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General Hospital Psychiatry 2023Delirium is a complex and heterogeneous condition that significantly affects patient outcome. This study aimed to conduct a systematic review and meta-analysis to... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Delirium is a complex and heterogeneous condition that significantly affects patient outcome. This study aimed to conduct a systematic review and meta-analysis to investigate the effects of melatonin and melatonin receptor agonists (MRAs) on delirium prevention and treatment.
METHOD
Randomized controlled studies, using MRAs as an intervention and placebo as a control were included. We conducted meta-analyses with random-effects model and trial sequential analysis.
RESULTS
A total of 33 studies involving 4850 participants were included. The meta-analysis revealed a significant preventive effect of MRAs on delirium (risk ratio = 0.65, p < 0.01), while no significant therapeutic effect was observed. Additionally, MRAs were associated with a significant reduction in mortality rate (risk ratio = 0.90, p = 0.02) in delirium prevention studies. Furthermore, subgroup analyses revealed that assessment scales and the frequency of delirium detection may be significant moderators of the delirium-preventive efficacy of MRAs.
CONCLUSION
This study provides evidence of the potential effects of MRAs in preventing delirium and reducing mortality. Further research is required to elucidate the therapeutic potential of MRAs for delirium and identify specific patient populations that may benefit from this agent.
Topics: Humans; Delirium; Receptors, Melatonin; Randomized Controlled Trials as Topic; Hypnotics and Sedatives; Melatonin
PubMed: 37826886
DOI: 10.1016/j.genhosppsych.2023.08.011 -
Age and Ageing Apr 2024Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review the association between pain (at rest, movement, pain severity) and delirium in this population.
METHODS
PubMed, EMBASE, CINAHL, PsycINFO, Cochrane and Web of Science were searched (January 1982-November 2022) for Medical Subject Heading terms and synonyms ('Pain', 'Analgesic', 'Delirium'). Study eligibility: (1) validated pain measure as exposure, (2) validated delirium tool as an outcome; participant eligibility: (1) medical or surgical (planned/unplanned) inpatients, (2) admission length ≥ 48 h and (3) median cohort age over 65 years. Study quality was assessed with the Newcastle Ottawa Scale. We collected/calculated odds ratios (ORs) for categorical data and standard mean differences (SMDs) for continuous data and conducted multi-level random-intercepts meta-regression models. This review was prospectively registered with PROSPERO [18/5/2020] (CRD42020181346).
RESULTS
Thirty studies were selected: 14 reported categorical data; 16 reported continuous data. Delirium prevalence ranged from 2.2 to 55%. In the multi-level analysis, pain at rest (OR 2.14; 95% confidence interval [CI] 1.39-3.30), movement (OR 1.30; 95% CI 0.66-2.56), pain categorised as 'severe' (OR 3.42; 95% CI 2.09-5.59) and increased pain severity when measured continuously (SMD 0.33; 95% CI 0.08-0.59) were associated with an increased delirium risk. There was substantial heterogeneity in both categorical (I2 = 0%-77%) and continuous analyses (I2 = 85%).
CONCLUSION
An increase in pain was associated with a higher risk of developing delirium. Adequate pain management with appropriate analgesia may reduce incidence and severity of delirium.
Topics: Humans; Aged; Inpatients; Pain; Pain Management; Hospitals; Delirium
PubMed: 38610062
DOI: 10.1093/ageing/afae073 -
Nursing in Critical Care Sep 2023Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients.
AIM
This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients.
STUDY DESIGN
A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI.
RESULTS
We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001).
CONCLUSION
This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS.
RELEVANCE TO CLINICAL PRACTICE
These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.
