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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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Hall AJ, Clement ND, MacLullich AMJ, White TO, Duckworth AD. Vaccination against COVID-19 reduced the mortality risk of COVID-positive hip fracture patients to baseline levels: the nationwide data-linked IMPACT Protect study. Osteoporos Int 2024; 35:353-363. [PMID: 37897507 DOI: 10.1007/s00198-023-06954-w] [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: 06/08/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023]
Abstract
This nationwide study used data-linked records to assess the effect of COVID-19 vaccination among hip fracture patients. Vaccination was associated with a lower risk of contracting COVID-19 and, among COVID-positive patients, it reduced the mortality risk to that of COVID-negative patients. This provides essential data for future communicable disease outbreaks. PURPOSE COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. METHODS This nationwide cohort study included all patients aged > 50 years that sustained a hip fracture in Scotland between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to government-managed population level records of COVID-19 vaccination and laboratory testing. RESULTS There were 13,345 patients with a median age of 82.0 years (IQR 74.0-88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34-0.48, p < 0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12-3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk of death (OR 0.93, CI 0.53-1.60, p = 0.783). CONCLUSION Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents data that will be valid in the management of future outbreaks.
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Affiliation(s)
- Andrew J Hall
- Golden Jubilee Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK.
- School of Medicine, University of St Andrews, North Haugh, St Andrews, KY16 9TF, UK.
- National Treatment Centre - Fife Orthopaedics, NHS Fife, Kirkcaldy, UK.
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.
| | - N D Clement
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - A M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing & Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - T O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - A D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
- Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK
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Penfold RS, Squires C, Angus A, Shenkin SD, Ibitoye T, Tieges Z, Neufeld KJ, Avelino-Silva TJ, Davis D, Anand A, Duckworth AD, Guthrie B, MacLullich AMJ. Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review. J Am Geriatr Soc 2024. [PMID: 38241503 DOI: 10.1111/jgs.18751] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Multiple short delirium detection tools have been validated in research studies and implemented in routine care, but there has been little study of these tools in real-world conditions. This systematic review synthesized literature reporting completion rates and/or delirium positive score rates of detection tools in large clinical populations in general hospital settings. METHODS PROSPERO (CRD42022385166). Medline, Embase, PsycINFO, CINAHL, and gray literature were searched from 1980 to December 31, 2022. Included studies or audit reports used a validated delirium detection tool performed directly with the patient as part of routine care in large clinical populations (n ≥ 1000) within a general acute hospital setting. Narrative synthesis was performed. RESULTS Twenty-two research studies and four audit reports were included. Tools used alone or in combination were the Confusion Assessment Method (CAM), 4 'A's Test (4AT), Delirium Observation Screening Scale (DOSS), Brief CAM (bCAM), Nursing Delirium Screening Scale (NuDESC), and Intensive Care Delirium Screening Checklist (ICDSC). Populations and settings varied and tools were used at different stages and frequencies in the patient journey, including on admission only; inpatient, daily or more frequently; on admission and as inpatient; inpatient post-operatively. Tool completion rates ranged from 19% to 100%. Admission positive score rates ranged from: CAM 8%-51%; 4AT 13%-20%. Inpatient positive score rates ranged from: CAM 2%-20%, DOSS 6%-42%, and NuDESC 5-13%. Postoperative positive score rates were 21% and 28% (4AT). All but two studies had moderate-high risk of bias. CONCLUSIONS This systematic review of delirium detection tool implementation in large acute patient populations found clinically important variability in tool completion rates, and in delirium positive score rates relative to expected delirium prevalence. This study highlights a need for greater reporting and analysis of relevant healthcare systems data. This is vital to advance understanding of effective delirium detection in routine care.
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Affiliation(s)
- Rose S Penfold
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Susan D Shenkin
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Karin J Neufeld
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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Ottens TH, Hermes C, Page V, Oldham M, Arora R, Bienvenu OJ, van den Boogaard M, Caplan G, Devlin JW, Friedrich ME, van Gool WA, Hanison J, Hansen HC, Inouye SK, Kamholz B, Kotfis K, Maas MB, MacLullich AMJ, Marcantonio ER, Morandi A, van Munster BC, Müller-Werdan U, Negro A, Neufeld KJ, Nydahl P, Oh ES, Pandharipande P, Radtke FM, Raedt SD, Rosenthal LJ, Sanders R, Spies CD, Vardy ERLC, Wijdicks EF, Slooter AJC. The Delphi Delirium Management Algorithms. A practical tool for clinicians, the result of a modified Delphi expert consensus approach. Delirium (Bielef) 2024; 2024:10.56392/001c.90652. [PMID: 38348284 PMCID: PMC10861222 DOI: 10.56392/001c.90652] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Delirium is common in hospitalised patients, and there is currently no specific treatment. Identifying and treating underlying somatic causes of delirium is the first priority once delirium is diagnosed. Several international guidelines provide clinicians with an evidence-based approach to screening, diagnosis and symptomatic treatment. However, current guidelines do not offer a structured approach to identification of underlying causes. A panel of 37 internationally recognised delirium experts from diverse medical backgrounds worked together in a modified Delphi approach via an online platform. Consensus was reached after five voting rounds. The final product of this project is a set of three delirium management algorithms (the Delirium Delphi Algorithms), one for ward patients, one for patients after cardiac surgery and one for patients in the intensive care unit.
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Affiliation(s)
- Thomas H Ottens
- Intensive Care Unit, Haga Teaching Hospital
- Intensive Care Medicine, University Medical Center Utrecht
| | - Carsten Hermes
- Intensive Care Unit, Haga Teaching Hospital
- Intensive Care Medicine, University Medical Center Utrecht
- Critical Care, Watford General Hospital
- School of Medicine and Dentisty, University of Rochester
- Psychiatry, University of Rochester Medical Center
- Harrington Heart and Vascular Institute, University Hospitals of Cleveland
- Division of Cardiac Surgery, Case Western Reserve University
- School of Medicine, Johns Hopkins University
- Intensive Care Medicine, Radboud University Nijmegen Medical Centre
- School of Clinical Medicine, UNSW Sydney
- Geriatric Medicine, Prince of Wales Hospital
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital
- Bouve College of Health Sciences, Northeastern University
- Abteilung für Sozialpsychiatrie, Hollabrunn, Austria
- Neurology, Amsterdam University Medical Centers
- Anaesthesia, Manchester University NHS Foundation Trust
- Neurology, Friedrich-Ebert-Krankenhaus
- Beth Israel Deaconess Medical Center
- Harvard Medical School
- Anaesthesia, Intensive Care and Acute Poisoning, Pomeranian Medical University
- Neurology, Northwestern Medicine
- Feinberg School of Medicine, Northwestern University
- Usher Institute Ageing and Health, University of Edinburgh
- Geriatric Medicine, Beth Israel Deaconess Medical Center
- Rehabilitation, Fondazione Teresa Camplani
- Geriatric Medicine, University Medical Center Groningen
- Geriatrics, Charité - Universitätsmedizin Berlin
- Intensive Care Unit, IRCCS Ospedale San Raffaele
- Faculty of Health Sciences, McMaster University
- Intensive Care Unit, University Hospital Schleswig-Holstein
- Geriatric Medicine and Gerontology, Johns Hopkins Medicine
- Anesthesiology and Critical Care Medicine, Vanderbilt University Medical Center
- University of Southern Denmark
- Anaesthesia and Intensive Care, Nykøbing F. Hospital
- Vrije Universiteit Brussel
- Neurology, Universitair Ziekenhuis Brussel
- Psychiatry, Northwestern Memorial Hospital
- Faculty of Medicine and Health, University of Sydney
- Anaesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin
- Northern Care Alliance NHS Foundation Trust, Oldham, United Kingdom
- University of Manchester, Manchester, United Kingdom
- Neurology, Mayo Clinic
- Psychiatry, University Medical Center Utrecht
- Brain Center, University Medical Center Utrecht
| | | | - Mark Oldham
- School of Medicine and Dentisty, University of Rochester
- Psychiatry, University of Rochester Medical Center
| | - Rakesh Arora
- Harrington Heart and Vascular Institute, University Hospitals of Cleveland
- Division of Cardiac Surgery, Case Western Reserve University
| | | | | | - Gideon Caplan
- School of Clinical Medicine, UNSW Sydney
- Geriatric Medicine, Prince of Wales Hospital
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital
- Bouve College of Health Sciences, Northeastern University
| | | | | | - James Hanison
- Anaesthesia, Manchester University NHS Foundation Trust
| | | | | | - Barbara Kamholz
- Intensive Care Unit, Haga Teaching Hospital
- Intensive Care Medicine, University Medical Center Utrecht
- Critical Care, Watford General Hospital
- School of Medicine and Dentisty, University of Rochester
- Psychiatry, University of Rochester Medical Center
- Harrington Heart and Vascular Institute, University Hospitals of Cleveland
- Division of Cardiac Surgery, Case Western Reserve University
- School of Medicine, Johns Hopkins University
- Intensive Care Medicine, Radboud University Nijmegen Medical Centre
- School of Clinical Medicine, UNSW Sydney
- Geriatric Medicine, Prince of Wales Hospital
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital
- Bouve College of Health Sciences, Northeastern University
- Abteilung für Sozialpsychiatrie, Hollabrunn, Austria
- Neurology, Amsterdam University Medical Centers
- Anaesthesia, Manchester University NHS Foundation Trust
- Neurology, Friedrich-Ebert-Krankenhaus
- Beth Israel Deaconess Medical Center
- Harvard Medical School
- Anaesthesia, Intensive Care and Acute Poisoning, Pomeranian Medical University
- Neurology, Northwestern Medicine
- Feinberg School of Medicine, Northwestern University
- Usher Institute Ageing and Health, University of Edinburgh
- Geriatric Medicine, Beth Israel Deaconess Medical Center
- Rehabilitation, Fondazione Teresa Camplani
- Geriatric Medicine, University Medical Center Groningen
- Geriatrics, Charité - Universitätsmedizin Berlin
- Intensive Care Unit, IRCCS Ospedale San Raffaele
- Faculty of Health Sciences, McMaster University
- Intensive Care Unit, University Hospital Schleswig-Holstein
- Geriatric Medicine and Gerontology, Johns Hopkins Medicine
- Anesthesiology and Critical Care Medicine, Vanderbilt University Medical Center
- University of Southern Denmark
- Anaesthesia and Intensive Care, Nykøbing F. Hospital
- Vrije Universiteit Brussel
- Neurology, Universitair Ziekenhuis Brussel
- Psychiatry, Northwestern Memorial Hospital
- Faculty of Medicine and Health, University of Sydney
- Anaesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin
- Northern Care Alliance NHS Foundation Trust, Oldham, United Kingdom
- University of Manchester, Manchester, United Kingdom
- Neurology, Mayo Clinic
