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The New England Journal of Medicine Oct 2017A 75-year-old man is admitted for scheduled major abdominal surgery. He is functionally independent, with mild forgetfulness. His intraoperative course is uneventful,... (Review)
Review
A 75-year-old man is admitted for scheduled major abdominal surgery. He is functionally independent, with mild forgetfulness. His intraoperative course is uneventful, but on postoperative day 2, severe confusion and agitation develop. What is going on? How would you manage this patient’s care? Could his condition have been prevented?
Topics: Aged; Delirium; Hospitalization; Humans; Male; Postoperative Complications; Practice Guidelines as Topic; Risk Factors
PubMed: 29020579
DOI: 10.1056/NEJMcp1605501 -
JAMA Sep 2017Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often... (Review)
Review
IMPORTANCE
Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.
OBJECTIVE
To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.
EVIDENCE REVIEW
Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.
FINDINGS
Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.
CONCLUSIONS AND RELEVANCE
Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
Topics: Aged; Antipsychotic Agents; Biomarkers; Delirium; Electroencephalography; Emergence Delirium; Geriatric Assessment; Humans; Practice Guidelines as Topic; Severity of Illness Index
PubMed: 28973626
DOI: 10.1001/jama.2017.12067 -
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 -
Lancet (London, England) Oct 2016Delirium is a postoperative complication that occurs frequently in patients older than 65 years, and presages adverse outcomes. We investigated whether prophylactic... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Delirium is a postoperative complication that occurs frequently in patients older than 65 years, and presages adverse outcomes. We investigated whether prophylactic low-dose dexmedetomidine, a highly selective α adrenoceptor agonist, could safely decrease the incidence of delirium in elderly patients after non-cardiac surgery.
METHODS
We did this randomised, double-blind, placebo-controlled trial in two tertiary-care hospitals in Beijing, China. We enrolled patients aged 65 years or older, who were admitted to intensive care units after non-cardiac surgery, with informed consent. We used a computer-generated randomisation sequence (in a 1:1 ratio) to randomly assign patients to receive either intravenous dexmedetomidine (0·1 μg/kg per h, from intensive care unit admission on the day of surgery until 0800 h on postoperative day 1), or placebo (intravenous normal saline). Participants, care providers, and investigators were all masked to group assignment. The primary endpoint was the incidence of delirium, assessed twice daily with the Confusion Assessment Method for intensive care units during the first 7 postoperative days. Analyses were done by intention-to-treat and safety populations. This study is registered with Chinese Clinical Trial Registry, www.chictr.org.cn, number ChiCTR-TRC-10000802.
FINDINGS
Between Aug 17, 2011, and Nov 20, 2013, of 2016 patients assessed, 700 were randomly assigned to receive either placebo (n=350) or dexmedetomidine (n=350). The incidence of postoperative delirium was significantly lower in the dexmedetomidine group (32 [9%] of 350 patients) than in the placebo group (79 [23%] of 350 patients; odds ratio [OR] 0·35, 95% CI 0·22-0·54; p<0·0001). Regarding safety, the incidence of hypertension was higher with placebo (62 [18%] of 350 patients) than with dexmedetomidine (34 [10%] of 350 patients; 0·50, 0·32-0·78; p=0·002). Tachycardia was also higher in patients given placebo (48 [14%] of 350 patients) than in patients given dexmedetomidine (23 [7%] of 350 patients; 0·44, 0·26-0·75; p=0·002). Occurrence of hypotension and bradycardia did not differ between groups.
INTERPRETATION
For patients aged over 65 years who are admitted to the intensive care unit after non-cardiac surgery, prophylactic low-dose dexmedetomidine significantly decreases the occurrence of delirium during the first 7 days after surgery. The therapy is safe.
FUNDING
Braun Anaesthesia Scientific Research Fund and Wu Jieping Medical Foundation, Beijing, China. Study drugs were manufactured and supplied by Jiangsu Hengrui Medicine Co, Ltd, Jiangsu, China.