Topics: Humans; Critical Illness; Network Meta-Analysis; Delirium; Intensive Care Units; Critical Care
PubMed: 35624556
DOI: 10.1111/nicc.12780 -
European Geriatric Medicine Apr 2024Delirium has been recognized as an atypical presenting feature of COVID-19 in older adults and is independently associated with mortality. We aimed to perform an updated... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Delirium has been recognized as an atypical presenting feature of COVID-19 in older adults and is independently associated with mortality. We aimed to perform an updated systematic review of the literature and proportional meta-analysis to assess prevalence and incidence of delirium in older adults with COVID-19, addressing differences according to sex, frailty status, and settings.
METHODS
We searched databases for English-language articles on prevalence and incidence of delirium in older adults with COVID-19, published between March 2020 and January 2023.
RESULTS
Of the 1171 articles identified, 66 met selection criteria and were included in the meta-analysis (n = 35,035 participants, age-range 66-90 years old, 46.6% females). We observed similar pooled prevalence (20.6% [95% Confidence Interval (CI) 17.8-23.8%]) and incidence (21.3% [95% CI 14.7-30%]) of delirium. Pooled occurrence (both prevalence and incidence) of delirium was similar according to sex (females 21.3% [95% CI 16-27.5%] vs. males 23.8%% [95% CI 18.2-30.4%], p-value = 0.55) and study setting (nursing homes 22.5% [95% CI 14.2-33.6%] vs. hospital 20.3% [95% CI 17-24%], p = 0.68), but it was significantly higher in frail versus non-frail patients (37% [95% CI 26.6-48.8%] vs. 12.5% [95% CI 7.8-19.6%], p-value < 0.01). Delirium definitions and assessment tools largely varied across studies.
CONCLUSION
This review delineates delirium as a common feature of COVID-19, particularly in frail older adults, and supports its formal inclusion among COVID-19 symptoms. The considerable heterogeneity in delirium assessment highlights the need for an operational strategy to standardize definitions and tools utilization in the management of frail older adults.
Topics: Male; Female; Aged; Humans; Aged, 80 and over; COVID-19; Pandemics; Frail Elderly; Frailty; Delirium
PubMed: 38498073
DOI: 10.1007/s41999-023-00906-7 -
Indian Journal of Critical Care... Sep 2023Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic... (Review)
Review
INTRODUCTION
Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic use of melatonin and melatonergics has been shown to have a positive effect in reducing the incidence of delirium in many clinical trials. Our study was thus proposed to find out the role of melatonin on the incidence and severity of ICU delirium, ICU and hospital length of stay (LOS), requirement, duration of mechanical ventilation, and ICU mortality.
METHODOLOGY
A systematic search of various databases was performed to find out the trials which compare melatonin with a placebo or standard therapy for delirium prevention with the results conveyed as mean differences (MDs) or risk ratios. The statistical software, Review Manager (RevMan, version 5.4), was used for data synthesis.
RESULTS
Twelve studies were included in the meta-analysis. Prophylactic administration of melatonin or ramelteon was not associated with a statistically significant reduction in the incidence of delirium (odds ratio [OR] 0.63; confidence interval [CI]: 0.60, 1.32; = 0.22), the severity of delirium (MD: 0.22; 95% CI: From -1.36 to 1.81; = 0.78), ICU LOS (MD: 0.05; 95% CI: From -0.65 to 0.75; = 0.89), hospital LOS (MD: -1.46; 95% CI: From -4.50 to -1.59; = 0.35), need for mechanical ventilation (OR: 0.74, 95% CI: 0.38-1.44; = 0.37), and ICU mortality (MD: 0.78; 95% CI: 0.56; 1.11; = 0.62). However, a significant reduction in the duration of mechanical ventilation (MD: -0.85; 95% CI: From -1.64 to -0.06; = 0.03) was found.
CONCLUSION
Our meta-analysis suggests that melatonin when given prophylactically has no significant role in reducing the incidence and severity of delirium, ICU and hospital LOS, need for mechanical ventilation, duration of mechanical ventilation, and ICU mortality. Further studies are warranted.
HOW TO CITE THIS ARTICLE
Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023;27(9):675-685.
