-
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 -
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 -
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 -
Revista Espanola de Geriatria Y... 2008Delirium and dementia are highly prevalent neurocognitive syndromes in the elderly. These syndromes are defined by level of consciousness, clinical onset, and potential... (Review)
Review
Delirium and dementia are highly prevalent neurocognitive syndromes in the elderly. These syndromes are defined by level of consciousness, clinical onset, and potential reversibility, etc. Frequently, both syndromes coincide in the elderly patient and share many epidemiologic, pathogenic and clinical features, which are reviewed in this article. There is no solid scientific evidence that explains the association between delirium and dementia. The present article proposes a change of paradigm in the diagnostic, preventive and therapeutic approach to delirium in the elderly that recognizes the inherent complexity of this geriatric syndrome and, unlike dichotomic models, explores the complex interrelations between both geriatric syndromes. Delirium is viewed as an important model to investigate cognitive disorders and dementia.
Topics: Aged; Delirium; Dementia; Humans; Prognosis
PubMed: 19422115
DOI: No ID Found -
BMJ (Clinical Research Ed.) Jun 2016
Review
Topics: Delirium; Disease Management; Humans; Psychomotor Agitation; Terminal Care; Terminally Ill
PubMed: 27283962
DOI: 10.1136/bmj.i3085 -
Journal of the American College of... Feb 2015
Topics: Aged; Aged, 80 and over; Delirium; Humans; Perioperative Care; Postoperative Complications; Risk Assessment; Risk Factors
PubMed: 25535170
DOI: 10.1016/j.jamcollsurg.2014.10.019 -
British Journal of Anaesthesia Dec 2009Postoperative delirium and cognitive dysfunction (POCD) are topics of special importance in the geriatric surgical population. They are separate entities, whose... (Review)
Review
Postoperative delirium and cognitive dysfunction (POCD) are topics of special importance in the geriatric surgical population. They are separate entities, whose relationship has yet to be fully elucidated. Although not limited to geriatric patients, the incidence and impact of both are more profound in geriatric patients. Delirium has been shown to be associated with longer and more costly hospital course and higher likelihood of death within 6 months or postoperative institutionalization. POCD has been associated with increased mortality, risk of leaving the labour market prematurely, and dependency on social transfer payments. Here, we review their definitions and aetiology, and discuss treatment and prevention in elderly patients undergoing major non-cardiac surgery. Good basic care demands identification of at-risk patients, awareness of common perioperative aggravating factors, simple prevention interventions, recognition of the disease states, and basic treatments for patients with severe hyperactive manifestations.
Topics: Age Factors; Aged; Cognition Disorders; Delirium; Humans; Postoperative Complications; Risk Factors
PubMed: 20007989
DOI: 10.1093/bja/aep291 -
Anesthesiology Feb 2022
Topics: Anesthesia, Epidural; Delirium; Humans
PubMed: 34843616
DOI: 10.1097/ALN.0000000000004078 -
International Journal of Geriatric... Nov 2018Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established...
Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.
Topics: Biomedical Research; Clinical Trials as Topic; Delirium; Evidence-Based Medicine; Humans
PubMed: 28271556
DOI: 10.1002/gps.4696 -
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