- Psychiatry, University Medical Center Utrecht
- Brain Center, University Medical Center Utrecht
| | - Katarzyna Kotfis
- Anaesthesia, Intensive Care and Acute Poisoning, Pomeranian Medical University
| | - Matthew B Maas
- Neurology, Northwestern Medicine
- Feinberg School of Medicine, Northwestern University
| | | | | | | | | | | | | | | | - Peter Nydahl
- Intensive Care Unit, University Hospital Schleswig-Holstein
| | - Esther S Oh
- Geriatric Medicine and Gerontology, Johns Hopkins Medicine
| | | | - Finn M Radtke
- University of Southern Denmark
- Anaesthesia and Intensive Care, Nykøbing F. Hospital
| | - Sylvie De Raedt
- Vrije Universiteit Brussel
- Neurology, Universitair Ziekenhuis Brussel
| | - Lisa J Rosenthal
- Feinberg School of Medicine, Northwestern University
- Psychiatry, Northwestern Memorial Hospital
| | | | - Claudia D Spies
- Anaesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin
| | - Emma R L C Vardy
- Northern Care Alliance NHS Foundation Trust, Oldham, United Kingdom
- University of Manchester, Manchester, United Kingdom
| | | | - Arjen J C Slooter
- Intensive Care Medicine, University Medical Center Utrecht
- Psychiatry, University Medical Center Utrecht
- Brain Center, University Medical Center Utrecht
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Farrow L, Clement ND, Mitchell L, Sattar M, MacLullich AMJ. Erratum. Bone Joint J 2024; 106-B:107. [PMID: 38160691 DOI: 10.1302/0301-620x.106b1.bjj-2023-00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
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Farrow L, Clement ND, Mitchell L, Sattar M, MacLullich AMJ. Does the time to surgery influence outcomes for patients with a hip fracture who undergo total hip arthroplasty? Bone Joint J 2023; 105-B:1201-1205. [PMID: 37907072 DOI: 10.1302/0301-620x.105b11.bjj-2023-0597.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Aims Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = 'acute group' vs > 36 hours = 'delayed' group). Those with delays due to being "medically unfit" were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Grampian Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Nick D Clement
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lewis Mitchell
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Mariam Sattar
- Grampian Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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7
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Allan L, O'Connell A, Raghuraman S, Bingham A, Laverick A, Chandler K, Connors J, Jones B, Um J, Morgan-Trimmer S, Harwood R, Goodwin VA, Ukoumunne OC, Hawton A, Anderson R, Jackson T, MacLullich AMJ, Richardson S, Davis D, Collier L, Strain WD, Litherland R, Glasby J, Clare L. A rehabilitation intervention to improve recovery after an episode of delirium in adults over 65 years (RecoverED): study protocol for a multi-centre, single-arm feasibility study. Pilot Feasibility Stud 2023; 9:162. [PMID: 37715277 PMCID: PMC10503099 DOI: 10.1186/s40814-023-01387-y] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Delirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible. METHODS The study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants' own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals. DISCUSSION Findings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care. TRIAL REGISTRATION The feasibility study was registered: ISRCTN15676570.
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Affiliation(s)
- Louise Allan
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Abby O'Connell
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Shruti Raghuraman
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alison Bingham
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Abigail Laverick
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Kirstie Chandler
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - James Connors
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Benjamin Jones
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jinpil Um
- University of Exeter Medical School, University of Exeter, Exeter, UK.
| | | | - Rowan Harwood
- School of Health Sciences, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Victoria A Goodwin
- Department of Ageing and Rehabilitation, University of Exeter, Exeter, UK
| | - Obioha C Ukoumunne
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter, EX1 2LU, UK
| | - Annie Hawton
- Health Economics Group, University of Exeter Medical School, Exeter, UK
| | - Rob Anderson
- Exeter HS&DR Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Thomas Jackson
- Institute of Inflammation and Ageing, University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WD, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing and Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah Richardson
- AGE Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Lesley Collier
- Faculty of Health and Well-Being, University of Winchester, Winchester, SO22 4NR, UK
| | - William David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5AX, UK
| | | | - Jon Glasby
- School of Social Policy, University of Birmingham, Birmingham, UK
| | - Linda Clare
- University of Exeter Medical School, University of Exeter, Exeter, UK
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8
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Hall AJ, Clement ND, Kay RS, Penfold RS, MacLullich AMJ, White TO, Duckworth AD. COVID-19 is associated with increased care needs and a decreased likelihood of returning home following a hip fracture: The IMPACT frailty study. Musculoskeletal Care 2023; 21:786-796. [PMID: 36905636 DOI: 10.1002/msc.1753] [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] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/19/2023] [Accepted: 02/22/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE The primary aim was to evaluate the impact of COVID-19 on frailty in patients surviving a hip fracture. Secondary aims were to assess impact of COVID-19 on (i) length of stay (LoS) and post-discharge care needs, (ii) readmissions, and (iii) likelihood of returning to own home. METHODS This propensity score-matched case-control study was conducted in a single centre between 01/03/20-30/11/21. A 'COVID-positive' group of 68 patients was matched to 141 'COVID-negative' patients. 'Index' and 'current' Clinical Frailty Scale (CFS) scores were assigned for frailty at admission and at follow-up. Data were extracted from validated records and included: demographics, injury factors, COVID-19 status, delirium status, discharge destination, and readmissions. For subgroup analysis controlling for vaccination availability, the periods 1 March 2020-30 November 2020 and 1 February 2021-30 November 2021 were considered pre-/post-vaccine periods. RESULTS Median age was 83.0 years, 155/209 (74.2%) were female and median follow-up was 479 days (interquartile range [IQR] 311). There was an equivalent median increase in CFS in both groups (+1.00 [IQR 1.00-2.00, p = 0.472]). However, adjusted analysis demonstrated COVID-19 was independently associated with a greater magnitude change (Beta coefficient [β] 0.27, 95% confidence interval [95% CI] 0.00-0.54, p = 0.05). COVID-19 in the post-vaccine availability period was associated with a smaller increase versus pre-vaccine (β -0.64, 95% CI -1.20 to -0.09, p = 0.023). COVID-19 was independently associated with increased acute LoS (β 4.40, 95% CI 0.22-8.58, p = 0.039), total LoS (β 32.87, 95% CI 21.42-44.33, p < 0.001), readmissions (β 0.71, 95% CI 0.04-1.38, p = 0.039), and a four-fold increased likelihood of pre-fracture home-dwelling patients failing to return home (odds ratio 4.52, 95% CI 2.08-10.34, p < 0.001). CONCLUSIONS Hip fracture patients that survived a COVID-19 infection had increased frailty, longer LoS, more readmissions, and higher care needs. The health and social care burden is likely to be higher than prior to the COVID-19 pandemic. These findings should inform prognostication, discharge-planning, and service design to meet the needs of these patients.
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Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Robert S Kay
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rose S Penfold
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing and Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing and Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
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Johansen A, Sahota O, Dockery F, Black AJ, MacLullich AMJ, Javaid MK, Ahern E, Gregson CL. Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture. Age Ageing 2023; 52:afad172. [PMID: 37776543 PMCID: PMC10542103 DOI: 10.1093/ageing/afad172] [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: 04/13/2023] [Indexed: 10/02/2023] Open
Abstract
Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.
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Affiliation(s)
- Antony Johansen
- University Hospital of Wales and College of Medicine, Cardiff University, Cardiff CF14 4XW, UK
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
| | - Opinder Sahota
- Department of Health Care of Older People, Nottingham University Hospital, Nottingham NG7 2UH, UK
| | | | - Alison J Black
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - Alasdair M J MacLullich
- Ageing and Health Research Group, University of Edinburgh, Edinburgh EH9 3EG, UK
- Scottish Hip Fracture Audit (SHFA), Edinburgh, UK
| | - M Kassim Javaid
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford OX3 7HE, UK
| | - Emer Ahern
- Cork University Hospital and University College Cork, Cork, Ireland
- Health Service Executive, Dublin 8D08 W2A8, Ireland
- Irish Hip Fracture Database (IHFD), National Office of Clinical Audit, Dublin 2, D02 VN51, Ireland
| | - Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK
- Older Persons Unit, Royal United Hospital NHS Trust, Combe Park, Bath BA1 3NG, UK
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10
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Clement ND, Penfold RS, Duffy A, Murthy K, MacLullich AMJ, Duckworth AD. Completion of the Emergency Department "Big 6" in Patients with an Acute Hip Fracture Is Associated with a Lower Mortality Risk and Shorter Length of Hospital Stay. J Clin Med 2023; 12:5559. [PMID: 37685625 PMCID: PMC10488202 DOI: 10.3390/jcm12175559] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
The aims of this study were to assess whether completion of the emergency department (ED) Big 6 interventions (provision of pain relief, screening for delirium, early warning score (EWS) system, full blood investigation and electrocardiogram, intravenous fluids therapy, and pressure area care) in those presenting with an acute hip fracture were associated with mortality risk and length of acute hospital stay. A retrospective cohort study was undertaken. All patients aged ≥50 years that were admitted with a hip fracture via the ED at a single centre during a 42-month period were included. A total of 3613 patients (mean age 80.9; 71% female) were included. The mean follow up was 607 (range 240 to 1542) days. A total of 1180 (32.7%) patients had all six components completed. Pain relief (90.8%) was the most frequently completed component and pressure area assessment (57.6%) was the least. Completion of each of the individual Big 6 components, except for pressure areas assessment, were associated with a significantly (p ≤ 0.041) lower mortality risk at the 90-days, one-year and final follow-up. The completion of all components of the Big 6 was associated with a significantly (2.4 hours, p = 0.002) shorter time to theatre. Increasing number of Big 6 components completed were independently associated with a lower mortality risk: when all six were completed, the hazard ratio was 0.64 (95% CI 0.52 to 0.78, p < 0.001). Completion of an increasing number of Big 6 components was independently associated with shorter length of hospital stay and completion of all six was associated with a 2.3 (95% CI 0.9 to 3.8)-day shorter acute stay. The findings provide an evidence base to support the ongoing use of the Big 6 in the ED.
