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International Journal of Nursing Studies Feb 2023The effect of the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of analgesia and sedation;... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The effect of the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment) on patient outcomes such as delirium is potentially optimised when the bundle is implemented in its entirety.
OBJECTIVE
To systematically synthesise the evidence on the effectiveness of the ABCDEF bundle delivered in its entirety on delirium, function, and quality of life in adult intensive care unit patients.
DESIGN
Systematic review and meta-analysis.
DATA SOURCE
Electronic databases including MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Joanna Briggs Institute's Evidence Based Practice, Australian New Zealand Clinical Trials Registry, and Embase were searched from 2000 until December 2021.
REVIEW METHODS
Inclusion criteria included (1) adult intensive care unit patients (2) studies that described the ABCDE or ABCDEF bundle in its entirety (3) studies that evaluated delirium, functional outcomes, or quality of life. Studies were excluded if they investigated long-term intensive care unit rehabilitation patients. Two reviewers independently screened records and full text, extracted data, and undertook quality appraisals with discrepancies discussed until consensus was reached. Random effects meta-analyses were conducted for delirium but was not possible for other outcomes. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess the certainty of the synthesised findings of the body of evidence. The study protocol was registered on PROSPERO (CRD 42019126407).
RESULTS
A total of 18 studies (29,576 patients) were included in the descriptive synthesis. Meta-analysis of six studies (2000 patients) identified decreased delirium incidence following implementation of the ABCDEF bundle when compared with standard practice, (risk ratio = 0.57; CI, 0.36-0.90 p = 0.02) although heterogeneity was high (I = 92%). When compared with standard practice, a meta-analysis of five studies (3418 patients) showed the ABCDEF bundle statistically significantly reduced the duration of intensive care unit delirium (mean difference (days) - 1.37, 95% CI -2.61 to -0.13 p = 0.03; I 96%). Valid functional assessments were included in two studies, and quality of life assessment in one.
CONCLUSIONS
Although the evidence on the effect of the ABCDEF bundle delivered in its entirety is limited, positive patient delirium outcomes have been shown in this meta-analysis. As this meta-analysis was based on only 4736 patients in eight studies, further evidence is required to support its use in the adult intensive care unit.
REGISTRATION DETAILS
PROSPERO (CRD 42019126407).
Topics: Adult; Humans; Critical Illness; Quality of Life; Australia; Intensive Care Units; Critical Care; Delirium
PubMed: 36577261
DOI: 10.1016/j.ijnurstu.2022.104410 -
International Journal of Nursing Studies Oct 2021Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted... (Review)
Review
BACKGROUND
Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted nonpharmacologic interventions.
OBJECTIVE
To examine and synthesize qualitative data on patient and family member delirium experiences and relieving factors in the Intensive Care Unit (ICU).
DESIGN
We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family quotes about delirium during critical care, published in English in a peer-reviewed journal since 1980. Data sources included PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane and Clinicaltrials.gov.
METHODS
Systematic searches yielded 3238 identified articles, of which 14 reporting 13 studies were included. Two reviewers independently extracted data into a Microsoft Excel spreadsheet. Qualitative meta-synthesis was performed through line-by-line coding of relevant quotes, organization of codes into descriptive themes, and development of analytical themes. Five patients/family members with experience of ICU delirium contributed to the thematic analysis.
RESULTS
Qualitative meta-synthesis resulted in four major themes and two sub-themes. Key new patient and family-centric insights regarding delirium-related distress in the ICU included articulation of the distinct emotions experienced during and after delirium (for patients, predominantly fear, anger and shame); its 'whole-person' nature; and the value that patients and family members placed on clinicians' compassion, communication, and connectedness.
CONCLUSIONS
Distinct difficult emotions and other forms of distress are experienced by patients and families during ICU delirium, during which patients and families highly value human kindness and empathy. Future studies should further explore and address the many facets of delirium-related distress during critical care using these insights and include patient-reported measures of the predominant difficult emotions.
Topics: Adult; Critical Care; Delirium; Family; Humans; Intensive Care Units; Patients; Qualitative Research
PubMed: 34343884
DOI: 10.1016/j.ijnurstu.2021.104030 -
Neurosurgical Review Feb 2022Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery... (Meta-Analysis)
Meta-Analysis Review
Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.
