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Annals of Neurology Dec 2023Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative...
OBJECTIVE
Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients.
METHODS
Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR).
RESULTS
Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = -0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [-0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03-1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09-1.22, p < 0.001).
INTERPRETATION
Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024-1035.
Topics: Humans; Female; Aged; Male; Delirium; Blood-Brain Barrier; Postoperative Complications; Emergence Delirium; Risk Factors; Organometallic Compounds
PubMed: 37615660
DOI: 10.1002/ana.26771 -
BMJ Open Jun 2023Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes.
DESIGN
Prospective randomised controlled trial.
SETTING
Single centre, conducted at the neurosurgical department of the Erasmus Medical Center, Rotterdam, the Netherlands.
PARTICIPANTS
Adult patients undergoing craniotomy were eligible.
INTERVENTIONS
Patients in the intervention group received preferred recorded music before, during and after the operation until day 3 after surgery. Patients in the control group were treated according to standard of clinical care.
PRIMARY AND SECONDARY OUTCOME MEASURES
Primary outcome was presence or absence of postoperative delirium within the first 5 postoperative days measured with the Delirium Observation Screening Scale (DOSS) and, in case of a daily mean score of 3 or higher, a psychiatric evaluation with the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Secondary outcomes included anxiety, heart rate variability (HRV), depth of anaesthesia, delirium severity and duration, postoperative complications, length of stay and location of discharge.
RESULTS
We enrolled 189 patients (music=95, control=94) from July 2020 through September 2021. Delirium, as assessed by the DOSS, was less common in the music (n=11, 11.6%) than in the control group (n=21, 22.3%, OR:0.49, p=0.048). However, after DSM-5 confirmation, differences in delirium were not significant (4.2% vs 7.4%, OR:0.47, p=0.342). Moreover, music increased the HRV (root mean square of successive differences between normal heartbeats, p=0.012). All other secondary outcomes were not different between groups.
CONCLUSION
Our results support the efficacy of music in reducing the incidence of delirium after craniotomy, as found with DOSS but not after DSM-5 confirmation, substantiated by the effect of music on preoperative autonomic tone. Delirium screening tools should be validated and the long-term implications should be evaluated after craniotomy.
TRIAL REGISTRATION NUMBER
Trialregister.nl: NL8503 and ClinicalTrials.gov: NCT04649450.
Topics: Adult; Humans; Music; Neurosurgery; Prospective Studies; Delirium; Neurosurgical Procedures
PubMed: 37369412
DOI: 10.1136/bmjopen-2022-069957 -
Journal of Anesthesia Feb 2022
Topics: Delirium; Humans
PubMed: 32743672
DOI: 10.1007/s00540-020-02833-4 -
CNS Spectrums Oct 2022
Topics: Humans; COVID-19; Psychopharmacology; Delirium
PubMed: 33843550
DOI: 10.1017/S1092852921000286 -
Anesthesia and Analgesia Jun 2022
Topics: Delirium; Humans; Perioperative Care; Postoperative Complications; Risk Factors
PubMed: 35595689
DOI: 10.1213/ANE.0000000000006072 -
Current Opinion in Anaesthesiology Oct 2023This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent... (Review)
Review
PURPOSE OF REVIEW
This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent findings to guide clinicians and researchers in choosing the most appropriate tools.
RECENT FINDINGS
The incidence of delirium in hospitalized patients ranges from 5% to over 50%, depending on the population of patients studied. Failure to diagnose delirium in a timely manner is associated with serious adverse outcomes, including death and institutionalization. Valid assessment tests are needed for delirium detection, as early identification and treatment of delirium may help to prevent complications. Currently, there are more than 30 available instruments, which have been developed to assist with the screening and diagnosis of delirium. However, these tools vary greatly in sensitivity, specificity, and administration time, and their overabundance challenges the selection of specific tool as well as direct comparisons and interpretation of results across studies.
SUMMARY
Overlooking or misdiagnosing delirium may result in poor patient outcomes. Familiarizing healthcare workers with the variety of delirium assessments and selecting the most appropriate tool to their needs is an important step toward improving awareness and recognition of delirium.