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Affiliation(s)
- Nick D. Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK;
| | - Rose S. Penfold
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH25 9RG, UK; (R.S.P.); (A.M.J.M.)
| | - Andrew Duffy
- Lothian Analytical Services, NHS Lothian, Edinburgh EH4 2XU, UK;
| | - Krishna Murthy
- Department of Emergency Medicine, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, UK;
| | - Alasdair M. J. MacLullich
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH25 9RG, UK; (R.S.P.); (A.M.J.M.)
| | - Andrew D. Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK;
- Department of Orthopaedics and Usher Institute, University of Edinburgh, Little France, Edinburgh EH16 4SA, UK
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11
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Ibitoye T, Jackson TA, Davis D, MacLullich AMJ. Trends in delirium coding rates in older hospital inpatients in England and Scotland: full population data comprising 7.7M patients per year show substantial increases between 2012 and 2020. Delirium Commun 2023; 2023:84051. [PMID: 37654785 PMCID: PMC7614999 DOI: 10.56392/001c.84051] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background Little information is available on change in delirium coding rates over time in major healthcare systems. We examined trends in delirium discharge coding rates in older patients in hospital admissions to the National Health Service (NHS) in England and Scotland between 2012 and 2020. Methods Hospital administrative coding data were sourced from NHS Digital England and Public Health Scotland. We examined rates of delirium (F05 from ICD-10) in patients aged ≥70 years in 5 year and ≥90 age bands. Results There were approximately 7,000,000 discharges/year in England and 700,000/year in Scotland. Substantially increased delirium coding was observed for all age bands between 2012/2013 and 2019/2020 (p<0.001, Mann Kendall's tau). In the ≥90 age band, there was a 4-fold increase between 2012 and 2020. Conclusion Delirium coding rates have shown large increases in the NHS in England and Scotland, likely reflecting several factors including policy initiatives, detection tool implementation and education.
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Affiliation(s)
- Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, The University of Edinburgh
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh
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12
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Penfold RS, Hall AJ, Anand A, Clement ND, Duckworth AD, MacLullich AMJ. Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services. Bone Jt Open 2023; 4:447-456. [PMID: 37326476 DOI: 10.1302/2633-1462.46.bjo-2023-0045.r1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Aims Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A's Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care.
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Affiliation(s)
- Rose S Penfold
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Hip Fracture Audit, Edinburgh, UK
| | - Andrew J Hall
- Scottish Hip Fracture Audit, Edinburgh, UK
- Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- NHS Lothian, Edinburgh, UK
| | - Nick D Clement
- Scottish Hip Fracture Audit, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Hip Fracture Audit, Edinburgh, UK
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13
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McCartney H, Noble E, MacLullich AMJ, Davis DHJ, Evans J, Shenkin SD, Muniz-Terrera G, Sandeman D, Tieges Z. A systematic review of studies reporting on neuropsychological and functional domains used for assessment of recovery from delirium in acute hospital patients. Int J Geriatr Psychiatry 2023; 38:e5943. [PMID: 37294207 DOI: 10.1002/gps.5943] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Assessing for recovery in delirium is essential in guiding ongoing investigation and treatment. Yet, there is little scrutiny and no research or clinical consensus on how recovery should be measured. We reviewed studies which used tests of neuropsychological domains and functional ability to track recovery of delirium longitudinally in acute hospital settings. METHODS/DESIGN We systematically searched databases (MEDLINE, PsycInfo, CINAHL, Embase, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials), from inception to October 14th , 2022. Inclusion criteria were: adult acute hospital patients (≥18 years) diagnosed with delirium by a validated tool; 1+ repeat assessment using an assessment tool measuring domains of delirium/functional recovery ≤7 days from baseline. Two reviewers independently screened articles, performed data extraction, and assessed risk of bias. A narrative data synthesis was completed. RESULTS From 6533 screened citations, we included 39 papers (reporting 32 studies), with 2370 participants with delirium. Studies reported 21 tools with an average of four repeat assessments including baseline (range 2-10 assessments within ≤7 days), measuring 15 specific domains. General cognition, functional ability, arousal, attention and psychotic features were most commonly assessed for longitudinal change. Risk of bias was moderate to high for most studies. CONCLUSIONS There was no standard approach for tracking change in specific domains of delirium. The methodological heterogeneity of studies was too high to draw firm conclusions on the effectiveness of assessment tools to measure delirium recovery. This highlights the need for standardised methods for assessing recovery from delirium.
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Affiliation(s)
- Haruno McCartney
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Erin Noble
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Jonathan Evans
- School of Health and Wellbeing, University of Glasgow, Scotland, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Scotland, UK
| | - Graciela Muniz-Terrera
- Edinburgh Dementia Prevention and Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
- Department of Social Medicine, Ohio University, Athens, Ohio, USA
| | - Daisy Sandeman
- School of Health in Social Science, University of Edinburgh, Scotland, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
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14
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Ditzel FL, Slooter AJC, van den Boogaard M, Boonstra M, van Nesselrooij TA, Kromkamp M, Pop-Purceleanu M, Rood PJT, Osse RJ, Chan CK, MacLullich AMJ, Tieges Z, Neufeld KJ, Hut SCA. The Delirium Interview as a new reference standard in studies on delirium assessment tools. J Am Geriatr Soc 2023; 71:1923-1930. [PMID: 36807119 DOI: 10.1111/jgs.18263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/01/2023] [Accepted: 01/07/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports. METHODS We tested the diagnostic accuracy of our standardized Delirium Interview by comparing delirium assessments of the reported results with live assessments. Our reference, the live assessment, was performed by two delirium experts and one well-trained researcher who registered the results. Their delirium assessment was compared to the majority vote of three other independent delirium experts who judged the rapportage of the Delirium Interview. Our total pool consisted of 13 delirium experts with an average of 13 ± 8 years of experience. RESULTS We included 98 patients (62% male, mean age 69 ± 12 years), of whom 56 (57%) intensive care units (ICUs) patients, 22 (39%) patients with a Richmond Agitation Sedation Scale (RASS) < 0 and 26 (27%) non-verbal assessments. The overall prevalence of delirium was 28%. The Delirium Interview had a sensitivity of 89% (95% confidence interval [CI]: 71%-98%) and specificity of 82% (95% CI: 71%-90%), compared to the diagnosis of an independent panel of two delirium experts and one researcher who examined the patients themselves. Negative and positive predictive values were 95% (95% CI: 86%-0.99%), respectively, 66% (95% CI: 49%-80%). Stratification into ICU and non-ICU patients yielded similar results. CONCLUSION The Delirium Interview is a feasible reference method for large study cohorts evaluating delirium assessment tools since experts could assess delirium with high accuracy without seeing the patient at the bedside.
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Affiliation(s)
- Fienke L Ditzel
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michel Boonstra
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Timotheus A van Nesselrooij
- Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marjan Kromkamp
- Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Monica Pop-Purceleanu
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul J T Rood
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
- School of Health Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Robert Jan Osse
- Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Carol K Chan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Suzanne C A Hut
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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15
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Tsui A, Yeo N, Searle SD, Bowden H, Hoffmann K, Hornby J, Goslett A, Weston-Clarke M, Lanham D, Hogan P, Seeley A, Rawle M, Chaturvedi N, Sampson EL, Rockwood K, Cunningham C, Ely EW, Richardson SJ, Brayne C, Terrera GM, Tieges Z, MacLullich AMJ, Davis D. Extremes of baseline cognitive function determine the severity of delirium: a population study. Brain 2023; 146:2132-2141. [PMID: 36856697 PMCID: PMC10151184 DOI: 10.1093/brain/awad062] [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: 01/31/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 03/02/2023] Open
Abstract
Although delirium is a significant clinical and public health problem, little is understood about how specific vulnerabilities underlie the severity of its presentation. Our objective was to quantify the relationship between baseline cognition and subsequent delirium severity. We prospectively investigated a population-representative sample of 1510 individuals aged ≥70 years, of whom 209 (13.6%) were hospitalized across 371 episodes (1999 person-days assessment). Baseline cognitive function was assessed using the modified Telephone Interview for Cognitive Status, supplemented by verbal fluency measures. We estimated the relationship between baseline cognition and delirium severity [Memorial Delirium Assessment Scale (MDAS)] and abnormal arousal (Observational Scale of Level of Arousal), adjusted by age, sex, frailty and illness severity. We conducted further analyses examining presentations to specific hospital settings and common precipitating aetiologies. The median time from baseline cognitive assessment to admission was 289 days (interquartile range 130 to 47 days). In admitted patients, delirium was present on at least 1 day in 45% of admission episodes. The average number of days with delirium (consecutively positive assessments) was 3.9 days. Elective admissions accounted for 88 bed days (4.4%). In emergency (but not elective) admissions, we found a non-linear U-shaped relationship between baseline global cognition and delirium severity using restricted cubic splines. Participants with baseline cognition 2 standard deviations below average (z-score = -2) had a mean MDAS score of 14 points (95% CI 10 to 19). Similarly, those with baseline cognition z-score = + 2 had a mean MDAS score of 7.9 points (95% CI 4.9 to 11). Individuals with average baseline cognition had the lowest MDAS scores. The association between baseline cognition and abnormal arousal followed a comparable pattern. C-reactive protein ≥20 mg/l and serum sodium <125 mM/l were associated with more severe delirium. Baseline cognition is a critical determinant of the severity of delirium and associated changes in arousal. Emergency admissions with lowest and highest baseline cognition who develop delirium should receive enhanced clinical attention.
