Delirium Group Research Articles

Prevalence of Delirium in a Population of Elderly Outpatients with Dementia: A Retrospective Study.

Delirium is a multifactorial geriatric syndrome and often occurs in patients with cognitive impairment. It also remains under-recognized, specifically in elderly outpatients, because signs of delirium might overlap with symptoms of dementia. The aim of the present study is to retrospectively apply the chart-based delirium instrument on a cohort of elderly outpatients with dementia, to assess prevalence and features of delirium in this population. We randomly selected 650 medical records of outpatients referred to the "Neurogenetic Regional Centre" (CRN) of Lamezia Terme. Each evaluation included demographics, medical history, drugs, type and severity of dementia, and cognitive and functional status. Delirium was identified by the application of the chart-based delirium instrument. The prevalence of delirium was 13.3%. The study population was divided, according to the presence of delirium, into two subgroups. Compared to the no delirium group, the delirium group was significantly older and had greater cognitive impairment with lower MMSE scores both at baseline and at the end of the follow up. They also had a significant lower score on the ADL and IADL. In this group, a higher intake of antihypertensive and antipsychotic drugs, together with a lower intake of cholinesterase inhibitors and memantine, was observed. In this study, the chart-based delirium instrument was applied to an outpatient population affected by dementia and followed for a long time. Our data confirm the importance that age and frailty play on the genesis of delirium and suggest attention should be paid to the pharmacological treatment of these patients.

Delirium is associated with increased mortality in the geriatric population

Objective: The aim of this study was to investigate the prevalence of delirium and its association with mortality rates in elderly inpatients.Methods: The medical records of 1435 patients over 65 years old who were treated at a regional university hospital and were referred to the university’s Consultation and Liaison Psychiatry Clinic for psychological evaluation were retrospectively analyzed. Patients with and without a diagnosis of delirium were compared. The National Survival Database was used to determine mortality rates.Results: The prevalence of delirium was 25.5%. The delirium group was older (p < .0001) and had a larger proportion of males (p < .0001). Mortality rate was higher in the delirium group at 1, 2, 3, 4, and 5 years (p < .0001 for all). Age, gender, lower urinary system diseases, chronic liver disease, solid hematologic malignancy, infections, and Alzheimer’s disease emerged as significant parameters associated with mortality. Multivariate analysis of these parameters indicated that comorbid diseases (lower urinary system diseases, chronic liver disease, solid hematologic malignancy, infections, and Alzheimer’s disease) are risk factors for mortality independent of demographic data such as age and gender.Conclusions: Independent of all other factors, delirium is associated with higher mortality risk.

The Diagnostic Sensitivity of the Memorial Delirium Assessment Scale—Spanish Version

BackgroundAlthough Memorial Delirium Assessment Scale (MDAS) is a successful tool for delirium evaluation and monitoring, it is nevertheless important to determine whether cutoff scores vary according to the studied population. The main objective of this study was to evaluate the diagnostic sensitivity of the recently validated Spanish version of the MDAS. The secondary objective was to analyze possible diagnostic differences when used in a hospice or general hospital setting. MethodologyA prospective study was conducted with advanced cancer patients in two settings (hospice and general hospital). A diagnosis of delirium was established according to clinical criteria and the Confusion Assessment Method. Sensitivity (S), specificity (Sp), positive predictive value, and negative predictive value were determined according to the receiver operating characteristics curve. The MDAS values for different centers were studied using nonparametric tests (Mann-Whitney). ResultsA total of 67 patients were included, 28 of whom had been diagnosed with delirium (15/40 hospice and 13/27 general hospital). The mean MDAS scores were 13.6 and 5.5 for the delirium and nondelirium groups, respectively. A cutoff score of 7 gave the optimal screening diagnosis balance (S 92.6%, Sp 71.8%, positive predictive value 70.1%, and negative predictive value 93.3%). Diagnoses of anxiety and depression were not related with delirium (P ≤ 0.44). A diagnosis of dementia was related to delirium (P ≤ 0.052) but did not influence the diagnostic sensitivity of MDAS (P ≤ 0.26). No differences were found between hospice and general hospital settings as regards the diagnostic sensitivity of MDAS. ConclusionA screening cutoff of 7 appears to be optimal for MDAS Spanish version. No differences were found between advanced cancer patients cared for in a hospice or general hospital. However, more research is required to define the MDAS cutoff for patients with advanced cancer and dementia.

