The Delphi Delirium Management Algorithms. A practical tool for clinicians, the result of a modified Delphi expert consensus approach

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.

Persistent delirium in older hospital patients: an updated systematic review and meta-analysis

Introduction

Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration.

Methods

We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression.

Results

We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months.

Conclusions

This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings.

Intranasal insulin for treatment of delirium in older hospitalised patients: study protocol for a randomised controlled trial

INTRODUCTION

Delirium is one of the most common conditions diagnosed in hospitalised older people and is associated with numerous adverse outcomes, yet there are no proven pharmacological treatments. Recent research has identified cerebral glucose hypometabolism as a pathophysiological mechanism offering a therapeutic target in delirium. Insulin, delivered via the intranasal route, acts directly on the central nervous system and has been shown to enhance cerebral metabolism and improve cognition in patients with mild cognitive impairment and dementia. This trial will determine whether intranasal insulin can reduce the duration of delirium in older hospitalised patients.

METHODS AND ANALYSIS

This is a prospective randomised, placebo-controlled, double-blind study with 6 months follow-up. One hundred patients aged 65 years or older presenting to hospital with delirium admitted under geriatric medicine will be recruited. Participants will be randomised to intranasal insulin detemir or placebo administered twice daily until delirium resolves, defined as Confusion Assessment Method (CAM) negative for 2 days, or discharge from hospital. The primary outcome measure will be duration of delirium using the CAM. Secondary outcome measures will include length of hospital stay, severity of delirium, adherence to treatment, hospital complications, new admission to nursing home, mortality, use of antipsychotic medications during hospital stay and cognitive and physical function at 6 months postdischarge.

ETHICS AND DISSEMINATION

This trial has been approved by the South Eastern Sydney Human Research and Ethics Committee. Dissemination plans include submission to a peer-reviewed journal for publication and presentation at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618000318280.

Virtual models of care for people with palliative care needs living in their own home: A systematic meta-review and narrative synthesis

BACKGROUND

Access to palliative care in the community enables people to live in their preferred place of care, which is often home. Community palliative care services struggle to provide timely 24-h services to patients and family. This has resulted in calls for 'accessible and flexible' models of care that are 'responsive' to peoples' changing palliative care needs. Digital health technologies provide opportunities to meet these requirements 24-h a day.

AIM

To identify digital health technologies that have been evaluated for supporting timely assessment and management of people living at home with palliative care needs and/or their carer(s), and the evidence-base for each.

DESIGN

A systematic review of systematic reviews ('meta-review'). Systematic reviews evaluating evidence for virtual models of palliative or end-of-life care using one or more digital health technologies were included. Systematic reviews were evaluated using the Risk of Bias Tool for Systematic Reviews. A narrative approach was used to synthesise results.

DATA SOURCES

Medline, Embase, Web of Science, CINAHL and Cochrane Database of systematic reviews were searched for English-language reviews published between 2015 and 2020.

RESULTS

The search yielded 2266 articles, of which 12 systematic reviews met criteria. Sixteen reviews were included in total, after four reviews were found via handsearching. Other than scheduled telehealth, video-conferencing, or after-hours telephone support, little evidence was found for digital health technologies used to deliver virtual models of palliative care.

CONCLUSIONS

There are opportunities to test new models of virtual care, beyond telehealth and/or video conferencing, such as 24-h command centres, and rapid response teams.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Prospero CRD42020200266.

Toward best practice methods for delirium biomarker studies: An international modified Delphi study

BACKGROUND

Delirium is a serious and distressing neurocognitive condition common in people with advanced illness. The understanding of delirium pathophysiology is limited and largely hypothetical. To accelerate empirical understanding of delirium pathophysiology, robust scientific methods for conducting and reporting delirium biomarker studies are urgently needed. The aim of this study was to develop international consensus on the core elements of high-quality delirium biomarker studies.

