Delirium Research Articles

Factors associated with Acute Confusion Syndrome in elderly people hospitalized in the Geriatrics service. 2020

Introduction: population aging is unprecedented; it has no parallels in the history of humanity. Objective: characterize the factors associated with Acute Confusion Syndrome in elderly people admitted to the Geriatrics ward of the “Dr. Agostinho Neto” from Guantánamo, in the period from January to December 2020. Method: analytical observational, retrospective case-control study in the geriatrics ward of the “Dr. Agostinho Neto” from Guantánamo belonging to the country Cuba during the period from January to December 2020, the study population and sample consisted of 133 patients, the variables were studied: age, sex, origin, functional level, polypharmacy, personal pathological history, diagnosis at admission and associated factors. Individual medical records were used as the primary source to obtain data by developing a form. Results: it can be seen that the female sex prevailed with 72 patients (54,55 %), the age group of 70-79 years was the one with the highest incidence, with 51 patients, for 38,64 % of the total, within This group with the highest incidence is that of patients who did not present delirium with 34 subjects for 25,76 %. Conclusions: there is a high frequency of Acute Confusion Syndrome in older adults hospitalized in the Geriatrics service, mainly in females aged between 70-79 years, high blood pressure was identified as the main personal pathological history.

Downregulation of the glucose transporter GLUT 1 in the cerebral microvasculature contributes to postoperative neurocognitive disorders in aged mice

IntroductionGlucose transporter 1 (GLUT1) is essential for glucose transport into the brain and is predominantly expressed in the cerebral microvasculature. Downregulation of GLUT1 precedes the development of cognitive impairment in neurodegenerative conditions. Surgical trauma induces blood–brain barrier (BBB) disruption, neuroinflammation, neuronal mitochondria dysfunction, and acute cognitive impairment. We hypothesized that surgery reduces the expression of GLUT1 in the BBB that in turn disrupts its integrity and contributes to metabolic dysregulation in the brain that culminates in postoperative cognitive impairment.MethodologyUsing an abdominal surgery model in aged WT mice, we assessed the perioperative changes in cognitive performance, tight junction proteins expression, GLUT1 expression, and the associated metabolic effects in the hippocampus. Thereafter, we evaluated the effects of these parameters in aged mice with conditional overexpression of GLUT1, and then again in aged mice with conditional overexpression of GLUT1 with or without prior exposure to the GLUT1 inhibitor ST-31.ResultsWe showed a significant decline in cognitive performance, along with GLUT1 reduction and diminished glucose metabolism, especially in the ATP level in the postoperative mice compared with controls. Overexpression of GLUT1 expression alleviated postoperative cognitive decline and improved metabolic profiles, especially in adenosine, but did not directly restore ATP generation to control levels. GLUT1 inhibition ameliorated the postoperative beneficial effects of GLUT1 overexpression.ConclusionsSurgery-induced GLUT1 reduction significantly contributes to postoperative cognitive deficits in aged mice by affecting glucose metabolism in the brain. It indicates the potential of targeting GLUT1 to ameliorate perioperative neurocognitive disorders.

THU624 Opioid Induced Adrenal Insufficiency (OIAI) Presenting With Altered Mental Status

