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1.
J Am Geriatr Soc. 2019 Jan 21. doi: 10.1111/jgs.15751. [Epub ahead of print]

Deprescribing in the Pharmacologic Management of Delirium: A Randomized Trial in the Intensive Care Unit.

Campbell NL1,2,3,4,5, Perkins AJ4, Khan BA2,3,4,5,6, Gao S2,3,6, Farber MO6, Khan S2,3,6, Wang S6,7, Boustani MA2,3,4,5,6.

Author information

1
Purdue University College of Pharmacy, West Lafayette, Indiana.
2
Indiana University Center for Aging Research, Indianapolis, Indiana.
3
Regenstrief Institute, Inc, Indianapolis, Indiana.
4
Indiana University Center for Health Innovation and Implementation Science and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana.
5
Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, Indiana.
6
Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana.
7
Roudebush Veterans Administration Medical Center, Indianapolis, Indiana.

Abstract

OBJECTIVE:

Benzodiazepines and anticholinergics are risk factors for delirium in the intensive care unit (ICU). We tested the impact of a deprescribing intervention on short-term delirium outcomes.

DESIGN:

Multisite randomized clinical trial.

SETTING:

ICUs of three large hospitals.

PARTICIPANTS:

Two hundred adults aged 18 years or older and admitted to an ICU with delirium, according to the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU). Participants had a contraindication to haloperidol (seizure disorder or prolonged QT interval) or preference against haloperidol as a treatment for delirium, and were excluded for serious mental illness, stroke, pregnancy, or alcohol withdrawal. Participants were randomized to a deprescribing intervention or usual care. The intervention included electronic alerts combined with pharmacist support to deprescribe anticholinergics and benzodiazepines.

MEASUREMENTS:

Primary outcomes were delirium duration measured by the CAM-ICU and severity measured by the Delirium Rating Scale Revised-98 (DRS-R-98) and the CAM-ICU-7; secondary outcomes included adverse events and mortality.

RESULTS:

Participants had a mean age of 61.8 (SD = 14.3) years, 59% were female, and 52% were African American, with no significant differences in baseline characteristics between groups. No differences between groups were identified in the number exposed to anticholinergics (P = .219) or benzodiazepines (P = .566), the median total anticholinergic score (P = .282), or the median total benzodiazepine dose in lorazepam equivalents (P = .501). Neither median delirium/coma-free days (P = .361) nor median change in delirium severity scores (P = .582 for DRS-R-98; P = .333 for CAM-ICU-7) were different between groups. No differences in adverse events or mortality were identified.

CONCLUSIONS:

When added to state-of-the-art clinical services, this deprescribing intervention had no impact on medication use in ICU participants. Given the age of the population, results of clinical outcomes may not be easily extrapolated to older adults. Nonetheless, improved approaches for deprescribing or preventing anticholinergics and benzodiazepines should be developed to determine the impact on delirium outcomes.

KEYWORDS:

anticholinergic; benzodiazepine; delirium; deprescribing

PMID:
30664239
DOI:
10.1111/jgs.15751
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2.
Pharmacotherapy. 2019 Jan 21. doi: 10.1002/phar.2222. [Epub ahead of print]

Effectiveness of Melatonin for the Prevention of Intensive Care Unit Delirium.

Author information

1
Touro University of California College of Pharmacy, Vallejo, CA.
2
University of San Francisco Medical Center, San Francisco, CA.
3
University of California San Francisco Medical Center, San Francisco, CA.

Abstract

STUDY OBJECTIVE:

Intensive care unit (ICU) delirium is an acute brain dysfunction that has been associated with increased mortality, prolonged ICU and hospital lengths of stay, and development of post-ICU cognitive impairment. Melatonin may help to restore sleep and reduce the occurrence of ICU delirium. The purpose of this study was to evaluate the effectiveness of melatonin for the prevention of ICU delirium in critically ill adults.

DESIGN:

Retrospective, observational cohort study.

SETTING:

Large academic medical center.

PATIENTS:

A total of 232 adults were included who were admitted to the medical-surgical or cardiac ICUs between 2013 and 2017 who had a negative Confusion Assessment Method for the ICU (CAM-ICU). Of those, the melatonin group consisted of 117 patients who received melatonin for at least 48 hours; the control group consisted of 115 patients who were admitted for at least 4 days (average time of melatonin initiation), did not receive melatonin during their ICU stay, and did not receive antipsychotics within the first 4 days of their ICU stay.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was development of delirium, which was assessed by using the CAM-ICU. The CAM-ICU was measured twice daily by nursing staff. The development of delirium was significantly lower in the melatonin group: 9 (7.7%) versus 28 (24.3%) patients (p=0.001). This finding remained significant in multivariate logistic models controlling for age, sex, history of hypertension, need for emergent surgery, Acute Physiology and Chronic Health Evaluation II score, mechanical ventilation, ICU length of stay, dexmedetomidine use, and benzodiazepine use. For those patients who developed delirium, patients in the control group had, on average, 20.9 delirium-free days without coma in 28 days compared with 19.9 days in the melatonin group (p=0.72). In the melatonin group, melatonin was used for a mean ± SD of 6.3 ± 7.9 days, with a median dose of 3.5 mg/night (range 1-10 mg).

CONCLUSION:

The development of ICU delirium was significantly lower in the melatonin group compared with that in the control group. To our knowledge, this is one of the only studies that has examined the use of melatonin for the prevention of ICU delirium. Melatonin may be a promising agent for the prevention of ICU delirium; however, a randomized study is needed to further validate its efficacy. This article is protected by copyright. All rights reserved.