Early postoperative delirium after hemiarthroplasty in elderly patients aged over 70 years with displaced femoral neck fracture.

PurposePostoperative delirium is a risk factor for worse outcome after hip fracture surgery in elderly patients. Postoperative delirium is associated with anesthesia, postoperative pain, and patient factors. We investigated the incidence, predictors, and prognostic implications of post-operative delirium after hemiarthroplasty (HA) in elderly patients with femoral neck fracture.Patients and methodsA total of 356 consecutive patients aged >70 years who underwent HA for femoral neck fracture were enrolled. Diagnosis of delirium was made by a psychiatrist based on patient status and an objective scoring system. The patients were divided into 2 categories according to the HA onset time (immediate [≤24 h after surgery] vs delayed delirium [>24 h after surgery]) and its incidence, predictors and mortality were evaluated.ResultsPostoperative delirium was diagnosed in 110 patients (30.9%) during hospitalization. Immediate and delayed delirium occurred in 59 (53.6%), and 51 (46.4%) patients, respectively. The independent predictors of immediate delirium included age (odds ratio [OR] 1.47, 95% CI 0.98–2.23, p=0.066), and general anesthesia (OR 2.25, 95% CI 1.17–4.43, p=0.015). The independent predictors of delayed delirium were parkinsonism (OR 5.75, 95% CI 1.66–19.96, p=0.006), intensive care unit stay (OR 1.85, 95% CI 0.97–3.56, p=0.064), and higher American Society of Anesthesiologists grade (OR 2.33, 95% CI 0.90–6.07, p=0.083). On Kaplan–Meier survival analysis, the 2-year survival rate was significantly lower in the immediate delirium group than those in the delayed and control groups (71.0% vs 83.6% vs 87.8%, respectively; p=0.031).ConclusionImmediate and delayed delirium after HA for femoral neck fracture had different predictors and immediate delirium was associated with worse prognosis.

Clock-Drawing Test as a Bedside Assessment of Post-operative Delirium Risk in Elderly Patients with Accidental Hip Fracture.

Currently applied cognitive tests for assessing the risk of post-operative delirium require time and specialised medical staff, in addition to the patients' mental strain. We investigated the four-point scoring Clock-Drawing Test (CDT-4) as a preoperative independent predictor for post-operative delirium. A total of 100 consecutive patients aged over 65years admitted for accidental hip fracture were assessed for delirium using the Confusion Assessment Method Scale. The cognitive function was rated with mini-mental state examination, Montreal Cognitive Assessment Scale (MoCA), and CDT-4. Descriptive statistics were performed, and a logistic regression model for post-operative delirium was applied. Out of the 100 enrolled patients 98 underwent hip repair surgery and 65 (66%) had post-operative delirium, with 24 (42%) incident cases. The median (IQR) ages were 78 (72-83) and 84 (80-87)years for the non-delirium and post-operative delirium groups, respectively. The logistic regression concluded with age and CDT-4 as independent preoperative predictors, while controlling for gender, pre-surgery delirium, MoCA visual, and MoCA attention: OR 1.32 [95% CI (1.099-1.585); p=0.003] for age; OR 0.153 [95% CI (0.033-0.719); p=0.017] for CDT-4. Employing CDT-4 as a bedside assessment of delirium risk may help to preoperatively stratify and prioritise the patients for preventive perioperative care in a timely manner.

Don't Hold Your Breath: Implementation of “Bedside Wake-Up and Breathe” Handoff in Improving Compliance With Spontaneous Awakening (SAT) and Breathing Trials (SBT)

