-
Minerva Anestesiologica Jun 2022Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing approach incorporating regional anesthesia techniques has been suggested to decrease its incidence. Due to the lack of conclusive evidence on the topic, we conducted a systematic review and meta-analysis to investigate the potential impact of regional anesthesia and analgesia on postoperative delirium.
EVIDENCE ACQUISITION
PubMed, Embase, and the Cochrane central register of Controlled trials (CENTRAL) databases were searched for randomized trials comparing regional anesthesia or analgesia to systemic treatments in patients having any type of surgery. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We pooled the results separately for each of these two applications by random effects modelling. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and strength of conclusions.
EVIDENCE SYNTHESIS
Eighteen trials (3361 subjects) were included. Using regional techniques for surgical anesthesia failed to reduce the risk of postoperative delirium, with a relative risk (RR) of 1.21 (95% CI: 0.79 to 1.85); P=0.3800. In contrast, regional analgesia reduced the relative risk of perioperative delirium by a RR of 0.53 (95% CI: 0.42 to 0.68; P<0.0001), when compared to systemic analgesia. Post-hoc subgroup analysis for hip fracture surgery yielded similar findings.
CONCLUSIONS
These results show that postoperative delirium may be decreased when regional techniques are used in the postoperative period as an analgesic strategy. Intraoperative regional anesthesia alone may not decrease postoperative delirium since there are other factors that may influence this outcome.
Topics: Aged; Anesthesia, Conduction; Anesthesia, Local; Delirium; Hip Fractures; Humans
PubMed: 35164487
DOI: 10.23736/S0375-9393.22.16076-1 -
JAMA Neurology Nov 2020Delirium is associated with increased hospital costs, health care complications, and increased mortality. Long-term consequences of delirium on cognition have not been... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Delirium is associated with increased hospital costs, health care complications, and increased mortality. Long-term consequences of delirium on cognition have not been synthesized and quantified via meta-analysis.
OBJECTIVE
To determine if an episode of delirium was an independent risk factor for long-term cognitive decline, and if it was, whether it was causative or an epiphenomenon in already compromised individuals.
DATA SOURCES
A systematic search in PubMed, Cochrane, and Embase was conducted from January 1, 1965, to December 31, 2018. A systematic review guided by Preferred Reporting Items for Systematic Reviews and Meta-analyses was conducted. Search terms included delirium AND postoperative cognitive dysfunction; delirium and cognitive decline; delirium AND dementia; and delirium AND memory.
STUDY SELECTION
Inclusion criteria for studies included contrast between groups with delirium and without delirium; an objective continuous or binary measure of cognitive outcome; a final time point of 3 or more months after the delirium episode. The electronic search was conducted according to established methodologies and was executed on October 17, 2018.
DATA EXTRACTION AND SYNTHESIS
Three authors extracted data on individual characteristics, study design, and outcome, followed by a second independent check on outcome measures. Effect sizes were calculated as Hedges g. If necessary, binary outcomes were also converted to g. Only a single effect size was calculated for each study.
MAIN OUTCOMES AND MEASURES
The planned main outcome was magnitude of cognitive decline in Hedges g effect size in delirium groups when contrasted with groups that did not experience delirium.
RESULTS
Of 1583 articles, data subjected from the 24 studies (including 3562 patients who experienced delirium and 6987 controls who did not) were included in a random-effects meta-analysis for pooled effect estimates and random-effects meta-regressions to identify sources of study variance. One study was excluded as an outlier. There was a significant association between delirium and long-term cognitive decline, as the estimated effect size (Hedges g) for 23 studies was 0.45 (95% CI, 0.34-0.57; P < .001). In all studies, the group that experienced delirium had worse cognition at the final time point. The I2 measure of between-study variability in g was 0.81. A multivariable meta-regression suggested that duration of follow-up (longer with larger gs), number of covariates controlled (greater numbers were associated with smaller gs), and baseline cognitive matching (matching was associated with larger gs) were significant sources of variance. More specialized subgroup and meta-regressions were consistent with predictions that suggested that delirium may be a causative factor in cognitive decline.
CONCLUSIONS AND RELEVANCE
In this meta-analysis, delirium was significantly associated with long-term cognitive decline in both surgical and nonsurgical patients.
Topics: Brief Psychiatric Rating Scale; Cognitive Dysfunction; Delirium; Humans; Observational Studies as Topic; Risk Factors
PubMed: 32658246
DOI: 10.1001/jamaneurol.2020.2273 -
Journal of the American Medical... Oct 2022To critically appraise and quantify the performance studies by employing machine learning (ML) to predict delirium. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To critically appraise and quantify the performance studies by employing machine learning (ML) to predict delirium.