KEYWORDS:

Delirium; intensive-care unit; melatonin; sleep

PMID:
30663785
DOI:
10.1002/phar.2222
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3.
Australas J Ageing. 2019 Jan 17. doi: 10.1111/ajag.12608. [Epub ahead of print]

Use of medicines that may precipitate delirium prior to hospitalisation in older Australians with delirium: An observational study.

Author information

1
Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.

Abstract

OBJECTIVE:

To assess the use of medicines associated with delirium prior to hospital admission in older Australian patients with a recorded diagnosis of delirium.

METHODS:

A retrospective observational study was conducted using de-identified data from the Australian Government Department of Veterans' Affairs Health Care Claims Database. The prevalence of use of medicines associated with delirium was determined in people 65 years or older with a delirium diagnosis.

RESULTS:

Three-quarters of the total 22 923 older patients included were taking at least one medicine associated with delirium, the median number of medications per patient was two (interquartile range, 1-3). The most frequently used medicines known to be associated with delirium were psycholeptics, opioids and tricyclic antidepressants.

CONCLUSION:

A substantial proportion of older hospitalised patients with a delirium diagnosis were taking medicines known or suspected to precipitate delirium prior to admission. There may be an opportunity to decrease medication-associated delirium by reducing use of risky medication.

KEYWORDS:

delirium; drug utilization; inappropriate prescribing; medication review; older patients

4.
Acute Med Surg. 2018 Dec 3;6(1):54-59. doi: 10.1002/ams2.378. eCollection 2019 Jan.

Validation of the Prediction of Delirium for Intensive Care model to predict subsyndromal delirium.

Author information

1
Department of Emergency and Critical Care Medicine Tokyo Medical University Shinjuku-ku Tokyo Japan.

Abstract

Aim:

Subsyndromal delirium is associated with prolonged intensive care unit stays, and prolonged mechanical ventilation requirements. The Prediction of Delirium for Intensive Care (PRE-DELIRIC) model can predict delirium. This study was designed to verify if it can also predict development of subsyndromal delirium.

Methods:

We undertook a single-center, retrospective observation study in Japan. We diagnosed subsyndromal delirium based on the Intensive Care Delirium Screening Checklist. We calculated the sensitivity and specificity of the PRE-DELIRIC model and obtained a diagnostic cut-off value.

Results:

We evaluated data from 70 patients admitted to the mixed medical intensive care unit of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. The prevalence of subsyndromal delirium by Intensive Care Delirium Screening Checklist was 31.4%. The area under the receiver operating characteristic curve was 0.83 of the PRE-DELIRIC model for subsyndromal delirium. The calculated cut-off value was 36 points with a sensitivity of 94.3% and specificity of 57.1%. Subsyndromal delirium was associated with a higher incidence of delirium (odds ratio, 8.81; < 0.01).

Conclusion:

The PRE-DELIRIC model could be a tool for predicting subsyndromal delirium using a cut-off value of 36 points.

KEYWORDS:

Critical care; delirium; intensive care unit; psychiatry; sleep

5.
JAMA Surg. 2019 Jan 16. doi: 10.1001/jamasurg.2018.5093. [Epub ahead of print]

Association Between Postoperative Delirium and Long-term Cognitive Function After Major Nonemergent Surgery.

Author information

1
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill.
2
Medical student, University of North Carolina School of Medicine, Chapel Hill.
3
Division of Hospitalist Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill.
4
Division of Neuromuscular Diseases, Department of Neurology, Duke University School of Medicine, Durham, North Carolina.
5
Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill.
6
Center for Aging and Health, Division of Geriatric Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill.

Abstract

Importance:

Postoperative delirium is associated with decreases in long-term cognitive function in elderly populations.

Objective:

To determine whether postoperative delirium is associated with decreased long-term cognition in a younger, more heterogeneous population.

Design, Setting, and Participants:

A prospective cohort study was conducted at a single academic medical center (≥800 beds) in the southeastern United States from September 5, 2017, through January 15, 2018. A total of 191 patients aged 18 years or older who were English-speaking and were anticipated to require at least 1 night of hospital admission after a scheduled major nonemergent surgery were included. Prisoners, individuals without baseline cognitive assessments, and those who could not provide informed consent were excluded. Ninety-day follow-up assessments were performed on 135 patients (70.7%).

Exposures:

The primary exposure was postoperative delirium defined as any instance of delirium occurring 24 to 72 hours after an operation. Delirium was diagnosed by the research team using the Confusion Assessment Method (CAM).

Main Outcomes and Measures:

The primary outcome was change in cognition at 90 days after surgery compared with baseline, preoperative cognition. Cognition was measured using a telephone version of the Montreal Cognitive Assessment (T-MoCA) with cognitive impairment defined as a score less than 18 on a scale of 0 to 22.

Results:

Of the 191 patients included in the study, 110 (57.6%) were women; the mean (SD) age was 56.8 (16.7) years. For the primary outcome of interest, patients with and without delirium had a small increase in T-MoCA scores at 90 days compared with baseline on unadjusted analysis (with delirium, 0.69; 95% CI, -0.34 to 1.73 vs without delirium, 0.67; 95% CI, 0.17-1.16). The initial multivariate linear regression model included age, preoperative American Society of Anesthesiologists Physical Status Classification System score, preoperative cognitive impairment, and duration of anesthesia. Preoperative cognitive impairment proved to be the only notable confounder: when adjusted for preoperative cognitive impairment, patients with delirium had a 0.70-point greater decrease in 90-day T-MoCA scores than those without delirium compared with their respective baseline scores (with delirium, 0.16; 95% CI, -0.63 to 0.94 vs without delirium, 0.86; 95% CI, 0.40-1.33).