PubMed: 37719343
DOI: 10.5005/jp-journals-10071-24529 -
Frontiers in Pediatrics 2023This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic... (Review)
Review
A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care.
INTRODUCTION
This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence.
METHODS
A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations.
RESULTS
A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence.
CONCLUSION
This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).
PubMed: 37868267
DOI: 10.3389/fped.2023.1264717 -
Heart & Lung : the Journal of Critical... 2024The use of sedative and analgesic drugs during non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is controversial. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of sedative and analgesic drugs during non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is controversial.
OBJECTIVES
To assess the clinical effectiveness of sedative and analgesic medications used during NIV for patients with ARF to no sedation or analgesia. In addition, to investigate the characteristics of dexmedetomidine in comparison to other medications.
METHODS
PubMed, Embase, Web of Science, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched. Mean differences (MDs) or pooled risk ratios (RRs) were computed using random-effects models. We applied the Cochrane risk-of-bias assessment tool 2.0 to assess the methodological quality of eligible studies and the GRADE approach to evaluate the evidence certainty.
RESULTS
Twenty-one studies were selected. Whether in Group A (using sedative and analgesic drugs vs. nonuse) or Group B (using dexmedetomidine vs. other drugs), the rates of tracheal intubation and delirium, the length of NIV, and the length of stay in the intensive care unit (ICU LOS) all decreased in both experimental groups (P < 0.05). And there were no significant differences in all-cause mortality and the incidence of hypotension between the two groups (P > 0.05), while both Group A and Group B's experimental groups had greater incidences of bradycardia.
CONCLUSIONS
Administering sedative and analgesic medications during NIV can reduce the risk of tracheal intubation and delirium. Additionally, dexmedetomidine outperformed other sedative medications in terms of these clinical outcomes, making it the better option when closely monitoring patients' vital signs.
Topics: Humans; Respiration, Artificial; Dexmedetomidine; Hypnotics and Sedatives; Pain; Intensive Care Units; Noninvasive Ventilation; Analgesics; Analgesia; Delirium
PubMed: 37769542
DOI: 10.1016/j.hrtlng.2023.09.005 -
Frontiers in Cardiovascular Medicine 2023Delirium is a common symptom of heart failure (HF) and is associated with increased mortality, prolonged hospital stays, and heightened medical costs. The impact of... (Review)
Review
BACKGROUND
Delirium is a common symptom of heart failure (HF) and is associated with increased mortality, prolonged hospital stays, and heightened medical costs. The impact of delirium on the prognosis of HF patients is currently controversial. Therefore, we conducted a meta-analysis to evaluate the prognostic significance of delirium in HF.
METHODS
Relevant articles were systematically searched in PubMed, Cochrane Library, Web of Science, and Embase based on the PRISMA guidelines. Studies that reported mortality and hospitalization-related outcomes in HF patients with or without delirium using raw or adjusted hazard ratio (HR) and odds ratio (OD) were included. Meta-analysis was then performed to evaluate the effect of delirium in HF patients. Outcomes of interest were all-cause mortality and events of the hospitalization.
RESULTS
Of the 1,501 studies identified, 7 eligible studies involving 12,830,390 HF patients (6,322,846 males and 6,507,544 females) were included in the meta-analysis. There were 91,640 patients with delirium (0.71%) and 12,738,750 patients without delirium (99.28%). HF patients with delirium had higher OR for in-hospital mortality (1.95, 95% CI = 1.30-2.91, = 0.135), higher pooled HR for 90-day mortality (2.64, 95% CI = 1.06-1.56, 0.215), higher pooled HR for 1-year mortality (2.08, 95% CI = 1.34-3.22, = 0.004), and higher pooled HR for 30-day readmission rate (4.15, 95% CI = 2.85-6.04, = 0.831) than those without delirium.
CONCLUSION
Current evidence suggests that combined delirium increases the risk of HF-related mortality and hospitalization-related outcomes in patients with HF. However, more research is needed to assess the impact of delirium on the prognosis of HF patients.