SESSION TITLE: Patient Safety and Quality Improvement SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: Studies have shown that compliance with the evidence-based ABCDEF bundle (SAT, SBT, Choice of Sedation, Delirium Screening, Early Mobility and Family Involvement) allows for earlier liberation from mechanical ventilation, reduced delirium, decreased ICU length of stay, and improved survival. There are multiple factors affecting the execution of SAT/SBT in ICU patients such as interdisciplinary communication and coordination of care between respiratory therapists, nurses, and physicians to ensure proper sequence of the individual components. However, there is limited published research on the effectiveness of bedside sign-off by respiratory therapists in improving the execution of SAT/SBTs. After adopting the ABCDEF bundle in 2015, the ICU team at Orange Regional Medical Center (ORMC), Middletown, NY implemented a “Bedside Wake-Up and Breathe” handoff protocol in June 2016 to improve bundle compliance. The protocol required respiratory therapists to perform independent bedside assessments and communicate with nurses to prepare and execute SATs/SBTs at 6 am before morning rounds. The overall aim of the study was to have a structured protocol that optimized the ABCDEF bundle, enhancing early weaning of mechanically ventilated patients and decreasing ICU length of stay at ORMC. METHODS: We used the ABCDEF protocol established by the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University Medical Center in order to record SAT/SBT data within the first seven days of the ICU length of stay for ventilated patients. Inclusion and exclusion criteria was based on that of the ABCDEF protocol. We collected data from March 2016 to August 2016 on 103 patients. The pre-intervention group (March-May 2016) included 58 patients and the post-intervention group (June-August 2016) included 45 patients. The intervention was implementation of the “Bedside Wake-Up and Breathe” handoff protocol on mechanically ventilated patients. We used a statistical t-test to compare the average number of SATs and SBTs per mechanically ventilated patient within the first seven days of intubation in the ICU and the average length of stay in the ICU between the pre-intervention and post-intervention period. RESULTS: There was a statistically significant increase in the average number of SATs in the first seven days of intubation between the pre-intervention group (n=58) and post-intervention group (n=45), with 0.74 average SATs per patient in pre and 1.46 average SATs per patient in post (t-test, p-value<0.05). Similarly, there was a statistically significant increase in the average number of SBTs per patient, with 0.74 in pre and 1.15 in post (t-test, p-value<0.05). The pre-intervention length of stay in the ICU was 9.33 days, which was significantly more than the post-intervention length of stay at 5.44 days (t-test, p-value<0.05). CONCLUSIONS: Implementation of the “Bedside Wake-Up and Breathe” handoff protocol, which aimed to facilitate the ABCDEF bundle, successfully increased the average number of SATs/SBTs completed in the first seven days of mechanical ventilation and reduced the average length of stay in the ICU. CLINICAL IMPLICATIONS: Bedside sign-off by respiratory therapists can improve interdisciplinary communication in the ICU and patient outcomes. DISCLOSURE: The following authors have nothing to disclose: Nakia Sarad, Kathleen Holsaeter, Bryony Lucas, Donya Nazery, Harshal Lal, Aamir Gilani No Product/Research Disclosure Information

Risk factors for the incidence of delirium in cerebrovascular patients in a Neurosurgery Intensive Care Unit: A prospective study.

To explore the incidence of delirium in cerebrovascular patients admitted in our Neurosurgery Intensive Care Unit and analyse the risk factors leading to delirium. Delirium is one of the most common mental disorders in general hospitals, but the incidence of different kinds of diseases and studies varies. Cerebrovascular patients in our Neurosurgery Intensive Care Unit are high-risk groups for delirium; identifying risk factors for delirium and taking early interventions are crucial for patient prognosis. A prospective study. A convenience sampling method was used to collect data from 128 patients in the Neurosurgery Intensive Care Unit of Xuanwu Hospital, Capital Medical University, Beijing, China, between May 2016-January 2017. Researchers used Confusion Assessment Method for the Intensive Care Unit (Chinese version) to assess each patient's delirium statement twice a day at regular times. We also collected other independent data variables and followed up the short-term clinical outcomes daily. On the basis of Confusion Assessment Method for the Intensive Care Unit evaluation, patients were divided into a delirium group and a nondelirium group. The prevalence of delirium among the 128 patients was 42.2%. Multivariate analysis showed that severity of illness, fever, the use of physical restraints and sleep deprivation were independent predictors of delirium in cerebrovascular patients in the Neurosurgery Intensive Care Unit. Cerebrovascular patients in the Neurosurgery Intensive Care Unit with a critical condition, fever or use of physical restraints or experiencing sleep deprivation were more prone to delirium. Cerebrovascular patients in the Neurosurgery Intensive Care Unit showed a high incidence of delirium. There are many risk factors leading to delirium, some of which are independent predictors of intensive care delirium. Patients with delirium will suffer various adverse effects upon their short-term clinical outcomes. Therefore, nurses should pay close attention to changes in a patient's mental state and learn about the risk factors associated with delirium, in order to be able to take early measures to prevent delirium.