Conclusions and Relevance:

Although a statistically significant association between 90-day cognition and postoperative delirium was not noted, patients with preoperative cognitive impairment appeared to have improvements in cognition 90 days after surgery; however, this finding was attenuated if they became delirious. Preoperative cognitive impairment alone should not preclude patients from undergoing indicated surgical procedures.

6.
JAMA Netw Open. 2018 Aug 3;1(4):e181405. doi: 10.1001/jamanetworkopen.2018.1405.

Performance of Electronic Prediction Rules for Prevalent Delirium at Hospital Admission.

Author information

1
Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island.
2
College of Nursing, The Pennsylvania State University, University Park.
3
Brown University, Warren Alpert Medical School and School of Public Health, Providence, Rhode Island.

Abstract

Importance:

Delirium at admission is associated with increased hospital morbidity and mortality, but it may be missed in up to 70% of cases. Use of a predictive algorithm in an electronic medical record (EMR) system could provide critical information to target assessment of those with delirium at admission.

Objectives:

To develop and assess a prediction rule for delirium using 2 populations of veterans and compare this rule with previously confirmed rules.

Design, Setting, and Participants:

In a diagnostic study, randomly selected EMRs of hospitalized veterans from the Veterans Affairs (VA) External Peer Review Program at 118 VA medical centers with inpatient facilities were reviewed for delirium risk factors associated with the National Institute for Health and Clinical Excellence (NICE) delirium rule in a derivation cohort (October 1, 2012, to September 30, 2013) and a confirmation cohort (October 1, 2013, to March 31, 2014). Delirium within 24 hours of admission was identified using key word terms. A total of 39 377 veterans 65 years or older who were admitted to a VA medical center for congestive heart failure, acute coronary syndrome, community-acquired pneumonia, and chronic obstructive pulmonary disease were included in the study.

Exposure:

The EMR calculated delirium risk.

Main Outcomes and Measures:

Delirium at admission as identified by trained nurse reviewers was the main outcome measure. Random forest methods were used to identify accurate risk factors for prevalent delirium. A prediction rule for prevalent delirium was developed, and its diagnostic accuracy was tested in the confirmation cohort. This consolidated NICE rule was compared with previously confirmed scoring algorithms (electronic NICE and Pendlebury NICE).

Results:

A total of 27 625 patients were included in the derivation cohort (28 118 [92.2%] male; mean [SD] age, 75.95 [8.61] years) and 11 752 in the confirmation cohort (11 536 [98.2%] male; mean [SD] age, 75.43 [8.55] years). Delirium at admission was identified in 2343 patients (8.5%) in the derivation cohort and 882 patients (7.0%) in the confirmation cohort. Modeling techniques identified cognitive impairment, infection, sodium level, and age of 80 years or older as the dominant risk factors. The consolidated NICE rule (area under the receiver operating characteristic [AUROC] curve, 0.91; 95% CI, 0.91-0.92; P < .001) had significantly higher discriminatory function than the eNICE rule (AUROC curve, 0.81; 95% CI, 0.80-0.82; P < .001) or Pendlebury NICE rule (AUROC curve, 0.87; 95% CI, 0.86-0.88; P < .001). These findings were confirmed in the confirmation cohort.

Conclusions and Relevance:

This analysis identified preexisting cognitive impairment, infection, sodium level, and age of 80 years or older as delirium screening targets. Use of this algorithm in an EMR system could direct clinical assessment efforts to patients with delirium at admission.

7.
JAMA Netw Open. 2018 Aug 3;1(4):e181018. doi: 10.1001/jamanetworkopen.2018.1018.

Development and Validation of an Electronic Health Record-Based Machine Learning Model to Estimate Delirium Risk in Newly Hospitalized Patients Without Known Cognitive Impairment.

Author information

1
School of Medicine, University of California, San Francisco.
2
Clinical Innovation Center, Department of Medicine, University of California, San Francisco.
3
Department of Neurology, University of California, San Francisco.
4
Institute for Computational Health Sciences, University of California, San Francisco.

Abstract

Importance:

Current methods for identifying hospitalized patients at increased risk of delirium require nurse-administered questionnaires with moderate accuracy.

Objective:

To develop and validate a machine learning model that predicts incident delirium risk based on electronic health data available on admission.

Design, Setting, and Participants:

Retrospective cohort study evaluating 5 machine learning algorithms to predict delirium using 796 clinical variables identified by an expert panel as relevant to delirium prediction and consistently available in electronic health records within 24 hours of admission. The training set comprised 14 227 adult patients with non-intensive care unit hospital stays and no delirium on admission who were discharged between January 1, 2016, and August 31, 2017, from UCSF Health, a large academic health institution. The test set comprised 3996 patients with hospital stays who were discharged between August 1, 2017, and November 30, 2017.

Exposures:

Patient demographic characteristics, diagnoses, nursing records, laboratory results, and medications available in electronic health records during hospitalization.

Main Outcomes and Measures:

Delirium was defined as a positive Nursing Delirium Screening Scale or Confusion Assessment Method for the Intensive Care Unit score. Models were assessed using the area under the receiver operating characteristic curve (AUC) and compared against the 4-point scoring system AWOL (age >79 years, failure to spell world backward, disorientation to place, and higher nurse-rated illness severity), a validated delirium risk-assessment tool routinely administered in this cohort.