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Affiliation(s)
- Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Natalie Yeo
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Samuel D Searle
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS B3H 2E1, Canada
| | - Helen Bowden
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Katrin Hoffmann
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Joanne Hornby
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Arley Goslett
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | | | - David Lanham
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Patrick Hogan
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Anna Seeley
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Nuffield Department of Primary Care, University of Oxford, Oxford, OX2 6GG, UK
| | - Mark Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Nish Chaturvedi
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | | | - Kenneth Rockwood
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS B3H 2E1, Canada
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute, Dublin 2, Republic of Ireland
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah J Richardson
- AGE Research Group, Translational and Clinical Research Institute, Newcastle University, UK
| | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, UK
- SMART Technology Centre, Glasgow Caledonian University, Glasgow, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
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16
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Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [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: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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17
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MacLullich AMJ, Hosie A, Tieges Z, Davis DHJ. Three key areas in progressing delirium practice and knowledge: recognition and relief of distress, new directions in delirium epidemiology and developing better research assessments. Age Ageing 2022; 51:afac271. [PMID: 36441120 PMCID: PMC9704028 DOI: 10.1093/ageing/afac271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/21/2022] [Indexed: 11/29/2022] Open
Abstract
Delirium presents formidable challenges: it affects one in four of older hospitalised adults, greatly elevates the risk of multiple short- and long-term complications including dementia and causes significant distress. Delirium care remains generally poor. Yet, there are clear grounds for optimism; the last decade has seen impactful policy advances and a tripling of research output. Here, we highlight three linked areas which have strong potential to transform delirium practice and knowledge in the near term. Delirium-related distress is strikingly underrepresented in practice guidance and research. Proactive recognition combined with effective clinical responses based on good communication provides a critical and largely untapped opportunity to improve care. Delirium epidemiology research is well positioned to produce novel insights through advanced prospective designs in populations such as emergency medical patients with detailed pre-, intra- and post-delirium assessments allied with fluid, imaging and other biomarkers. Research-grade assessment of delirium currently involves a chaotic array of tools, methods and diagnostic algorithms. Areas for development: expand and analytically distinguish the range of features assessed (including distress), optimise feature assessment including use of validated neuropsychological tests where possible, produce standardised algorithms which articulate explicit pathways from features to diagnosis, and create new fine-grained approaches to the measurement of severity. Delirium practice and knowledge show accelerating growth. This is encouraging but much of the necessary progress is still to come. Innovation in these three highlighted areas, as well as many others, will open up exciting possibilities in enhancing the care of patients with this common and often devastating condition.
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Affiliation(s)
- Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Annmarie Hosie
- School of Nursing and Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network Sydney, Darlinghurst, NSW, Australia
- IMPACCT – Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Ultimo, NSW, Australia
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
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18
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Farrow L, Brasnic L, Martin C, Ward K, Adam K, Hall AJ, Clement ND, MacLullich AMJ. A nationwide study of blood transfusion in hip fracture patients. Bone Joint J 2022; 104-B:1266-1272. [DOI: 10.1302/0301-620x.104b11.bjj-2022-0450.r1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
- Grampian Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Lorena Brasnic
- Institute of Applied Health Sciences, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Caroline Martin
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Kirsty Ward
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Karen Adam
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Andrew J. Hall
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - Nick D. Clement
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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19
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Anand A, Soon RA, Ho ZX, Shenkin SD, MacLullich AMJ, Mills NL. Automated electronic health record frailty assessment for older cardiac patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2790] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Frailty is an established risk factor for poorer outcomes in older hospitalised patients, but most measures require additional clinical review. Such formal frailty assessments are rarely undertaken in acute cardiac patients. However, routine electronic health records increasingly record health and functional deficits that together may represent the frailty phenotype.
Purpose
To report the outcomes of acute cardiac patients in relation to an automated frailty measurement, derived from routine electronic health records.
Methods
This retrospective observational cohort study included consecutive patients aged ≥70 years old who were managed under the specialist care of a consultant cardiologist between April 2016 and August 2020 in three acute hospitals across Edinburgh, Scotland. The Continuous Dynamic Evaluation of Frailty (CODE-f) score was derived from national Care Assurance Standards data that is mandated for older patient hospital care. This includes measures of cognition, functional dependence, nutrition, falls risk, continence, skin health and mobility. A total of 31 data points were included in an unweighted frailty index with scores ranging between 0 (no markers present) and 1 (all present). No CODE-f score was generated if insufficient data was completed (>33% missing). The primary outcome was mortality at 1 year after hospital admission. Secondary outcomes were length of first (index) hospital stay and the number of days spent alive and out of hospital in the year after index admission (“home time”). In a nested cohort study of 318 consecutive patients at one hospital site, the Clinical Frailty Scale (CFS) was determined from manual electronic case note review for comparison with CODE-f scores.
Results
A total of 2,406 patients were included (mean age 79±6 years, 60% male). The CODE-f could be generated in 2,158 (90%) patients, with a mean score of 0.20±0.21. The primary outcome occurred in 352 (15%) patients. Those in the highest scoring CODE-f quartile (>0.35) had greater than 3-fold increased risk of death at 1 year compared to patients in the lowest quartile (<0.07), after adjustment for age and sex (27% versus 9%, adjusted odds ratio 3.44, 95% confidence intervals [CI] 2.47 to 4.82, p<0.001). Increasing median length of index hospital stay was observed at CODE-f scores above 0.3 (Figure A). In the highest CODE-f quartile, nearly one third of patients experienced less than 9 months home time in the following year, compared to fewer than 1 in 10 in the lowest two quartiles (Figure B). In the nested cohort study, CODE-f scores were well correlated with the CFS (r=0.50, 95% CI 0.41 to 0.58, p<0.001).
Conclusion
An automated electronic health record measure can identify frail older adults at risk of poorer recovery and death after acute cardiac illness. This could inform complex treatment decisions and future care planning for this patient group.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Chief Scientist Office
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Affiliation(s)
- A Anand
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - R A Soon
- University of Edinburgh , Edinburgh , United Kingdom
| | - Z X Ho
- University of Edinburgh , Edinburgh , United Kingdom
| | - S D Shenkin
- University of Edinburgh, Ageing and Health Research Group , Edinburgh , United Kingdom
| | - A M J MacLullich
- University of Edinburgh, Ageing and Health Research Group , Edinburgh , United Kingdom
| | - N L Mills
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
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20
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Hall AJ, Clement ND, MacLullich AMJ, White TO, Duckworth AD. COVID-19 during the index hospital admission confers a 'double-hit' effect on hip fracture patients and is associated with a two-fold increase in 1-year mortality risk. Musculoskeletal Care 2022; 20:705-717. [PMID: 35929286 PMCID: PMC9538200 DOI: 10.1002/msc.1674] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/25/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022]
Abstract
Purpose The aims were to: (1) determine 1‐year mortality rates for hip fracture patients during the first UK COVID‐19 wave, and (2) assess mortality risk associated with COVID‐19. Methods A nationwide multicentre cohort study was conducted of all patients presenting to 17 hospitals in March‐April 2020. Follow‐up data were collected one year after initial hip fracture (‘index’) admission, including: COVID‐19 status, readmissions, mortality, and cause of death. Results Data were available for 788/833 (94.6%) patients. One‐year mortality was 242/788 (30.7%), and the prevalence of COVID‐19 within 365 days of admission was 142/788 (18.0%). One‐year mortality was higher for patients with COVID‐19 (46.5% vs. 27.2%; p < 0.001), and highest for those COVID‐positive during index admission versus after discharge (54.7% vs. 39.7%; p = 0.025). Anytime COVID‐19 was independently associated with 50% increased mortality risk within a year of injury (HR 1.50, p = 0.006); adjusted mortality risk doubled (HR 2.03, p < 0.001) for patients COVID‐positive during index admission. No independent association was observed between mortality risk and COVID‐19 diagnosed following discharge (HR 1.16, p = 0.462). Most deaths (56/66; 84.8%) in COVID‐positive patients occurred within 30 days of COVID‐19 diagnosis (median 11.0 days). Most cases diagnosed following discharge from the admission hospital occurred in downstream hospitals. Conclusion Almost half the patients that had COVID‐19 within 365 days of fracture had died within one year of injury versus 27.2% of COVID‐negative patients. Only COVID‐19 diagnosed during the index admission was associated independently with an increased likelihood of death, indicating that infection during this time may represent a ‘double‐hit’ insult, and most COVID‐related deaths occurred within 30 days of diagnosis.
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Affiliation(s)
- Andrew J Hall
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | | | - Alasdair M J MacLullich
- Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Ageing and Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
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21
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Hall AJ, Clement ND, MacLullich AMJ, Simpson AHRW, Johansen A, White TO, Duckworth AD. The delivery of an emergency audit response to a communicable disease outbreak can inform future orthopaedic investigations and clinical practice : lessons from IMPACT Hip Fracture Global Audits. Bone Joint Res 2022; 11:346-348. [PMID: 35642472 PMCID: PMC9233410 DOI: 10.1302/2046-3758.116.bjr-2022-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Ageing & Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Antony Johansen
- University Hospital of Wales, Cardiff University, Cardiff, UK.,National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Tim O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
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22
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Hall AJ, Clement ND, MacLullich AMJ, Simpson AHRW, White TO, Duckworth AD. The IMPACT of COVID-19 on trauma & orthopaedic surgery provides lessons for future communicable disease outbreaks : minimum reporting standards, risk scores, fragility trauma services, and global collaboration. Bone Joint Res 2022; 11:342-345. [PMID: 35642467 PMCID: PMC9233405 DOI: 10.1302/2046-3758.116.bjr-2022-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342–345.
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Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK
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23
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Vardy ERLC, Anand A, Cheng M, Ibitoye T, MacLullich AMJ. 795 A POSITIVE 4AT DELIRIUM ASSESSMENT TOOL SCORE ON HOSPITAL ADMISSION IS LINKED TO MORTALITY, LENGTH OF STAY AND ‘HOME TIME’: A STUDY OF 82,770 HOSPITAL ADMISSIONS IN EDINBURGH AND SALFORD. Age Ageing 2022. [DOI: 10.1093/ageing/afac037.795] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Delirium is linked with poor outcomes but studies using large-scale routine data are scarce. The 4AT (www.the4AT.com) is a brief (~2 minutes), well-validated tool for detection of delirium and cognitive impairment. We performed a two-centre study (Edinburgh and Salford) of Electronic Health Record (EHR) 4AT scores and outcomes in 82,770 non-elective hospital admissions in patients aged ≥65. We determined relationships between 4AT scores 0 (no impairment), 1–3 (cognitive impairment but no delirium) and ≥ 4 (delirium), in relation to 30-day inpatient mortality, length of stay, and time at home (‘home time’) in the year following index admission.
Methods
We analysed EHR 4AT scores recorded within 24 hours of admission, and outcomes data were also derived from the EHR. The study period was between April 2016 (Edinburgh)/September 2017 (Salford) and April 2020 (both centres).
Results
4AT scores suggestive of delirium (≥4) were present in 25% in Salford, and 18% in Edinburgh. After adjustment for age and sex, 30-day inpatient mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0 group in Edinburgh (aOR 5.53, 95% confidence interval [CI] 4.99–6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98–3.87). Length of stay was more than double in patients with any abnormal 4AT score compared to a 4AT score of 0. The median ‘home time’ at 1 year was reduced by 112 days (Edinburgh) and 61 days (Salford) in the 4AT ≥4 compared to 4AT 0 days.
