Confusion Assessment Method Score Research Articles

Effects of esketamine on postoperative negative emotions and early cognitive disorders in patients undergoing non-cardiac thoracic surgery: A randomized controlled trial

Study objectiveTo investigate whether a single dosage of esketamine injection in the anesthesia period could improve postoperative negative emotions and early cognitive function in patients undergoing non-cardiac thoracic surgery. DesignA prospective single center double blinded randomized placebo-controlled trial. SettingPerioperative period; operating room, post anesthesia care unit and hospital ward. Patients129 adult patients that underwent elective non-cardiac thoracic surgery under general anesthesia. InterventionsDuring the operation, pharmacologic prevention of postoperative negative emotion and early cognitive disorder with 0.2 mg/kg (Low esketamine group) and 0.5 mg/kg esketamine (High esketamine group) vs. placebo. MeasurementsEmotion and early cognitive performance were assessed on the day before surgery (POD-1), postoperative day 1 (POD1) and day 3 (POD3) using HADS-A, HADS-D, Pain Visual Analogue Scale (VAS), Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and serum biomarkers (S100β, BDNF, IL-6, acetylcholine, and norepinephrine). Main resultsThe high esketamine group showed significantly lower HADS-A and HADS-D scores than control group on POD1 and POD3. No significant differences were observed between the low esketamine group and the control group. The esketamine-treated groups showed lower pain VAS scores than the control group at 2 h and on the first day after operation. There were no significant differences among the three groups in CAM and MMSE scores. However, the high esketamine group had lower S100β and IL-6 levels, and higher BDNF levels postoperatively, while serum acetylcholine and norepinephrine were not significantly different. ConclusionsA single intraoperative injection of 0.5 mg/kg esketamine can alleviate postoperative anxiety, depression, and pain to some extent. Although cognitive function behavioral evaluation did not show obvious benefits, it can also reduce the production of pro-inflammatory and brain injury-related factors while promoting the generation of brain-derived neurotrophic factor.Registration Trial registry: http://www.chictr.org.cn/; Identifier: ChiCTR2100047067.

Delirium is associated with failure to rescue after cardiac surgery

ObjectivePostoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. MethodsWe studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. ResultsAny episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. ConclusionsA single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.

The Efficacy of Low-Dose Risperidone Treatment for Post-Surgical Delirium in Elderly Orthopedic Patients.

Background: Delirium is an acute and typically reversible failure of essential cognitive and attentional functions and is a growing public health concern, with an incidence of 20-50% in patients older than 65 after major surgery and 61% in patients undergoing hip fracture surgery. Numerous treatment strategies have been examined with no conclusive results. The purpose of this study is to assess the efficacy of a three-day low-dose risperidone treatment protocol, 0.5 mg BID, in treating delirium in elderly hospitalized orthopedic surgery department patients. Methods: This study is a prospective non-randomized study involving the senior patient population, older than 65, in an Orthopedic Surgery Department in 2019 and 2020. Delirium was diagnosed by a confusion assessment method (CAM) questionnaire. A three-day 0.5 mg risperidone BID treatment protocol was initiated following diagnosis. Patient data collected included age, gender, chronic diseases, type of surgery and anesthesia and delirium characteristics. Results: The delirium study group included 47 patients with an average age of 84.4 years (±8.6), of whom 53.2% were females. Delirium incidence was 3.7% in all patients older than 65 (1759 patients) and 9.3% in the proximal femoral fracture group. We did not correlate electrolyte imbalance, anemia, polypharmacy and chronic diseases to delirium onset characteristics. Following the three-day low-dose risperidone treatment protocol, 0.5 mg BID, 14.9% of the patients showed CAM score normalization after one day of treatment, and 93.6% within two days. Conclusions: We found our rigid three-day low-dose risperidone treatment protocol, 0.5 mg BID, efficacious in fast delirium resolution, without side effects.

Transcutaneous Electrical Acupoint Stimulation for Preventing Postoperative Delirium: A Meta-Analysis.