DESIGN
A systematic review and meta-analysis.
SETTING AND PARTICIPANTS
Articles reporting the use of ML to predict delirium in adult patients were included. Studies were excluded if (1) the primary goal was only the identification of various risk factors for delirium; (2) the full-text article was not found; and (3) the article was published in a language other than English/Chinese.
METHODS
PubMed, Embase, Cochrane Library database, Web of Science, Grey literature, and other relevant databases for the related publications were searched (from inception to December 15, 2021). The data were extracted using a standard checklist, and the risk of bias was assessed through the prediction model risk of bias assessment tool. Meta-analysis with the area under the receiver operating characteristic curve, sensitivity, and specificity as effect measures, was performed with Metadisc software. Cochran Q and I statistics were used to assess the heterogeneity. Meta-regression was performed to determine the potential effect of adjustment for the key covariates.
RESULTS
A total of 22 studies were included. Only 4 of 22 studies were quantitatively analyzed. The studies varied widely in reporting about the study participants, features and selection, handling of missing data, sample size calculations, and the intended clinical application of the model. For ML models, the overall pooled area under the receiver operating characteristic curve for predicting delirium was 0.89, sensitivity 0.85 (95% confidence interval 0.84‒0.85), and specificity 0.80 (95% confidence interval 0.81-0.80).
CONCLUSIONS AND IMPLICATIONS
We found that the ML model showed excellent performance in predicting delirium. This review highlights the potential shortcomings of the current approaches, including low comparability and reproducibility. Finally, we present the various recommendations on how these challenges can be effectively addressed before deploying these models in prospective analyses.
Topics: Adult; Delirium; Humans; Machine Learning; Prospective Studies; ROC Curve; Reproducibility of Results
PubMed: 35922015
DOI: 10.1016/j.jamda.2022.06.020 -
Journal of the American Geriatrics... Jun 2022This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults presenting to the emergency department (ED).
METHODS
Health sciences librarian designed electronic searches were conducted from database inception through September 2021. Two authors reviewed studies, and included studies that evaluated interventions for the prevention and/or treatment of delirium and excluded non-ED studies. The risk of bias (ROB) was evaluated by the Cochrane ROB tool or the Newcastle-Ottawa (NOS) scale. Meta-analysis was conducted to estimate a pooled effect of multifactorial programs on delirium prevention.
RESULTS
Our search strategy yielded 11,900 studies of which 10 met study inclusion criteria. Two RCTs evaluated pharmacologic interventions for delirium prevention; three non-RCTs employed a multi-factorial delirium prevention program; three non-RCTs evaluated regional anesthesia for hip fractures; and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium. Only four studies demonstrated a significant impact on delirium incidence or duration of delirium-one RCT of melatonin reduced the incidence of delirium (OR 0.19, 95% CI 0.06 to 0.62), one non-RCT study on a multi-factorial program decreased inpatient delirium prevalence (41% to 19%) and the other reduced incident delirium (RR 0.37, 95% CI 0.22 to 0.61). One case-control study on the use of ED Foley catheters in the ED increased the duration of delirium (proportional OR 3.1, 95% CI 1.3 to 7.4). A pooled odds ratio for three multifactorial programs on delirium prevention was 0.46 (95% CI 0.31-0.68, I = 0).
CONCLUSION
Few interventions initiated in the ED were found to consistently reduce the incidence or duration of delirium. Delirium prevention and treatment trials in the ED are still rare and should be prioritized for future research.
Topics: Aged; Case-Control Studies; Delirium; Emergency Service, Hospital; Humans; Incidence; Inpatients
PubMed: 35274738
DOI: 10.1111/jgs.17740 -
Intensive Care Medicine Sep 2021To compare the effects of prevention interventions on delirium occurrence in critically ill adults. (Meta-Analysis)
Meta-Analysis
PURPOSE
To compare the effects of prevention interventions on delirium occurrence in critically ill adults.
METHODS
MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects.
RESULTS
Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care.
CONCLUSION
Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
Topics: Adult; Bayes Theorem; Critical Illness; Delirium; Humans; Network Meta-Analysis; Randomized Controlled Trials as Topic; Respiration, Artificial
PubMed: 34379152
DOI: 10.1007/s00134-021-06490-3 -
International Journal of Environmental... Aug 2021Delirium is a common neurobehavioral complication in hospitalized patients that can occur in the acute phase and lead to poor long-term outcomes. The purpose of this...