Topics: Adrenergic alpha-2 Receptor Agonists; Aged; Analgesics, Non-Narcotic; China; Confusion; Critical Care; Delirium; Dexmedetomidine; Double-Blind Method; Drug Administration Schedule; Evidence-Based Medicine; Female; Humans; Incidence; Infusions, Intravenous; Intensive Care Units; Male; Middle Aged; Primary Prevention; Respiration, Artificial; Surgical Procedures, Operative; Time Factors; Treatment Outcome
PubMed: 27542303
DOI: 10.1016/S0140-6736(16)30580-3 -
BMC Geriatrics Feb 2019Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a...
BACKGROUND
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.
METHODS
A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.
RESULTS
One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0-1.7, p = 0.034).
CONCLUSIONS
Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.
Topics: Aged; Aged, 80 and over; Anti-Bacterial Agents; Bacteriuria; Delirium; Evidence-Based Medicine; Female; Humans; Male; Nursing Homes; Risk; Urinary Tract Infections
PubMed: 30717706
DOI: 10.1186/s12877-019-1049-7 -
Critical Care (London, England) Jul 2012Delirium is a frequent form of acute brain dysfunction in critically ill patients, and several detection tools for it have been developed for use in the Intensive Care... (Meta-Analysis)
Meta-Analysis Review
The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies.
INTRODUCTION
Delirium is a frequent form of acute brain dysfunction in critically ill patients, and several detection tools for it have been developed for use in the Intensive Care Unit (ICU). The objective of this study is to evaluate the current evidence on the accuracy of the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) for the diagnosis of delirium in critically ill patients.
METHODS
A systematic review was conducted to identify articles on the evaluation of the CAM-ICU and the ICDSC in ICU patients. A MEDLINE, SciELO, CINAHL and EMBASE databases search was performed for articles published in the English language, involving adult populations and comparing these diagnostic tools with the gold standard, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Results were summarized by meta-analysis. The QUADAS scale was used to assess the quality of the studies.
RESULTS
Nine studies evaluating the CAM-ICU (including 969 patients) and four evaluating the ICDSC (n = 361 patients) were included in the final analysis. The pooled sensitivity of the CAM-ICU was 80.0% (95% confidence interval (CI): 77.1 to 82.6%), and the pooled specificity was 95.9% (95% CI: 94.8 to 96.8%). The diagnostic odds ratio was 103.2 (95% CI: 39.6 to 268.8). The pooled area under the summary receiver operating characteristic curve (AUC) was 0.97. The pooled sensitivity of the ICDSC was 74% (95% CI: 65.3 to 81.5%), and the pooled specificity was 81.9% (95% CI: 76.7 to 86.4%). The diagnostic odds ratio was 21.5 (95% CI: 8.51 to 54.4). The AUC was 0.89.
CONCLUSIONS
The CAM-ICU is an excellent diagnostic tool in critically ill ICU patients, whereas the ICDSC has moderate sensitivity and good specificity. The available data suggest that both CAM-ICU and the ICDSC can be used as a screening tool for the diagnosis of delirium in critically ill patients.
Topics: Checklist; Confusion; Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units
PubMed: 22759376
DOI: 10.1186/cc11407 -
JAMA Internal Medicine Apr 2015Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these strategies for preventing subsequent adverse outcomes has been limited to small studies to date.
OBJECTIVE
To evaluate available evidence on multicomponent nonpharmacological delirium interventions in reducing incident delirium and preventing poor outcomes associated with delirium.
DATA SOURCES
PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews from January 1, 1999, to December 31, 2013.
STUDY SELECTION
Studies examining the following outcomes were included: delirium incidence, falls, length of stay, rate of discharge to a long-term care institution (institutionalization), and change in functional or cognitive status.