Delirium post-stroke: short- to long-term effect on anxiety and depression compared to effect on cognition

BackgroundDelirium is common after stroke and has significant negative impact on mortality, morbidity, cognitive function, and institutionalization. Despite these known effects, any impact of delirium on the emotional well-being of stroke survivors is unclear.MethodsA post hoc analysis was performed on our prospective cohort study of 156 stroke patients. Hospital Anxiety and Depression (HAD) scale scores were compared between patients with delirium and patients without delirium at 1-month, 6-month, and 12-month post-stroke.ResultsContrary to the negative impact of delirium on cognition and functional status, we did not discern any influence on HAD scale scores in the short to long term. The median scores of the HAD anxiety scale were 4 (interquartile range IQR 3) at 1 month, 5.5 (IQR 8.75) at 6 months, and 6 (IQR 5) at 12 months in the delirium group compared to 5 (IQR 7) at 1 month (p = 0.6), 4 (IQR 7) at 6 months (p = 0.4), and 6 (IQR 5.75) at 12 months (p = 0.9) in the non-delirium group, respectively. Similarly, the median scores of the HAD depression scale were 5 (IQR 4) at 1 month, 4 (IQR 6.5) at 6 months, and 3 (IQR 6) at 12 months in the delirium group compared to 6 (IQR 5.75) at 1 month (p = 0.9), 5 (IQR 7) at 6 months (p = 0.9), and 6 (IQR 5) at 12 months (p = 0.5) in the non-delirium group.ConclusionDelirium may not have a significant effect on the development of anxiety or depression after stroke which differs in its effect on cognitive function and functional status.

Risk factors and clinical outcomes of delirium in osteoporotic hip fractures.

This study is performed to identify risk factors for delirium in osteoporotic hip fractures and to evaluate the hospitalization cost and clinical outcomes of delirium in osteoporotic hip. A total of 221 patients with osteoporotic hip fractures were assessed for eligibility between 2010 and 2014. Among them, 37 patients with delirium were allocated into the delirium group (group D) and 37 patients without delirium were allocated into the non-delirium group (group ND) by matching demographic factors. Risk factors such as time between admission and operation, body mass index, American Society of Anesthesiologists status, cognitive impairment, preoperative urinary catheter, electrolyte imbalance, preoperative hemoglobin, polymedication (medications > 5), pneumonia, anesthesia time, operation time, estimated blood loss, and total amount of transfusion were evaluated for correlation with incidence of delirium. The hospitalization cost was evaluated, and clinical outcomes such as readmission, mortality, and activity level at 1-year follow-up were evaluated. In multivariate analysis, polymedication ( p = 0.028) and preoperative indwelling urinary catheter insertion status ( p = 0.007) were related to the incidence of delirium in patients with osteoporotic hip fractures. Group D showed a significantly higher hospitalization cost compared to group ND. However, delirium did not have a significant effect on length of hospital stay, readmission rate, postoperative 1-year mortality, and activity level. Polymedication and preoperative urinary catheter were related to perioperative delirium. In addition, delirium in osteoporotic hip fractures may not have a detrimental effect on clinical outcomes; however, hospitalization cost seemed to be increased due to delirium.

Plasma melatonin levels in hip fracture patients with and without delirium: A confirmation study

BackgroundMelatonin plays a major role in maintaining circadian rhythm. Changes in melatonin metabolism might lead to circadian rhythm disturbances which are often observed in delirious patients. AimTo assess if high morning plasma melatonin concentrations were associated with delirium. MethodsConsecutive hip fracture patients aged ≥65 years were included. Delirium was assessed daily with the Confusion Assessment MethodBlood samples were collected at 11.00am on weekdays during first week of hospitalization. Melatonin was analyzed by liquid chromatography-tandem mass spectrometry. ResultsWe analyzed 389 samples of 144 participants [mean age 84.0, 70 experienced delirium]. A Generalized Estimating Equations (GEE) model with outcome melatonin level in highest tertile ( >3.36 pg/ml) and covariates delirium group (i.e. never, before, during, post delirium), cognitive impairment, age, sex and anesthesia type, was constructed. Highest melatonin levels were associated with postoperative samples (Odds Ratio(OR) 2.11 compared to preoperative samples; 95% Confidence Interval(CI) 1.17–3.82, p=0.01) and higher age (OR 1.05 per year; CI 1.01–1.11, p=0.03), but not with delirium group(p=0.35). ConclusionUndergoing surgery and aging in general may induce changes in melatonin metabolism. Future research should focus on daily multiple melatonin measurements to determine whether melatonin supplementation might be beneficial for delirium treatment or prevention.

Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation

There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes.

Quality Enhancement Program: A Delirium-caring Culture Nurturing Program in Acute Geriatric Setting- 2-years Review

Introduction: Delirium in elderly is not only associated with higher mortality and morbidity, it also leads to prolonged hospital stay, falls and workplace violence causing harms to both patients and frontline staff. However, delirium is often under-diagnosed or mismanaged. The main reason is lack of awareness and understanding of delirium among healthcare workers (HCWs). Thus, a structured Delirium-caring Culture Nurturing Program (DCNP) was established since November 2013. Objectives: 1. To enhance HCWs knowledge and awareness on delirium management. 2. To establish a strong delirium-caring culture. Methodology: 1. Functional Group Delirium functional group was set up for data collection and to provide specialty trainings. It also played a leading role in implementing a delirium program. 2. Quality Assurance An algorithm was established based on the guideline for geriatric care of Hospital Authority to demonstrate a standardized workflow of delirium care in ward. 3. Knowledge Enhancement Up-to-date and evidence-based trainings were provided to HCWs from theory to practice. Activities included seminars, behavior-based safety program, simulation workshops, self-initiative talks and case sharing etc. 4. Environmental strategies Delirious patient would be clustered to less disturbed cubicle, single room would be provided if possible. ‘Reality orientation’ signage was used to promote effective communication between HCWs. 5. Caregivers engagement Caregivers were empowered to actively participate in the delirium nursing care plan by providing disease education and allowing flexible visiting hours. 6. Multidisciplinary collaboration Nurses collaborated with other health professionals to initiate discharge planning for some delirious cases with anticipated discharge problems. Results: From 11/2013 to 12/2015, 240 patients with mean age of 82.7 were recruited to the delirium program. 177 (74%) of them were diagnosed delirium and prompt interventions were provided. Of these patients, 110 (62%) returned their mental status upon discharge or before transfer. Recruitment rate and conversion rate from delirious to premorbid status increased around 21% and 7% through 2 years respectively. Moreover, 100% of HCWs agreed enhancing in delirium knowledge and 98% agreed that the delirium-caring culture in ward was getting stronger, hence beneficial to delirium management. Conclusion: The comprehensive DCNP is effective in establishing a strong delirium-caring culture in ward, thus increasing staff knowledge and awareness on delirium. As a result, early detection of delirium and early interventions can be provided.

Postoperative delirium incidence and oxidative stress in laparoscopic surgery

Postoperative delirium is a common complication of all types of surgery, especially in elderly patients (2). Overproduction of free oxygen radicals and decrease of organism defense mechanisms is believed to be involved in multiorgan failure, especially in the brain (4). It is important to determinate the susceptibility, incidence and preventive measures for postoperative delirium (8). Our objective was to identify an oxidative stress indicator that predicts the appearance of postoperative delirium in patients that undergoes laparoscopic renal or gynecological surgery for malignant diseases and the possible correlations between certain anesthetic drugs and postoperative delirium occurrence. This study included 29 patients that were treated for localized kidney or uterine cancer by trans peritoneal laparoscopic radical surgery procedures (nephrectomy or hysterectomy) between 2014 and 2016. They were randomized in two groups: the sevoflurane group (n=14 patients) and propofol group (n=15 patients). Blood samples were collected before anesthesia induction, at the end of surgery and at 24 h after surgery and the levels of malondialdehyde (MDA) and superoxide dismutase (SOD) were measured. Postoperative delirium was assessed using Confusion Assessment Method for the ICU (CAM-ICU). All patients with delirium from both groups developed the condition on the first postoperative day. In the sevoflurane group, postoperative delirium has observed in 6/14 patients (42%) and in the propofol group, 5/15 patients (33%) have developed the same postoperative syndrome. There was a significant increase of malondialdehyde levels in the delirium group compared to the non-delirium group in patients, sevoflurane and propofol, at the end of surgery. (p&lt;0.05) There were statistical difference between delirium group and non-delirium group in both sevoflurane and propofol patients, regarding superoxide dismutase levels before anesthesia induction (p&lt;0.05). Postoperative delirium incidence can be predicted by preoperative superoxide dismutase levels assessment in patients that undergoes laparoscopic urologic or gynecological surgery for malignant diseases.