Results:

The training set included 14 227 patients (5113 [35.9%] aged >64 years; 7335 [51.6%] female; 687 [4.8%] with delirium), and the test set included 3996 patients (1491 [37.3%] aged >64 years; 1966 [49.2%] female; 191 [4.8%] with delirium). In total, the analysis included 18 223 hospital admissions (6604 [36.2%] aged >64 years; 9301 [51.0%] female; 878 [4.8%] with delirium). The AWOL system achieved a baseline AUC of 0.678. The gradient boosting machine model performed best, with an AUC of 0.855. Setting specificity at 90%, the model had a 59.7% (95% CI, 52.4%-66.7%) sensitivity, 23.1% (95% CI, 20.5%-25.9%) positive predictive value, 97.8% (95% CI, 97.4%-98.1%) negative predictive value, and a number needed to screen of 4.8. Penalized logistic regression and random forest models also performed well, with AUCs of 0.854 and 0.848, respectively.

Conclusions and Relevance:

Machine learning can be used to estimate hospital-acquired delirium risk using electronic health record data available within 24 hours of hospital admission. Such a model may allow more precise targeting of delirium prevention resources without increasing the burden on health care professionals.

8.
Surg Endosc. 2019 Jan 14. doi: 10.1007/s00464-018-6483-7. [Epub ahead of print]

Lower risk of postoperative delirium using laparoscopic approach for major abdominal surgery.

Author information

1
Department of Surgery, Asahi General Hospital, 1326 I, Asahi, Chiba, 289-2511, Japan.
2
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
3
Department of Surgery, Asahi General Hospital, 1326 I, Asahi, Chiba, 289-2511, Japan. nbtanaka@hospital.asahi.chiba.jp.
4
Department of Surgery, Asahi General Hospital, 1326 I, Asahi, Chiba, 289-2511, Japan. yokawaguchi-tky@umin.ac.jp.
5
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. yokawaguchi-tky@umin.ac.jp.

Abstract

BACKGROUND:

A laparoscopic approach is increasingly being used for major abdominal surgeries and is reportedly associated with a lower incidence of postoperative complications. However, the association of laparoscopic approach and postoperative delirium remains unclear. We aimed to retrospectively investigate risk factors for postoperative delirium after abdominal surgery particularly assessing the association between a laparoscopic approach and postoperative delirium.

METHODS:

We retrospectively studied 801 patients who underwent major abdominal surgery between April 2012 and December 2013. Among these, 181 (22.6%) patients underwent a laparoscopic and 620 (77.4%) patients underwent an open procedure. A Cox proportional hazard model analysis was used to identify risk factors for the development of postoperative delirium or overall survival within 180 days after surgery. Cumulative incidence of postoperative delirium was assessed using a propensity score-matching analysis.

RESULTS:

Postoperative delirium occurred in 56 patients (7.0%). A Multivariate Cox proportional hazard model analysis revealed that a laparoscopic approach reduced the risk of postoperative delirium [hazard ratio (HR) 0.30, 95% confidence interval (CI) 0.07-0.84, p = 0.019]. Postoperative delirium was associated with worse overall survival within 180 days (HR 4.91, 95% CI 1.96-12.22, p = 0.001) after adjusting for other confounders using the Cox proportional hazard model analysis. Patients who developed postoperative delirium showed worse outcomes including higher rate of morbidity except delirium (p < 0.001), longer hospitalization (p < 0.001), and post-discharge institutionalization (p < 0.001). After propensity score-matching, cumulative incidence rates of postoperative delirium were significantly lower in the laparoscopic group compared to the open group (30-day cumulative incidence rate, 1.7% vs. 7.8%, p = 0.006).

CONCLUSIONS:

The risk of postoperative delirium after major abdominal surgery is reduced using laparoscopic approach. Postoperative delirium should be prevented as it precipitates adverse postoperative events.

KEYWORDS:

Laparoscopic approach; Major abdominal surgery; Open approach; Postoperative delirium

9.
Z Gerontol Geriatr. 2019 Jan 8. doi: 10.1007/s00391-018-01492-1. [Epub ahead of print]

What do geriatric patients experience during an episode of delirium in acute care hospitals? : A qualitative study.

Author information

1
Forum Palliative PraxisGeriatrie, Weißgerber Lände 40/19, 1030, Vienna, Austria. monique.weissenberger-leduc@gmx.at.
2
NÖGUS - NÖ Gesundheits- und Sozialfonds, St. Pölten, A-3100, Austria.
3
Universitätsklinik für Geriatrie der PMU, Uniklinikum Salzburg Christian-Doppler-Klinik, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria.

Abstract

BACKGROUND:

Predispositions and triggers for delirium, such as noxious agents are known and behavior can be monitored; however, there is little to no information available regarding the experience of patients during delirium episodes. Not much is known about a person's world of experiences, which therefore mostly remains as a sort of black box.

OBJECTIVE:

This study was motivated by the following question: "What do (Austrian) geriatric patients experience during an episode of delirium in an acute care hospital?" The main objective of this article is to present little snippets from the experiences and to allow geriatric patients to speak for themselves.

PATIENTS AND METHODS:

From 2013 to 2016 interviews were carried out within the framework of a qualitative investigation. For data collection narrative interviews according to Fritz Schütze were employed and 10 interviews were conducted in a hospital setting with German-speaking Austrian patients aged between 75 and 90 years (mean age 80.2 years; 7 female and 3 male). The individual interviews lasted between 60 and 120 min. Primary data in the form of individual interpretation and interpretation groups from interview transcripts were marked and coded according to Mayring.

RESULTS:

All patients who participated in the interviews subjectively recognized delirium as a negative experience. The data analysis led to three main categories with subcategories: changes in sensory perception, extraordinarily strong emotions and memories. It is important to differentiate between two very different types of memories: firstly, personal fate or life changes and secondly, those regarding experiences of war.