DATA EXTRACTION AND SYNTHESIS
Two experienced physician reviewers independently and blindly abstracted data on outcome measures using a standardized approach. The reviewers conducted quality ratings based on the Cochrane risk-of-bias criteria for each study.
MAIN OUTCOMES AND MEASURES
We identified 14 interventional studies. The results for outcomes of delirium incidence, falls, length of stay, and institutionalization were pooled for the meta-analysis, but heterogeneity limited our meta-analysis of the results for change in functional or cognitive status. Overall, 11 studies demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58). Four randomized or matched trials reduced delirium incidence by 44% (OR, 0.56; 95% CI, 0.42-0.76). The rate of falls decreased significantly among intervention patients in 4 studies (OR, 0.38; 95% CI, 0.25-0.60); in 2 randomized or matched trials, the rate of falls was reduced by 64% (OR, 0.36; 95% CI, 0.22-0.61). Length of stay and institutionalization also trended toward decreases in the intervention groups, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) day shorter and the odds of institutionalization 5% lower (OR, 0.95; 95% CI, 0.71-1.26). Among higher-quality randomized or matched trials, length of stay trended -0.33 (95% CI, -1.38 to 0.72) day shorter, and the odds of institutionalization trended 6% lower (OR, 0.94; 95% CI, 0.69-1.30).
CONCLUSIONS AND RELEVANCE
Multicomponent nonpharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization. Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.
Topics: Accidental Falls; Confusion; Delirium; Humans; Incidence; Institutionalization; Length of Stay; Observer Variation; Odds Ratio; Quality of Life; Research Design; Treatment Outcome
PubMed: 25643002
DOI: 10.1001/jamainternmed.2014.7779 -
European Journal of Anaesthesiology Feb 2024Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role...
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
Topics: Adult; Humans; Emergence Delirium; Anesthesiology; Postoperative Complications; Delirium; Consensus; Critical Care; Risk Factors
PubMed: 37599617
DOI: 10.1097/EJA.0000000000001876 -
American Family Physician Mar 2003Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication... (Review)
Review
Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication or drug withdrawal. Delirium affects 10 to 30 percent of hospitalized patients with medical illness; more than 50 percent of persons in certain high-risk populations are affected. The associated morbidity and mortality make diagnosis of this condition extremely important. Patients with delirium can present with agitation, somnolence, withdrawal, and psychosis. This variation in presentation can lead to diagnostic confusion and, in some cases, incorrect attribution of symptoms to a primary psychiatric disorder. To make the distinction, it is important to obtain the history of the onset and course of the condition from family members or caregivers. Primary care physicians must be able to recognize delirium so that the underlying etiology can be ascertained and addressed. The management of delirium involves identifying and correcting the underlying problem, and symptomatically managing any behavioral or psychiatric symptoms. Low doses of antipsychotic drugs can help to control agitation. The use of benzodiazepines should be avoided except in cases of alcohol or sedative-hypnotic withdrawal. Environmental interventions, including frequent reorientation of patients by nursing staff and education of patients and families, should be employed in all cases.
Topics: Antipsychotic Agents; Delirium; Diagnosis, Differential; Haloperidol; Humans; Length of Stay; Risk Factors; Severity of Illness Index
PubMed: 12643363
DOI: No ID Found -
BMC Medicine Jul 2019Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).
METHODS
This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.
RESULTS
Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%).
CONCLUSIONS
The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.
TRIAL REGISTRATION
International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
Topics: Acute Disease; Aged; Aged, 80 and over; Algorithms; Checklist; Confusion; Delirium; Diagnostic Tests, Routine; Diagnostic and Statistical Manual of Mental Disorders; Emergency Service, Hospital; Female; Geriatric Assessment; Humans; Inpatients; Male; Neuropsychological Tests; Predictive Value of Tests; Reproducibility of Results; Sensitivity and Specificity
PubMed: 31337404
DOI: 10.1186/s12916-019-1367-9