Analysis of risk factors for delirium in elderly patients with hip fractures

Objective To investigate risk factors for postoperative delirium in elderly patients with hip fractures and determine whether the delirium can influence the outcome of hip fracture. Method A retrospective case control study was performed for 521 patients (≥60 years) with hip fractures treated surgically from January 2012 to December 2014.There were 170 males and 351 females, with the age of (79.3±8.3)years. Confusion assessment method (CAM) was applied to diagnose delirium after surgery, and the subjects were divided into delirium group (n=159) and control group (n=362) according to the presence of delirium. Univariate and multivariate analyses were performed to identify the riks factors for postoperative delirium, including age, gender, comorbidities, body mass index, American Society of Anesthesiologists (ASA) classification, type of fracture, haemoglobin, PaO2,albumen, type of anesthesia, type of anesthesia, amount of bleeding, time between admission to surgery, length of operation, type of operation and amount of blood transfusion. Perioperative complications and mortality within 1 year after operation were compared between the two groups. Results Univariate analysis revealed dementia, ASA classification, haemoglobin, PaO2,albumen, interval between admission to surgery, anesthesia method, operation time, and surgery methods were risk factors for postoperative delirium incidence (P<0.05). While multivariate analysis showed only dementia (OR=6.211, 95%CI 2.482-23.498), long interval between admission to surgery (OR=3.505, 95%CI 1.478-6.342), arthroplasty (OR=2.015, 95%CI 1.783-3.481), and PaO2≤60 mmHg (OR=2.766, 95%CI 1.783-5.039) were the significant risk factors for postoperative delirium after hip surgery in the elderly. Incidences of lung infection, wound infection, cardiovascular events, cerebrovascular events and deep venous thrombosis in delirium group were higher than those in control group, but only incidences of lung infection and wound infection reached significant differences (P<0.05). Mortality in delirium group was higher than that in control group within 1 year after operation, but there was significant difference only within 3 months after operation (P<0.05). Conclusions Incidence of delirium is high after hip fracture surgery in the elderly. Dementia, long interval between admission to surgery, arthroplasty and PaO2≤60 mmHg are significant risk factors for postoperative delirium incidence, and the delirium patients are associated with high early mortality. Key words: Hip fractures; Delirium; Aged

Association of White Matter Lesions, Cerebral Atrophy, Intracranial Extravascular Calcifications, and Ventricular-Communicating Hydrocephalus with Delirium Among Veterans.

The literature regarding the underlying neuropathogenesis of delirium on head computed tomography (CT) is limited. The aim of this research was to investigate, using case-control retrospective chart review, the association of white matter lesions (WML), cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus in older adult military veterans with and without delirium hospitalized in a Veterans Affairs Medical Center. Head CT scans were examined for WML, atrophy, and intracranial extravascular calcifications globally in the cortex, subcortex (frontal, temporal, parietal, occipital lobes), basal ganglia (globus pallidus, caudate, putamen), and internal capsule, in addition to the presence of ventricular-communicating hydrocephalus. WML were graded as not present, <1 cm, 1 to 2 cm, or >2 cm. Atrophy, cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus were graded as present or not present. There was a significant association of WML in the temporal lobe periventricular cortical and subcortical brain and a significant association of atrophy in the parietal lobes and the cerebellum in hospitalized older adult military veterans with delirium compared with hospitalized older adult military veterans without delirium. There were no differences between the delirium and nondelirium groups for intracranial extravascular calcifications and ventricular-communicating hydrocephalus. The results suggest that atrophy in the parietal lobes and the cerebellum of hospitalized older adult military veterans may be associated with an elevated risk of delirium when compared with age, race, and sex-matched control veterans. Continuing efforts are needed to clarify the role of atrophy during delirium in the veteran and nonveteran older adult population to reduce progressive frailty and decreased quality of life secondary to hospital and posthospital-discharge delirium.

Low plasma leptin level at admission predicts delirium in critically ill patients: A prospective cohort study