METHODS

A three-round modified Delphi survey was conducted from February to August 2019. Participants were international researchers experienced in conducting delirium studies from a range of settings (hospital, university, research centres). Round one commenced with open-ended questions developed from results from a prior systematic review and the REMARK (REporting recommendations for tumour MARKer prognostic studies) checklist. Responses were qualitatively analysed, and closed statements were developed. Participants then ranked the importance of these statements using a 5-point Likert scale in rounds 2 and 3. A priori consensus was defined as ≥70% participant agreement. Descriptive statistics for each item were computed including the mean Likert scores, SD and median participant scores.

RESULTS

Twenty-eight participants completed survey round one, 16 completed round two and 19 completed the final round. Consensus was achieved for a total of 60 items.

CONCLUSION

The Delphi survey identified items that expert researchers agreed were important in the conduct of delirium biomarker studies. These reporting items provide a strong platform for improved methodological quality and opportunities to synthesise future delirium biomarker studies.

A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes

BACKGROUND

Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis.

METHODS

A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others.

RESULTS

The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting.

CONCLUSION

There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.

Adherence to a multifactorial fall prevention program following paramedic care: Predictors and impact on falls and health service use. Results from an RCT a priori subgroup analysis

OBJECTIVE

To identify predictors and impact of adherence to a multifactorial fall-prevention program on falls and health service utilisation.

METHODS

Randomised controlled trial with a priori subgroup analysis within intervention group according to adherence. Participants were community dwelling, (≥65 years), not transported to hospital following fall-related paramedic care. The Attitudes to Falls-Related Interventions Scale (AFRIS) was completed at baseline, adherence levels were measured (three-point scale) at six months, and falls and health service utilisation were recorded for 12 months. Multivariate logistic regression and area under the curve were calculated with 95% confidence interval (CI).

RESULTS

Attitudes to Falls-Related Interventions Scale scores (n = 85) were independent of baseline characteristics. At six months, 39 (46%) participants reported full adherence. Independent predictors of adherence were positive AFRIS (OR 4.10, 95% CI 1.48-11.39) and receiving 3+ recommendations (OR 3.36, 95% CI 1.26-9.00). Adherers experienced fewer falls (IRR 0.53, 95% CI 0.45-0.80) and fall-related health service use (emergency department presentations IRR 0.37, 95% CI 0.17-0.82) compared to non-adherers.

CONCLUSION

Older adults who adhere to recommendations benefit, regardless of fall-risk profile.

Does ‘Hospital in the Home’ treatment prevent delirium?

Delirium is a common problem, mostly affecting older patients in hospital, which results in greater mortality, nursing-home placement and cognitive and functional impairment. Delirium can be triggered by a wide range of conditions, treatments and procedures, as well as by certain environments. Some hospital environments have been causally implicated, but until it was possible to compare treatment in-hospital with treatment in other places, the observation remained at the level of an association. However, the development of ‘Hospital in the Home’ services has allowed clinicians to explore this question scientifically. Recently, a number of studies comparing treatment of acute conditions, both medical and surgical, and rehabilitation in hospital with treatment at home, have found a lower incidence of delirium with home treatment, as well as lower rates of the sequelae of delirium. Since delirium is an indicator of a wide range of subsequent poor outcomes, this information has broad implications for the delivery of hospital-level services to older patients, and means that health services should seek to provide Hospital in the Home services wherever older patients are treated.

Patient satisfaction: the Australian patient perspective

The literature reveals little Australian academic study of the phenomenon of patient satisfaction and identifies severalproblems in current research practice. A theoretical discussion about the phenomenon of 'patient satisfaction' is for themost part absent, the rigour in the methods applied is often dubious, a definition of patient satisfaction is not agreedand the patient experience is often not the focus of research. To address some of these issues inductive research wasconducted with Australian patients to explore what they considered important for patient satisfaction to exist. A seriesof 52 interviews were conducted with twenty elective surgery patients in an Australian teaching hospital. Patients wereinterviewed on admission to hospital, within one week of discharge from hospital and between six and eight weeksafter discharge. Research with patients identified 16 themes that were important to make a patient's hospital staysatisfactory. Qualitative data have provided a foundation to better understand what 'patient satisfaction' means in itseveryday use. Such an approach is faithful to the concerns and priorities of the patients who are the users of healthcare services.