Topics: Critical Care; Delirium; Humans; Incidence; Intensive Care Units; Neurosurgery
PubMed: 34396454
DOI: 10.1007/s10143-021-01619-w -
Cureus Dec 2022Urinary tract infection (UTI) is common in older adults, mainly due to several age-related risk factors. Symptoms of UTI are atypical in the elderly population, like... (Review)
Review
Urinary tract infection (UTI) is common in older adults, mainly due to several age-related risk factors. Symptoms of UTI are atypical in the elderly population, like hypotension, tachycardia, urinary incontinence, poor appetite, drowsiness, frequent falls, and delirium. UTI manifests more commonly and specifically for this age group as delirium or confusion in the absence of a fever. This systematic review aims to highlight the relationship between UTI and delirium in the elderly population by understanding the pathologies individually and collectively. A systematic review is conducted by searching PubMed with regular keywords and major Medical Subject Heading (MeSH) keywords, Science Direct, and Google Scholar. The inclusion criteria consisted of studies based on male and female human populations above the age of 65 in the English language, available in full text published between 2017 and 2022. However, the exclusion criteria were animal studies, clinical trials, literature published before 2017, and papers published in any other language except English. A total of 106 articles were identified, and nine final studies were selected after a quality assessment, following which a valid relationship between delirium and UTI was identified in this systematic review.
PubMed: 36632270
DOI: 10.7759/cureus.32321 -
Journal of the American Medical... Jan 2021To investigate the association between anticholinergic drug burden (ADB), measured with anticholinergic drug scales, and delirium and delirium severity. (Review)
Review
OBJECTIVES
To investigate the association between anticholinergic drug burden (ADB), measured with anticholinergic drug scales, and delirium and delirium severity.
DESIGN
Systematic review.
SETTING AND PARTICIPANTS
All available studies.
METHODS
A systematic literature search was performed in Medline, Embase, PsycINFO, Web of Science, CINAHL, Cochrane library, and Google Scholar. Studies evaluating the association between ADB (measured as a total score) and delirium or delirium severity, published in English, were eligible for inclusion.
RESULTS
Sixteen studies, including 148,756 persons, were included. Fifteen studies investigated delirium. ADB was measured with the Anticholinergic Risk Scale (ARS, n = 5), the Anticholinergic Cognitive Burden Scale (ACB, n = 6), the list of Chew (n = 1), the Anticholinergic Drug Scale (ADS, n = 5), a modified version of the ARS (n = 1), and a modified version of the ACB (n = 1). A high ADB, measured with the ARS, was associated with delirium (5/5). Also with the modified version of the ARS and ACB, an association was found between a high ADB and delirium during 3-month (1/1) and 1-year follow-up (1/1), respectively. When ADB was assessed with other scales, the results were inconclusive, with only 1 positive association for the ACB (1/6) and ADS (1/5) each. The possible association between ADB and delirium severity has also been investigated (ADS n = 2, Summers Drug Risk Number n = 1). One study found an association between a high ADB, measured with the ADS, and an increase in severity of delirium.
CONCLUSIONS AND IMPLICATIONS
ADB assessed with the ARS is consistently associated with delirium. The association found between the modified versions of the ARS and ACB and delirium needs confirmation. When ADB was assessed with other scales, the findings were inconclusive. The current findings suggest that the ARS might be a useful tool to identify patients at increased risk for delirium.