Conclusions
This large study using routine clinical data confirms the relationships between delirium and poor outcomes previously reported in smaller research studies. Further, the results demonstrate the feasibility and value of using a brief clinical tool to identify delirium as a strong marker of adverse outcomes, and will be helpful in guiding policy development around patient safety including better treatment of delirium.
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Affiliation(s)
- E R L C Vardy
- Salford Royal NHS Foundation trust, Northern Care Alliance, Stott Lane, Salford
| | - A Anand
- Cardiovascular sciences, University of Edinburgh
| | - M Cheng
- Salford Royal NHS Foundation trust, Northern Care Alliance, Stott Lane, Salford
| | - T Ibitoye
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh
| | - A M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh
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Tieges Z, Lowrey J, MacLullich AMJ. What delirium detection tools are used in routine clinical practice in the United Kingdom? Survey results from 91% of acute healthcare organisations. Eur Geriatr Med 2021; 12:1293-1298. [PMID: 34008099 PMCID: PMC8626368 DOI: 10.1007/s41999-021-00507-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/28/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Our aim was to collect information on delirium assessment processes and pathways in non-intensive care settings in the United Kingdom (UK). METHODS We sent a Freedom of Information request to 169 UK National Health Service (NHS) hospitals, trusts and health boards (units) in July 2020 to obtain data on usage of delirium assessment tools in clinical practice and delirium pathways or guidelines. RESULTS We received responses from 154/169 units (91% response rate). Of these, 146/154 (95%) units reported use of formal delirium assessment processes and 131/154 (85%) units had guidelines or pathways in place. The 4'A's Test (4AT) was the most widely used tool, with 117/146 (80%) units reporting use. The Confusion Assessment Method was used in 65/146 (45%) units, and the Single Question to identify Delirium (SQiD) in 52/146 (36%) units. CONCLUSIONS Our findings show that the 4AT is the most commonly used tool in the UK, with 80% of units reporting use. This study adds to our knowledge of real-world uptake of delirium detection methods at scale. Future studies should evaluate real-world implementation of delirium assessment tools further via (1) tool completion rates and (2) rates of positive scores against the expected of prevalence delirium in the clinical population concerned.
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Affiliation(s)
- Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK.
- SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Jacqueline Lowrey
- College of Medicine and Veterinary Medicine, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
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Tieges Z, Quinn T, MacKenzie L, Davis D, Muniz-Terrera G, MacLullich AMJ, Shenkin SD. Correction to: Association between components of the delirium syndrome and outcomes in hospitalised adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:490. [PMID: 34503451 PMCID: PMC8427852 DOI: 10.1186/s12877-021-02419-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK. .,School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Terence Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lorn MacKenzie
- Academic and Clinical Central Office for Research and Development, University of Edinburgh, Edinburgh, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - Graciela Muniz-Terrera
- Centre for Clinical Brain Sciences and Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
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Hasemann W, Duncan N, Clarke C, Nouzova E, Süßenbach LM, Keerie C, Assi V, Weir CJ, Evans J, Walsh T, Wilson E, Quasim T, Middleton D, Weir AJ, Barnett JH, Stott DJ, MacLullich AMJ, Tieges Z. Comparing performance on the Months of the Year Backwards test in hospitalised patients with delirium, dementia, and no cognitive impairment: an exploratory study. Eur Geriatr Med 2021; 12:1257-1265. [PMID: 34156656 PMCID: PMC8626373 DOI: 10.1007/s41999-021-00521-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/17/2021] [Accepted: 05/19/2021] [Indexed: 12/17/2022]
Abstract
Aim To investigate performance of the Months of the Year Backwards (MOTYB) test in older hospitalised patients with delirium, dementia, and no cognitive impairment. Findings Half of the patients with delirium (46%) could not engage with MOTYB compared to only 11% of patients with dementia without delirium. In patients able to give responses, those with delirium or dementia performed significantly worse than those without cognitive impairment. Message Our findings show the potential value of analysing response patterns, especially initial engagement, self-correction, and ability to continue to do the task in addition to considering exclusively the capacity to correctly recite the months until July, June or January. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00521-4. Purpose To investigate performance of the Months of the Year Backwards (MOTYB) test in older hospitalised patients with delirium, dementia, and no cognitive impairment. Methods Secondary analysis of data from a case–control study of 149 hospitalised patients aged ≥ 65 years with delirium [with or without dementia (N = 50)], dementia [without delirium (N = 46)], and no cognitive impairment (N = 53). Verbatim transcripts of MOTYB audio recordings were analysed to determine group differences in response patterns. Results In the total sample [median age 85y (IQR 80–88), 82% female], patients with delirium were more often unable to recite months backward to November (36/50 = 72%) than patients with dementia (21/46 = 46%; p < 0.01) and both differed significantly from patients without cognitive impairment (2/53 = 4%; p’s < 0.001). 121/149 (81%) of patients were able to engage with the test. Patients with delirium were more often unable to engage with MOTYB (23/50 = 46%; e.g., due to reduced arousal) than patients with dementia (5/46 = 11%; p < 0.001); both groups differed significantly (p’s < 0.001) from patients without cognitive impairment (0/53 = 0%). There was no statistically significant difference between patients with delirium (2/27 = 7%) and patients with dementia (8/41 = 20%) in completing MOTYB to January, but performance in both groups differed (p < 0.001 and p < 0.02, respectively) from patients without cognitive impairment (35/53 = 66%). Conclusion Delirium was associated with inability to engage with MOTYB and low rates of completion. In patients able to engage with the test, error-free completion rates were low in delirium and dementia. Recording of engagement and patterns of errors may add useful information to MOTYB scoring. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00521-4.
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Affiliation(s)
- Wolfgang Hasemann
- University Department of Geriatric Medicine FELIX PLATTER Basel, Burgfelderstrasse, 101 4055, Basel, Switzerland. .,Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Nikki Duncan
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Caoimhe Clarke
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Eva Nouzova
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Lisa-Marie Süßenbach
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher, University of Edinburgh, Edinburgh, Scotland, UK
| | - Valentina Assi
- Edinburgh Clinical Trials Unit, Usher, University of Edinburgh, Edinburgh, Scotland, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jonathan Evans
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Tim Walsh
- Dept of Critical Care Medicine and Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland, UK
| | - Elizabeth Wilson
- Dept of Critical Care Medicine and Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Pain Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Duncan Middleton
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, UK
| | - Alexander J Weir
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, UK
| | | | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK.,SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, Scotland, UK
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Hall AJ, Clement ND, MacLullich AMJ, Ojeda-Thies C, Hoefer C, Brent L, White TO, Duckworth AD. IMPACT of COVID-19 on hip fracture services: A global survey by the International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics. Surgeon 2021; 20:237-240. [PMID: 34103268 PMCID: PMC8141714 DOI: 10.1016/j.surge.2021.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 02/12/2021] [Revised: 03/10/2021] [Accepted: 04/25/2021] [Indexed: 12/19/2022]
Abstract
Introduction The Coronavirus Disease 2019 (COVID-19) pandemic resulted in major disruption to hip fracture services. This frail patient group requires specialist care, and disruption to services is likely to result in increases in morbidity, mortality and long-term healthcare costs. Aims To assess disruption to hip fracture services during the COVID-19 pandemic. Methods A questionnaire was designed for completion by a senior clinician or service manager in each participating unit between April–September 2020. The survey was incorporated into existing national-level audits in Germany (n = 71), Scotland (n = 16), and Ireland (n = 16). Responses from a further 82 units in 11 nations were obtained via an online survey. Results There were 185 units from 14 countries that returned the survey. 102/160 (63.7%) units reported a worsening of overall service quality, which was attributed predominantly to staff redistribution, reallocation of inpatient areas, and reduced access to surgical facilities. There was a high rate of redeployment of staff to other services: two thirds lost specialist orthopaedic nurses, a third lost orthogeriatrics services, and a quarter lost physiotherapists. Reallocation of inpatient areas resulted in patients being managed by non-specialised teams in generic wards, which increased transit of patients and staff between clinical areas. There was reduced operating department access, with 74/160 (46.2%) centres reporting a >50% reduction. Reduced theatre efficiency was reported by 135/160 (84.4%) and was attributed to staff and resource redistribution, longer anaesthetic and transfer times, and delays for preoperative COVID-19 testing and using personal protective equipment (PPE). Conclusion Hip fracture services were disrupted during the COVID-19 pandemic and this may have a sustained impact on health and social care. Protection of hip fracture services is essential to ensure satisfactory outcomes for this vulnerable patient group.
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Affiliation(s)
- Andrew J Hall
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, UK; Scottish Orthopaedic Research Trust into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK.
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK; Department of Geriatric Medicine, Usher Institute, University of Edinburgh, UK
| | | | | | - Louise Brent
- National Office of Clinical Audit, Dublin, Ireland
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, UK; Scottish Orthopaedic Research Trust into Trauma (SORT-IT), UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Department of Orthopaedics & Trauma, Usher Institute, University of Edinburgh, UK; Scottish Orthopaedic Research Trust into Trauma (SORT-IT), UK
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Tieges Z, MacLullich AMJ, Anand A, Cassaroni M, O'Connor M, Ryan D, Saller T, Arora R, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin S, Galvin R. 33 Diagnostic Test Accuracy of the 4AT for Delirium Detection: Systematic Review and Meta-Analysis. Age Ageing 2021. [DOI: 10.1093/ageing/afab029.12] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short (<2 min) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.
Methods
We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.
Results
17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good.
Conclusions
The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.
