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Practical Neurology Jun 2023Delirium is an acute disorder of fluctuating attention and awareness with cardinal features that allow it to be positively distinguished from other causes of an acute... (Review)
Review
Delirium is an acute disorder of fluctuating attention and awareness with cardinal features that allow it to be positively distinguished from other causes of an acute confusional state. These features include fluctuations, prominent inattentiveness with other cognitive deficits, a change in awareness and visual hallucinations. We describe a framework for diagnosing delirium, noting the need to consider certain caveats and differential diagnoses. Delirium is a clinical diagnosis where a thorough history and clinical examination are much more helpful diagnostically than any single test or combination of tests.
Topics: Humans; Delirium; Cognition Disorders; Diagnosis, Differential; Cognitive Dysfunction
PubMed: 36581459
DOI: 10.1136/pn-2022-003373 -
The Journals of Gerontology. Series A,... Nov 2022
Topics: Humans; Delirium
PubMed: 35943887
DOI: 10.1093/gerona/glac163 -
Current Opinion in Pulmonary Medicine Nov 2022Sleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU)... (Review)
Review
PURPOSE OF REVIEW
Sleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU) affects physiology and clinical outcomes, as well as the most recent advances in sleep and circadian rhythm promoting interventions including therapeutics.
RECENT FINDINGS
On a molecular level, clock genes dysrhythmia and altered immunity are clearly linked, particularly in sepsis. Melatonin may also be associated with insulin sensitivity in ICU patients. Clinically, changes in sleep architecture are associated with delirium, and sleep-promoting interventions in the form of multifaceted care bundles may reduce its incidence. Regarding medications, one recent randomized controlled trial (RCT) on melatonin showed no difference in sleep quality or incidence of delirium.
SUMMARY
Further investigation is needed to establish the clinical relevance of sleep and circadian disruption in the ICU. For interventions, standardized protocols of sleep promotion bundles require validation by larger multicenter trials. Administratively, such protocols should be individualized to both organizational and independent patient needs. Incorporating pharmacotherapy such as melatonin and nocturnal dexmedetomidine requires further evaluation in large RCTs.
Topics: Critical Care; Delirium; Dexmedetomidine; Humans; Intensive Care Units; Melatonin; Sleep
PubMed: 36101905
DOI: 10.1097/MCP.0000000000000912 -
Canadian Journal on Aging = La Revue... Mar 2020Le délirium est un problème de santé majeur aux conséquences potentiellement graves. Malheureusement, la prise en charge de ce trouble est souvent sous-optimale.... (Review)
Review
Le délirium est un problème de santé majeur aux conséquences potentiellement graves. Malheureusement, la prise en charge de ce trouble est souvent sous-optimale. Nous considérons que les lacunes dans les soins offerts aux patients avec délirium sont liées aux particularités de cette condition, qui affecte la perception du « soi » de la personne qui en souffre. Cette atteinte entraîne un comportement hors de contrôle chez la personne avec délirium et l'expose à une déshumanisation mécaniste. Une solution consisterait à favoriser une vision élargie du « soi », inspirée de la philosophie et des sciences cognitives récentes, afin d'aider les cliniciens dans la compréhension du comportement pathologique en tant que manifestation de la perturbation de la pensée. Une approche centrée sur l'éthique des soins, intégrant un nouveau cadre pour la relation patient-soignant, est proposée. Considérées dans leur ensemble, les propositions novatrices émises pourraient faciliter l'élaboration d'un cadre de pratiques et de relations plus attentionnées et plus efficaces pour le traitement du délirium. Delirium is a major health care problem with potentially serious consequences. Sub-optimal management is an unfortunate but pervasive hallmark of the disorder. We argue that lapses in the care of delirious patients are related to the peculiarities of delirium as a disorder that affects the “self” of the sufferer. Therefore, corruption of self renders behaviour outside the control of the delirious individual and places the person at risk of mechanistic dehumanisation. A proposed solution is to foster an expanded view of the self, taken from recent philosophy and cognitive science, which would allow the clinician to understand pathological behaviour as indicative of disruption to thought. An ethics of care approach that reframes the patient/carer relationship is proposed. These unique propositions could, together, facilitate the development of a framework of more caring and effective practices and relationships for delirium treatment.