This meta-analysis of randomized controlled trials (RCTs) aims to evaluate the efficacy and safety of transcutaneous electrical acupoint stimulation (TEAS) for postoperative delirium (POD) in surgical patients. Based on database searches of the Wanfang, China National Knowledge Infrastructure (CNKI), VIP, Chinese Biology Medicine (CBM), PubMed, Cochrane Library, and Web of Science, relevant RCTs published before December 30, 2022, were extracted. Outcome indicators included the incidence of POD, changes in Confusion Assessment Method (CAM) scores, Visual Analogue Scale (VAS) scores, and the intraoperative consumption of anesthetics. Data were pooled and analyzed by Review Manager 5.3, and publication bias detection was conducted using Stata 17.0. A meta-analysis containing 715 experimental and 717 control participants from 12 RCTs was performed. The overall results showed that TEAS had obvious superiority with a lower incidence of POD on any day during the postoperative 1 week. In subgroup analyses, the CAM scores on the third postoperative day were significantly lower in the TEAS group than in the control group (MD = -0.52, 95% CI: -1.02 to -0.03, P = 0.04), the VAS scores on the first postoperative day were significantly lower in the TEAS group than in the control group (MD = -0.19, 95% CI: -0.36 to -0.02, P = 0.03), the consumption of propofol and remifentanil were both significantly lower in the TEAS group compared with the control group (MD = -23.1, 95% CI: -37.27 to -8.94, P = 0.001; MD = -105.69, 95% CI: -174.20 to -37.19, P = 0.002). No serious adverse events of TEAS were reported in any of the referenced studies. TEAS has an obvious curative effect in preventing POD and pain in the earlier stage of surgical patients. It could be a promising assisted anesthesia technique in the future.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit.

Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU. Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Effect of light therapy on delirium in older patients with Alzheimer's disease-related dementia

Light therapy has been used as a non-pharmacologic treatment to modulate biorhythms in patients with mental and psychological conditions. These conditions include affective disorders and depression. Delirium is a syndrome characterized by an acute change in a patient's mental status. We hypothesized that light therapy might suppress delirium in patients with Alzheimer's disease (AD). A 4-week randomized controlled trial was conducted in which AD participants were randomly assigned to a treatment group or a control group. Delirium, defined by the Confusion Assessment Method (CAM), was evaluated at baseline and after 4 weeks. The Neuropsychiatric Inventory (NPI) and Zarit Caregiver Burden Interview (ZBI) were also conducted to assess the behavior of patients and the burden of their caregivers. For this study, 61 participants were initially recruited. A total of 34 and 27 participants were included in the treatment and control groups, respectively. After treatment with light therapy, the CAM score decreased during the second and fourth week. The NPI score in the therapy group also decreased during the second and fourth week. From the caregiver's perspective, after light therapy, the ZBI score significantly decreased during the second and fourth week. Compared with the control group, patients who underwent CAM and NPI assessments showed a small but significant improvement after 4 weeks of light therapy. In conclusion, a course of 4-week light therapy significantly suppressed delirium in patients with AD. The combined effects of light therapy and conventional treatment were superior to that of conventional treatment alone.

Addition of Valerian and Lemon Balm Extract to Quetiapine Reduces Agitation in Critically Ill Patients with Delirium: A Pilot Randomized Clinical Trial.

BackgroundThis study was pointed to evaluate the efficacy and safety of valerian and lemon balm additional to the quetiapine in critically ill patients with delirium and agitation.MethodsWe conducted a randomized, double-blind, placebo-controlled study. Fifty-three adult intensive care unit (ICU) patients (according to ICU Confusion Assessment Method scores) who were treated for delirium received quetiapine and Neurogol syrup (a combination of valerian and lemon balm) or placebo 5 mL every 12 hours for five consecutive days. Improvement in agitation according to the Richmond Sedation and Restlessness Scale was considered the main outcome.ResultsThe trial was completed for 53 patients (27 in the treatment group and 26 in the placebo group). The baseline characteristics between the groups were similar. In the treatment group, the number of agitated patients was significantly reduced and the difference was statistically significant (p = 0.000). Compared with the placebo group, the length of ICU stay in the treatment group was significantly reduced (p = 0.001). The Glasgow Coma Scale improved significantly at the end of day 5 (p = 0.04). There was no statistical difference in the improvement of delirium between the study groups (p = 0.14). Neurogol syrup was well tolerated.ConclusionThe addition of Neurogol to quetiapine (a combination of valerian and lemon balm) can reduce agitation and shorten the length of stay in the ICU without adverse effects. Clearly, more research is still needed to investigate the role of herbal medicines in ICUs and their efficacy and safety.How to cite this articleAlikiaie B, Shahmoradi E, Yekdaneh A, Mousavi S. Addition of Valerian and Lemon Balm Extract to Quetiapine Reduces Agitation in Critically Ill Patients with Delirium: A Pilot Randomized Clinical Trial. Indian J Crit Care Med 2021;25(7):785–790.