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Affiliation(s)
- Z Tieges
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - A M J MacLullich
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - A Anand
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - M Cassaroni
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - M O'Connor
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - D Ryan
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - T Saller
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - R Arora
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - Y Chang
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - K Agarwal
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - G Taffet
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - T Quinn
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - S Shenkin
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - R Galvin
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
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Tieges Z, Quinn T, MacKenzie L, Davis D, Muniz-Terrera G, MacLullich AMJ, Shenkin SD. Association between components of the delirium syndrome and outcomes in hospitalised adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:162. [PMID: 33673804 PMCID: PMC7934253 DOI: 10.1186/s12877-021-02095-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 11/20/2020] [Accepted: 02/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background Delirium is a heterogeneous syndrome with inattention as the core feature. There is considerable variation in the presence and degree of other symptom domains such as altered arousal, psychotic features and global cognitive dysfunction. Delirium is independently associated with increased mortality, but it is unclear whether individual symptom domains of delirium have prognostic importance. We conducted a systematic review and meta-analysis of studies in hospitalised adults in general settings to identify the relationship between symptom domains of delirium and outcomes. (PROSPERO: CRD42018093935). Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials from inception to November 2019. We included studies of hospitalised adults that reported associations between symptom domains of delirium and 30-day mortality (primary outcome), and other outcomes including mortality at other time points, length of stay, and dementia. Reviewer pairs independently screened articles, extracted data, and assessed risk of bias (Risk of Bias Assessment tool for Non-randomized Studies) and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework. We performed random-effects meta-analyses stratified by delirium domain where possible. Results From 7092 citations we included 6 studies (6002 patients, 1112 with delirium). Higher mortality (ranging from in-hospital to follow-up beyond 12 months) was associated with altered arousal (pooled Odds Ratio (OR) 2.80, 95% Confidence Interval (CI) 2.33–3.37; moderate-quality evidence), inattention (pooled OR 2.57, 95% CI 1.74–3.80; low-quality evidence), and in single studies with disorientation, memory deficits and disorganised thoughts. Risk of bias varied across studies but was moderate-to-high overall, mainly due to selection bias, lack of blinding of assessments and unclear risk of selective outcome reporting. We found no studies on the association between psychotic features, visuospatial deficits or affective disturbances in delirium and outcomes, or studies reporting non-mortality outcomes. Conclusions Few studies have related symptom domains of delirium to outcomes, but the available evidence suggests that altered arousal and inattention in delirium are associated with higher mortality than normal arousal and attention in people with or without delirium. Measurable symptom domains of delirium may have value in predicting survival and stratifying patients for treatment. We recommend that future delirium studies report outcomes by symptom domain. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02095-z.
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Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK. .,School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Terence Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lorn MacKenzie
- Academic and Clinical Central Office for Research and Development, University of Edinburgh, Edinburgh, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - Graciela Muniz-Terrera
- Centre for Clinical Brain Sciences and Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
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30
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Abstract
AIMS The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission. METHODS A nationwide multicentre retrospective cohort study was conducted of all patients presenting with a hip fracture to 17 Scottish centres in March and April 2020. Demographics, presentation blood tests, COVID-19 status, Nottingham Hip Fracture Score, management, length of stay, and 30-day mortality were recorded. RESULTS In all, 78/833 (9.4%) patients were diagnosed with COVID-19. The 30-day survival of patients with COVID-19 was significantly lower than for those without (65.4% vs 91%; p < 0.001). Diagnosis of COVID-19 within seven days of admission (likely community acquired) was independently associated with male sex (odds ratio (OR) 2.34, p = 0.040, confidence interval (CI) 1.04 to 5.25) and symptoms of COVID-19 (OR 15.56, CI 6.61 to 36.60, p < 0.001). Diagnosis of COVID-19 made between seven and 30 days of admission to hospital (likely hospital acquired) was independently associated with male sex (OR 1.73, CI 1.05 to 2.87, p = 0.032), Nottingham Hip Fracture Score ≥ 7 (OR 1.91, CI 1.09 to 3.34, p = 0.024), pulmonary disease (OR 1.68, CI 1.00 to 2.81, p = 0.049), American Society of Anesthesiologists (ASA) grade ≥ 3 (OR 2.37, CI 1.13 to 4.97, p = 0.022), and length of stay ≥ nine days (OR 1.98, CI 1.18 to 3.31, p = 0.009). A total of 38 (58.5%) COVID-19 cases were probably hospital acquired infections. The false-negative rate of a negative swab on admission was 0% in asymptomatic patients and 2.9% in symptomatic patients. CONCLUSION COVID-19 was independently associated with a three times increased 30-day mortality rate. Nosocomial transmission may have accounted for approximately half of all cases during the first wave of the pandemic. Identification of risk factors for having COVID-19 on admission or acquiring COVID-19 in hospital may guide pathways for isolating or shielding patients respectively. Length of stay was the only modifiable risk factor, which emphasizes the importance of high-quality and timely care in this patient group. Cite this article: Bone Joint J 2021;103-B(5):888-897.
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Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Nick D Clement
- Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tim O White
- Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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31
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Gillies MA, Ghaffar S, Moppett IK, Docherty AB, Clarke S, Rea N, Stephen J, Keerie C, Ray DC, White TO, MacLullich AMJ, Mills NM, Rowley MR, Murthy K, Pearse RM, Stanworth SJ, Walsh TS. A restrictive versus liberal transfusion strategy to prevent myocardial injury in patients undergoing surgery for fractured neck of femur: a feasibility randomised trial (RESULT-NOF). Br J Anaesth 2021; 126:77-86. [PMID: 32703548 DOI: 10.1016/j.bja.2020.06.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 12/09/2019] [Revised: 04/30/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimum transfusion strategy in patients with fractured neck of femur is uncertain, particularly if there is coexisting cardiovascular disease. METHODS We conducted a prospective, single-centre, randomised feasibility trial of two transfusion strategies. We randomly assigned patients undergoing surgery for fractured neck of femur to a restrictive (haemoglobin, 70-90 g L-1) or liberal (haemoglobin, 90-110 g L-1) transfusion strategy throughout their hospitalisation. Feasibility outcomes included: enrolment rate, protocol compliance, difference in haemoglobin, and blood exposure. The primary clinical outcome was myocardial injury using troponin estimations. Secondary outcomes included major adverse cardiac events, postoperative complications, duration of hospitalisation, mortality, and quality of life. RESULTS We enrolled 200 (22%) of 907 eligible patients, and 62 (31%) showed decreased haemoglobin (to 90 g L-1 or less) and were thus exposed to the intervention. The overall protocol compliance was 81% in the liberal group and 64% in the restrictive group. Haemoglobin concentrations were similar preoperatively and at postoperative day 1 but lower in the restrictive group on day 2 (mean difference [MD], 7.0 g L-1; 95% confidence interval [CI], 1.6-12.4). Lowest haemoglobin within 30 days/before discharge was lower in the restrictive group (MD, 5.3 g L-1; 95% CI, 1.7-9.0). Overall, 58% of patients in the restrictive group received no transfusion compared with 4% in the liberal group (difference in proportion, 54.5%; 95% CI, 36.8-72.2). The proportion with the primary clinical outcome was 14/26 (54%, liberal) vs 24/34 (71%, restrictive), and the difference in proportion was -16.7% (95% CI, -41.3 to 7.8; P=0.18). CONCLUSION A clinical trial of two transfusion strategies in hip fracture with a clinically relevant cardiac outcome is feasible. CLINICAL TRIAL REGISTRATION NCT03407573.
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Affiliation(s)
- Michael A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK.
| | - Sadia Ghaffar
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Iain K Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Annemarie B Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Sarah Clarke
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Nicola Rea
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David C Ray
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Timothy O White
- Department of Trauma and Orthopaedics, Royal Infirmary Edinburgh, Edinburgh, UK
| | | | - Nicholas M Mills
- BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Megan R Rowley
- Scottish National Blood Transfusion Service, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Krishna Murthy
- Department of Emergency Medicine, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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Abstract
An Erratum to this paper has been published: https://doi.org/10.1038/s41572-020-00236-z.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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Hall R, Stíobhairt A, Allerhand M, MacLullich AMJ, Tieges Z. The Observational Scale of Level of Arousal: A brief tool for assessing and monitoring level of arousal in patients with delirium outside the ICU. Int J Geriatr Psychiatry 2020; 35:1021-1027. [PMID: 32394506 DOI: 10.1002/gps.5324] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Altered level of arousal, encompassing drowsiness and hypervigilance, affects at least 10% of acutely unwell patients. Existing scales provide limited coverage of milder changes in level of arousal. We devised the Observational Scale of Level of Arousal (OSLA) to enable more detailed arousal assessment. Here, we provide a preliminary case-control study of performance of the OSLA in assessing abnormal level of arousal associated with delirium outside the ICU. METHODS Hip fracture patients (N = 108, median age = 82 years) were assessed for delirium pre- and post-operatively using the Confusion Assessment Method and the Delirium Rating Scale-Revised-98. The OSLA has four graded items assessing eye opening, eye contact, posture, and movement (score range 0 [normal arousal]-15). We assessed the psychometric and diagnostic characteristics of the OSLA. Adjusted linear mixed effects models were used to explore responsiveness of the OSLA to within-patient change in delirium status. RESULTS A total of 44 patients (40.7%) were diagnosed with delirium. OSLA scores were higher in delirium (pooled median = 3, InterQuartile Range [IQR] = 2-5) compared to no delirium (pooled median = 1, IQR = 1-2; P-values <.05 to <.001). The Area under the Receiver Operating Characteristic curve was 0.82 (95% Confidence Interval (CI) = 0.77-0.86). OSLA scores were responsive to change in delirium status (ß = -3.09. SE = 1.41, P < .03). CONCLUSIONS This study provides preliminary evidence supporting use of the OSLA as an instrument for identifying abnormal level of arousal associated with delirium and monitoring this longitudinally. Further validation in larger cohorts with blinded raters is required. J Am Geriatr Soc 68:-, 2020.
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Affiliation(s)
- Roanna Hall
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK.,Medicine of the Elderly Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Antaine Stíobhairt
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Mike Allerhand
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK.,Medicine of the Elderly Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
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Abstract
AIMS The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. METHODS A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. RESULTS Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 109/l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. CONCLUSION COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219-1228.
