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International Journal of Geriatric... Nov 2018Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established...
Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.
Topics: Biomedical Research; Clinical Trials as Topic; Delirium; Evidence-Based Medicine; Humans
PubMed: 28271556
DOI: 10.1002/gps.4696 -
American Journal of Physical Medicine &... Oct 2018Delirium is an acute and fluctuating disturbance in cognition attention and awareness that is often a reflection of abnormal physiological condition of an individual.... (Review)
Review
Delirium is an acute and fluctuating disturbance in cognition attention and awareness that is often a reflection of abnormal physiological condition of an individual. Delirium is highly prevalent among an older population and is associated with high mortality, poor medical and functional outcomes, and high healthcare cost. Delirium often has iatrogenic triggers, and it has been recognized as a quality indicator of healthcare organizations. Despite its high prevalence and significance, more than 50% of the delirium cases are underrecognized by healthcare professionals and remained untreated. Most patients in inpatient rehabilitation facilities are older adults with multiple risk factors for delirium including operation, intensive care stay, multiple co-morbidities, and impaired mobility. Early detection, intervention, and primary prevention of delirium will allow patients to avoid additional morbidities and reach their maximum functional potential during their rehabilitation stay. After the systematic implementation of delirium screening in our inpatient rehabilitation facility, we found that 10.3% of patients were screened positive for delirium at admission. This review discusses the systematic implementation of screening and intervention for delirium as well as the epidemiology of delirium to increase the awareness and guide clinical practice for clinicians in inpatient rehabilitation facilities.
Topics: Aged; Delirium; Disease Management; Early Diagnosis; Female; Health Plan Implementation; Humans; Inpatients; Male; Mass Screening; Middle Aged; Prevalence; Rehabilitation Centers; Risk Factors
PubMed: 29742533
DOI: 10.1097/PHM.0000000000000962 -
Dementia and Geriatric Cognitive... 2022The large number of heterogeneous instruments in active use for identification of delirium prevents direct comparison of studies and the ability to combine results. In a...
INTRODUCTION
The large number of heterogeneous instruments in active use for identification of delirium prevents direct comparison of studies and the ability to combine results. In a recent systematic review we performed, we recommended four commonly used and well-validated instruments and subsequently harmonized them using advanced psychometric methods to develop an item bank, the Delirium Item Bank (DEL-IB). The goal of the present study was to find optimal cut-points on four existing instruments and to demonstrate use of the DEL-IB to create new instruments.
METHODS
We used a secondary analysis and simulation study based on data from three previous studies of hospitalized older adults (age 65+ years) in the USA, Ireland, and Belgium. The combined dataset included 600 participants, contributing 1,623 delirium assessments, and an overall incidence of delirium of about 22%. The measurements included the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnostic criteria for delirium, Confusion Assessment Method (long form and short form), Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98 (total and severity scores), and Memorial Delirium Assessment Scale (MDAS).
RESULTS
We identified different cut-points for each existing instrument to optimize sensitivity or specificity, and compared instrument performance at each cut-point to the author-defined cut-point. For instance, the cut-point on the MDAS that maximizes both sensitivity and specificity was at a sum score of 6 yielding 89% sensitivity and 79% specificity. We then created four new example instruments (two short forms and two long forms) and evaluated their performance characteristics. In the first example short form instrument, the cut-point that maximizes sensitivity and specificity was at a sum score of 3 yielding 90% sensitivity, 81% specificity, 30% positive predictive value, and 99% negative predictive value.
DISCUSSION/CONCLUSION
We used the DEL-IB to better understand the psychometric performance of widely used delirium identification instruments and scorings, and also demonstrated its use to create new instruments. Ultimately, we hope that the DEL-IB might be used to create optimized delirium identification instruments and to spur the development of a unified approach to identify delirium.
Topics: Aged; Delirium; Diagnostic and Statistical Manual of Mental Disorders; Humans; Psychometrics; Reproducibility of Results; Sensitivity and Specificity
PubMed: 35533663
DOI: 10.1159/000522522 -
Annals of Neurology Dec 2023Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative...
OBJECTIVE
Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients.
METHODS
Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR).
RESULTS
Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = -0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [-0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03-1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09-1.22, p < 0.001).
INTERPRETATION
Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024-1035.
Topics: Humans; Female; Aged; Male; Delirium; Blood-Brain Barrier; Postoperative Complications; Emergence Delirium; Risk Factors; Organometallic Compounds
PubMed: 37615660
DOI: 10.1002/ana.26771 -
Lakartidningen Mar 2018
Topics: Delirium; Humans; Quality of Health Care; Sweden
PubMed: 29558009
DOI: No ID Found -
BMJ Open Jun 2023Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes.
DESIGN
Prospective randomised controlled trial.
SETTING
Single centre, conducted at the neurosurgical department of the Erasmus Medical Center, Rotterdam, the Netherlands.
PARTICIPANTS
Adult patients undergoing craniotomy were eligible.
INTERVENTIONS
Patients in the intervention group received preferred recorded music before, during and after the operation until day 3 after surgery. Patients in the control group were treated according to standard of clinical care.