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.

Validating the Mandarin version of the Memorial delirium assessment scale in general medical hospital patients.

Delirium is a common neuropsychiatric condition in the general hospital population. Thus, the goal of the present study is to extend the use of diagnostic tools for delirium by developing and validating a Mandarin version of the Memorial Delirium Assessment Scale (MDAS). Participants were sampled from two general Mackay Memorial Hospital locations in Taipei and Danshui. Board-certified psychiatrists assessed patients using the MDAS, confusion assessment method (CAM), and Mini-Mental State Examination (MMSE). Another consultation-liaison psychiatrist confirmed the diagnosis of delirium. We assessed the reliability and validity of the MDAS, and the receiver operating characteristic curve was used to determine the optimal cut-off point for identifying delirium. Of the 61 patients assessed, 29 were diagnosed with delirium. The mean MDAS score was 16.7 for delirium patients and 4.1 for nondelirium patients. The MDAS has good internal consistency, with a Cronbach's alpha coefficient of 0.912. Interrater reliability was 0.996 (95% confidence interval [CI]: 0.992-0.998). The diagnostic cut-off value for the Mandarin version of the MDAS was 9, with a high sensitivity (93.1%) and specificity (96.9%). Factor analysis revealed a two-factor structure; these factors accounted for 58.37% and 14.42% of the variance. A high correlation was found between the MDAS and the CAM scores (r = -0.849, p <.001) as well as the MMSE (r=-0.875, p < .001). The Mandarin MDAS exhibited good reliability and validity for assessing general hospital patients.

Regional cerebral oxygen saturation and postoperative delirium in endovascular surgery: a prospective cohort study

BackgroundDelirium is an acute mental disorder and common postoperative complication. Monitoring regional cerebral oxygen saturation (rSO2) in endovascular therapeutic surgery may allow real-time monitoring of cerebral desaturation, avoiding profound cerebral dysfunction, and reducing the incidence of delirium. We sought to examine the incidence of delirium in patients undergoing endovascular surgery.MethodsThis was a clinical cohort trial (registered with http://www.clinicaltrials.gov [NCT02356133]). We monitored the rSO2 of 43 patients undergoing general anesthesia and cerebral endovascular surgery. The occurrence of delirium after surgery was recorded with the Confusion Assessment Method (CAM). Multivariate logistic regression was performed to identify the main predictor of delirium.ResultsrSO2 was significantly different between the delirium and no-delirium groups. The occurrence of delirium was 35% in our cohort, and higher rSO2 desaturation scores were significantly associated with profound delirium (higher CAM score; odds ratio = 1.002; P = 0.021). The maximum declines of systolic blood pressure were 24.86 (21.78–27.93) and 32.98 (28.78–37.19) in the no-delirium and delirium groups, respectively, which were significantly different (P = 0.002) but not closely associated with delirium in multivariate analysis (P = 0.512). Anesthesia, mechanical ventilation duration, and having two vascular risk factors differed significantly between groups but were poorly associated with delirium outcome.ConclusionsElevated rSO2 desaturation score was predictive of the occurrence of postoperative delirium following endovascular surgery. Monitoring rSO2 is invaluable for managing controlled hypotension during endovascular surgery and reducing postoperative delirium.Trial registrationClinicalTrials.gov, NCT02356133. Registered 1 February 2015. All statistical analysis results submitted August 4, 2018.