CONCLUSION:

Scandinavian and Anglo-American literature describe different categories, such as a change in reality, strong emotions and dramatic episodes in the experience of delirium, which can be transferred to Austria. Others consider the biography of each individual patient in context with the sociocultural history of Austria, especially following developments after 1940.

KEYWORDS:

Geriatric care; Hermeneutics; Interview; Personal narratives; Qualitative research

10.
Geriatr Orthop Surg Rehabil. 2018 Dec 5;9:2151459318814823. doi: 10.1177/2151459318814823. eCollection 2018.

Predictors and Sequelae of Postoperative Delirium in Geriatric Hip Fracture Patients.

Author information

1
Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Abstract

Introduction:

Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients.

Methods:

We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium.

Results:

In total, 8,439 geriatric hip fracture patients were identified of whom 2,569 patients (30.4%) had postoperative delirium. Age (OR 1.03 [1.02-1.04, p < 0.001), white race (OR 1.54 [1.19-2.00], p = 0.001), American Society of Anesthesiologists classification (OR 1.20 [1.07-1.36], p = 0.003), baseline dementia (OR 2.46 [2.11-2.86], p < 0.001), and preoperative delirium (OR 10.06 [8.12-12.45], p < 0.001) were independent risk factors for postoperative delirium in multivariate analysis. Patients with postoperative delirium had a significantly higher risk-adjusted 30-day mortality (12.0% vs. 4.8%, OR 2.22 [1.74-2.84], p < 0.001) and morbidity profile. Postoperative delirium was also independently associated with higher rates of discharge to (OR 1.65 [1.32-2.06], p < 0.001) and prolonged stay in (OR 1.79 [1.53-2.09], p < 0.001) an inpatient facility, hospital readmission (OR 1.94 [1.58-2.38], p < 0.001) and hospital length of stay (7.6 ± 5.0 vs. 6.1 ± 4.1 days, p < 0.001), as well as lower rates of immediate postoperative weight bearing (OR 0.73 [0.63-0.86], p < 0.001).

Discussion:

Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes.

Conclusions:

Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.

KEYWORDS:

delirium; fragility fractures; geriatric trauma; systems of care; trauma surgery

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

11.
Crit Care Med. 2019 Jan 2. doi: 10.1097/CCM.0000000000003596. [Epub ahead of print]

Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients.

Author information

1
Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
2
Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
3
Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
4
Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands.
5
Department of Intensive Care, IJsselland Hospital, Rotterdam, The Netherlands.
6
Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.
7
Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands.
8
Department of Pulmonology and Critical Care, New York University - Langone, New York, NY.
9
Department of Pulmonology and Critical Care, Columbia University Medical Center - New York Presbyterian, New York, NY.
10
Department of Intensive Care, Pontificia Universidad Catolica de Chile, Santiago, Chile.
11
Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital University Medical Center Rotterdam, Rotterdam, The Netherlands.

Abstract

OBJECTIVES:

Implementation of delirium guidelines at ICUs is suboptimal. The aim was to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation.

DESIGN:

A prospective multicenter, pre-post, intervention study.

SETTING:

ICUs in one university hospital and five community hospitals.

PATIENTS:

Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015.

INTERVENTIONS:

Multifaceted, three-phase (baseline, delirium screening, and guideline) implementation program of delirium guidelines in adult ICUs.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction improved: the mean delirium duration decreased from 5.6 to 3.3 days (-2.2 d; 95% CI, -3.2 to -1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4-0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change.

CONCLUSIONS:

This large pre-post implementation study of delirium-oriented measures based on the 2013 Pain, Agitation, and Delirium guidelines showed improved health professionals' adherence to delirium guidelines and reduced brain dysfunction. Our findings provide empirical support for the differential efficacy of the guideline bundle elements in a real-life setting and provide lessons for optimization of guideline implementation programs.

12.
Support Care Cancer. 2019 Jan 3. doi: 10.1007/s00520-018-4604-4. [Epub ahead of print]

Trajectory of severity of postoperative delirium symptoms and its prospective association with cognitive function in patients with gastric cancer: results from a prospective observational study.

Author information

1
Department of Psychology, Pusan National University, Busan, South Korea.
2
Public Health and Medical Service, Seoul National University Hospital, Seoul, South Korea.
3
Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
4
Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, South Korea.
5
Department of Human Factors Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea.
6
Department of Psychiatry, Inha University Hospital, Incheon, South Korea.
7
Department of Surgery, Seoul National University Hospital, Seoul, South Korea.
8
Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea. hahm@snu.ac.kr.
9
Department of Neuropsychiatry, Seoul National University Hospital, Seoul, South Korea. hahm@snu.ac.kr.

Abstract

PURPOSE:

Delirium is a common neurocognitive complication in cancer. Despite this, the studies examining the trajectory of the severity of delirium symptoms and its impact on health outcome in gastric cancer is rather limited. This study examined the trajectory of delirium symptom severity (DSS) following resection surgery for gastric cancer and its prospective association with cognitive function.

METHODS:

A three-wave prospective observational study was conducted with 242 gastric cancer patients admitted for resection surgery at a teaching hospital in South Korea from May 2016 to November 2017. DSS was assessed by the clinical staff before and 1, 2, 3, and 7 days after surgery using the Delirium Rating Scale-Revised-98. A survey including the Functional Assessment of Cancer Therapy-Cognitive Scale (FACT-Cog) and Mini-Mental State Examination (MMSE) was administered before surgery (T0), 7 days after (T1), and 3 to 6 months after surgery (T2).

