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Public Health Sep 2023Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be...
OBJECTIVES
Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic.
STUDY DESIGN
Retrospective epidemiological assessment.
METHODS
The medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed.
RESULTS
The overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before.
CONCLUSIONS
Medically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.
Topics: Humans; SARS-CoV-2; COVID-19; Retrospective Studies; Pandemics; Delirium
PubMed: 37517161
DOI: 10.1016/j.puhe.2023.06.031 -
International Journal of Surgery... 2013Delirium is highly prevalent, occurring in 20% of acute hospital inpatients and up to 62% of surgical patients. It is a significant predictor of poor outcomes including... (Review)
Review
Delirium is highly prevalent, occurring in 20% of acute hospital inpatients and up to 62% of surgical patients. It is a significant predictor of poor outcomes including mortality and institutionalisation, however it is often viewed as simply a marker of underlying illness and is frequently overlooked in older adults. Although delirium is commonly comorbid with dementia, it represents a more urgent diagnosis, requiring prompt intervention. Delirium presents most commonly with hypoactive features (e.g. withdrawal and reduced spontaneous movement and speech). The common stereotype of hyperactive delirium tremens (e.g. agitation, hallucinations), although more visible, is less common. All presentations share acute disimprovement of cognitive function. Delirium is a highly predictable and preventable occurrence, however a major barrier to improving delirium care and impacting upon outcomes is that it remains poorly detected, particularly in surgical populations and especially in patients with hypoactive presentations. Routine ward-based screening for delirium, particularly in high-risk populations, and improved staff awareness of the significance of the problem can improve detection rates. Preventative strategies, particularly multicomponent approaches, have been most efficacious in improving patient outcomes. Optimising perioperative risk factors can lead to reduced incidence. Appropriate treatment of delirium requires thorough investigation, management of the underlying illness, avoidance of complications and simplification of the care environment. Studies suggest a role for pharmacological prophylaxis, particularly in relation to anaesthetic and sedative agents used intra- and post-operatively. Furthermore, gathering evidence suggests that judicious use of antipsychotic medications may be helpful in delirium prevention and treatment.
Topics: Delirium; Humans; Perioperative Care
PubMed: 23277227
DOI: 10.1016/j.ijsu.2012.12.015 -
Age and Ageing Nov 2013Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes... (Review)
Review
UNLABELLED
Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i)
PATHOGENESIS
recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii)
PREVENTION
delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii)
ASSESSMENT
though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv)
MANAGEMENT
studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.
Topics: Age Factors; Aging; Animals; Brain; Delirium; Hospitalization; Humans; Predictive Value of Tests; Prognosis; Risk Factors
PubMed: 24067500
DOI: 10.1093/ageing/aft148 -
Intensive & Critical Care Nursing Dec 2023Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit...
OBJECTIVES
Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit.
RESEARCH METHODOLOGY
A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation.
FINDINGS
Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment.
CONCLUSIONS
The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment.
IMPLICATIONS FOR CLINICAL PRACTICE
Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.
Topics: Humans; Delirium; Qualitative Research; Intensive Care Units; Cognition; Nurses
PubMed: 37541066
DOI: 10.1016/j.iccn.2023.103508 -
Critical Care (London, England) 2008Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring... (Review)
Review
Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to 80% of the sickest intensive care unit (ICU) populations. Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continues to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument. Patients with delirium have longer hospital stays and lower 6-month survival than do patients without delirium, and preliminary research suggests that delirium may be associated with cognitive impairment that persists months to years after discharge. Little evidence exists regarding the prevention and treatment of delirium in the ICU, but multicomponent interventions reduce the incidence of delirium in non-ICU studies. Strategies for the prevention and treatment of ICU delirium are the subjects of multiple ongoing investigations.
Topics: Delirium; Humans; Intensive Care Units; Prognosis; Risk Factors
PubMed: 18495054
DOI: 10.1186/cc6149 -
BMC Geriatrics Mar 2023Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses. Preoperative anxiety has been suggested as a possible precipitating factor for the development of POD. As such, we aimed to explore the association between preoperative anxiety and POD in older surgical patients.
METHODS
Electronic databases including MEDLINE (via PubMed), EMBASE (via Embase.com), Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete; via EBSCOhost) and clinical trial registries were systematically searched to identify prospective studies examining preoperative anxiety as a risk factor for POD in older surgical patients. We used Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies to assess the quality of included studies. The association between preoperative anxiety and POD was summarized with odds ratios (ORs) and 95% confidence intervals (CIs) using DerSimonian-Laird random-effects meta-analysis.
RESULTS
Eleven studies were included (1691 participants; mean age ranging between 63.1-82.3 years). Five studies used a theoretical definition for preoperative anxiety, with the Anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) as the instrument being most often used. When using dichotomized measures and within the HADS-A subgroup analysis, preoperative anxiety was significantly associated with POD (OR = 2.17, 95%CI: 1.01-4.68, I = 54%, Tau = 0.4, n = 5; OR = 3.23, 95%CI: 1.70-6.13, I = 0, Tau = 0, n = 4; respectively). No association was observed when using continuous measurements (OR = 0.99, 95%CI: 0.93-1.05, I = 0, Tau = 0, n = 4), nor in the subgroup analysis of STAI-6 (six-item version of state scale of Spielberger State-Trait Anxiety Inventory, OR = 1.07, 95%CI: 0.93-1.24, I = 0, Tau = 0, n = 2). We found the overall quality of included studies to be moderate to good.
