Clinical Diagnosis Of Delirium Research Articles

Determination of the risk factors and delirium in the intensive care unit

Delirium is a pathology that occurs especially in elderly patients, is triggered by an underlying condition, leads to an increase in the frequency of mortality and morbidity in patients, and causes a serious cost burden to clinics. Prevention of delirium is the simplest and most feasible approach. Despite all these, the clinical diagnosis of delirium is still inadequate and overlooked. In this review, current clinical practices for delirium, including etiology, pathophysiology, diagnosis, and treatment management, are reviewed.

219 Delirium snapshot—inpatient rates and demographics of delirium in an Irish university teaching hospital

Abstract Background Delirium has been repeatedly demonstrated to increase morbidity and mortality both in the inpatient setting and post-discharge. This study sets out to examine the rates and demographics of delirium in the inpatient setting and identify significant risk factors for its development. Methods Data was collected on inpatients on a single day (13/12/22) using an internet application developed by the Hospital’s Quality and Improvement Department. Biographical data, length of stay (LOS), source of admission, admission diagnosis, clinical diagnosis of delirium and/or dementia and preadmission and current continence data were gathered from medical or nursing notes. Data was analysed and statistical significance determined via Pearson’s Chi-Squared Test. Results Data was available for 309 inpatients. The point prevalence of delirium was 25.2% (78/309). About half of delirious patients were female (41/78) and (38/78) had a previous diagnosis of dementia (p = <0.01). Almost a quarter of the cohort had pre-existing cognitive impairment (73/309, 23.6%). Nursing home residents had the highest percentage of delirium 17/42 (40.5%) by admission source (p = 0.01). Delirium prevalence increased with age reaching 37.5% in those over 90 years, (p = 0.03). Delirium was more prevalent in those with a longer LOS (19.8% LOS <7 days compared to 44.6% LOS >7 days). Delirium rates were higher in those incontinent or catheterized both at baseline and during admission (p = <0.01), as well as in those requiring assistance with mobility (p = <0.01). Conclusion Approximately a quarter of all inpatients experienced delirium during their admission. However, these figures were significantly higher in at risk categories such as those aged ≥70, Nursing Home residents and those with cognitive impairment. Despite extensive awareness and education of the risks of delirium, its prevalence remains too high. Further interventions are urgently needed.

Comparison Between Deltascan Single Channel Electroencephalography (EEG), Confusion Assessment Method-Intensive Care Unit (CAM-ICU) Score and Clinical Assessment in Diagnosing Delirium in Intubated Patients in the Intensive Care Unit.

BackgroundThe aim of this article is to assess the feasibility of using single-channel electroencephalography (EEG) measurement for detecting delirium in intubated Intensive care (ICU) patients and to assess the level of agreement between the EEG measurements, the CAM-ICU score and the clinical diagnosis of delirium.Materials and methodsThis study was an exploratory pilot between May 2021 and September 2021 including intubated patients in the ICU. For this study the Prolira® (Arnhem, The Netherlands) Deltascan single-channel EEG was used and compared with the Confusion Assessment Method (CAM)-ICU and the clinical diagnosis of delirium by ICU physicians.ResultsIn total 23 patients were found eligible for this study, of which 20 were included in the final analysis. The patients mean age was 63.0 ± 8.8 years, and the majority (thirteen) was male (65%). In total 17 of the 20 patients (85%) received the diagnosis delirium by the medical team. There were no statistically significant differences between the Deltascan and CAM-ICU measurements in diagnosing delirium per time point (p values respectively 0.21; 0.90; 0.34; 0.11; 0.056 and 0.091). AUCs for the agreement between the CAM-ICU and the Deltascan measurements were respectively: 0.676 ± 0.205; 0.333 ± 0.224; 0.402 ± 0.146; 0.488 ± 0.202; 0.06 ± 0.077 and 0.06 ± 0.109 (all p>0.05). AUCs for the level of agreement between the clinical diagnosis delirium and Deltascan were: 0.676 ± 0.152; 0.686 ± 0.146; 0.711 ± 0.132; 0.688 ± 0.136; 0.500 ± 0.158 and 0.700 ± 0.211 (all p>0.05).ConclusionIn this exploratory study, we showed that there is no statistical agreement between CAM-ICU and Delta scan measurements. Secondly, there is a higher agreement, although not statistically significant between the clinical diagnoses of a delirium (by a clinician) with the Deltascan measurements. Despite this small study we think that the Deltascan can be of additional value in intubated ICU patients and therefore larger studies are needed to substantiate our findings.

