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Deutsches Arzteblatt International Mar 2022Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German...
BACKGROUND
Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients.
METHODS
The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]).
RESULTS
The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02).
CONCLUSION
Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.
Topics: Activities of Daily Living; Aged; Delirium; Hospitalization; Hospitals; Humans; Length of Stay
PubMed: 35197189
DOI: 10.3238/arztebl.m2022.0131 -
Age and Ageing Apr 2020Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst...
Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst strategies to prevent and reverse delirium are the cornerstones of optimal care, the care for delirious patients who are approaching the end of life and their families pose specific challenges particularly if delirium is refractory flagging a grave prognosis. These include addressing additional supportive care needs, clinical decision-making about the degree of investigation and intervention, minimising distress from the symptoms of delirium itself and considering other concurrent problems contributing to agitation. A fine balance is needed to address other symptoms such as pain whilst minimizing psychoactive medication load. There is need for regular and clear information and communication about prognosis and goals of care. Witnessing a delirium episode in a loved one in close proximity to death requires consideration of the needs of the family into bereavement care. Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease; who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise quality of life. It is an approach which can be provided regardless of setting and diagnosis, and by both specialist palliative care teams and other health professionals.
Topics: Communication; Death; Delirium; Humans; Palliative Care; Quality of Life
PubMed: 31925413
DOI: 10.1093/ageing/afz171 -
BMC Neurology Mar 2022Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM)... (Review)
Review
BACKGROUND
Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments.
METHODS
We therefore conducted a scoping review on EEG findings in delirium. One thousand two hundred thirty-six articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis.
RESULTS
EEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive.
CONCLUSION
Future studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed.
Topics: Delirium; Electroencephalography; Humans; Intensive Care Units
PubMed: 35277128
DOI: 10.1186/s12883-022-02557-w -
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 -
Alzheimer's & Dementia : the Journal of... Jan 2024Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium...
BACKGROUND
Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology.
METHODS
The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts.
RESULTS
Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations.
DISCUSSION
The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes.
HIGHLIGHTS
Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.
Topics: Humans; Delirium; Research Design; Data Collection; Diagnostic and Statistical Manual of Mental Disorders
PubMed: 37522255
DOI: 10.1002/alz.13419 -
European Neurology 2023In the elderly, the association of delirium and dementia can cause diagnostic problems because they share the same symptom of confusion. Delirium is often misdiagnosed... (Review)
Review
BACKGROUND
In the elderly, the association of delirium and dementia can cause diagnostic problems because they share the same symptom of confusion. Delirium is often misdiagnosed as dementia and treated inappropriately, ignoring that it could be successfully addressed, which can lead to increased health risks up to death.
SUMMARY
Confusion indicates that functional reserve fails to compensate for the action of stressors. The decline in reserve is linked to aging-related changes in blood flow, mitochondria, cerebrospinal fluid, and immune function, as well as the appearance of structural precursors of disease. It is greater in dementia that adds a large burden of pathology, especially degenerative and vascular.
KEY MESSAGES
Based on their common background linking normal and pathological brain aging, it can be argued that delirium and dementia are always associated to some extent and can aggravate each other. The clinical approach to their association, which currently relies on the preliminary diagnosis of delirium according to ad hoc protocols, could be simplified by taking delirium for granted so that its causative stressors, usually the most common diseases of old age and/or drug abuse, could be addressed immediately. This approach would benefit all demented patients: not only those who are in such a serious condition that they need to be hospitalized due to the risk of death, but also those with clouded delirium.
Topics: Humans; Aged; Dementia; Delirium; Aging
PubMed: 36958295
DOI: 10.1159/000530226 -
International Psychogeriatrics Aug 2023We examined whether preadmission history of depression is associated with less delirium/coma-free (DCF) days, worse 1-year depression severity and cognitive impairment.
OBJECTIVES
We examined whether preadmission history of depression is associated with less delirium/coma-free (DCF) days, worse 1-year depression severity and cognitive impairment.
DESIGN AND MEASUREMENTS
A health proxy reported history of depression. Separate models examined the effect of preadmission history of depression on: (a) intensive care unit (ICU) course, measured as DCF days; (b) depression symptom severity at 3 and 12 months, measured by the Beck Depression Inventory-II (BDI-II); and (c) cognitive performance at 3 and 12 months, measured by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global score.
SETTING AND PARTICIPANTS
Patients admitted to the medical/surgical ICU services were eligible.
RESULTS
Of 821 subjects eligible at enrollment, 261 (33%) had preadmission history of depression. After adjusting for covariates, preadmission history of depression was not associated with less DCF days (OR 0.78, 95% CI, 0.59-1.03 = 0.077). A prior history of depression was associated with higher BDI-II scores at 3 and 12 months (3 months OR 2.15, 95% CI, 1.42-3.24 = <0.001; 12 months OR 1.89, 95% CI, 1.24-2.87 = 0.003). We did not observe an association between preadmission history of depression and cognitive performance at either 3 or 12 months (3 months beta coefficient -0.04, 95% CI, -2.70-2.62 = 0.97; 12 months 1.5, 95% CI, -1.26-4.26 = 0.28).
CONCLUSION
Patients with a depression history prior to ICU stay exhibit a greater severity of depressive symptoms in the year after hospitalization.
Topics: Humans; Delirium; Depression; Prospective Studies; Risk Factors; Intensive Care Units; Cognition
PubMed: 34763741
DOI: 10.1017/S1041610221002556 -
Nursing Jan 2020Hospital-acquired delirium often goes unnoticed because the signs and symptoms resemble those of dementia and depression, making diagnosis difficult. This article...
Hospital-acquired delirium often goes unnoticed because the signs and symptoms resemble those of dementia and depression, making diagnosis difficult. This article explores the differences between delirium, dementia, and depression and discusses the role of nursing in patient assessment and education.
Topics: Delirium; Diagnosis, Differential; Humans; Iatrogenic Disease; Nursing Diagnosis; Patient Education as Topic; Risk Management
PubMed: 31855984
DOI: 10.1097/01.NURSE.0000615072.68682.f0 -
Pharmacotherapy Nov 2023Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in... (Review)
Review
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
Topics: Humans; Delirium; Intensive Care Units; Critical Illness; Cognitive Dysfunction; Critical Care
PubMed: 37133446
DOI: 10.1002/phar.2807 -
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