Implications of decreasing surgical lengths of stay

A recent study at the Prince of Wales Hospital (PoW) compared health outcomes and user satisfaction for conventional clinical pathways with a shortened pathway incorporating day of surgery admission (DOSA), early discharge and post acute care domiciliary visits for two high volume, elective surgical procedures (herniorrhaphy and laparoscopic cholecystectomy). This paper quantifies cost differences between the control and intervention groups for nursing salaries and wages, other ward costs, pathology and imaging. The study verified and measured the lower resource use that accompanies a significant reduction in length of stay (LOS). Costs of pre- and post-operative domiciliary visits were calculated and offset against savings generated by the re-engineered clinical pathway. Average costs per separation were at least $239 (herniorrhaphy) and $265 (laparoscopic cholecystectomy) lower for those on the DOSA pathway with domiciliary post acute care.

Use of pathology services in re-engineered clinical pathways

A significant proportion of pathology tests ordered in hospital are unnecessary. Specific measures targeting the increasing appropriateness of pathology service use have been shown to decrease overall ordering of laboratory tests. However, it is not clear whether general programmes to improve quality of care will have any impact on the use of pathology services. Use of pathology services was compared within two separate prospective controlled clinical trials of re-engineered clinical pathways for both elective (surgical) patients and acute unplanned (medical) admissions. Trial One was a controlled trial of a re-engineered surgical service. Booked patients in the treatment group were admitted on the day of surgery, care was guided by a clinical pathway, and patients were discharged early with domiciliary post-acute care. Controls were admitted on the day before surgery, treated according to usual practice and discharged according to surgeons' preferences. In Trial Two, acute medical patients admitted to hospital through the Emergency Department (ED) were randomised into a treatment (Hospital in the Home) or a control (inpatient) care pathway. In both studies, patients on the re-engineered clinical pathways were well matched demographically and clinically. Health outcomes and satisfaction ratings were comparable. Seventy per cent fewer laboratory tests were ordered in the elective surgery intervention group (P < 0.0001), while the treatment group of the acute medical patients had 25% fewer tests ordered (P = 0.0133). Pooled results also showed a significantly lower rate of test ordering (P < 0.001) for the treatment group (Mann-Whitney U-Wilcoxon ranked sum test). The findings of these audits of controlled, prospective trials suggested overuse of laboratory tests in New South Wales public hospitals, and that savings can be generated by using clinical pathways and applying clinical criteria to the ordering of tests without adversely affecting health outcomes.

Four studies of crisis in parents of prematures. 1965

The responses of 86 families to the birth of a premature baby have been investigated in four linked studies in order to refine the concept and understanding of crisis. Patterns of the grappling behavior during the crisis were identified which enabled accurate predictions of the short-term mental health outcome. Psychological tasks presented by the stress of premature delivery were also identified. The adequacy with which these tasks were accomplished was predictive of the patterns of early maternal care and mother-child relationships. Results indicate that this type of study is relevant to studies of the causation of mental health and mental illness and to preventive intervention. Certain methodologic and research implications are derived from these studies and point to further research effort which is now practical and desirable.