Abstract Disclosure: D. Bondarenko: None. M. Ahmad: None. G.A. McGrath: None. Background: Opioid suppression of the hypothalamic-pituitary-adrenal (HPA) axis via inhibition of corticotropin releasing hormone secretion leading to secondary adrenal insufficiency (AI) has been described in literature. Biochemical secondary AI is evident in 6-50% of patients on chronic opioids; fewer cases are reported presenting with clinical AI.1 We present a rare case of symptomatic opioid-induced AI (OIAI) with clinical improvement on initiation of hydrocortisone. Clinical Case: A 49-year-old female on daily buprenorphine (20 mg) and naltrexone (5 mg) presented to the hospital with syncope and hypotension (79/49 mmHg). AM cortisol was 6.2 mcg/dL, a cosyntropin stimulation test was performed, but there was technical difficulty with the results. She was started on midodrine 2.5 mg three times daily and referred to outpatient endocrinology for follow up. Weeks later, outpatient cosyntropin stimulation test showed baseline cortisol of 18 mcg/dL with increase to 26 mcg/dL. Simultaneous adrenocorticotrophic hormone (ACTH) was 16.9 pg/mL. AI was ruled out. Seven years later she presented with acute lethargy, confusion, and memory loss over several days. AM cortisol was 1.6 mcg/dL and cosyntropin stimulation test increased cortisol to 15.1 mcg/dL (normal response being 18 mcg/dL or greater). ACTH was 24 pg/mL. The abnormal cosyntropin stimulation test results are consistent with AI, and lack of elevation of morning ACTH is consistent with secondary AI.2 Hydrocortisone therapy was started and midodrine was held due to elevated blood pressure after initiation of steroids. She was discharged on hydrocortisone 15 mg each morning and 5 mg each afternoon. Within 10 days of initiation of glucocorticoid replacement therapy her neurologic symptoms improved and midodrine discontinued. Prescription Drug Monitoring Program (PDMP) review shows reduction of buprenorphine (16 mg) and naltrexone (4 mg). Conclusion: Data on management of OIAI and recovery of the HPA axis with or without cessation of opioid therapy is limited. This case highlights that opioids should be considered as a potential cause of secondary AI. Further follow-up of this case and other OIAI cases would provide insight into management of opioid therapy, continuation of glucocorticoid therapy, and recovery of HPA axis. This data could provide basis for OIAI management recommendations. Reference: (1) Fountas, A., Prof, S.V.U., Karavitaki, N. Opioid-induced endocrinopathies. Lancet Diabetes Endocrinol. 2020;8(1);68-80. (2) Bornstein, S.R., Allolio, B., Arlt, W., et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocr. 2016;101(2);364-389. Presentation: Thursday, June 15, 2023

THU392 Type B Insulin Resistance: A Rare Cause Of Hypoglycemia

Abstract Disclosure: S.Z. Bhat: None. A. Sidhaye: None. A.H. Hamrahian: None. Introduction: Non-diabetic hypoglycemia in patients with diabetes mellitus is rare. Type B insulin resistance syndrome (TBIRS), caused by insulin receptor antibodies, presents with severe insulin resistance, but can uncommonly result in a hypoglycemic picture. Clinical Case: A 59-year-old woman with a history of SLE, T2DM, and primary hyperparathyroidism was admitted for acute confusion and found to have a POC glucose of 30 mg/dl. Her symptoms improved after IV glucose administration. She was on a stable basal-bolus insulin regimen of 0.8 U/kg/day and had unintentional 100-pound weight loss over 1 year. Significant exam findings included BMI of 29 kg/m2, gingival hyperplasia, and acanthosis nigricans. Aside from insulin, she took no medications strongly associated with hypoglycemia. Labs including CBC, CMP, TFTs, and morning cortisol were normal. HbA1C and adiponectin levels were 7.7%, and 28 µg/ml (5-28), respectively. Given the suspicion of exogenous insulin-mediated hypoglycemia, only correctional insulin was used during hospitalization. She had a repeat hypoglycemic episode on the 2nd day with minimal insulin use. A 72-hour fasting test showed a whole blood glucose of 44 mg/dL with concurrent serum C-peptide of 1.72 ng/mL, serum insulin 55 mIU/L and pro-insulin 21.9 pmol/L 12 hours into fasting. MRCP showed an 11 mm cystic lesion in the pancreas and widespread lymphadenopathy. The CGM noted significant fasting and post-prandial hypoglycemia. Diagnosis of insulinoma was considered unlikely due to persistent post-prandial hyperglycemia. Oral hypoglycemic panel and insulin autoantibodies were negative. The patient’s history of SLE, high-normal adiponectin, history of hyperglycemia and the presence of acanthosis nigricans favored work-up for insulin resistance syndromes. Due to the non-availability of insulin receptor antibody testing in the US, blood work was sent to Dr. Lutz Schomburg’s lab at Institute for Experimental Endocrinology, Berlin, Germany. The patient’serum was positive for insulin receptor antibodies, tested via an immunoassay technique, with elevated binding index (BI) of 248, 251 and 247 on 3 different samples of the patient, and normal binding index in the control sample, leading to the diagnosis of type B insulin resistance syndrome (BI >3 is positive, >10 indicates high positivity). The patient was treated with diet modification and CGM use, with improvement in the frequency of hypoglycemic episodes. She declined immunomodulation therapy. Conclusion: Hypoglycemia is an uncommon presentation of TBIRS and should be considered in the differential of non-diabetic hypoglycemia, particularly in patients with a history of auto-immune disease. The mechanism for hypoglycemia is purported to be an insulin-mimetic effect of insulin receptor antibodies at low titers. Presentation: Thursday, June 15, 2023

