Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series

DESCRIPTION

The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium.

OBJECTIVES

To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations.

METHODS

A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations.

RESULTS

The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards).

CONCLUSIONS

Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.

Genomic gain at 6p21: a new cryptic molecular rearrangement in secondary myelodysplastic syndrome and acute myeloid leukemia

Fluorescence in situ hybridization and comparative genomic hybridization characterized 6p rearrangements in eight primary and in 10 secondary myeloid disorders (including one patient with Fanconi anemia) and found different molecular lesions in each group. In primary disorders, 6p abnormalities, isolated in six patients, were highly heterogeneous with different breakpoints along the 6p arm. Reciprocal translocations were found in seven. In the 10 patients with secondary acute myeloid leukemia/myelodysplastic syndrome (AML/MDS), the short arm of chromosome 6 was involved in unbalanced translocations in 7. The other three patients showed full or partial trisomy of the 6p arm, that is, i(6)(p10) (one patient) and dup(6)(p) (two patients). In 5/7 patients with unbalanced translocations, DNA sequences were overrepresented at band 6p21 as either cryptic duplications (three patients) or cryptic low-copy gains (two patients). In the eight patients with cytogenetic or cryptic 6p gains, we identified a common overrepresented region extending for 5-6 megabases from the TNF gene to the ETV-7 gene. 6p abnormalities were isolated karyotype changes in four patients. Consequently, in secondary AML/MDS, we hypothesize that 6p gains are major pathogenetic events arising from acquired and/or congenital genomic instability.