RESULTS:

Out of 242 participants, 48.8% (118) completed the survey at all three time points, 43.4% (105) did so for two time points, and 7.9% (19) for one time point. No cases of full delirium were observed over four postoperative time points. Latent growth curve modeling analyses indicated that DSS declined over 3 days after surgery. Age and anesthesia time were positively associated with the initial level of DSS. A medication history for memory complaints was related to a slower recovery from delirium symptoms. While the use of propofol as an anesthetic agent was associated with lower initial DSS, it predicted a slower recovery from DSS. A higher initial DSS predicted a lower T1 MMSE score.

CONCLUSIONS:

Severity of postoperative delirium symptoms predicts a short-term and objective cognitive function post-surgery. Monitoring and timely treatment of postoperative delirium symptoms is needed to diminish cognitive consequences in gastric cancer patients.

KEYWORDS:

Anesthesia; Cognitive function; Delirium; Gastrectomy; Gastric cancer

13.
JAMA Otolaryngol Head Neck Surg. 2019 Jan 3. doi: 10.1001/jamaoto.2018.3820. [Epub ahead of print]

Risk Factors Associated With Postoperative Delirium in Patients Undergoing Head and Neck Free Flap Reconstruction.

Author information

1
Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus.
2
Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada.
3
Department of Otolaryngology-Head & Neck Surgery, Virginia Commonwealth University, Richmond.
4
Department of Otolaryngology-Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.

Abstract

Importance:

Postoperative delirium (POD) is associated with an increased rate of adverse events, higher health care costs, and longer hospital stays. At present, limited data are available regarding the risk factors for developing POD in patients undergoing head and neck free flap reconstruction. Identification of patients at high risk of developing POD will allow implementation of risk-mitigation strategies.

Objective:

To determine the frequency of and risk factors associated with POD in patients undergoing free flap reconstruction secondary to head and neck disease.

Design, Setting, and Participants:

This retrospective cohort study included 515 patients undergoing free flap reconstruction from January 1, 2006, through December 31, 2012, at the James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Care Center, a tertiary care cancer hospital. Preoperative, intraoperative, and postoperative data were collected retrospectively. Data from January 1, 2006, through December 31, 2012, were analyzed, and the final date of data analysis was January 8, 2018.

Interventions:

Head and neck free flap reconstruction.

Main Outcomes and Measures:

The primary outcome was the development of POD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Univariable and multivariable logistic regression were used to identify risk factors associated with POD.

Results:

Five hundred fifteen patients underwent free flap reconstruction during the study period (66.2% male; mean [SD] age, 60.1 [12.8] years). Of these, 56 patients (10.9%) developed POD. On multivariable analysis, risk factors associated with POD included increased age (odds ratio [OR], 1.06; 95% CI, 1.02-1.11), male sex (OR, 5.02; 95% CI, 1.47-17.20), increased operative time (OR for each 1-minute increase, 1.004 [95% CI, 1.001-1.006]; OR for each 1-hour increase, 1.26 [95% CI, 1.08-1.46]), advanced nodal disease (OR, 3.00; 95% CI, 1.39-6.46), and tobacco use (OR, 7.23; 95% CI, 1.43-36.60). Preoperative abstinence from alcohol was identified as a protective factor (OR, 0.24; 95% CI, 0.12-0.51).

Conclusions and Relevance:

This study identified variables associated with a higher risk of developing POD. Although many of these risk factors are nonmodifiable, they provide a target population for quality improvement initiatives. Furthermore, preoperative alcohol abstinence may be useful in preventing POD.

14.
Aging Ment Health. 2018 Dec 29:1-8. doi: 10.1080/13607863.2018.1548569. [Epub ahead of print]

Arousal changes and delirium in acute medically-ill male older patients with and without dementia: a prospective study during hospitalization.

Author information

1
a Faculty of Medicine , University of Coimbra , Coimbra , Portugal.
2
b Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal.
3
c Deparment of Internal Medicine, Centro Hospitalar Universitário de Coimbra, Coimbra , Portugal.
4
d Coimbra Institute for Clinical and Biomedical Research (iCBR) , Faculty of Medicine, University of Coimbra, Coimbra , Portugal.

Abstract

OBJECTIVES:

Previous research has characterized the prevalence, natural course and outcomes of delirium superimposed in dementia but much less is known about the relation between preexisting dementia and the emergence of altered arousal (such as drowsiness, obtundation, stupor or agitation) during acute medical illness. This study aimed to determine the natural course of delirium and abnormal arousal states in acute medically-ill older patients with and without prior dementia during hospital stay.

METHODS:

Observational prospective study in an acute male geriatric ward. Patients aged ≥ 65 years old were assessed by a psychiatrist within the first 72h of admission and in every other day until discharge to determine the level of arousal and the presence of delirium. Prior cognitive impairment, sociodemographic data, chronic comorbidities, psychotropic prescription and functional status were assessed at baseline.

RESULTS:

43.5% of participants in the final sample (n= 269) had dementia. Prior dementia was associated with higher rates of moderate/severe hypoarousal (29.9% vs. 4.6%; p<0.001) and delirium (20.5% vs. 7.2%; p<0.001) at admission. RASS ≤ -3 at admission predicted a 4-fold increased intra-hospital mortality risk and RASS ≠ 0 had a sensitivity of 82.8% and a specificity of85.9% for delirium.

CONCLUSIONS:

Moderate/severe hypoarousal is associated with adverse outcomes and should be assessed as part of delirium spectrum, particularly in subjects with prior dementia.

KEYWORDS:

Arousal; delirium; dementia

15.
Medicine (Baltimore). 2018 Dec;97(52):e13881. doi: 10.1097/MD.0000000000013881.

Pharmacologic interventions for preventing delirium in adult patients after cardiac surgery: Protocol of a systematic review and network meta-analysis.

