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BMC Geriatrics Feb 2019Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a...
BACKGROUND
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.
METHODS
A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.
RESULTS
One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0-1.7, p = 0.034).
CONCLUSIONS
Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.
Topics: Aged; Aged, 80 and over; Anti-Bacterial Agents; Bacteriuria; Delirium; Evidence-Based Medicine; Female; Humans; Male; Nursing Homes; Risk; Urinary Tract Infections
PubMed: 30717706
DOI: 10.1186/s12877-019-1049-7 -
Journal of Neurology Dec 2023Our systematic review examines the effectiveness and safety of non-pharmacologic and pharmacologic interventions in preventing or treating traumatic brain injury...
BACKGROUND
Our systematic review examines the effectiveness and safety of non-pharmacologic and pharmacologic interventions in preventing or treating traumatic brain injury (TBI)-related delirium in acute care.
METHODS
We searched four electronic databases (MEDLINE, EMBASE, CENTRAL/CDSR, and PsycINFO) to identify randomized controlled trials (RCTs), quasi-experimental, and observational studies. Eligible studies included adults with TBI, at least one comparator group, delirium as an outcome and took place in acute care. Two reviewers independently completed all study screening, data abstraction, and risk of bias assessment using the Cochrane risk of bias 2 tool for RCTs or risk of bias in non-randomized studies-of interventions tool for observational studies. We implemented the PROGRESS-Plus framework to describe social determinants of health (SDoH) reporting.
RESULTS
We identified 20,022 citations, reviewed 301 in full text, and included eight studies in the descriptive synthesis. The mean age of study participants ranged from 32 to 62 years. 12.5% of included studies reported SDoH. Included studies had moderate-to-high risk of bias. Studies compared reorientation programs and an intervention bundle to usual care, but these interventions were not better than usual care in treating TBI-related delirium. Individual studies found that rosuvastatin and aripiprazole were more efficacious than placebo, and dexmedetomidine was more efficacious than propofol and haloperidol for preventing TBI-related delirium. No studies reported safety as the primary outcome.
CONCLUSIONS
We identified efficacious pharmacologic interventions for preventing TBI-related delirium, but these studies were at moderate-to-high risk of bias, which limits our confidence in these findings. Future studies should incorporate safety outcomes, and a diverse study population, including older adults.
Topics: Humans; Aged; Adult; Middle Aged; Haloperidol; Brain Injuries, Traumatic; Propofol; Delirium
PubMed: 37634162
DOI: 10.1007/s00415-023-11889-7 -
European Journal of Oncology Nursing :... Dec 2023Delirium is a prevalent neuropsychiatric syndrome in older people with cancer. However, there are no meta-analyses assessing its incidence exclusively in this... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Delirium is a prevalent neuropsychiatric syndrome in older people with cancer. However, there are no meta-analyses assessing its incidence exclusively in this population. This study aims to assess the incidence proportion of delirium in older people with cancer in the hospital area.
METHODS
A systematic review and meta-analysis were carried out. MEDLINE, Scopus, and EBSCO were searched from inception to December 2021. PRISMA guidelines were followed. Inclusion criteria were original peer-reviewed studies with experimental (randomised controlled trials), observational, and cross-sectional designs assessing delirium older inpatients (≥65 years) with oncological diseases in medical and post-surgical hospital areas and using validated screening or diagnostic methods. A web-based system was used to manage the screening process. Study quality was assessed with Joanna Briggs Institute Critical Appraisal tools. The statistical analysis was performed in RevMan v5.4.0 (Cochrane Collaboration, Oxford, UK), using a random-effects model to calculate incidence and 95% confidence intervals (CIs).
RESULTS
Based on 37 included articles, the incidence proportion of delirium ranged from 3.8% to 61.4%, in a total of 11,847 older patients with cancer. Meta-analysis showed a pooled incidence of 22.6% (95% confidence interval 18.5%, 26.7%; I = 97%, p < 0.001). The main tools for detection were the Diagnostic Statistical Manual criteria and the Confusion Assessment Methods scale.
CONCLUSIONS
The incidence proportion of delirium in older inpatients with cancer is 22.6%. Incidence in the medical setting was higher than in the post-surgical areas. There is a need for high-quality studies examining delirium in older people with cancer.
Topics: Humans; Aged; Delirium; Incidence; Cross-Sectional Studies; Neoplasms
PubMed: 37976755
DOI: 10.1016/j.ejon.2023.102457 -
Therapeutic Advances in... 2023As an atypical antipsychotic drug, olanzapine is one of the most commonly used drugs for delirium control. There are no systematic evaluations or meta-analyses of the...
BACKGROUND
As an atypical antipsychotic drug, olanzapine is one of the most commonly used drugs for delirium control. There are no systematic evaluations or meta-analyses of the efficacy and safety of olanzapine for delirium control in critically ill adults.
OBJECTIVES
In this meta-analysis, we evaluated the efficacy and safety of olanzapine for delirium control in critically ill adults in the intensive care unit (ICU).