Topics: Cholinergic Antagonists; Delirium; Humans; Pharmaceutical Preparations
PubMed: 32703688
DOI: 10.1016/j.jamda.2020.04.019 -
Brain Sciences Apr 2022Delirium is a neuropsychiatric syndrome represented by an acute disturbance in attention, awareness and cognition, highly prevalent in older, and critically ill... (Review)
Review
Delirium is a neuropsychiatric syndrome represented by an acute disturbance in attention, awareness and cognition, highly prevalent in older, and critically ill patients, and associated with poor outcomes. This review synthesized existing evidence on the effectiveness of music interventions on delirium in adults, and music interventions (MIs), psychometric assessments and outcome measures used. We searched MEDLINE, PsychINFO, SCOPUS, Clinical Trials and CENTRAL for quantitative designs comparing any MIs to standard care or another intervention. From 1150 studies 12 met the inclusion criteria, and 6 were included in the meta-analysis. Narrative synthesis showed that most studies focused on prevention, few assessed delirium severity, with the majority of studies reporting beneficial effects. The summary relative risk for incident delirium comparing music vs. no music in postsurgical and critically ill older patients was 0.52 (95% confidential interval (CI): 0.20−1.35, I2 = 79.1%, heterogeneity <0.0001) for the random effects model and 0.47 (95% CI: 0.34−0.66) using the fixed effects model. Music listening interventions were more commonly applied than music therapy delivered by credentialed music therapists, and delirium assessments methods were heterogeneous, including both standardized tools and systematic observations. Better designed studies are needed addressing effectiveness of MIs in specific patient subgroups, exploring the correlations between intervention-types/dosages and delirium symptoms.
PubMed: 35624955
DOI: 10.3390/brainsci12050568 -
Journal of Psychosomatic Research Aug 2021Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to... (Review)
Review
BACKGROUND
Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies.
METHOD
Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles.
RESULTS
2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions.
CONCLUSION
Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
Topics: Biomarkers; Cognition Disorders; Delirium; Humans; Intensive Care Units; Length of Stay
PubMed: 34098376
DOI: 10.1016/j.jpsychores.2021.110530 -
JAMA Network Open Jan 2023Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the...
IMPORTANCE
Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.
OBJECTIVE
To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.
EVIDENCE REVIEW
A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.
FINDINGS
A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.
CONCLUSIONS AND RELEVANCE
In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
Topics: Adult; Humans; Male; Female; Disease Susceptibility; Delirium; Precipitating Factors; Prospective Studies; Case-Control Studies
PubMed: 36607634
DOI: 10.1001/jamanetworkopen.2022.49950 -
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 -
BMJ (Clinical Research Ed.) Jun 2015To determine the relation between delirium in critically ill patients and their outcomes in the short term (in the intensive care unit and in hospital) and after... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To determine the relation between delirium in critically ill patients and their outcomes in the short term (in the intensive care unit and in hospital) and after discharge from hospital.
DESIGN
Systematic review and meta-analysis of published studies.
DATA SOURCES
PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 January 2015.
ELIGIBILITY CRITERIA FOR SELECTION STUDIES
Reports were eligible for inclusion if they were prospective observational cohorts or clinical trials of adults in intensive care units who were assessed with a validated delirium screening or rating system, and if the association was measured between delirium and at least one of four clinical endpoints (death during admission, length of stay, duration of mechanical ventilation, and any outcome after hospital discharge). Studies were excluded if they primarily enrolled patients with a neurological disorder or patients admitted to intensive care after cardiac surgery or organ/tissue transplantation, or centered on sedation management or alcohol or substance withdrawal. Data were extracted on characteristics of studies, populations sampled, identification of delirium, and outcomes. Random effects models and meta-regression analyses were used to pool data from individual studies.
RESULTS
Delirium was identified in 5280 of 16,595 (31.8%) critically ill patients reported in 42 studies. When compared with control patients without delirium, patients with delirium had significantly higher mortality during admission (risk ratio 2.19, 94% confidence interval 1.78 to 2.70; P<0.001) as well as longer durations of mechanical ventilation and lengths of stay in the intensive care unit and in hospital (standard mean differences 1.79 (95% confidence interval 0.31 to 3.27; P<0.001), 1.38 (0.99 to 1.77; P<0.001), and 0.97 (0.61 to 1.33; P<0.001), respectively). Available studies indicated an association between delirium and cognitive impairment after discharge.
CONCLUSIONS
Nearly a third of patients admitted to an intensive care unit develop delirium, and these patients are at increased risk of dying during admission, longer stays in hospital, and cognitive impairment after discharge.
Topics: Adult; Cognition Disorders; Critical Care; Critical Illness; Delirium; Epidemiologic Methods; Female; Humans; Length of Stay; Male; Patient Discharge; Respiration, Artificial; Treatment Outcome
PubMed: 26041151
DOI: 10.1136/bmj.h2538