Delirium is a common neurobehavioral complication in hospitalized patients that can occur in the acute phase and lead to poor long-term outcomes. The purpose of this study was to identify non-pharmacological nursing interventions for the prevention and treatment of delirium in hospitalized adult patients. We conducted a systematic review to synthesize the findings of published studies. We searched the PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL databases for randomized controlled trials in January 2021. We report this systematic review according to the PRISMA 2009 checklist. The study was registered on PROSPERO (CRD42021226538). Nine studies were systematically reviewed for non-pharmacological nursing interventions for the prevention and treatment of delirium. The types of non-pharmacological nursing interventions included multicomponent intervention, multidisciplinary care, multimedia education, music listening, mentoring of family caregivers concerning delirium management, bright light exposure, ear plugs, and interventions for simulated family presence using pre-recorded video messages. These results could help nurses select and utilize non-pharmacological nursing interventions for the prevention and treatment of delirium in clinical nursing practice.
Topics: Adult; Cognition; Delirium; Ear Protective Devices; Humans; Patients; Randomized Controlled Trials as Topic
PubMed: 34444602
DOI: 10.3390/ijerph18168853 -
Medicine Jun 2022The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and ABCDEF (Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement) care bundles consist of small sets of evidence-based interventions and are part of the science behind Intensive Care Unit (ICU) liberation. This review sought to analyse the process of implementation of ABCDE and ABCDEF care bundles in ICUs, identifying barriers, facilitators and changes in perception and attitudes of healthcare professionals; and to estimate care bundle effectiveness and safety.
METHODS
We selected qualitative and quantitative studies addressing the implementation of ABCDE and ABCDEF bundles in the ICU, identified on MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, Epistemonikos, PsycINFO, Virtual Health Library and Open Grey, without restriction on language or date of publication, up to June 2018. The outcomes measured were ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behaviour of the stakeholders; and change in knowledge of health professionals. Two reviewers independently selected the studies, performed data extraction, and assessed risk of bias and methodological quality. A meta-analysis of random effects was performed.
RESULTS
Twenty studies were included, 13 of which had a predominantly qualitative and 7 a quantitative design (31,604 participants). The implementation strategies were categorized according to the taxonomy developed by the Cochrane Effective Practice and Organization of Care Group and eighty strategies were identified. The meta-analysis results showed that implementation of the bundles may reduce length of ICU stay, mechanical ventilation time, delirium, ICU and hospital mortality, and promoted early mobilization in critically-ill patients.
CONCLUSIONS
: This study can contribute to the planning and execution of the implementation process of ABCDE and ABCDEF care bundles in ICUs. However, the effectiveness and safety of these bundles need to be corroborated by further studies with greater methodological rigor.
PROTOCOL REGISTRATION
PROSPERO CRD42019121307.
Topics: Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units; Patient Care Bundles
PubMed: 35758388
DOI: 10.1097/MD.0000000000029499 -
International Journal of Nursing Studies Jul 2022Delirium presents a serious health problem in critically ill patients in intensive care units. However, knowledge regarding the selections of the optimal... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Delirium presents a serious health problem in critically ill patients in intensive care units. However, knowledge regarding the selections of the optimal non-pharmacological interventions remains unclear.
OBJECTIVES
To compare the effects of non-pharmacological interventions by combining direct and indirect evidence on the incidence and duration of delirium in intensive care units.
DESIGN
A systematic review and network meta-analysis.
DATA SOURCES
A comprehensive search of five electronic databases, including PubMed, EMBASE, CINAHL, Cochrane CENTRAL, and ProQuest Dissertations and Theses A&I were conducted. Only randomized control trials published from the inception to December 28, 2021 were included.
REVIEW METHODS
Two reviewers independently screened the title and abstract for eligibility according to the inclusion and exclusion criteria. The random-effect network meta-analysis was used to estimate the comparative effects of non-pharmacological interventions in reducing delirium incidence and duration.
RESULTS
A total of 29 studies with 7005 critically ill patients were enrolled. Twenty-six and eleven studies reported the delirium incidence and duration, respectively. Component-based intervention comparison revealed that multicomponent strategy was the most effective non-pharmacological intervention compared to usual care in reducing incidence of ICU delirium (Odd ratio [OR]=0.43, 95% CI= 0.22-0.84) but not ICU delirium duration. Treatment-based intervention comparisons indicated that specific multi-treatment interventions significantly reduced the ICU delirium incidence and duration, particularly the involvement of early mobilization and family participation (OR = 0.12 with 95% CI = 0.02 to 0.83; mean difference = -1.34 with 95% CI = -2.52 to -0.16, respectively).
CONCLUSION
Our study suggests that the multicomponent strategy was the most effective non-pharmacological intervention in reducing the incidence of ICU delirium. Early mobilization and family participation involvement in non-pharmacological interventions seemed to be more effective in reducing the incidence of ICU delirium. These results of network-meta analysis could be an important evidence-based for clinical healthcare providers to optimize the critical care protocol.
