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Clinics in Geriatric Medicine May 2020Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic... (Review)
Review
Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.
Topics: Aged; Attention; Cognition; Delirium; Diagnosis, Differential; Humans; Patient Care Management; Preventive Medicine
PubMed: 32222295
DOI: 10.1016/j.cger.2019.11.001 -
Annals of Internal Medicine Oct 2020Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute... (Review)
Review
Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called , , or . All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.
Topics: Aged; Delirium; Humans; Risk Factors
PubMed: 33017552
DOI: 10.7326/AITC202010060 -
Intensive Care Medicine Oct 2021Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently... (Review)
Review
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
Topics: Adult; COVID-19; Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units; Pandemics; SARS-CoV-2
PubMed: 34401939
DOI: 10.1007/s00134-021-06503-1 -
Seminars in Respiratory and Critical... Feb 2021Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality,...
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (ssess, prevent, and manage pain; oth SAT and SBT; hoice of analgesia and sedation; elirium: assess, prevent, and manage; arly mobility and exercise; amily engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
Topics: Adult; Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units; Pain
PubMed: 32746469
DOI: 10.1055/s-0040-1710572 -
Nature Reviews. Disease Primers Nov 2020Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a... (Review)
Review
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
Topics: Cognitive Dysfunction; Delirium; Humans; Quality of Life
PubMed: 33184265
DOI: 10.1038/s41572-020-00223-4 -
The Medical Clinics of North America May 2022Delirium is an acute and fluctuating disorder characterized by a disturbance in attention and cognition. Delirium is underdiagnosed by clinicians, but there are... (Review)
Review
Delirium is an acute and fluctuating disorder characterized by a disturbance in attention and cognition. Delirium is underdiagnosed by clinicians, but there are excellent diagnostic tools using history and physical examination that can assist clinicians in making the diagnosis in multiple settings (ie, CAM, CAM-ICU, 3D-CAM, bCAM, 4AT, and UB-CAM). Delirium is caused by underlying medical conditions and is often multifactorial, so a full diagnosis requires a careful assessment for a wide range of underlying conditions. Physical examination has not been well studied in this regard, but still can provide useful clues to the clinician.
Topics: Delirium; Humans
PubMed: 35491066
DOI: 10.1016/j.mcna.2021.12.003 -
Der Orthopade Feb 2022Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is... (Review)
Review
BACKGROUND
Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients.
DIAGNOSTIC
Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential.
TREATMENT
In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.
Topics: Aged; Delirium; Humans
PubMed: 35037987
DOI: 10.1007/s00132-021-04209-2 -
Wiener Medizinische Wochenschrift (1946) Apr 2022Delirium is the most common acute disorder of cognitive function in older patients. Delirium is life threatening, often under-recognized, serious, and costly. The causes... (Review)
Review
Delirium is the most common acute disorder of cognitive function in older patients. Delirium is life threatening, often under-recognized, serious, and costly. The causes are multifactorial, with old age and neurocognitive disorders as the main risk factors. Etiologies are various and multifactorial, and often related to acute medical illness, adverse drug reactions, or medical complications. To date, diagnosis is clinically based, depending on the presence or absence of certain features. In view of the multifactorial etiology, multicomponent approaches seem most promising for facing patients' needs. Pharmacological intervention, neither for prevention nor for treatment, has been proven effective unanimously. This article reviews the current clinical practice for delirium in geriatric patients, including etiology, pathophysiology, diagnosis, prognosis, treatment, prevention, and outcomes.
Topics: Aged; Delirium; Drug-Related Side Effects and Adverse Reactions; Humans; Prognosis; Risk Factors
PubMed: 35006521
DOI: 10.1007/s10354-021-00904-z -
Seminars in Respiratory and Critical... Oct 2019Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive... (Review)
Review
Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive impairment, one of the domains in "Post-ICU Syndrome" (PICS). The ICU environment affects several potentially modifiable risk factors for delirium, such as disorientation and disruption, of the sleep-wake cycle. Innovative solutions aim to transform standard concepts of ICU room design to limit potential stressors, and utilizing the patient care space as a treatment tool, exerting positive, therapeutic effects. The main areas affected by most architectural and interior design modifications are sound environment, light control, floor planning, and room arrangement. Implementation of corresponding solutions is challenging considering the significant medical and technical demands of ICUs. This article discusses innovative concepts and promising approaches in ICU design that may be used to prevent stress and to support the healing process of patients, potentially limiting the impact of delirium and PICS.
Topics: Cognitive Dysfunction; Critical Care; Delirium; Humans; Intensive Care Units; Risk Factors; Syndrome
PubMed: 31826268
DOI: 10.1055/s-0039-1698404 -
Clinics in Perinatology Mar 2022Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity,... (Review)
Review
Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity, neurosedative exposure, and environmental disruptions that put infants at risk for delirium. Regular use of scoring systems should be considered to improve delirium detection. When identified, initial steps in management should include resolving underlying causes and implementation of standard nonpharmacologic measures. Mounting pediatric evidence suggests that the atypical antipsychotics, as well as the α-2 agonists, may be additionally beneficial in treating delirium as well as improving the ability to wean off other neurosedative medications.
Topics: Antipsychotic Agents; Benzodiazepines; Child; Delirium; Humans; Infant; Infant, Newborn; Olanzapine; Risperidone
PubMed: 35209993
DOI: 10.1016/j.clp.2021.11.001