Principles of community psychiatry

Our primary goal in community psychiatry is to satisfy the service needs of a bounded population for whose mental health we have accepted responsibility and accountability. We base our programs on public health practice models: These direct us to focus on segments of our population which are currently exposed to harmful biopsycho-social factors that increase their risk of becoming mentally ill. We focus on preventing psychosocial problems or their consequences by reducing their population rates: either the incidence of new cases (primary prevention), the prevalence of all existing cases (secondary prevention), and the rates of residual disability (tertiary prevention). We increase our efficiency and effectiveness by organizing our program on the basis of crisis theory which demands that we reach out to people in crisis and provide them with immediate guidance and help to master their current difficulties during the short period when they are open to influence and amenable to change in ways that have long term mental health consequences. We spread our own influence by organizing support groups and we multiply many-fold our impact on the huge problems involved in covering the needs of our population by recruiting the collaboration of other professional caregivers and non-professional helpers. We enhance the mental health component in the daily work of all caregiving agencies and institutions and individual professionals in the community through education and mental health consultation and collaboration. We also reach out to assist non-professional caregiving individuals and organizations, especially those who provide mutual help to fellow sufferers. In our latest work we are currently identifying harmful practices in our caregiving systems that actually harm those people whom we are trying to help. We are in the process of developing methods for reducing this system-generated damage.

Decreasing lengths of stay: the cost to the community

BACKGROUND

Patients who are discharged earlier from hospital frequently require support from professional and unpaid carers at home after discharge. Hospitals save money per patient by discharging earlier, but it is not known whether the costs to community services and unpaid caters outweigh the savings to the hospital.

METHODS

We prospectively studied the total costs, patient satisfaction, time off work and pain scores of 224 patients who underwent elective herniorrhaphy or laparoscopic cholecystectomy and who lived locally before and after re-engineering the elective surgical service. The components of the re-engineered surgical service were a peri-operative unit, pre-admission anaesthetic assessment based on self-reported questionnaires, day of surgery admissions, enhanced patient education, clinical pathways, and post-acute care.

RESULTS

The patients treated through the re-engineered surgical service had a significantly shorter length of stay (LOS) (mean LOS: 2.2 vs 3.2 days; P < 0.001) but neither they nor their carers required more time off work. Significant determinants of time off work were smoking, heavy lifting at work and a higher pain score at day 7. Patients treated through the re-engineered surgical service recorded significantly higher satisfaction with their treatment. The cost saving to the hospital outweighed the cost of increased services provided in the community, so that the overall cost of providing treatment was over $200 less per patient through the re-engineered service.

CONCLUSIONS

This study demonstrates that changes in care provision that result in shorter LOS and greater cost effectiveness may better meet patients' needs than existing systems.

Effect of hormone replacement therapy on left ventricular hypertrophy

The mechanisms behind the reduction in cardiovascular morbidity and mortality in postmenopausal women receiving hormone replacement therapy are not fully understood. In this case-control study, we report a statistically significant lower left ventricular mass in a group of elderly women who were receiving hormone replacement therapy for >10 years than in age-matched controls.

A post-acute respiratory outreach service

This paper describes an outreach nursing service for patients discharged from a Sydney hospital after treatment for an acute episode of chronic airflow limitation (CAL) and people referred for early exacerbation of the condition. In its first two years, 395 patients received the home-based service. The readmission rate of these patients within 28 days of discharge was approximately half that of the hospital's CAL patients in the year before the service was available. The cost of the outreach service in 1994-5 and 1995-6 was 36% and 61% lower respectively than the cost of hospitalizing the estimated 57 patients whose admission or readmission to hospital was avoided because their conditioned was managed at home by the outreach service.

Organization of preventive psychiatry programs

Primary prevention seeks to lower the rate of new cases of psychosocial disorder in a high risk population by reducing the impact of pathogenic life stressors, and by increasing psychosocial supports that enable people to master their adversity in healthy ways. The organization of such a program in Jerusalem is described. It seeks to prevent psychosocial disorders in children of divorced parents. The entire population at risk is contacted in order to reach out to the subpopulation who are unable to cope on their own, but who can be helped to master their difficulties by the coordinated efforts of community caregivers.