The path innovation of industrial upgrading and transformation of regional economy to the cognitive impairment of the patients

BackgroundWith the development of digital economy, industrial upgrading and transformation of the regional economy has become an important way to promote economic development and improve competitiveness. In this context, there is also increasing attention to patients with cognitive impairment. Cognitive impairment is an elderly disease that affects physical and mental health and life quality. Therefore, it has great practical significance to study the application of industrial upgrading and transformation path innovation of regional economy to cognitive impairment patients from the perspective of the digital economy.Objects and Methods100 patients with cognitive impairment were selected as research objects by quantitative investigation. The Stanford Acute Stress Response Questionnaire and 3-min Confusion Assessment Scale were used to assess anxiety level and cognitive state. The study also analyzed and compared the application of the digital economy in the treatment of cognitive impairment.ResultsResearch shows that accessible information and services provided through digital platforms and tools have a positive impact on cognitively impaired patients. According to the data, 80% of the patients used the online health management platform to acquire personalized rehabilitation programs and telemedicine services. They reported that the adoption of digital technologies has made them more autonomous and improved their quality of life and happiness.ConclusionsThe wide application of digital platforms and tools provides more opportunities and resources for patients with cognitive impairment. It also promotes the management and rehabilitation of cognitive impairment.

P10 Collapse, confusion and acute kidney injury presenting in the context of bullous skin disease in a young male patient

P10 Collapse, confusion and acute kidney injury presenting in the context of bullous skin disease in a young male patient

A rehabilitation intervention to improve recovery after an episode of delirium in adults over 65 years (RecoverED): study protocol for a multi-centre, single-arm feasibility study

BackgroundDelirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible.MethodsThe study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants’ own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals.DiscussionFindings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care.Trial registrationThe feasibility study was registered: ISRCTN15676570

42 Resolution of delirium upon discharge & mortality rates among frail older persons attending an Emergency Department frailty service

Abstract Background Delirium is an acute confusional state, frequently associated with older hospitalised patients and has been found to be related to several adverse outcomes including longer length of stay and mortality. Better baseline cognition has been linked with a lower risk of delirium however those with high baseline cognition may experience greater cognitive decline post delirium. Methods We undertook a retrospective study of 92 patients who attended the Frailty service in the Emergency Department between 01/01/2023 and 31/01/2023. We screened for delirium using the 4AT within 12 hours of presentation to the ED and collected additional data collected to define baseline cognitive status, delirium resolution, and length of stay and discharge disposition. Results Delirium prevalence in this cohort was estimated at 22%. Overall delirium had resolved for our patients at discharge in 56% of cases. In the cognitively intact at baseline group (29%) delirium had resolved at discharge in 33% of cases only. For patients with baseline cognitive impairment (71%) delirium had resolved in 50% of cases. The mortality rate for patients with delirium was 14% with average CFS of 6. All patients who died had cognitive impairment at baseline. The mortality rate for patients without delirium was 1.4%. Length of stay ranged from 0 to 80 days. Length of stay for patients with delirium & baseline cognitively intact was 39 days. Length of stay for patients with delirium and baseline cognitively impaired was 8 days. Conclusion Two thirds of patients who were cognitively intact at baseline experienced longer length of stays & non resolution of delirium at discharge. There may be a need for dedicated follow up of these patients post-acute discharge. There was a higher mortality rate for patients with delirium and baseline cognitive impairment. Future studies may address illness acuity, delirium severity and duration & emergency department length of stay as influencers on mortality rate.

Elaboração de um protocolo de classificação de risco para pacientes oncológicos em Cuidados Paliativos Domiciliares

ABSTRACT Home-based Palliative Care services specialized in the treatment of cancer patients aim to identify and control physical, psychosocial, and spiritual symptoms at home. Some challenges encountered are the complexity of symptoms, reduced survival of patients with advanced cancer, and limitations of the health care system. To stratify the priority of care for patients with advanced cancer in home Palliative Care, a risk classification protocol was developed. This article is an experience report on the process of creating a risk classification protocol for patients with advanced cancer treated at a home Palliative Care service in Rio de Janeiro. The initial stage involved meetings of the home care team at an oncology hospital and structured searches in the literature. Afterwards, the clinical situations of more complex management at home were listed and named as warning signs and symptoms: pain, shortness of breath, nausea/ vomiting, bleeding, and acute mental confusion. An assessment and triage protocol was developed with five categories/colors to determine the priority of patient care. The developed triage system has easy applicability and requires a brief training of the health professional so that it can be used during home visits.

Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure.

Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF). Retrospective cohort. AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30,2019. We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment. The analytic cohort consisted of 29,591 Veterans (mean age 78.5±10.0years; female 2.9%; n= 865). Acute APs were administered to 9.9% (n= 2941). Those receiving APs had differences in prior dementia [37.1%, n= 1091, vs 22.3%, n= 5942; standardized mean difference (SMD)= 0.33] and hospital delirium diagnoses (7.7%, n= 227 vs 2.8%, n= 754; SMD= 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7). In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.

Neurocognitive Care to Reverse Solitary Confinement in Prison: Case Report

Inmate populations have been found to have mental health problems and substance abuse much higher than non-incarcerated populations. Caring for incarcerated patients is problematic, given the limitations on access to healthcare services within detention facilities. A case report of a patient with psychomotor agitation and psychoactive substances use, prone to hetero and self-aggression, is presented. The patient was treated for a month in a Mexican state detention center by nursing students, under supervision and pedagogical support. Using the nursing process, focused on psychosocial health needs, six priority diagnoses were identified: anxiety, ineffective health maintenance behaviors, acute confusion, risk of self-directed violence and violence directed at others, as well as discomfort. Based on these diagnoses, care plans using cognitive stimulation was carried out with the goals of decreased anxiety, increased self-care, increased self-responsibility, better anger control, management of hallucination. The cognitive stimulation was a primary intervention that helped with other interventions to achieve holistic goals, such as improving hygiene. Improvements in the patient’s general ability to function led to, among other aspects, the release of solitary confinement and adaptation to social environment of the prison. Patient improvements reflect the importance of professional nursing care in mental health care in correctional healthcare.

Update on the diagnosis and treatment of delirium

Delirium is an acute confusional state with typically fluctuating disturbances of attention, cognition, and qualitative awareness. Its incidence depends on the patient group. In the development of delirium, predisposing factors such as age, frailty, multimorbidity, surgical interventions, and pre-existing dementia are of high clinical relevance. The diagnosis of delirium should be based on symptoms and validated screening methods (e.g., Confusion Assessment Method). As delirium is adirect physiological consequence of amedical condition, the potential underlying cause(s) should be diagnosed. Prevention and therapy are primarily multimodal, non-pharmacological treatments such as reorientation, early mobilization, and sleep improvement. If symptomatic pharmacological treatment is necessary (e.g., due to delirium-related agitation), careful drug selection should be made depending on the patient population and symptoms.

Comparative safety of adding serotonin and norepinephrine reuptake inhibitors (SNRIs) versus nonsteroidal anti-inflammatory drugs (NSAIDs) to short-acting opioids for non-malignant pain in nursing homes.

The comparative safety of serotonin and norepinephrine reuptake inhibitors (SNRIs) as adjuvants to short-acting opioids in older adults is unknown even though SNRIs are commonly used. We compared the effects of SNRIs versus nonsteroidal anti-Inflammatory drugs (NSAIDs) on delirium among nursing home residents when SNRIs or NSAIDs were added to stable regimens of short-acting opioids. Using 2011-2016 national Minimum Data Set (MDS) 3.0 and Medicare claims data to implement a new-user design, we identified a cohort of nursing home residents receiving short-acting opioids who initiated either an SNRI or an NSAID. Delirium was defined from the Confusion Assessment Method in MDS 3.0 assessments and ICD9/10 codes using Medicare hospitalization claims. Propensity score matching balanced underlying differences for initiating treatments on 39 demographic and clinical characteristics (nSNRIs = 5350; nNSAIDs = 5350). Fine and Gray models provided hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for the competing risk of death. Hydrocodone was the most commonly used short-acting opioid (48%). Residents received ~23 mg daily oral morphine equivalent at the time of SNRIs/NSAIDs initiation. The majority were women, non-Hispanic White, and aged ≥75 years. There were no differences in any of the confounders after propensity matching. Over 1 year, 10.8% of SNRIs initiators and 8.9% of NSAIDs initiators developed delirium. The rate of delirium onset was similar in SNRIs and NSAID initiators (HR(delirium in nursing home or hospitalization for delirium):1.10; 95% CI: 0.97-1.24; HR(hospitalization for delirium): 1.06; 95% CI: 0.89-1.25), and were similar regardless of baseline opioid daily dosage. Among nursing home residents, adding SNRIs to short-acting opioids does not appear to increase risk of delirium relative to initiating NSAIDs. Understanding the comparative safety of pain regimens is needed to inform clinical decisions in a medically complex population often excluded from clinical research.