TWEETABLE ABSTRACT
Network meta-analysis of 29 randomised controlled trials with 7005 patients finds that multicomponent interventions, particularly those involving early mobilization, family participation, cognitive stimulation, reorientation, sensory stimulation, environment control and clinical adjustment, is the most effective non-pharmacological strategy to reduce the incidence of delirium in intensive care units.
Topics: Adult; Critical Illness; Delirium; Humans; Incidence; Intensive Care Units; Network Meta-Analysis
PubMed: 35468538
DOI: 10.1016/j.ijnurstu.2022.104239 -
International Journal of Nursing Studies Jan 2021Delirium is a critical and highly prevalent problem among critically ill patients. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Delirium is a critical and highly prevalent problem among critically ill patients. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most recommended assessment tools for detecting intensive care unit (ICU) delirium.
OBJECTIVES
To synthesize the current evidence and compared the diagnostic accuracy of the two tools in the detection of delirium in adults in ICUs.
DESIGN
Systematic review and meta-analysis.
DATA SOURCE
A comprehensive search of the following electronic databases was performed using PubMed, Embase, CINAHL and ProQuest Dissertations and Theses A&I. The date range searched was from database inception to April 26, 2019.
REVIEW METHODS
Two researchers independently identified articles, systematically abstracted data and evaluated the sensitivity and specificity of the CAM-ICU or the ICDSC against standard references. Bivariate diagnostic statistical analysis with a random-effects model was performed to summarize the pooled sensitivity and specificity of the two tools.
RESULTS
In total, 29 CAM-ICU and 12 ICDSC studies were identified. The pooled sensitivity was 0.84 and 0.83 and pooled specificity was 0.95 and 0.87 for the CAM-ICU and the ICDSC, respectively. The CAM-ICU had higher summary specificity than the ICDSC did (p = 0.04). The percentage of hypoactive delirium, ICU type, use of mechanical ventilation, number of participants, and female percentage moderated the accuracy of the tools. Most of the domains of patient selection, index test, reference standards, and flow and timing were rated as having a low or unclear risk of bias.
CONCLUSIONS
Although both the CAM-ICU and the ICDSC are accurate assessment tools for screening delirium in critically ill patients, the CAM-ICU is superior in ruling out patients without ICU delirium and detecting delirium in patients in the medical ICU and those receiving mechanical ventilation. Further investigations are warranted to validate our findings. The study protocol is registered at PROSPERO (CRD42020133544).
Topics: Adult; Checklist; Critical Care; Critical Illness; Delirium; Female; Humans; Intensive Care Units; Reproducibility of Results
PubMed: 33120134
DOI: 10.1016/j.ijnurstu.2020.103782 -
International Journal of Nursing Studies Dec 2022Many studies have developed or validated prediction models to estimate the risk of delirium after cardiac surgery, but the quality of the model development and model... (Review)
Review
BACKGROUND
Many studies have developed or validated prediction models to estimate the risk of delirium after cardiac surgery, but the quality of the model development and model applicability remain unknown.
OBJECTIVES
To systematically review and critically evaluate currently available prediction models for delirium after cardiac surgery.
DATA SOURCES
PubMed, EMBASE, and MEDLINE were systematically searched. This systematic review was registered in PROSPERO (Registration ID: CRD42021251226).
STUDY SELECTION
Prospective or retrospective cohort studies were considered eligible if they developed or validated prediction models or scoring systems for delirium in the ICU. We included studies involving adults (age ≥18 years) undergoing cardiac surgery and excluded studies that did not validate a prediction model.
DATA EXTRACTION
Data extraction was independently performed by two authors using a standardized data extraction form based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies checklist. Quality of the models was assessed with the Prediction Model Risk of Bias Assessment Tool (PROBAST).
DATA SYNTHESIS
Of 5469 screened studies, 13 studies described 10 prediction models. The postoperative delirium incidence varied from 11.3 % to 51.6 %. The most frequently used predictors were age and cognitive impairment. The reported areas under the curve or C-statistics were between of 0.74 and 0.91 in the derivation set. The reported AUCs in the external validation set were between 0.54 and 0.90. All the studies had a high risk of bias, mainly owing to poor reporting of the outcome domain and analysis domain; 10 studies were of high concern regarding applicability.
CONCLUSIONS
The current models for predicting postoperative delirium in the ICU after cardiac surgery had a high risk of bias according to the PROBAST. Future studies should focus on improving current prediction models or developing new models with rigorous methodology.
Topics: Adolescent; Adult; Humans; Cardiac Surgical Procedures; Delirium; Prospective Studies; Retrospective Studies
PubMed: 36208541
DOI: 10.1016/j.ijnurstu.2022.104340