The pathophysiology of delirium remains poorly understood. Low leptin level has been associated with features leading to delirium such as dysregulated immune functions and loss of neuroprotective effects. The purpose of the present study was to investigate the relationship between plasma leptin level at intensive care unit (ICU) entry and subsequent occurrence of delirium in critically ill patients. This single-center prospective cohort study in China allocated 336 critically ill patients admitted to ICU between 05/2015 and 05/2016 into a delirium group (n=102) and non-delirium group (n=234) based on whether delirium occurred during their stay at the ICU. Patients were examined at least twice daily and delirium was diagnosed using the Confusion Assessment Method for the ICU (CAM-ICU). Blood samples were obtained after ICU entry. Plasma leptin concentrations were measured by ELISA. Delirium occurred in 30.4% (102/336) of patients. Patients who developed delirium showed significantly lower leptin level at ICU entry than those who did not (6.1±3.2 vs. 9.2±5.9ng/mL; P<0.001). Low plasma leptin level at ICU entry was independently associated with subsequent occurrence of delirium (OR, 0.865; 95%CI, 0.802–0.934; P<0.001). Other independent risk factors for delirium included increasing age (OR, 1.050; 95%CI, 1.020–1.080; P=0.001) and Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score (OR, 1.148; 95%CI, 1.092–1.208; P<0.001). Patients who developed delirium had a prolonged duration of ICU stay and higher mortality. Low plasma leptin level at ICU entry was associated with the occurrence of delirium in critically ill patients.

Attention, vigilance and visuospatial function in hospitalized elderly medical patients–relationship to delirium syndromal status and motor subtype profile

ObjectiveThe early and efficacious detection of neurocognitive disorders poses a key diagnostic challenge. We examined how nine bedside cognitive tests perform across the spectrum of delirium and motor subtypes.MethodsThe performance on a battery of nine bedside cognitive tests were compared in elderly medical inpatients with DSM-IV delirium, subsyndromal delirium, and no neurocognitive disorder and in different motor subtypes of patients with delirium.ResultsOne hundred and ninety-eight patients (mean age 79.14 ± 8.26) were assessed with no delirium (n = 43), subsyndromal delirium (n = 45), and full syndromal delirium (n = 110). The ability to meaningfully engage with the tests varied from 59% for vigilance B test to 85% for Spatial Span forward test and was found to be least in the full syndromal delirium group. The no delirium group was distinguished from the delirium groups for all the tests and from the full syndromal delirium group for the vigilance B test and global visuospatial function test. The subsyndromal delirium group differed from the full syndromal delirium group in respect of global visuospatial function test, spatial span backwards and vigilance A tests. Patients with full syndromal delirium were best identified using the interlocking pentagons test and clock drawing test. The ability to engage with testing was higher for those in the no subtype group.ConclusionsSimple bedside tests of attention, vigilance, and visuospatial ability are useful to help to distinguish neurocognitive disorders namely subsyndromal delirium from other presentations.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Attention, vigilance and visuospatial functioning in hospitalised elderly medical inpatients – relationship to delirium syndromal status and motor subtype profile

ObjectiveThe early and efficacious detection of neurocognitive disorders poses a key diagnostic challenge. We examined how bedside cognitive tests perform across the spectrum of delirium and motor subtypes.MethodsThe performance on a battery of bedside cognitive tests were compared in elderly medical inpatients with DSM-IV delirium, subsyndromal delirium, and no neuro cognitive disorder and in motor subtypes.ResultsOne hundred and ninety-eight patients (mean age 79.14 ± 8.26) were assessed with no delirium (n = 43), subsyndromal delirium (n = 45), and full syndromal delirium (n = 110). The ability to meaningfully engage with the tests varied from 59% for vigilance B test to 85% for Spatial Span forward test and was found to be least in the full syndromal delirium group. The no delirium group was distinguished from the delirium groups for all the tests and from the full syndromal delirium group for the vigilance B test and global visuospatial function test. The subsyndromal delirium group differed from the full syndromal delirium group in respect of global visuospatial function test, spatial span backwards and vigilance A tests. Patients with full syndromal delirium were best identified using the interlocking pentagons test and clock drawing test whereas those with subsyndromal delirium were best identified using interlocking pentagons test and months backwards test. Those with subsyndromal delirium were significantly better in their ability to engage than those with full syndromal delirium.ConclusionsSimple bedside tests of attention, vigilance, and visuospatial ability are useful to help to distinguish neurocognitive disorders namely subsyndromal delirium from other presentations.Disclosure of interestThe author haS not supplied his/her declaration of competing interest.