Early detection of delirium – using the CAM score

Background: Delirium is common in elderly patients and has been identified as an independent marker for increased mortality and hospital-acquired complications, yet it is poorly recognized by health care providers. The aim of this study was to investigate whether systematic use of the validated screening tool Confusion Assessment Method (CAM) would result in a higher recognizing of delirium in patients ≥ 65 years old admitted at Odense Emergency Department (FAM).&#x0D; Methods: All caregivers in the Emergency department (ED) at Odense University Hospital received 2 hours of education in delirium and how to use the CAM score. They were asked to systematically perform CAM score in all patients ≥ 65 years at arrival to the ED and at least every 8 hours. During 2 periods of 5 days - one before the caregivers was educated (pre-CAM) and one 4 weeks after CAM scoring was started (during-CAM). A research team interviewed all ≥ 65 year old patients and their caregivers at the first and second day of admission. In relation to the interviews all patients underwent a cognitive assessment using the CAM by a trained investigator. These results were blinded to the clinical personal. After discharge patient files were screened with the aim to identify any delirium registered by the clinical personal.&#x0D; Results: Out of 276 screened patients 192 where included in the project. 100 patients and were included in the pre-CAM group and 92 patients in the during-CAM group. According to the registrations by the research team 24 of 100 (24% 95%CI 16%-34%) patients experience delirium in the pre-CAM group and 18 of 92 (20% 95%CI 12%-29%) in the during-CAM group. Increasing age and comorbidity was related to delirium. Prevalence of the diagnoses delirium registered in the patient file increased from 1 of 24 (4% 95%CI 0%-21%) to 9 of 18 (50% 95%CI 26%-74%).&#x0D; Conclusion: One out of four elderly acute patients has deliria symptoms during the first 2 days at hospital. Systematic CAM scoring does not change the prevalence but increase the awareness significantly. The high prevalence underlines the clinical importance of the problem.

Sleep Deprivation in Neurointensive Care Unit Patients From Serial Neurological Checks: How Much Is Too Much?

Hourly neurological examinations are frequently performed in the neurointensive care unit (NICU) to quickly detect neurological deterioration. These examinations require the patient to be awakened hourly for days disrupting the sleep cycle and potentially causing neurological deterioration through sleep deprivation and the development of delirium. This pilot study's aim was to describe the prevalence of neurologic deterioration and delirium in patients receiving hourly neuro checks. A 6-month prospective observational cohort study was conducted within the NICU at Mayo Clinic Florida. Twenty subjects were enrolled between July 24, 2016, and January 30, 2017. Neurological deterioration as defined as a decrease in Glasgow Coma Scale score of 2 or more, an increase in National Institute of Health Stroke Scale score by 4 or more, or a change in Confusion Assessment Method score for use in intensive care unit patients from negative to positive occurred in 19 of 20 patients (95%) for a total of 67 events, with most patients having multiple events. Seventy-five percent of the subjects experienced a decrease in Glasgow Coma Scale score of 2 or more at least once during the study period. The largest number of events occurred within the first 24 hours (39%). Surprisingly, 75% of the subjects also developed delirium. Forty percent of the subjects demonstrating neurological deterioration received computed tomography imaging to evaluate the change. Sixty-seven percent lacked deterioration evident on computed tomography imaging, and the deterioration was not attributed to medication effect or seizure by an experienced provider. Neurological deterioration is prevalent in the NICU population. Although hourly neurological examinations may be beneficial in the acute phase of neurological injury, prolonged use may be paradoxically harmful due to sleep deprivation.

Cerebrospinal Fluid Apolipoprotein E Levels in Delirium

Background/Aims: Delirium and the apolipoprotein E ε4 allele are risk factors for late-onset Alzheimer disease (LOAD), but the connection is unclear. We looked for an association. Methods: Inpatients with delirium (n = 18) were compared with LOAD outpatients (n = 19), assaying blood and cerebrospinal fluid (CSF) using multiplex ELISA. Results: The patients with delirium had a higher Confusion Assessment Method (CAM) score (5.6 ± 1.2 vs. 0.0 ± 0.0; p < 0.001) and Delirium Index (13.1 ± 4.0 vs. 2.9 ± 1.2; p = 0.001) but a lower Mini-Mental State Examination (MMSE) score (14.3 ± 6.8 vs. 20.8 ± 4.6; p = 0.003). There was a reduction in absolute CSF apolipoprotein E level during delirium (median [interquartile range]: 9.55 μg/mL [5.65–15.05] vs. 16.86 μg/mL [14.82–20.88]; p = 0.016) but no differences in apolipoprotein A1, B, C3, H, and J. There were no differences in blood apolipoprotein levels, and no correlations between blood and CSF apolipoprotein levels. CSF apolipoprotein E correlated negatively with the CAM score (r = –0.354; p = 0.034) and Delirium Index (r = –0.341; p = 0.042) but not with the Acute Physiology and Chronic Health Evaluation (APACHE) index, or the MMSE or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Conclusion: Reduced CSF apolipoprotein E levels during delirium may be a mechanistic link between two important risk factors for LOAD.