Cerebral amyloid angiopathy-related inflammation: a rare but important cause of acute confusion on the general medical take.

Cerebral amyloid angiopathy-related inflammation: a rare but important cause of acute confusion on the general medical take.

Association of Delirium and Depression with Respiratory and Outcome Measures in COVID-19 Inpatients.

Delirium (DEL) and depression (DEP) may impair the course and severity of acute respiratory illness. The impact of such syndromes on respiratory and outcome parameters in inpatients with COVID-19 needs clarification. To clarify the relationship between DEL and DEP and respiratory outcome measures, we enrolled 100 inpatients from COVID-19 units of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS of Rome. Participants were divided into those with DEL, DEP, or absence of either delirium or depression (CONT). Delirium severity was assessed with the Neelson and Champagne Confusion Scale (NEECHAM). Psychopathology was assessed with the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), and the Brief Psychiatric Rating Scale (BPRS). Dependent variables include: (a) respiratory parameters, i.e., partial pressure of oxygen in arterial blood (PaO2), oxygen saturation (SpO2), ratio between arterial partial pressure of oxygen (PaO2), and fraction of inspired oxygen (PaO2/FiO2); (b) outcome parameters, i.e., duration of hospitalization and number of pharmacological treatments used during the hospitalization. We investigated between-group differences and the relationships between severity of delirium/depression and the dependent variables. Duration of hospitalization was longer for DEL than for either DEP or CONT and for DEP compared to CONT. NEECHAM and HAM-D scores predicted lower PaO2 and PaO2/FiO2 levels in the DEL and DEP groups, respectively. In DEP, BPRS scores positively correlated with duration of hospitalization. Delirium impacted the course of COVID-19 more severely than depression. The mechanisms by which delirium and depression worsen respiratory parameters differ.

Expression of concern: “Postoperative cognitive deficits and neuroinflammation in the hippocampus triggered by surgical trauma are exacerbated in aged rats” [Progress in Neuro-Psychopharmacology & Biological Psychiatry 34 (2010) 1426–1432

Expression of concern: “Postoperative cognitive deficits and neuroinflammation in the hippocampus triggered by surgical trauma are exacerbated in aged rats” [Progress in Neuro-Psychopharmacology & Biological Psychiatry 34 (2010) 1426–1432

Prevention and management of delirium in hospital

Delirium is a geriatric syndrome. Its prevalence is ranging from 20-70% in hospitalised patients in different clinical settings. Incident delirium is commonly seen among post-surgical and critical care patients. Identification of vulnerable patients and avoiding precipitants is paramount in prevention. Proactive screening of them with a validated tool at different points during the hospital stay helps early identification of delirium. Treating the underlying condition which triggered it, and multi-domain nonpharmacological interventions are an essential part of the management of established delirium. Enhancing the competencies of health care professionals and development and validation of local delirium care pathways in the local set-up are essential steps in achieving better patient outcomes. Received 5 April 2023, accepted 18 June 2023.

Descriptive spectrum of thiamine deficiency in pregnancy: Apotentially preventable condition.

Pregnancy, a nutritionally demanding situation in terms of macro- and micronutrient supply owing to heightened maternal, placental, and fetal needs, significantly affects thiamine reserves. Thiamine deficiency during pregnancy and the postpartum period, presenting with varied manifestations and outcomes, is a relatively common condition in our population. The study aimed to understand the various manifestations and outcomes of acute thiamine deficiency in pregnant and postpartum women, emphasizing the significance of early recognition and thiamine therapy to prevent serious complications during pregnancy and after childbirth. This prospective study conducted in a tertiary care center in North India enrolled consecutive pregnant and postpartum women presenting with clinical features consistent with thiamine deficiency disorders, such as thiamine deficiency-related neuropathy, high-output heart failure, heart failure with reduced ejection fraction, Wernicke's encephalopathy, gastric beriberi, and thiamine-responsive acute pulmonary hypertension. In addition to capturing medical history including drug intake, dietary consumption, and comorbidities, women underwent brief relevant clinical examinations and laboratory assessments, including whole-blood thiamine levels. Response to intravenous thiamine supplementation was also monitored. Data of 31 women (12 pregnant, 19 postpartum) with a diagnosis of acute thiamine deficiency and a mean age of 28.88 ± 2.69 years were analyzed. The mean thiamine level was 1.28 ± 0.44 μg/dL with mean blood lactate of 3.46 ± 3.33. The most common presentation was gastric beriberi (n = 10), followed by paraparesis (n = 6), high-output heart failure (n = 6), acute pulmonary hypertension, heart failure with reduced ejection fraction (n = 3 each), and an acute confusional state (n = 2). All patients responded to thiamine challenge. In the context of borderline thiamine status, particularly in our population with endemic thiamine deficiency and heightened demand for thiamine during pregnancy and the peripartum period, the deficiency can have varied and serious manifestations of dry and wet beriberi. Early recognition of the clinical features and thiamine therapy can be life-saving. There is a need for validated clinical criteria owing to the non-availability of thiamine testing in resource-limited settings.