DATA SOURCES AND METHODS
From inception to October 2022, 12 electronic databases were searched. We retrieved randomized controlled trials (RCTs) and retrospective cohort studies of critically ill adults with delirium that compared the effects of olanzapine and other interventions, including routine care (no intervention), nonpharmaceutical interventions and pharmaceutical interventions. The main outcome measures were the (a) relief of delirium symptoms and (b) a decrease in delirium duration. Secondary outcomes were ICU and in-hospital mortality, ICU and hospital length of stay, incidence of adverse events, cognitive function, sleep quality, quality of life, mechanical ventilation time, endotracheal intubation rate and delirium recurrence rate. We applied a random effects model.
RESULTS
Data from 10 studies (four RCTs and six retrospective cohort studies) involving 7076 patients (2459 in the olanzapine group and 4617 in the control group) were included. Olanzapine did not effectively relieve delirium symptoms (OR = 1.36, 95% CI [0.83, 2.28], = 0.21), nor did it shorten the duration of delirium [standardized mean difference (SMD) = 0.02, 95% CI [-1.04, 1.09], = 0.97] when compared with other interventions. Pooled data from three studies showed that the use of olanzapine reduced the incidence of hypotension (OR = 0.44, 95% CI [0.20, 0.95], = 0.04) compared with other pharmaceuticals. There was no significant difference in other secondary outcomes, including ICU or hospital length of stay, in-hospital mortality, extrapyramidal reactions, QTc interval prolongation, or overall incidence of other adverse reactions. The number of included studies was not sufficient for performing a comparison between olanzapine and no intervention.
CONCLUSION
Compared with other interventions, olanzapine has no advantage in alleviating delirium symptoms and shortening delirium duration in critically ill adults. However, there is some evidence that the rate of hypotension was lower in patients who received olanzapine than in those who received other pharmaceutical interventions. There was a nonsignificant difference in the length of ICU or hospital stay, in-hospital mortality, and other adverse reactions. This study provides reference data for delirium research and clinical drug intervention strategies in critically ill adults.
REGISTRATION
Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42021277232).
PubMed: 36845642
DOI: 10.1177/20451253231152113 -
Ageing Research Reviews Sep 2023Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been... (Meta-Analysis)
Meta-Analysis Review
Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P = .01) and Nu-DESC 0.99 vs 0.90, P = .003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings.
Topics: Humans; Female; Aged; Delirium; Reproducibility of Results; Sensitivity and Specificity; Diagnostic and Statistical Manual of Mental Disorders
PubMed: 37527704
DOI: 10.1016/j.arr.2023.102025 -
Cancers May 2023The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main... (Review)
Review
BACKGROUND
The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages.
OBJECTIVE
To determine which delirium screening instrument is the most accurate in older people with cancer.
METHODS
A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded.
RESULTS
From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group.
CONCLUSIONS
Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.
PubMed: 37345143
DOI: 10.3390/cancers15102807 -
Journal of Clinical Anesthesia Nov 2023To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients.
DESIGN
A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022.
SETTING
Postoperative assessments.
PATIENTS
Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded.
MEASUREMENTS
Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI.
MAIN RESULTS
Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00).
CONCLUSIONS
Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
Topics: Humans; Aged; Emergence Delirium; Delirium; Hospitalization; Postoperative Complications; Length of Stay
PubMed: 37515876
DOI: 10.1016/j.jclinane.2023.111221 -
Journal of Neurosciences in Rural... Apr 2021Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher... (Review)
Review
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were "delirium," "delirious," "delirium tremens" AND "India." No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms "delirium," "delirious," "delirium tremens" in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( = 81), and these were followed by, case reports ( = 58), review articles ( = 10), letter to the editor (not as case reports but as a communication; = 13), editorials ( = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
PubMed: 33927516
DOI: 10.1055/s-0041-1725211 -
BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
The American Journal of Emergency... Sep 2022In the emergency department, delirium associated with serious adverse outcomes is common in geriatric patients. We performed a meta-analysis and estimated the prevalence... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In the emergency department, delirium associated with serious adverse outcomes is common in geriatric patients. We performed a meta-analysis and estimated the prevalence of delirium and its related factors among geriatric emergency department patients.
METHODS
PubMed, Embase, Web of Science, Cochrane Library, CINAHL, PsycINFO, and CBM databases were searched before November 7, 2021. The random-effects model was used to estimate the prevalence of delirium. In addition, subgroup analyses were performed based on continent or region, publication year, age, sample size, and diagnostic criteria or assessment methods.
RESULTS
30 studies involving 19,534 geriatric patients in the emergency department were included. The overall pooled crude prevalence estimate of delirium was 15.2% [95% confidence interval (CI) 12.5-18.0%]. Subgroup analyses revealed that the region, publication year, age, sample size, and delirium assessment methods were significantly correlated with the prevalence of delirium. Meta-regression analysis showed that the publication year was positively, while the sample size was negatively associated with the pooled prevalence of delirium.
CONCLUSION
In the emergency department, delirium is common in geriatric patients. We should pay specific attention to delirium screening, prevention, and treatment in geriatric patients. Overall appropriate interventions should be utilized to reduce the occurrence of delirium and the adverse outcomes.
Topics: Aged; Delirium; Emergency Service, Hospital; Humans; Mass Screening; Prevalence
PubMed: 35841845
DOI: 10.1016/j.ajem.2022.05.058