Wen J1,2, Zeng H3, Li Z3, He G4, Jin Y2.

Author information

1
Shanghai University of Traditional Chinese Medicine, Shanghai.
2
Shanghai University of Medicine & Health Sciences, Shanghai.
3
The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou.
4
The First Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China.

Abstract

BACKGROUND:

Delirium is common in adult patients undergoing cardiac surgery and related to a high morbidity and mortality. Although a variety of pharmacologic interventions have been applied in delirium prevention, there is still uncertainty concerning which drug is optimal. Thus, we plan to conduct a systematic review and network meta-analysis (NMA) of published studies to assess the efficacy and safety of pharmacologic interventions for preventing delirium among those patients.

METHODS:

A systematic literature search will be conducted in Embase, PubMed, and the Cochrane Library. The primary outcome will be the incidence of postoperative delirium. Secondary outcomes will include all-cause mortality and length of hospital or intensive care unit stay. A frequentist NMA will be conducted using Stata version 14.0. The inconsistency between direct and indirect comparisons will be evaluated using a node splitting method. In addition, surface under the cumulative ranking area will be used to evaluate superiority of different treatments.

RESULTS:

The findings of our review will be submitted to a peer-reviewed publication.

CONCLUSION:

Our study will generate convincing evidence regarding the effectiveness and safety of different pharmacologic interventions for delirium prevention in cardiac surgery patients.

PMID:
30593196
PMCID:
PMC6314755
DOI:
10.1097/MD.0000000000013881
[Indexed for MEDLINE]
Free PMC Article
Icon for Wolters Kluwer Icon for PubMed Central Icon for South & East Metropolitan Health Service Library, Australia
16.
Eur J Emerg Med. 2018 Dec 20. doi: 10.1097/MEJ.0000000000000587. [Epub ahead of print]

CAM-ICU may not be the optimal screening tool for early delirium screening in older emergency department patients: a prospective cohort study.

Author information

1
Departments of Gerontology and Geriatrics.
2
Emergency Medicine.
3
Internal Medicine, Section of Acute Care, Leiden University Medical Center.
4
Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
5
Institute for Evidence-Based Medicine in Old Age (IEMO), Leiden.

Abstract

OBJECTIVES:

Delirium is a frequent problem among older patients in the emergency department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools for delirium have been proposed for the ED, such as the 6-Item Cognitive Impairment Test (6-CIT) and the Confusion Assessment Method-ICU (CAM-ICU). Previous validation of the CAM-ICU for use in the ED showed varying results, possibly because it was administered at different or unknown time points. The aim was to study the prevalence of delirium in older (≥70 years) ED patients using the CAM-ICU and 6-CIT.

PARTICIPANTS AND METHODS:

A prospective cohort study was carried out in one tertiary care and one secondary care hospital in the Netherlands. Patients aged 70 years and older attending the ED were included. Delirium screening was performed within 1 h after ED registration using the CAM-ICU. The 6-CIT was determined for comparison using a cut-off point of at least 14 points indicating possible delirium.

RESULTS:

A total of 997 patients were included in the study, with a median age of 78 years (interquartile range 74-84). Delirium as assessed with CAM-ICU was positive in only 13 (1.3%, 95% confidence interval: 0.8-2.2) patients. Ninety-five (9.5% 95% confidence interval: 7.9-11.5) patients had 6-CIT more than or equal to 14.

CONCLUSION:

We found a delirium prevalence of 1.3% using the CAM-ICU, which was much lower than the expected prevalence of around 10% as being frequently reported in the literature and what we found when using the 6-CIT. On the basis of these results, caution is warranted to use the CAM-ICU for early screening in the ED.

17.
J Cardiothorac Vasc Anesth. 2018 Nov 14. pii: S1053-0770(18)31027-9. doi: 10.1053/j.jvca.2018.11.010. [Epub ahead of print]

Postoperative Pain Management Strategies and Delirium After Transapical Aortic Valve Replacement: A Randomized Controlled Trial.

Author information

1
Department of Anesthesiology, Paula Stradina University Hospital, Riga, Latvia.
2
Department of Cardiac Surgery, Paula Stradina University Hospital, Riga, Latvia.
3
Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Canada.
4
Department of Interventional Cardiology, Toronto General Hospital, Toronto, Canada.
5
Department of Psychiatry, Toronto General Hospital, Toronto, Canada.
6
Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada.
7
Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada. Electronic address: george.djaiani@uhn.ca.

Abstract

OBJECTIVE(S):

This study was designed to compare 2 different perioperative analgesia strategies with respect to the incidence of postoperative delirium after a transapical approach for transcatheter aortic valve replacement (TAVR). The authors hypothesized that perioperative thoracic paravertebral analgesia with a local anesthetic would decrease opioid consumption and in turn reduce the incidence of postoperative delirium when compared with systemic opioid-based analgesia after a transapical TAVR procedure.

DESIGN:

Prospective, randomized controlled clinical trial.

SETTING:

Tertiary referral center, university hospital.

PARTICIPANTS:

The study comprised 44 patients undergoing a transapical TAVR procedure. Patients with a history of serious mental illness, delirium, and severe dementia and/or patients with contraindications to regional anesthesia were excluded.

INTERVENTIONS:

Patients were randomly assigned to either the paravertebral group (perioperative continuous thoracic paravertebral block with local anesthetic) or the patient-controlled analgesia group (systemically administered opioids) using a computer-generated randomization code in blocks of four patients.