Pitfalls in the diagnosis of delirium

The diagnosis of delirium is challenging and requires precise definitions in both clinical routine and in studies. To point out various pitfalls in the clinical diagnosis of delirium and discuss solutions. Review. Common problems include (a)clinical judgment of staff vs. the use of valid assessment tools, (b)different lists of criteria for delirium that may consider the symptoms of delirium differently and thus lead to inclusion or exclusion of patients, (c)different assessment tools that test the symptoms of delirium to different extents and thus have different accuracy, (d)patients with limited communication abilities, such as aphasia, where common tests often fail and alternative procedures may be more effective; (e)the decision whether to test delirium once, twice, three times, or more frequently in 24 h has consequences on the incidence and duration of delirium, (f)the end of delirium, often defined retrospectively as adelirium-free interval or prospectively as the time of transfer or occurrence of an exclusion criterion, can lead to considerable measurement inaccuracies. Although not all problems can be definitively answered, transparent definition, performance, and documentation of diagnostic procedures are recommended.

Early prediction of delirium in a pediatric cardiac intensive care unit: A pilot study

BackgroundPediatric delirium is associated with increased risk of mortality, prolonged time to extubation, and increased length of stay. If the risk of delirium could be identified early, then preventative strategies could be targeted. ObjectivesTo study the performance of an early delirium prediction model in children admitted to a pediatric cardiac intensive care unit using variables extracted from the electronic medical record 24 hours after admission. MethodsThis was a single center, IRB approved, retrospective study of children between 31 days and 18 years old who were admitted to the cardiac ICU for at least three consecutive days during a 1-year study period (January 1, 2018 to December 31, 2018). Using fifteen previously defined variables associated with delirium in children, we determined their presence at 24 hours after admission and created a model to predict the risk of delirium anytime during a child's stay. Delirium was considered present if a patient had at least one Cornell Assessment of Pediatric Delirium score of 9 or greater, required an antipsychotic or had an ICD-10 diagnosis of delirium. Repeated measures logistic regression between the preselected variables associated with delirium and the clinical diagnosis of delirium was performed. Variables significant in the unadjusted univariate analyses were entered into a multivariable model for adjustment. ResultsA total of 97 patients (113 admits) were included. The presence of four covariates at 24 hours following admit (serum albumin below 3 g/dl, blood transfusion, dexmedetomidine, and mechanical ventilation) were identified as significant predictors of delirium. The model demonstrated good discriminative ability with an area under the receiver operating characteristics curve of 0.74. ConclusionEarly prediction of delirium may be possible, but this model requires additional study and validation in a larger subset of subjects. Identification of patients at high-risk for delirium may facilitate targeted delirium prevention strategies.

Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey.

Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.

Orthopedic Surgery Triggers Attention Deficits in a Delirium-Like Mouse Model.

Postoperative delirium is a frequent and debilitating complication, especially amongst high risk procedures such as orthopedic surgery, and its pathogenesis remains unclear. Inattention is often reported in the clinical diagnosis of delirium, however limited attempts have been made to study this cognitive domain in preclinical models. Here we implemented the 5-choice serial reaction time task (5-CSRTT) to evaluate attention in a clinically relevant mouse model following orthopedic surgery. The 5-CSRTT showed a time-dependent impairment in the number of responses made by the mice acutely after orthopedic surgery, with maximum impairment at 24 h and returning to pre-surgical performance by day 5. Similarly, the latency to the response was also delayed during this time period but returned to pre-surgical levels within several days. While correct responses decreased following surgery, the accuracy of the response (e.g., selection of the correct nose-poke) remained relatively unchanged. In a separate cohort we evaluated neuroinflammation and blood-brain barrier (BBB) dysfunction using clarified brain tissue with light-sheet microscopy. CLARITY revealed significant changes in microglial morphology and impaired astrocytic-tight junction interactions using high-resolution 3D reconstructions of the neurovascular unit. Deposition of IgG, fibrinogen, and autophagy markers (TFEB and LAMP1) were also altered in the hippocampus 24 h after surgery. Together, these results provide translational evidence for the role of peripheral surgery contributing to delirium-like behavior and disrupted neuroimmunity in adult mice.

