the admission.
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Affiliation(s)
- Rachael A. Lawson
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Newcastle Institute for AgeingNewcastle UniversityNewcastle upon TyneUK
| | - Sarah J. Richardson
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Newcastle Institute for AgeingNewcastle UniversityNewcastle upon TyneUK
| | - Alison J. Yarnall
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Newcastle Institute for AgeingNewcastle UniversityNewcastle upon TyneUK,Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - David J. Burn
- Faculty of Medical ScienceNewcastle UniversityNewcastle upon TyneUK
| | - Louise M. Allan
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Institute of Health ResearchUniversity of ExeterExeterUK
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