PRIMARY AND SECONDARY OUTCOME MEASURES
Primary outcome was presence or absence of postoperative delirium within the first 5 postoperative days measured with the Delirium Observation Screening Scale (DOSS) and, in case of a daily mean score of 3 or higher, a psychiatric evaluation with the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Secondary outcomes included anxiety, heart rate variability (HRV), depth of anaesthesia, delirium severity and duration, postoperative complications, length of stay and location of discharge.
RESULTS
We enrolled 189 patients (music=95, control=94) from July 2020 through September 2021. Delirium, as assessed by the DOSS, was less common in the music (n=11, 11.6%) than in the control group (n=21, 22.3%, OR:0.49, p=0.048). However, after DSM-5 confirmation, differences in delirium were not significant (4.2% vs 7.4%, OR:0.47, p=0.342). Moreover, music increased the HRV (root mean square of successive differences between normal heartbeats, p=0.012). All other secondary outcomes were not different between groups.
CONCLUSION
Our results support the efficacy of music in reducing the incidence of delirium after craniotomy, as found with DOSS but not after DSM-5 confirmation, substantiated by the effect of music on preoperative autonomic tone. Delirium screening tools should be validated and the long-term implications should be evaluated after craniotomy.
TRIAL REGISTRATION NUMBER
Trialregister.nl: NL8503 and ClinicalTrials.gov: NCT04649450.
Topics: Adult; Humans; Music; Neurosurgery; Prospective Studies; Delirium; Neurosurgical Procedures
PubMed: 37369412
DOI: 10.1136/bmjopen-2022-069957 -
Anesthesiology Nov 2023
Topics: Humans; Hypnotics and Sedatives; Emergence Delirium; Dexmedetomidine; Delirium; Postoperative Complications
PubMed: 37589555
DOI: 10.1097/ALN.0000000000004659 -
Clinical Neurophysiology : Official... May 2020Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our...
OBJECTIVE
Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our understanding of development of delirium, we studied whether non-delirious individuals with a predisposition for delirium also show these EEG abnormalities.
METHODS
Elderly subjects (N = 206) underwent resting-state EEG measurements and were assessed on predisposing delirium risk factors, i.e. older age, alcohol misuse, cognitive impairment, depression, functional impairment, history of stroke and physical status. Delirium-related EEG characteristics of interest were relative delta power, alpha connectivity strength (phase lag index) and network integration (minimum spanning tree leaf fraction). Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and EEG characteristics that are associated with delirium, adjusting for confounding and multiple testing.
RESULTS
Functional impairment was related to a decrease in connectivity strength (adjusted R = 0.071, β = 0.201, p < 0.05). None of the other risk factors had significant influence on EEG delta power, connectivity strength or network integration.
CONCLUSIONS
Functional impairment seems to be associated with decreased alpha connectivity strength. Other predisposing risk factors for delirium had no effect on the studied EEG characteristics.
SIGNIFICANCE
Predisposition for delirium is not consistently related to EEG characteristics that can be found during delirium.
Topics: Aged; Brain; Cross-Sectional Studies; Delirium; Electrocardiography; Electroencephalography; Female; Humans; Male; Nerve Net
PubMed: 32199395
DOI: 10.1016/j.clinph.2020.01.023 -
Critical Care (London, England) Sep 2021Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes... (Review)
Review
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
Topics: Classification; Delirium; Humans; Phenotype; Risk Factors
PubMed: 34526093
DOI: 10.1186/s13054-021-03752-w -
Acta Medica Portuguesa Jan 2018Delirium is an acute, transient and fluctuating neuropsychiatric syndrome that is common in medical wards, particularly in the geriatric and palliative care population. (Review)
Review
INTRODUCTION
Delirium is an acute, transient and fluctuating neuropsychiatric syndrome that is common in medical wards, particularly in the geriatric and palliative care population.
MATERIAL AND METHODS
We present a brief literature review of the definition, pathophysiology, aetiology, diagnosis, prevention and treatment of delirium and its social and economic impact.
RESULTS AND DISCUSSION
Delirium is under-recognized, especially by health professionals, and is associated with higher morbidity, mortality and economic burden. Moreover, the presence of delirium interferes with the evaluation and approach to other symptoms. Furthermore, it causes significant distress in patient's families and health professionals. The best treatment for delirium is prevention which is based on multidisciplinary interventions that addresses the main risk factors. The scientific evidence for the treatment of delirium is scarce. Non-pharmacological approaches are usually the first choice, and includes environmental, behavioural and social strategies. Pharmacological options, mainly antipsychotics, are a second-line treatment used essentially to prevent self harm.
CONCLUSION
The recognition and prevention of delirium are crucial. Health professional education and training, patient clinical monitoring and families support are mandatory. Considering the impact of delirium on patients, relatives, health services and professionals we must be more aware of delirium and, why not, make it the 7th vital sign.
Topics: Algorithms; Delirium; Humans; Vital Signs
PubMed: 29573769
DOI: 10.20344/amp.9670