Topics: Humans; Delirium; Critical Care; Risk Assessment
PubMed: 37427443
DOI: 10.1097/ACO.0000000000001288 -
Clinical Neurophysiology : Official... May 2020Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our...
OBJECTIVE
Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our understanding of development of delirium, we studied whether non-delirious individuals with a predisposition for delirium also show these EEG abnormalities.
METHODS
Elderly subjects (N = 206) underwent resting-state EEG measurements and were assessed on predisposing delirium risk factors, i.e. older age, alcohol misuse, cognitive impairment, depression, functional impairment, history of stroke and physical status. Delirium-related EEG characteristics of interest were relative delta power, alpha connectivity strength (phase lag index) and network integration (minimum spanning tree leaf fraction). Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and EEG characteristics that are associated with delirium, adjusting for confounding and multiple testing.
RESULTS
Functional impairment was related to a decrease in connectivity strength (adjusted R = 0.071, β = 0.201, p < 0.05). None of the other risk factors had significant influence on EEG delta power, connectivity strength or network integration.
CONCLUSIONS
Functional impairment seems to be associated with decreased alpha connectivity strength. Other predisposing risk factors for delirium had no effect on the studied EEG characteristics.
SIGNIFICANCE
Predisposition for delirium is not consistently related to EEG characteristics that can be found during delirium.
Topics: Aged; Brain; Cross-Sectional Studies; Delirium; Electrocardiography; Electroencephalography; Female; Humans; Male; Nerve Net
PubMed: 32199395
DOI: 10.1016/j.clinph.2020.01.023 -
Acta Psychiatrica Scandinavica May 2023Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest.... (Review)
Review
INTRODUCTION
Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS.
METHOD
This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed.
RESULTS
There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months.
CONCLUSIONS
Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.
Topics: Humans; Critical Illness; Intensive Care Units; Critical Care; Delirium
PubMed: 36744298
DOI: 10.1111/acps.13534 -
Palliative & Supportive Care Apr 2021The prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled...
OBJECTIVE
The prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled studies. Therefore, this study assesses the prevalence rates and outcome of and odds ratios for managing services for delirium.
METHODS
In this prospective cohort study, based on the Diagnostic and Statistical Manual (DSM) 5, the Delirium Observation Screening (DOS) scale, and the Intensive Care Delirium Screening Checklist (ICDSC) construct, 28,118 patients from 35 managing services were included, and the prevalence rates and adverse outcomes were determined by simple logistic regressions and their corresponding odds ratios (ORs).
RESULTS
Delirious patients were older, admitted from institutions (OR 3.44-5.2), admitted as emergencies (OR 1.87), hospitalized twice longer, and discharged, transferred to institutions (OR 5.47-6.6) rather than home (OR 0.1), or deceased (OR 43.88). The rate of undiagnosed delirium was 84.2%. The highest prevalence rates were recorded in the intensive care units (47.1-84.2%, pooled 67.9%); in the majority of medical services, rates ranged from 20% to 40% (pooled 26.2%), except, at both ends, palliative care (55.9%), endocrinology (8%), and rheumatology (4.4%). Conversely, in surgery and its related services, prevalence rates were lower (pooled 13.1%), except for cardio- and neurosurgical services (53.3% and 46.4%); the lowest prevalence rate was recorded in obstetrics (2%).
SIGNIFICANCE OF RESULTS
Delirium remains underdiagnosed, and novel screening approaches are required. Furthermore, this study identified the impact of delirium on patients, determined the prevalence rates for 32 services, and elucidated the association between individual services and delirium.
Topics: Cohort Studies; Critical Care; Delirium; Humans; Intensive Care Units; Prevalence; Prospective Studies
PubMed: 32744222
DOI: 10.1017/S1478951520000632 -
Aging Clinical and Experimental Research Dec 2022Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the... (Review)
Review
Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.
Topics: Humans; Delirium; Cognition; Caregivers; Affect; Primary Prevention
PubMed: 36131074
DOI: 10.1007/s40520-022-02249-y