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Affiliation(s)
- Andrew J Hall
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK
| | - Luke Farrow
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK.,University of Aberdeen, Aberdeen, UK
| | - Alasdair M J MacLullich
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Paul J Jenkins
- Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Glasgow Royal Infirmary, Glasgow, UK.,Scottish Committee for Orthopaedics & Trauma, Edinburgh, UK
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
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36
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Khachaturian AS, Hayden KM, Devlin JW, Fleisher LA, Lock SL, Cunningham C, Oh ES, Fong TG, Fick DM, Marcantonio ER, Iyengar V, Rockwood K, Kuchel GA, Eckenhoff RG, MacLullich AMJ, Jones RN, Davis D, D'Antonio PM, Fargo KN, Albert MS, Williamson JD, Ling SM, Weiss J, Karlawish J, Petersen RC, Blazer DG, Khachaturian ZS, Inouye SK. International drive to illuminate delirium: A developing public health blueprint for action. Alzheimers Dement 2020; 16:711-725. [PMID: 32212231 DOI: 10.1002/alz.12075] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Ara S Khachaturian
- Campaign to Prevent Alzheimer's Disease, A Maryland-based 501(c)(3) not-for-profit corporation, Rockville, Maryland, USA
| | - Kathleen M Hayden
- Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Esther S Oh
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Marie Fick
- Penn State College of Nursing, Center of Geriatric Nursing Excellence, University Park, Pennsylvania, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vijeth Iyengar
- Administration for Community Living, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Kenneth Rockwood
- Divisions of Geriatric Medicine & Neurology, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Canada
| | - George A Kuchel
- Department of Geriatrics and Gerontology, University of Connecticut, Center on Aging, University of Connecticut, Farmington, Connecticut, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard N Jones
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School, Brown University, Butler Hospital, Providence, Rhode Island, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health & Ageing, Population Science & Experimental Medicine, Faculty of Pop Health Sciences, University College London, London, UK
| | | | | | - Marilyn S Albert
- Division of Cognitive Neuroscience, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff D Williamson
- Gerontology and Geriatric Medicine, Winston-Salem, North Carolina, USA
| | - Shari M Ling
- Centers for Medicare and Medicaid Services (CMS), Baltimore, Maryland, USA
| | - Joan Weiss
- Division of Medicine and Dentistry, Bureau of Health Workforce, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Jason Karlawish
- Division of Geriatrics, Department of Medicine, Ralston-Penn Center, Philadelphia, Pennsylvania, USA
| | - Ronald C Petersen
- Alzheimer's Disease Research Center, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan G Blazer
- Psychiatry & Behavioral Sciences, Geriatric Behavioral Health, School of Medicine, Durham, North Carolina, USA
| | - Zaven S Khachaturian
- Campaign to Prevent Alzheimer's Disease, A Maryland-based 501(c)(3) not-for-profit corporation, Rockville, Maryland, USA
| | - Sharon K Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Maryland, USA
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37
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Affiliation(s)
- T Saller
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - A M J MacLullich
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - R Perneczky
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
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38
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Slooter AJC, Otte WM, Devlin JW, Arora RC, Bleck TP, Claassen J, Duprey MS, Ely EW, Kaplan PW, Latronico N, Morandi A, Neufeld KJ, Sharshar T, MacLullich AMJ, Stevens RD. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med 2020; 46:1020-1022. [PMID: 32055887 PMCID: PMC7210231 DOI: 10.1007/s00134-019-05907-4] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Room F06.149, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Wim M Otte
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, Department of Pediatric Neurology, and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jan Claassen
- Department of Neurology and Neurosurgery, Columbia University Medical Center, New York City, NY, USA
| | - Matthew S Duprey
- School of Pharmacy, Northeastern University, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Quality Aging, Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, University of Brescia, Brescia, Italy
| | - Alessandro Morandi
- Department of Rehabilitation, Ancelle Hospital, Cremona, Italy.,Geriatric Research Group, Brescia, Italy
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tarek Sharshar
- Unité Neuropathologie Expérimentale, Département Infection Et Épidémiologie, Institut Pasteur, and Service D'Anesthésie-Réanimation, Hôpital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, and Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Robert D Stevens
- Departments of Anesthesiology, Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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39
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Tieges Z, Stott DJ, Shaw R, Tang E, Rutter LM, Nouzova E, Duncan N, Clarke C, Weir CJ, Assi V, Ensor H, Barnett JH, Evans J, Green S, Hendry K, Thomson M, McKeever J, Middleton DG, Parks S, Walsh T, Weir AJ, Wilson E, Quasim T, MacLullich AMJ. A smartphone-based test for the assessment of attention deficits in delirium: A case-control diagnostic test accuracy study in older hospitalised patients. PLoS One 2020; 15:e0227471. [PMID: 31978127 PMCID: PMC6980392 DOI: 10.1371/journal.pone.0227471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 12/19/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Delirium is a common and serious acute neuropsychiatric syndrome which is often missed in routine clinical care. Inattention is the core cognitive feature. Diagnostic test accuracy (including cut-points) of a smartphone Delirium App (DelApp) for assessing attention deficits was assessed in older hospital inpatients. METHODS This was a case-control study of hospitalised patients aged ≥65 years with delirium (with or without pre-existing cognitive impairment), who were compared to patients with dementia without delirium, and patients without cognitive impairment. Reference standard delirium assessment, which included a neuropsychological test battery, was based on Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A separate blinded assessor administered the DelApp arousal assessment (score 0-4) and attention task (0-6) yielding an overall score of 0 to 10 (lower scores indicate poorer performance). Analyses included receiver operating characteristic curves and sensitivity and specificity. Optimal cut-points for delirium detection were determined using Youden's index. RESULTS A total of 187 patients were recruited, mean age 83.8 (range 67-98) years, 152 (81%) women; n = 61 with delirium; n = 61 with dementia without delirium; and n = 65 without cognitive impairment. Patients with delirium performed poorly on the DelApp (median score = 4/10; inter-quartile range 3.0, 5.5) compared to patients with dementia (9.0; 5.5, 10.0) and those without cognitive impairment (10.0; 10.0, 10.0). Area under the curve for detecting delirium was 0.89 (95% Confidence Interval 0.84, 0.94). At an optimal cut-point of ≤8, sensitivity was 91.7% (84.7%, 98.7%) and specificity 74.2% (66.5%, 81.9%) for discriminating delirium from the other groups. Specificity was 68.3% (56.6%, 80.1%) for discriminating delirium from dementia (cut-point ≤6). CONCLUSION Patients with delirium (with or without pre-existing cognitive impairment) perform poorly on the DelApp compared to patients with dementia and those without cognitive impairment. A cut-point of ≤8/10 is suggested as having optimal sensitivity and specificity. The DelApp is a promising tool for assessment of attention deficits associated with delirium in older hospitalised adults, many of whom have prior cognitive impairment, and should be further validated in representative patient cohorts.
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Affiliation(s)
- Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, Edinburgh, United Kingdom
| | - David J. Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Robert Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Elaine Tang
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nikki Duncan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Caoimhe Clarke
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Valentina Assi
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Hannah Ensor
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer H. Barnett
- Cambridge Cognition Ltd, Cambridge, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan Evans
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Samantha Green
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Kirsty Hendry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Meigan Thomson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Jenny McKeever
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Duncan G. Middleton
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Stuart Parks
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Tim Walsh
- Critical Care Medicine and Anaesthesia, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Alexander J. Weir
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Elizabeth Wilson
- Critical Care Medicine and Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Tara Quasim
- Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, Edinburgh, United Kingdom
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40
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Torvell M, Hampton DW, Connick P, MacLullich AMJ, Cunningham C, Chandran S. A single systemic inflammatory insult causes acute motor deficits and accelerates disease progression in a mouse model of human tauopathy. Alzheimers Dement (N Y) 2019; 5:579-591. [PMID: 31650014 PMCID: PMC6804509 DOI: 10.1016/j.trci.2019.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction Neuroinflammation, which contributes to neurodegeneration, is a consistent hallmark of dementia. Emerging evidence suggests that systemic inflammation also contributes to disease progression. Methods The ability of systemically administered lipopolysaccharide (LPS - 500 μg/kg) to effect acute and chronic behavioural changes in C57BL/6 and P301S tauopathy mice was assessed. Markers of pathology were assessed in the brain and spinal cord. Results P301S mice display regional microgliosis. Systemic LPS treatment induced exaggerated acute sickness behaviour and motor dysfunction in P301S mice compared with wild-type controls and advanced the onset and accelerated chronic decline. LPS treatment was associated with increased tau pathology 24 hours after LPS injection and spinal cord microgliosis at the end stage. Discussion This is the first demonstration that a single systemic inflammatory episode causes exaggerated acute functional impairments and accelerates the long-term trajectory of functional decline associated with neurodegeneration in a mouse model of human tauopathy. The findings have relevance to management of human dementias. P301S microgliosis is regional; activation occurs in the spinal cord but not in the cortex. Systemic LPS injection caused acute neurological deficits in P301S mice. This was associated with increased tau pathology 24 hours after LPS injection. This was independent of microglial priming as measured by IL-1β hyperexpression. LPS injection advanced the onset of chronic decline in P301S mice.
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Affiliation(s)
- Megan Torvell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute at University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute at University of Cardiff, Cardiff, UK
| | - David W Hampton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | - Peter Connick
- The Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, Midlothian, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Colm Cunningham
- Trinity Biomedical Sciences Institute and Trinity College Institute of Neuroscience, School of Biochemistry and Immunology, Trinity College Dublin, Dublin, Ireland
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute at University of Edinburgh, Edinburgh, UK.,The Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, Midlothian, UK
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41
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
Background Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. Main body The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). Short conclusion In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy. .,Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands.,International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK.,Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy.,University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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42
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Abstract
Delirium research and clinical care have seen great strides in the last decade. Age and Ageing is making freely available an online collection of 15 papers published since 2012 which provides an overview of the range of research in delirium. It covers prevention and prediction, interventions and their health economic evaluations, outcomes following delirium, and clinical application in a review of the recent SIGN guidelines. The majority of studies took place in hospitals, but we also introduce some important research about another group at high risk of delirium: care home residents. We highlight the importance of delirium education. The studies comprised a range of methodologies (systematic reviews/meta-analysis, observational studies, trials and qualitative research). The selected papers are exemplars of work that has clear clinical implications. Given that delirium affects 15-20% of hospital patients, studies or analysis of existing data with clinical relevance have the potential for enormous impact on practice and on more efficient use of healthcare resources. There is, however, still a great deal of work to be done to implement what is known to be effective, and so reduce the incidence of this distressing condition, and to support those affected: not only patients, but also families and carers, as well as staff in secondary and primary care, including care homes.
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Affiliation(s)
- Alasdair M J MacLullich
- Geriatric Medicine Unit, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Susan D Shenkin
- Geriatric Medicine Unit, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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43
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17:138. [PMID: 31337404 PMCID: PMC6651960 DOI: 10.1186/s12916-019-1367-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). METHODS This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. RESULTS Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). CONCLUSIONS The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. TRIAL REGISTRATION International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
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Affiliation(s)
- Susan D. Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mary Godfrey
- Elderly Care and Rehabilitation and Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L. Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
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44
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Hov KR, Neerland BE, Undseth Ø, Wyller VBB, MacLullich AMJ, Qvigstad E, Skovlund E, Wyller TB. The Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial. Int J Geriatr Psychiatry 2019; 34:974-981. [PMID: 30901487 DOI: 10.1002/gps.5098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/06/2018] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this double-blinded randomised placebo-controlled trial was to investigate the efficacy of clonidine for delirium in medical inpatients greater than 65 years. METHODS Acutely admitted medical patients greater than 65 years with delirium or subsyndromal delirium were eligible for inclusion. Included patients were given a loading dose of either placebo or clonidine; 75 μg every third hour up to a maximum of four doses to reach steady state and further 75 μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days of treatment. The primary endpoint was the trajectory of the Memorial Delirium Assessment Scale (MDAS) for the 7 days of treatment. Presence of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and severity measured by MDAS were assessed daily until discharge or a maximum of 7 days after end of treatment. RESULTS Because of slower enrolment than anticipated, the study was halted early. Ten patients in each group were studied. The low recruitment rate was mainly due to the presence of multiple patient exclusion criteria for patient safety. There was no significant difference between the treatment group in the primary endpoint comparing the trajectory of MDAS for the 7 days of treatment using mixed linear models with log transformation, (P = .60). The treatment group did not have increased adverse effects. CONCLUSIONS No effect of clonidine for delirium was found, although the study was under powered. Further studies in less frail populations are now required.