Hyperactive and Hypoactive Delirium: What we know so Far

Delirium is a common and severe neuropsychiatric syndrome characterized by acute changes in attention, cognition, and consciousness. It can present in different clinical forms, including hyperactive and hypoactive delirium. Hyperactive delirium is characterized by increased psychomotor activity, agitation, and disruptive behavior, while hypoactive delirium is characterized by reduced psychomotor activity, somnolence, and decreased responsiveness. The diagnosis of hyperactive and hypoactive delirium involves a comprehensive evaluation of medical history, physical examination, and laboratory tests to identify underlying causes and exclude other conditions. Prompt recognition and accurate diagnosis are crucial for appropriate management and treatment. The management of hyperactive and hypoactive delirium aims at addressing the underlying etiology, ensuring patient safety, and alleviating distressing symptoms. Treatment strategies include the optimization of medical conditions, discontinuation or adjustment of offending medications, and supportive care. Pharmacological interventions, such as the use of sedative medications for hyperactive delirium or stimulant agents for hypoactive delirium, may be considered when necessary. Multidisciplinary collaboration involving healthcare professionals, including physicians, nurses, and therapists, is essential for the comprehensive care of patients with hyperactive and hypoactive delirium. In conclusion, hyperactive and hypoactive delirium are distinct clinical manifestations of an acute confusional state. Their identification, diagnosis, and management require a multidimensional approach to address the underlying causes and alleviate symptoms. Early recognition and appropriate interventions are crucial for improving patient outcomes and enhancing their overall well-being.

891-P: SGLT2 Inhibitors Use and Diabetic Ketoacidosis in the Inpatient Setting

Background: Current guidelines recommend SGLT2 inhibitors in patients with cardiovascular disease, chronic kidney disease and/or heart failure. Studies have demonstrated early initiation of SGLT2i in stable hospitalized patients to be safe and associated with benefits such as reduced hospitalization. However, SGLT2i are known to lower the threshold for developing diabetic ketoacidosis (DKA) and reported rates with real world use are higher than those seen in randomized controlled trials. There are limited studies evaluating the safe use of SGLT2i in the real world inpatient setting. Aim: The primary aim of this study is to determine the incidence of DKA in patients with diabetes admitted to hospital and started or continued on an SGLT2i. A secondary aim is to determine risk factors to inpatient SGLT2i associated acidosis and make recommendations for safe initiation in hospital. Methods: A retrospective chart review was performed on patients with diabetes admitted to a tertiary hospital with anion-gap metabolic acidosis (AGMA) between January 2020-June 2020 (prior to SGLTi being available on hospital formulary) compared to between January 2021-June 2021 (post-formulary). Patients were included if they were started or continued on an SGLT2i during their admission or were on an SGLT2i < 72h prior to admission. Results: 159 patient charts met our inclusion criteria, with 43.4% (n=69) admitted prior to SGLT2i being available on hospital formulary and 56.6% (n=90) admitted post-formulary. There was a 12.2% (n=11) increase in patients with AGMA with SGLT2i being available on hospital formulary. 41.0% of patients were above the age of 70, and common issues during admission were infection (66.7%), acute kidney injury (44.0%), surgery (23.3%), and/or confusion (23.9%). Conclusion: Increased use of SGLT2i in hospital resulted in an increase in incidence of inpatient DKA in older patients admitted with infection, AKI, surgery and/or confusion. Disclosure S.Zankar: None. A.Arnaout: None.