Effects of preoperative ulinastatin treatment on serum cytokines and post-operative delirium in elderly patients receiving lower limb joint replacement

Objective To investigated the effects of preoperative application of ulinastatin(UTI) on serum inflammatory factors and postoperative delirium in elderly patients receiving elective lower limb arthroplasty. Methods A prospective, double-blind, randomized controlled study was conducted. A total of 80 elderly patients(65-85 y old) with ASA grades of Ⅰ-Ⅲ were enrolled in elective lower limb arthroplasty. They were randomly and evenly assigned into ulinastatin treated-(UTI) and non-treated-(control) groups (n=40). Before surgery, 300 thousand units of UTI was added into 100 ml normal saline and was intravenously infused in 30 min in UTI group, while 100 ml normal saline was intravenously administered in control group in 30 min. All patients received tracheal intubation under general anesthesia during the operation and were subjected to iliac fascia space block guided by ultrasound. We measured minimum mental state examination(MMSE) scores 1 day before operation and assessed the existence of delirium with confusion assessment method(CAM) at postoperative 24 h(T2), 48 h(T3), and 72 h(T4). We collected peri-and post-operative information from the patients, including demographic information, intraoperative parameters (such as, duration of anesthesia and operation, volume of intraoperative bleeding and blood transfusion, dosage of anesthetics, etc.) and postoperative indices(VAS, postoperative recovery and adverse effects, etc.). We also collected 3 ml peripheral blood from patients before operation(T0) and at post-operative time points (T1, T2 and T3) to detect the serum proinflammatory cytokines, such as, TNF-α, IL-1β, IL-6, and S100β. Results The CAM scores in UTI group[(12.8±2.1), (13.1±2.9)] were significantly lower than those of control group[(14.0±2.5), (14.7±3.1)] at T2 and T3(P 0.05). S100β reached peak at T1 in both UTI and control groups. Compared with the control group, S100β in serum was significantly lower at T1 in UTI group[(304±142) ng/L vs (396±208) ng/L](P<0.05). In two groups of patients, IL-1β and IL-6 in serum at T0-T2 showed upward trends and reached peaks at T2. Compared with the control group, IL-1β and IL-6 in UTI group decreased significantly at T1 [IL-1β: (70.4±7.3) ng/L vs (81.6±8.5) ng/L, IL-6: (55±8) ng/L vs (62±8) ng/L] and T2 [IL-1β: (99.6±7.7) ng/L vs (105.7±8.0) ng/L, IL-6: (88±8) ng/L vs (99±11) ng/L](P<0.05). Conclusions Preoperative treatment with UTI can improve post-operative CAM scores and cognitive function in elderly patients receiving elective lower limb joint replacement. The effects of UTI may be related to its inhibition of inflammatory cytokines. Key words: Post-operative delirium; Ulinastatin; Inflammatory cytokine; Lower extremity; Arthroplasty, replacement

Feasibility of Using a Game-Based Cognitive Assessment for Older Adults in Emergency Care