Delirium in elderly patients undergoing chemotherapy for solid cancers and lymphoma

Introduction: Prevalence and risk factors for delirium in geriatric oncology patients is not well described. Aim: To determine the prevalence and factors associated with delirium in elderly patients undergoing chemotherapy for solid cancers. Methods: We reviewed medical records of patients with cancer aged ≥65 years who were admitted in 2015 with “delirium”, “encephalopathy”, “confusion”, or “altered mental status” within 30 days of chemotherapy for solid cancers and lymphoma. Descriptive and matched pair statistics were used to compare demographics, chemotherapy, medications, comorbidities, and laboratory data between the patients with clinical diagnosis of delirium and their controls matched by age, gender, and cancer diagnosis. Results: One hundred and twenty three patients were hospitalized in an academic comprehensive cancer center. Median (range) age was 71 (65 to 89). 60% were women. Most common cancers (%) were gastrointestinal (25), lymphoma (20), genitourinary (18), pulmonary (15) and breast (12). The most common admissions were for chemotherapy (22%) and infection (21%). 64% were treated with chemotherapy, 24% with chemo and immunotherapy, and 12% with immunotherapy only. A total of 43% received 2 anticancer agents, 32% one, and 18% three agents. Charted delirium prevalence was 7.3% (N=9/123). Five were men. Compared to matched controls, patients in whom delirium was recognized were more likely to have elevated BUNs, acute kidney injury (AKI) and hyponatremia. Conclusions: Delirium was infrequently documented in our cohort of elderly patients admitted for inpatient care following chemotherapy. Elevated BUN, AKI and hyponatremia were significantly associated with the clinical diagnosis and documentation of delirium.

Clinical Assessment and Management of Delirium in the Palliative Care Setting.

Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.Electronic supplementary materialThe online version of this article (doi:10.1007/s40265-017-0804-3) contains supplementary material, which is available to authorized users.

Applicability of Anticholinergic Risk Scale in hospitalized elderly persons

Abstract Objective: to define the applicability of the Anticholinergic Risk Scale (ARS) as a risk indicator of delirium in hospitalized elderly persons. Method: the medical records of elderly patients hospitalized in the medical wards of a teaching hospital were analyzed with the ARS, translated and adapted for medicines used in Brazil. The version of the Confusion Assessment Method (CAM) for the clinical diagnosis of delirium translated and validated by Fabbri et al. was used. Individuals aged ≥60 years were included in the evaluation of drug use. The sample was divided by gender and age to analyze the effect of these variables on the use of anticholinergic drugs based on the ARS, and association with delirium. Results: 123 elderly persons, 47 men and 76 women, with a mean age of 72.7(±9.2) years were included. The average consumption of drugs not listed in the ARS (some with anticholinergic action as Ipratropium and Scopolamine) was 6.1(±3.0) and the average number of drugs used listed in the ARS (Metoclopramide, Ranitidine, Atropine, Haloperidol and Risperidone) was 0.9±0.6. Four elderly persons had a score ≥3 (3.3% of total cases). Delirium was observed in 27 patients (21.9% of the total), none of whom scored more than two ARS points. There was no statistical significance regarding gender, age and delirium. Conclusion: the average score of the ARS was low among this population, and did not correlate with delirium. The ARS does not cover all anticholinergics, meaning this study should be repeated in a geriatric ward for comparison.

Delirium subtype identification and the validation of the Delirium Rating Scale—Revised‐98 (Dutch version) in hospitalized elderly patients

Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. The Dutch version of the Delirium Rating Scale-Revised-98 (DRS-R-98) appears to be a reliable method to classify delirium. The aim of this study was to determine the validity and reliability of the DRS-R-98 and to study clinical subtypes of delirium using the DRS-R-98. Patients received the Dutch version of the DRS-R-98, the Mini-Mental State Examination, the Confusion Assessment Method, and a clinical diagnosis of delirium according to DSM-IV criteria, and their relatives the Informant Questionnaire Cognitive Decline in the Elderly. The DRS-R-98 validation cohort (n=65) consisted of 23 patients with delirium, 22 patients with dementia, and 20 non-psychiatric comparison patients. For the delirium subtype study, a second cohort comprising 54 delirious patients was investigated. Median DRS-R-98 scores significantly distinguished delirium from dementia and no psychiatric disorder. Inter-rater reliability (intra-class correlation 0.97) and internal consistency (Crohnbach's alpha 0.94) were high. Positive scores of DRS-R-98 item 4 (affect liability) and item 7 (motor agitation) predicted the presence of non-hypoactive delirium, with a specificity of 89% and a sensitivity of 57%. The results show that the Dutch version of the DRS-R-98 is a valid and reliable measure of delirium severity and distinguishes patients with delirium from patients with dementia and comparison patients. Furthermore, the DRS-R-98 is able to exclude hypoactive delirium.