Loss, stress, and mental health

1. The loss of an attachment to a loved person or of some other significant attachment leads to a prolonged period of distress and disability. 2. The upset feelings are usually associated with reduction in cognitive effectiveness and problem-solving capacity, the magnitude of which is dependent on the intensity and duration of emotional arousal. There is a reduced capacity for collecting and processing information and for access to relevant memories that associate significant meaning to perceptions. There is also a deterioration in the clarity of the person's self-concept and in his capacity to assess his ability to persevere in the face of discomfort, which weakens his will to struggle. 3. The disability following loss of an attachment is the product of three interlocking factors: (a) the pain of the rupture in the bond and the agony of coming to terms with this reality, (b) the handicapping privation of the missing assets previously derived from the lost person or resource, and (c) the cognitive erosion and reduction in problem-solving capacities and of the will to persevere. 4. These factors may lead to poor mental health in the form of an acute adjustment disorder, or else of chronic psychopathology if the individual uses maladaptive ways of trying to escape his burdens through alienation from reality or through the irrational mechanisms of psychoneurotic symptoms, or if prolonged emotional tension leads to malfunctioning of a bodily system. On the other hand, if the individual masters his problems by working out ways of effective coping, he may emerge from the experience with increased competence and resilience. 5. Eventual mastery of the burdensome experience involves reorganization of the individual's "assumptive world," namely of his intrapsychic maps of external reality and his internal system for guiding and motivating his behavior, which have been disorganized by the loss of their anchorage in the ruptured attachment. 6. This reorganization is helped by the following: a. The maintenance of hope of eventual personal mastery that provides a basis for continued striving. b. Regular activity through adhering to a daily schedule of work and social interaction, even though this initially provides little emotional satisfaction and seems empty and meaningless. c. Seeking support from other people in compensating for current deficits and in helping lower the intensity of emotional arousal. d. Repeatedly remembering the values and guidance the person used to derive from the old attachments.(ABSTRACT TRUNCATED AT 400 WORDS)

Mastery of stress: psychosocial aspects

Psychological stress may increase an individual's vulnerability to mental and physical illness. This may be prevented if the individual receives social support in mastering the stressful situation in the form of cognitive guidance that compensates for the inevitable reduction in his problem-solving capacity caused by stress-induced emotional arousal. This guidance should also help the individual or compensate for this arousal and enable him to come to terms with inescapable changes in his life produced by the experience. Empirical researches confirm that exposure to high stress by individuals receiving adequate support does not increase the risk of mental and physical illness.

The psychologically orientated pediatrician and the provision of psychoanalytic psychotherapy

The experiences of a consultant pediatrician attempting to introduce into his practice an additional mode of treatment that he wished to offer to some of his patients, namely psychoanalytical psychotherapy, is described. Having previously operated successfully as an analytic psychotherapist with patients referred to him by a child psychiatrist, he attempted to function formally as an analytic psychotherapist with selected patients from his own pediatric practice. However, this significant change of role was not accepted by the children and their parents. Reasons are looked for to explain this finding, the significance of which may be of importance to pediatric practice in general and may have wider implications in the whole area of the doctor/patient relationship.

An approach to preventive intervention in child psychiatry

A conceptual model for primary prevention is proposed. Its five elements are (1) Risk Factors that increase the likelihood of (2) eventual Mental Disorder contingent upon (3) intervening psychological stresses that promote Crises, which the individual may master more or less effectively dependent on (4) his current psychological Competence and (5) the powerful influence of Social Supports. The paper summarizes recent preventive intervention efforts and evaluative studies that focus on these elements in seeking to reduce psychiatric disorders in child populations: reduction of risk factors through mental health consultation and collaboration by mental health clinicians with child care workers and administrators; improvement of competence in children t risk by special educational programs with children and their parents that seek to enhance their cognitive and emotional programs with children and their parents that seek to enhance their cognitive and emotional problem-solving and coping skills; crisis intervention for children and their families by anticipatory guidance and preventive intervention; and fostering protective social supports by convening supportive groups for persons in need, and organizing mutual help groups, both of which seek to provide individuals under stress with help with emotional reequilibrium and cognitive guidance to compensate for capacities that are usually temporalily eroded by the upheaval of crisis.