Background: Developed nations are currently facing a demographic shift towards a higher proportion of elderly people and increasing age-related health concerns. Elderly adults often enter into the health care system through emergency services. As a result, emergency departments (EDs) are an opportune environment for cognitive screening to improve patient outcomes. Existing methods are not designed for use in EDs and require administration by a trained test administrator. As an alternative, we suggest serious games as screening tools that can be self-administered or used with minimal assistance in emergency care. The use of validated and reliable serious games can encourage more efficient and engaging cognitive screening. Objective: Our objective was to investigate the feasibility and usability issues identified in the process of evaluating the validity and reliability of a game-based cognitive screening tool administered on an interactive tablet, for use by elderly adults in emergency care. Methods: We carried out a study in a hospital ED to evaluate the validity of the serious game with elderly adults over the age of 70 years (N=146). Validity was assessed in terms of the correlation of game performance with outcomes of current assessment methods. Comparative assessments included the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). We also assessed the reliability of our game-based assessment tool in a hospital ED for a large subset of the patients who underwent a revised protocol involving follow-up sessions at a minimum of every 8 hours (n=127). In both studies, research personnel (RP) administered the standard cognitive assessments and then asked the patients to play the serious game. Recruitment for the reliability study overlapped with our validation study, with 56 potential overlap cases. Results: In our validation group, 141 of 146 patients consented to play the serious game. Performance on the serious game correlated significantly with the MoCA (r=–0.339, P<.001), MMSE (r=–0.558, P<.001), CAM (r=0.565, P<.001), and other cognitive assessments. In our reliability study of 127 adults, we obtained data from 126 people. We observed good test-retest reliability with Pearson correlation r values between 0.5 and 0.7. These results supplement findings from our validation study that the assessment was correlated with MMSE, MoCA, and CAM scores. Usability feedback suggested that the game was too easy and the need to use a stylus for users with dry skin. All patients were able to play the serious game administered on a tablet either independently or with minimal assistance from RP. In the latter case, RP would assist by holding the tablet as some patients found it heavy. Conclusions: This research demonstrates the feasibility, validity, and reliability of using a game-based cognitive assessment in a clinical setting. Elderly users in an ED can use our screening tool by improving on the usability of the system by incorporating their feedback in our design process. This research shows that appropriately designed serious games can be self-administered or used with minimal assistance in a clinical setting repeatedly for each person. [iproc 2016;2(1):e35]

LO054: The emergency department usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium

Introduction: Delirium is an acute state of mental confusion that is a frequent complication in older adults with a hip fracture, and is often unrecognized by clinicians in the emergency department (ED). It is associated with prolonged hospitalization, functional decline, hospital readmission, and death. The Identification of Seniors At Risk (ISAR) and Confusion Assessment Method (CAM) are two standardized tools designed to facilitate prompt screening and detection of functional decline and delirium respectively amongst adults 65 and older. The objective of this study was to determine the ED usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium. Methods: This was a retrospective chart review of patients aged 65 and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. At this institution, both the ISAR and CAM are included in the standard ED nursing documentation and are intended to be completed for all patients over 65 years of age. Results: Of the 243 hip fracture cases included in this study, the ISAR and CAM scores were completed for 131 (53.9%) and 69 (28.4%) patients, respectively. There were 43 (17.7%) cases of recorded in-hospital acute delirium. Of the delirium cases, 20 (46.5%) had an ISAR assessment. Patients with an ISAR score of ≥3 were more likely to experience delirium compared to those with lower ISAR scores (28.3% vs 8.3%; Δ 20.0%, 95% CI: 6.6%, 34.9%). Of the 43 patients with delirium, 11 (25.6%) had a CAM score recorded. Patients with a positive CAM score (meeting 3 of 4 criteria in the diagnostic algorithm) were more likely to experience delirium compared to those with negative CAM scores (66.7% vs 11.1%; Δ 55.6%, 95% CI: 17.5%, 79.9%). Conclusion: Vigilant efforts are needed to ensure these screening tools are applied for all patients over the age of 65 presenting to the ED to improve the recognition and early management of delirium. Future research should focus on initiatives to improve delirium screening compliance by ED personnel.

Disaster Strikes! Long-Term Care Resident Outcomes Following a Natural Disaster

This report describes the outcomes of 17 long-term care residents who were participating in a nursing intervention study. The residents were evacuated for 5 days due to a severe summer storm that caused widespread power outages. These residents were seen the day of the storm and three times per week for 2 weeks following their return to the nursing home. More than half of the participants had significant changes in their NEECHAM Confusion Scale scores ( n = 11) and modified Confusion Assessment Method scores ( n = 9) scores, suggesting the onset of delirium. Two participants were hospitalized within the 2 weeks of the evacuation. One participant died unexpectedly. This report provides a rare look into the negative effects of a short-term evacuation due to a natural disaster.