PubMed: 37636295
DOI: 10.3389/fcvm.2023.1217965 -
Perioperative Medicine (London, England) Oct 2023Postoperative delirium (POD) is a common postoperative complication, characterized by disturbance of attention, perception, and consciousness within 1 week after... (Review)
Review
BACKGROUND
Postoperative delirium (POD) is a common postoperative complication, characterized by disturbance of attention, perception, and consciousness within 1 week after surgery, and linked to cognitive decline, increased mortality, and other serious surgical outcomes. Early identification and treatment of risk factors for POD could reduce the occurrence of delirium and the related poor outcomes. Malnutrition as a possible precipitating factor, defined as the poor anthropometric, functional, and clinical outcomes of nutrient deficiency, has been investigated. However, the evidence is controversial. The goal of this systematic review and meta-analysis was to comprehensively assess the correlation between preoperative malnutrition and POD.
METHODS
PubMed, Embase, Cochrane Library, and Web of Science were used to search prospective cohort articles that explored the correlation between preoperative malnutrition and POD from inception until September 30, 2022. Two researchers independently conducted the literature selection and data extraction. The quality of the literature was evaluated according to the Newcastle-Ottawa scale (NOS). Odds ratios (ORs) and 95% confidence intervals (CIs) for POD associated with malnutrition relative to normal nutritional status were calculated.
RESULTS
Seven prospective cohort studies qualified for the meta-analysis, which included 2701 patients. The pooled prevalence of preoperative malnutrition was 15.1% (408/2701), and POD occurred in 428 patients (15.8%). The NOS score was above 7 points in all 7 studies. Our results demonstrated that the pooled OR for malnutrition and POD was 2.32 (95% CI 1.62-3.32) based on a random-effects model. Our subgroup analysis suggested that the relationship between malnutrition and POD was significant in adults following noncardiac surgery (OR = 3.04, 95% CI, 1.99-4.62, P < 0.001), while there was no statistical significance in adults following cardiac surgery (OR = 1.76, 95% CI, 0.96-3.22, P = 0.07). Additionally, in the subgroup analysis based on different malnutrition assessment tools (MNA-SF versus others), a significant association was found in the MNA-SF group (OR = 3.04, 95% CI, 1.99-4.62, P < 0.001), but not in the others group (OR = 1.76, 95% CI, 0.96-3.22, P = 0.07). Other subgroup analyses showed that this association was not significantly affected by evaluation instruments for POD, location of the study, or quality of the article (all P < 0.05).
CONCLUSIONS
Based on the currently available evidence, our results suggested that preoperative malnutrition was independently associated with POD in adult surgical patients.
PubMed: 37884977
DOI: 10.1186/s13741-023-00345-9 -
Frontiers in Neuroscience 2023Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional... (Review)
Review
OBJECTIVE
Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional connectivity, but the requirement to lay still may limit measurement with existing functional imaging modalities in this population. Electroencephalography (EEG) may allow for a more feasible approach to the study of potential connectivity disturbances in delirium. We conducted a systematic review to investigate whether there are EEG-measurable differences in brain functional connectivity in the resting state associated with delirium.
METHODS
Medline, PubMed, PsychInfo, Embase and CINAHL were searched for relevant articles containing original data studying EEG functional connectivity measures in delirium.
RESULTS
The search yielded 1,516 records. Following strict inclusion criteria, four studies were included in the review. The studies used a variety of EEG measures including phase lag index, coherence, entropy, shortest path length, minimum spanning tree, and network clustering coefficients to study functional connectivity between scalp electrodes. Across connectivity measures, delirium was associated with decreased brain functional connectivity. All four studies found decreased alpha band connectivity for patients with delirium. None of the studies directly compared the different motor subtypes of delirium.
SIGNIFICANCE
This systematic review provides converging evidence for disturbances in oscillatory-based functional connectivity in delirium.
PubMed: 38033553
DOI: 10.3389/fnins.2023.1274837