CONCLUSIONS
An unclear association between preoperative anxiety and POD in older surgical patients was found in our study. Given the ambiguity in conceptualization and measurement instruments used for preoperative anxiety, more research is warranted in which a greater emphasis should be placed on how preoperative anxiety is operationalized and measured.
Topics: Humans; Aged; Aged, 80 and over; Emergence Delirium; Delirium; Prospective Studies; Anxiety; Postoperative Complications; Risk Factors
PubMed: 36997928
DOI: 10.1186/s12877-023-03923-0 -
CNS Neuroscience & Therapeutics Oct 2023Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns.
AIMS
Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns.
METHODS
Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital.
RESULTS
Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%).
CONCLUSION
The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.
Topics: Humans; Intensive Care Units; Machine Learning; Random Forest; Delirium
PubMed: 37122154
DOI: 10.1111/cns.14237 -
Annals of Cardiac Anaesthesia 2016Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed... (Review)
Review
Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.
Topics: Cardiac Surgical Procedures; Delirium; Humans; Postoperative Care; Postoperative Complications; Risk Factors
PubMed: 27052077
DOI: 10.4103/0971-9784.179634 -
Resuscitation Jun 2020To establish incidence, phenotype, long-term functional outcome, and early EEG predictors of delirium after cardiac arrest.
AIM
To establish incidence, phenotype, long-term functional outcome, and early EEG predictors of delirium after cardiac arrest.
METHODS
This is an ad hoc analysis of a prospective cohort study on outcome prediction of comatose patients after cardiac arrest. Patients with recovery of consciousness, who survived until hospital discharge, were subdivided in groups with and without delirium based on psychiatric consultation. Delirium phenotype and medical treatment were retrieved from patient files. All other data were prospectively collected. We used univariate analyses of baseline and early EEG characteristics for identification of possible delirium predictors. Association of delirium with neurological recovery at six months was analyzed with multinomial logistic regression analysis.
RESULTS
Of 233 patients, 141 survived until hospital discharge, of whom 47 (33%) were diagnosed with delirium. There were no differences in baseline characteristics between patients with and without delirium. All delirious patients were treated with relatively high dosages of psychopharmaceuticals, mostly haloperidol and benzodiazepine agonists. Prevalent characteristics were disturbed cognition, perception and psychomotor functioning (98%). Half of the patients had language disorders or shouting. Delirium was associated with longer ICU and hospital admission, and more frequent discharge to rehabilitation centre or nursing home. There was a trend towards poorer neurological recovery. EEG measurements within 12 h after cardiac arrest could predict delirium with 91% specificity and 40% sensitivity.
DISCUSSION
Delirium is common after cardiac arrest, and probably leads to longer hospitalization and poorer outcome. Optimal treatment is unclear. Early EEG holds potential to identify patients at risk.
Topics: Delirium; Electroencephalography; Heart Arrest; Humans; Phenotype; Prospective Studies; Treatment Outcome
PubMed: 32276001
DOI: 10.1016/j.resuscitation.2020.03.020 -
PloS One 2022The purpose of this study was to identify the types and contents of non-pharmacological delirium prevention interventions applied to inpatients in general wards, and to... (Meta-Analysis)
Meta-Analysis
The purpose of this study was to identify the types and contents of non-pharmacological delirium prevention interventions applied to inpatients in general wards, and to verified the effectiveness of the interventions on the incidence of delirium. We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform, PubMed and Google Scholar, and Korean DB such as RISS, DBpia, KISS, NDSL and KCI) using terms to identify delirium, prevention, and non-pharmacological. We searched all databases from their inception to January 2021 and imposed restriction on language of publication in English and Korean. We included studies if they were conducted as all types of randomized controlled trials (RCT), involving adult patients aged 19 years or more who were admitted to a general ward. We included trials comparing non-pharmacological intervention versus usual care. The entire process of data selection and extraction, assessment of risk of bias with ROB2.O was independently performed by three researchers. The estimated effect size was an odds ratio (OR) and 95% confidence interval. The fixed effects model and general inverse variance estimation method were adopted. The type of non-pharmacological delirium prevention interventions for inpatients in general ward was mainly multi-component intervention to correct delirium risk factors. The content and intensity of non-pharmacological interventions varied greatly depending on the characteristics of the patient and the clinical situation. As a result of the meta-analysis, non-pharmacological multi-component intervention was effective in reducing the incidence of delirium, and it was confirmed that it was effective in reducing the incidence of delirium in both the internal and surgical wards. It was confirmed by quantitative evidence that non-pharmacological interventions, especially multi-component interventions, were effective in preventing delirium in general ward inpatients.
Topics: Adult; Delirium; Hospitalization; Humans; Inpatients; Patients' Rooms; Randomized Controlled Trials as Topic
PubMed: 35522654
DOI: 10.1371/journal.pone.0268024