Disaster Strikes! Long-Term Care Resident Outcomes Following a Natural Disaster

This report describes the outcomes of 17 long-term care residents who were participating in a nursing intervention study. The residents were evacuated for 5 days due to a severe summer storm that caused widespread power outages. These residents were seen the day of the storm and three times per week for 2 weeks following their return to the nursing home. More than half of the participants had significant changes in their NEECHAM Confusion Scale scores (n = 11) and modified Confusion Assessment Method scores (n = 9) scores, suggesting the onset of delirium. Two participants were hospitalized within the 2 weeks of the evacuation. One participant died unexpectedly. This report provides a rare look into the negative effects of a short-term evacuation due to a natural disaster.

Randomized, Placebo‐Controlled Trial of the Cognitive Effect, Safety, and Tolerability of Oral Extended‐Release Oxybutynin in Cognitively Impaired Nursing Home Residents with Urge Urinary Incontinence

Determine the cognitive effect, safety, and tolerability of oral extended-release oxybutynin in cognitively impaired older nursing home residents with urge urinary incontinence. Randomized, double-blinded, placebo-controlled trial. Twelve skilled nursing homes. Fifty women aged 65 and older with urge incontinence and cognitive impairment. Four-week treatment with once-daily oral extended-release oxybutynin 5 mg or placebo. Withdrawal rates and delirium or change in cognition from baseline at 1, 3, 7, 14, 21, and 28 days after starting treatment using the Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and Severe Impairment Battery (SIB). The Brief Agitation Rating Scale, adverse events, falls incidence, and serum anticholinergic activity change with treatment were also assessed. Participants' mean age +/-standard deviation was 88.6+/-6.2, and MMSE baseline score was 14.5+/-4.3. Ninety-six percent of subjects receiving oxybutynin (n=26) and 92% receiving placebo (n=24) completed treatment (P=.50). The differences in mean change in CAM score from baseline to all time points were equivalent between the oxybutynin and placebo groups. Delirium did not occur in either group. One participant receiving oxybutynin was withdrawn because of urinary retention, which resolved without treatment. Mild adverse events occurred in 38.5% of participants receiving oxybutynin and 37.5% receiving placebo (P=.94). Short-term treatment using oral extended-release oxybutynin 5 mg once daily was safe and well tolerated, with no delirium, in older female nursing home participants with mild to severe dementia. Future research should investigate different dosages and long-term treatment.

Preoperative Factors Associated with Postoperative Change in Confusion Assessment Method Score in Hip Fracture Patients

Postoperative delirium is a major problem in elderly patients undergoing surgical repair of hip fracture. It is imperative to identify potentially treatable preoperative factors associated with the onset of postoperative delirium to optimize outcome. We sought to determine what preoperative variables are associated with postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. In a prospective, IRB-approved study, patients admitted to the geriatric hip fracture service were examined daily in the hospital for the occurrence of postoperative delirium. All patients with a preoperative diagnosis of dementia or delirium were eliminated. A positive confusion assessment method score ([+]CAM) was used to determine the presence of postoperative delirium during the acute hospital stay. To determine the association between preoperative variables (demographics, laboratory values, and comorbidities) and postoperative (+)CAM scores, χ2 and logistic regression analysis were performed with calculation for the odds ratios (OR). One-hundred-sixty-eight patients (72% women) were included in the analysis. Twenty-eight percent (n = 47) of patients had a (+)CAM score. Three variables were significant predictors of a (+)CAM score: (a) normal white blood cell count (OR, 2.2), (b) abnormal serum sodium (OR, 2.4); and (c) ASA physical status >II (OR, 11.3). The results suggest that preoperative medical conditions (abnormal serum sodium and ASA physical status >II) and an inability to mount a stress response (normal white blood cell count) may influence the patient’s postoperative mental status. In particular, two of the risk factors we identified may be amenable to therapy and are abnormal serum sodium and lack of an increase in white blood cell count during the stress of trauma and surgery.