Explore objective clinical variables for detecting delirium in ICU patients: a prospective case-control study

The aim of this case-control study is to explore clinical objective variables for diagnosing delirium of intensive care unit (ICU) patients. According to the method of prospective case-control study, critical adult postoperative patients who were transferred to ICU of Peking University People's Hospital from October 2015 to May 2016 and needed mechanical ventilation were included. After evaluating the Richmond agitation sedation scale score (RASS), the patients whose score were -2 or greater were sorted into two groups, delirium and non-delirium, according to the confusion assessment method for the ICU (CAM-ICU). Then these patients were observed by domestic multifunctional detector for electroencephalographic (EEG) variables such as brain lateralization, brain introvert, brain activity, brain energy consumption, focus inward, focus outward, cerebral inhibition, fatigue, sleep severity, sedation index, pain index, anxiety index, fidgety index, stress index and the cerebral blood flow (CBF) index which was named of perfusion index. Other variables including indexes of ICU blood gas analysis, which was consisted of variables of blood gas analysis, routine blood test and biochemistry, previous history and prognostic outcome was recorded. Binary logistic regression was used for multivariate analysis. Forty-three postoperative patients, who needed intensive care, were included. Eighteen were in delirium group and twenty-five in control group. Excluding the trauma, variables like gender, age, temperature, heart rate, respiratory rate, mean arterial pressure, acute physiology and chronic health evaluationII(APACHEII) score, organ failure, dementia and emergency surgery didn't show any statistical significance between two groups. The trauma in delirious patients increased obviously compared with the control group (33.3% vs. 4.0%, P = 0.031). Except for the brain activity [122.47 (88.62, 154.21) vs. 89.40 (86.27, 115.97), P = 0.034], there were no statistical differences in any other EEG and CBF variables. In ICU blood gas analysis, only pH value (7.43±0.42 vs. 7.47±0.31, P = 0.003), chloride concentration [Cl- (mmol/L): 114.66±4.32 vs. 111.90±3.08, P = 0.019], magnesium concentration [Mg2+ (mmol/L): 0.60±0.10 vs. 0.54±0.06, P = 0.035] and blood osmolality [mmol/L: 290.10 (284.15, 306.35) vs. 282.70 (280.20, 286.75), P = 0.014] were statistically significant. Compared with control group, the prognostic variables in delirium group such as duration of mechanical ventilation [days: 125.0 (49.0, 293.0) vs. 149.5 (32.0, 251.3)], length of stay in ICU [days: 216.5 (50.5, 360.8) vs. 190.0 (72.0, 330.5)] and mortality rate (22.2% vs. 24.0%) didn't appear to be statistically significant either (all P > 0.05). It was shown by multivariate logistic regression analysis that pH [odds ratio (OR) = 1.446, 95% confidence interval (95%CI) = 1.116-1.875, P = 0.005] and Cl- (OR = 0.708, 95%CI = 0.531-0.945, P = 0.019) were potential risk factors of delirium. The brain activity of HXD_I may contribute to the clinical diagnose of delirium, but it still remained to be proved further. The pH and Cl- are potential risk factors of delirium.

Cigarette smoking is an independent risk factor for post-stroke delirium

BackgroundPost-stroke delirium is a common problem in the care of stroke patients, and is associated with longer hospitalization, high short-term mortality, and an increased need for long-term care. Although post-stroke delirium occurs in approximately 10 ~ 30% of patients, little is known about the risk factors for post-stroke delirium in patients who experience acute stroke.MethodsA total of 576 consecutive patients who experienced ischemic stroke (mean age, 65.2 years; range, 23–93 years) were screened for delirium over a 2-year period in an acute stroke care unit of a tertiary referral hospital. We screened for delirium using the Confusion Assessment Method. Once delirium was suspected, we evaluated the symptoms using the Korean Version of the Delirium Rating Scale-Revised-98. Neurological deficits were assessed using the National Institutes of Health Stroke Scale at admission and discharge, and functional ability was assessed using the Barthel Index and modified Rankin Scale at discharge and 3 months after discharge.ResultsThirty-eight (6.7%) patients with stroke developed delirium during admission to the acute stroke care unit. Patients with delirium were significantly older (70.6 vs. 64.9 years of age, P = .001) and smoked cigarettes more frequently (40% vs. 24%, P = .033) than patients without delirium. In terms of clinical features, the delirium group experienced a significantly higher rate of major hemispheric stroke (55% vs. 26%, P < .001), exhibited poorer functional performance at discharge and 3 months after discharge, and stayed in hospital significantly longer. Independent risk factors for delirium were older age, history of cigarette smoking, and major hemispheric stroke.ConclusionAbrupt cessation of cigarette smoking may be a risk factor for post-stroke delirium in ischemic stroke patients. The development of delirium after stroke is associated with worse outcome and longer hospitalization.