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Affiliation(s)
- Karen R Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øystein Undseth
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Vegard Bruun Bratholm Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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45
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Cox SR, MacPherson SE, Ferguson KJ, Nissan J, Royle NA, MacLullich AMJ, Wardlaw JM, Deary IJ. Corrigendum to Correlational structure of 'frontal' tests and intelligence tests indicates two components with asymmetrical neurostructural correlates in old age Intelligence 46 (2014) 94-106. Intelligence 2019; 71:97. [PMID: 31186593 PMCID: PMC6259585 DOI: 10.1016/j.intell.2018.10.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
[This corrects the article DOI: 10.1016/j.intell.2014.05.006.].
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Affiliation(s)
- Simon R Cox
- Brain Research Imaging Centre, Neuroimaging Sciences, University of Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Department of Psychology, University of Edinburgh, UK
| | - Sarah E MacPherson
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Department of Psychology, University of Edinburgh, UK
| | - Karen J Ferguson
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Geriatric Medicine, University of Edinburgh, UK
| | - Jack Nissan
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK
| | - Natalie A Royle
- Brain Research Imaging Centre, Neuroimaging Sciences, University of Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Scottish Imaging Network, a Platform for Scientific Excellence (SINAPSE) Collaboration, UK
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Geriatric Medicine, University of Edinburgh, UK.,Endocrinology Unit, University of Edinburgh, UK
| | - Joanna M Wardlaw
- Brain Research Imaging Centre, Neuroimaging Sciences, University of Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Scottish Imaging Network, a Platform for Scientific Excellence (SINAPSE) Collaboration, UK
| | - Ian J Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK.,Department of Psychology, University of Edinburgh, UK
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46
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Abstract
Delirium, one of the most common manifestations of acute brain dysfunction, is a serious complication in patients receiving care throughout the hospital and a strong predictor of worse outcome. Although delirium monitoring is advocated in numerous evidence-based guidelines as part of routine clinical care, it is still not widely and consistently performed at the bedside in different patient care settings. In a debate on delirium monitoring in hospitalized patients at the 7th American Delirium Society meeting in Nashville, Tennessee, June 2017, areas related to the feasibility, acceptability, and effectiveness of routine delirium monitoring of hospitalized patients were identified, and arguments both for (pro) and against (con) the practice were presented. These arguments and others arising in the discussion were subsequently expanded. The goals were to present a conversation among clinicians and researchers from different settings and to identify the evidence-practice gaps for delirium monitoring for future research and organizational quality improvement programs. Further research is needed to determine whether or not delirium monitoring should become routine clinical care for every patient in every hospital setting.
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Affiliation(s)
- Annachiara Marra
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center.
| | - Katarzyna Kotfis
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Annmarie Hosie
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Alasdair M J MacLullich
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Pratik P Pandharipande
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - E Wesley Ely
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Brenda T Pun
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
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Green S, Reivonen S, Rutter LM, Nouzova E, Duncan N, Clarke C, MacLullich AMJ, Tieges Z. Investigating speech and language impairments in delirium: A preliminary case-control study. PLoS One 2018; 13:e0207527. [PMID: 30475831 PMCID: PMC6261049 DOI: 10.1371/journal.pone.0207527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/01/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Language impairment is recognized as as part of the delirium syndrome, yet there is little neuropsychological research on the nature of this dysfunction. Here we hypothesized that patients with delirium show impairments in language formation, coherence and comprehension. Methods This was a case-control study in 45 hospitalized patients (aged 65–97 years) with delirium, dementia without delirium, or no cognitive impairment (N = 15 per group). DSM-5 criteria were used for delirium. Speech was elicited during (1) structured conversational questioning, and (2) the "Cookie Theft" picture description task. Language comprehension was assessed through standardized verbal and written commands. Interviews were audio-recorded and transcribed. Results Delirium and dementia groups scored lower on the conversational assessment than the control group (p<0.01, moderate effect sizes (r) of 0.48 and 0.51, resp.). In the Cookie Theft task, the average length of utterances (i.e. unit of speech), indicating language productivity and fluency, distinguished patients with delirium from those with dementia (p<0.01, r = 0.50) and no cognitive impairment (p<0.01, r = 0.55). Patients with delirium performed worse on written comprehension tests compared to cognitively unimpaired patients (p<0.01, r = 0.63), but not compared to the dementia group. Conclusions Production of spontaneous speech, word quantity, speech content and verbal and written language comprehension are impaired in delirious patients compared to cognitively unimpaired patients. Additionally, patients with delirium produced significantly less fluent speech than those with dementia. These findings have implications for how speech and language are evaluated in delirium assessments, and also for communication with patients with delirium. A study limitation was that the delirium group included patients with co-morbid dementia, which precludes drawing conclusions about the specific language profile of delirium.
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Affiliation(s)
- Samantha Green
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Satu Reivonen
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nikki Duncan
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caoimhe Clarke
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- * E-mail:
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48
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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49
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Rutter LM, Nouzova E, Stott DJ, Weir CJ, Assi V, Barnett JH, Clarke C, Duncan N, Evans J, Green S, Hendry K, McGinlay M, McKeever J, Middleton DG, Parks S, Shaw R, Tang E, Walsh T, Weir AJ, Wilson E, Quasim T, MacLullich AMJ, Tieges Z. Diagnostic test accuracy of a novel smartphone application for the assessment of attention deficits in delirium in older hospitalised patients: a prospective cohort study protocol. BMC Geriatr 2018; 18:217. [PMID: 30223771 PMCID: PMC6142423 DOI: 10.1186/s12877-018-0901-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 05/20/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022] Open
Abstract
Background Delirium is a common and serious clinical syndrome which is often missed in routine clinical care. The core cognitive feature is inattention. We developed a novel bedside neuropsychological test for assessing inattention in delirium implemented on a smartphone platform (DelApp). We aim to evaluate the diagnostic performance of the DelApp in a representative cohort of older hospitalised patients. Methods This is a prospective study of older non-scheduled hospitalised patients (target n = 500, age ≥ 65), recruited from elderly care and acute orthopaedic wards. Exclusion criteria are: non-English speakers; severe vision or hearing impairment; photosensitive epilepsy. A structured reference standard delirium assessment based on DSM-5 criteria will be used, which includes a cognitive test battery administered by a trained assessor (Orientation-Memory-Concentration Test, Abbreviated Mental Test-10, Delirium Rating Severity Scale-Revised-98, digit span, months and days backwards, Vigilance A’ test) and assessment of arousal (Observational Scale of Level of Arousal, Richmond Agitation Sedation Scale). Prior change in cognition will be documented using the Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be categorized as delirium (with/without dementia), possible delirium, dementia, no cognitive impairment, or undetermined. A separate assessor (blinded to diagnosis and assessments) will administer the DelApp index test within 3 h of the reference standard assessment. The DelApp comprises assessment of arousal (score 0-4) and sustained attention (score 0-6), yielding a total score between 0 and 10 (higher score = better performance). Outcomes (length of stay, mortality and discharge location) will be collected at 12 weeks. We will evaluate a priori cutpoints derived from a previous case-control study. Measures of the accuracy of DelApp will include sensitivity, specificity, positive and negative predictive values, and area under the ROC curve. We plan repeat assessments on up to 4 occasions in a purposive subsample of 30 patients (15 delirium, 15 no delirium) to examine changes over time. Discussion This study evaluates the diagnostic test accuracy of a novel smartphone test for delirium in a representative cohort of older hospitalised patients, including those with dementia. DelApp has the potential to be a convenient, objective method of improving delirium assessment for older people in acute care. Trial registration Clinical trials.gov, NCT02590796. Registered on 29 Oct 2015. Protocol version 5, dated 25 July 2016. Electronic supplementary material The online version of this article (10.1186/s12877-018-0901-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Valentina Assi
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jennifer H Barnett
- Cambridge Cognition Ltd, Cambridge, UK.,Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Caoimhe Clarke
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nikki Duncan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jonathan Evans
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Samantha Green
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Kirsty Hendry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Meigan McGinlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jenny McKeever
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Duncan G Middleton
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Stuart Parks
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Robert Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Elaine Tang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Tim Walsh
- Critical Care Medicine and Anaesthesia, University of Edinburgh, Edinburgh, UK
| | - Alexander J Weir
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Elizabeth Wilson
- Critical Care Medicine and Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK. .,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK.
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50
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Burton JK, Lynch E, Reynish EL, MacLullich AMJ, Starr JM, Shenkin SD. 13USING ROUTINE SOCIAL CARE DATA TO EXPLORE CARE HOME ADMISSIONS: A COHORT ANALYSIS OF THE SCOTTISH CARE HOME CENSUS 2013–2016. Age Ageing 2018. [DOI: 10.1093/ageing/afy134.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J K Burton
- Alzheimer Scotland Dementia Research Centre University of Edinburgh
- Centre for Cognitive Ageing and Cognitive Epidemiology University of Edinburgh
- Geriatric Medicine University of Edinburgh
| | - E Lynch
- Health and Social Care Analysis Division Scottish Government
| | - E L Reynish
- Geriatric Medicine University of Edinburgh
- Dementia and Ageing Research Group University of Stirling
| | - A M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology University of Edinburgh
- Geriatric Medicine University of Edinburgh
| | - J M Starr
- Alzheimer Scotland Dementia Research Centre University of Edinburgh
- Centre for Cognitive Ageing and Cognitive Epidemiology University of Edinburgh
- Geriatric Medicine University of Edinburgh
| | - S D Shenkin
- Centre for Cognitive Ageing and Cognitive Epidemiology University of Edinburgh
- Geriatric Medicine University of Edinburgh
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