Topics: Aged; Dehumanization; Delirium; Delivery of Health Care; Health Knowledge, Attitudes, Practice; Humans
PubMed: 32008599
DOI: 10.1017/S0714980819000230 -
Ageing Research Reviews Jun 2024Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of... (Review)
Review
Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.
Topics: Humans; Delirium; Dexmedetomidine; Randomized Controlled Trials as Topic
PubMed: 38677599
DOI: 10.1016/j.arr.2024.102313 -
Anesthesia and Analgesia Oct 2022Postoperative cognitive dysfunction and delirium are undesirable consequences of surgery and anesthesia that regrettably do not have consistent predictive markers. Nor...
Postoperative cognitive dysfunction and delirium are undesirable consequences of surgery and anesthesia that regrettably do not have consistent predictive markers. Nor do they have reliable prophylactic or treatment methodologies. In an effort to better understand how anesthetic drugs alter the rate of postoperative delirium, Chang et al explore how patients with preoperative cognitive impairment respond to the influence of intraoperative ketamine. Patients aged 65 or older presenting for spine surgery lasting over three hours were assessed and divided into those with and without baseline cognitive impairment. Both groups either received intraoperative ketamine or did not. All patients who received intraoperative ketamine demonstrated an increase in power spectral density via electroencephalographic assessment. However, patients with preoperatively established cognitive impairment displayed a significantly diminished electroencephalographic response to ketamine. Furthermore, this subgroup also suffered an increased incidence of postoperative delirium. What is the interpretation of this finding? An accompanying editorial elegantly describes how disorders of cognition result from both predisposing and precipitating factors. In this case, patients with known cognitive impairment were more likely to endure delirium when exposed to ketamine. Is it possible that ketamine and other drugs could be used as agents to stratify cognitive risk? Should we definitively avoid such drugs as potentiators of cognitive dysfunction? A variety of contextual limitations must be entertained when interpreting the results of this study as summarized in this infographic. These are also elaborated in greater detail in both the primary article as well as its attendant editorial. The reader is encouraged to review both in their entirety for an in-depth scope of understanding.
Topics: Anesthetics; Brain; Delirium; Humans; Ketamine; Postoperative Complications
PubMed: 36108179
DOI: 10.1213/ANE.0000000000006212 -
Critical Care Nursing Clinics of North... Sep 2023Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to... (Review)
Review
Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.
Topics: Child; Humans; Delirium; Intensive Care Units; Intensive Care Units, Pediatric; Critical Care; Hospitalization; Pediatrics
PubMed: 37532385
DOI: 10.1016/j.cnc.2023.04.006 -
Sleep Medicine Clinics Jun 2022Hospitalization is a period of acute sleep deprivation for older adults due to environmental, medical, and patient factors. Although hospitalized patients are in need of... (Review)
Review
Hospitalization is a period of acute sleep deprivation for older adults due to environmental, medical, and patient factors. Although hospitalized patients are in need of adequate rest and recovery during acute illness, older patients face unique risks due to acute sleep loss during; hospitalization. Sleep loss in the hospital is associated with worse health outcomes, including; cardio-metabolic derangements and increased risk of delirium. Because older patients are at risk of; polypharmacy and medication side effects, a variety of nonpharmacological interventions are recommended first to improve sleep loss for hospitalized older adults.
Topics: Aged; Delirium; Hospitalization; Humans; Sleep; Sleep Deprivation
PubMed: 35659075
DOI: 10.1016/j.jsmc.2022.02.002 -
Clinics in Geriatric Medicine Nov 2023This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the... (Review)
Review
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
Topics: Humans; Delirium; Emergency Service, Hospital
PubMed: 37798064
DOI: 10.1016/j.cger.2023.05.006 -
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