MEASUREMENTS AND MAIN RESULTS:

Assessment of postoperative delirium was performed by trained research staff using the confusion assessment method for intensive care unit preoperatively and postoperatively every 12 hours or more often if needed according to the patient's condition during the first 7 postoperative days or until discharge. Pain was assessed with a 10 cm Visual Analog Scale pain score system during the 48 hours postoperatively. The sedation level was assessed using the Sedation Agitation Scale during the same period. Overall postoperative delirium was detected in 12/44 (27%) patients, with 7/22 (32%) in the patient-controlled analgesia and 5/22 (23%) in the paravertebral groups, respectively (p = 0.73). Both groups were similar with respect to demographic data, preoperative medications, and comorbidities. Paravertebral analgesia was associated with an opioid-sparing effect during surgery and during the 48-hour postoperative period. Sedation and pain scores were similar between the 2 groups. In addition, paravertebral analgesia was associated with earlier extubation times; however, the overall morbidity and mortality were similar between the 2 groups.

CONCLUSIONS:

Paravertebral analgesia in patients undergoing transapical TAVR procedures appears to have an opioid-sparing effect. However, it did not translate into a statistically significant decrease in the rate of postoperative delirium.

KEYWORDS:

paravertebral analgesia; postoperative delirium; systemic opioids; transapical transcatheter aortic valve replacement

18.
J Neurosurg Anesthesiol. 2018 Dec 14. doi: 10.1097/ANA.0000000000000569. [Epub ahead of print]

Home-based Cognitive Prehabilitation in Older Surgical Patients: A Feasibility Study.

Author information

1
Department of Anesthesiology.
2
Center for Consciousness Science.
3
Northeast Ohio Medical University, Rootstown, OH.
4
Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI.

Abstract

BACKGROUND:

Cognitive training is beneficial in various clinical settings, although its perioperative feasibility and impact remain unknown. The objective of this pilot study was to determine the feasibility of home-based cognitive prehabilitation before major surgery in older adults.

MATERIALS AND METHODS:

Sixty-one patients were enrolled, randomized, and allocated to either a home-based preoperative cognitive training regimen or no training before surgery. Outcomes included postoperative delirium incidence (primary outcome; assessed with the 3D-Confusion Assessment Method), perioperative cognitive function based on NIH Toolbox measures, hospital length of stay, and physical therapy session participation. Reasons for declining enrollment were reported, as were reasons for opting out of the training program.

RESULTS:

Postoperative delirium incidence was 6 of 23 (26%) in the prehabilitation group compared with 5 of 29 (17%) in the control group (P=0.507). There were no significant differences between groups in NIH Toolbox cognitive function scoring, hospital length of stay, or physical therapy participation rates. Study feasibility data were also collected and reported. The most common reasons for declining enrollment were lack of computer access (n=19), time commitment (n=9), and feeling overwhelmed (n=9). In the training group, only 5 of 29 (17%) included patients were able to complete the prescribed 7 days of training, and 14 of 29 (48%) opted out of training once home. Most common reasons were feeling overwhelmed (n=4) and computer difficulties (n=3).

CONCLUSIONS:

Short-term, home-based cognitive training before surgery is unlikely to be feasible for many older patients. Barriers to training include feeling overwhelmed, technical issues with training, and preoperative time commitment.

19.
JAMA Intern Med. 2018 Dec 17. doi: 10.1001/jamainternmed.2018.6975. [Epub ahead of print]

Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review.

Author information

1
Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
2
Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island.
3
Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
4
Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts.
5
Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
6
Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut.
7
Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.
8
University of Massachusetts Medical School, Worcester.
9
Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia.
10
Johns Hopkins University School of Medicine, Baltimore, Maryland.
11
Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
12
Department of Psychiatry, Massachusetts General Hospital, Boston.
13
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
14
Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.
15
Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York.
16
Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China.
17
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
18
Harvard Medical School, Boston, Massachusetts.
19
Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
20
Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Abstract

Importance:

Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition.

Objectives:

To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments.

Evidence Review:

This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus.

Findings:

Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale.

Conclusions and Relevance:

The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.

20.
J Clin Nurs. 2018 Dec 16. doi: 10.1111/jocn.14749. [Epub ahead of print]

Operative and anaesthetic factors influencing on delirium in the intensive care unit: An Analysis of electronic health records.

Author information

1
College of Nursing, The Catholic University of Korea, Seoul, Korea.

Abstract

AIMS AND OBJECTIVES:

To analyse the operation, anaesthesia and recovery-related factors affecting the occurrence of delirium in the intensive care unit.

BACKGROUND:

The occurrence rate of postoperative delirium is high in surgical patients. Postoperative delirium most frequently occurs usually within 3 days after an operation.

DESIGN:

This study used a secondary data analysis based on a case-control study.

METHODS:

This study analysed data extracted from the electronic health records at a university hospital from October 2009-July 2015. One hundred and eighty patients with delirium admitted to the intensive care unit through the recovery room after surgery, and 720 nondelirium controls were included. A total of 17 variables were selected, and hierarchical logistic regression was performed to identify operative and anaesthetic factors influencing on delirium. STROBE statement was applied for reporting this study.

RESULTS:

The operation, anaesthesia and recovery-related factors increasing the risk of delirium included Class II or higher in the classification system of American Society of Anesthesiologists physical status, continuous remifentanil infusion and lower than seven-point postanaesthesia recovery score at the time of admission to the recovery room.

CONCLUSION:

The operative and anaesthetic factors influencing the occurrence of delirium should be assessed when a patient is admitted to the ICU following an operation even if a patient is conscious.

RELEVANCE TO CLINICAL PRACTICE:

Identifying operative and anaesthetic risk factors for delirium can improve the prevention intervention and the patient outcome in the intensive care unit.

KEYWORDS:

delirium; electronic health records; intensive care unit; risk factor

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