Delirium In Older Adults Research Articles

Postoperative Delirium in Older Adults Is Associated with Prolonged Decreased Mobility

Kovar, Alexandra MD; Carmichael, Heather MD; Jones, Teresa MD; Nichols Robinson, Thomas MD, FACS Author Information

Approaches to Optimize Medication Data Analysis in Clinical Cohort Studies.

Methods for pharmacoepidemiologic studies of large-scale data repositories are established. Although clinical cohorts of older adults often contain critical information to advance our understanding of medication risk and benefit, the methods best suited to manage medication data in these samples are sometimes unclear and their degree of validation unknown. We sought to provide researchers, in the context of a clinical cohort study of delirium in older adults, with guidance on the methodological tools to use data from clinical cohorts to better understand medication risk factors and outcomes. Prospective cohort study. The Successful Aging After Elective Surgery (SAGES) prospective cohort. A total of 560 older adults (aged ≥70 years) without dementia undergoing elective major surgery. Using the SAGES clinical cohort, methods used to characterize medications were identified, reviewed, analyzed, and distinguished by appropriateness and degree of validation for characterizing pharmacoepidemiologic data in smaller clinical data sets. Medication coding is essential; the American Hospital Formulary System, most often used in the United States, is not preferred over others. Use of equivalent dosing scales (e.g., morphine equivalents) for a single medication class (e.g., opioids) is preferred over multiclass analgesic equivalency scales. Medication aggregation from the same class (e.g., benzodiazepines) is well established; the optimal prevalence breakout for aggregation remains unclear. Validated scale(s) to combine structurally dissimilar medications (e.g., anticholinergics) should be used with caution; a lack of consensus exists regarding the optimal scale. Directed acyclic graph(s) are an accepted method to conceptualize causative frameworks when identifying potential confounders. Modeling-based strategies should be used with evidence-based, a priori variable-selection strategies. As highlighted in the SAGES cohort, the methods used to classify and analyze medication data in clinically rich cohort studies vary in the rigor by which they have been developed and validated.

Vitamin D and Delirium in Older Adults: A Case-Control Study in Geriatric Acute Care Unit.

Objective: Vitamin D is involved in brain health and function. Our objective was to determine whether the serum 25-hydroxyvitamin D (25OHD) concentration was associated with delirium in a case-control study of geriatric inpatients.Methods: Sixty cases with delirium (mean ± SD, 84.8 ± 5.7years; 58.3% female) and 180 age- and gender-matched controls were enrolled in a geriatric acute care unit between 2012 and 2014. The diagnosis of delirium was made using the Confusion Assessment Method. Hypovitaminosis D was defined using consecutively the consensual threshold value of 50 nmol/L and a threshold value calculated from a sensitivity-specificity analysis. Age, gender, number of acute diseases, use of psychoactive drugs, season of testing, and serum concentrations of calcium, parathyroid hormone, creatinine, albumin, TSH, vitamin B9 and vitamin B12 were used as potential confounders.Results: The 60 cases with delirium exhibited lower 25OHD concentration than 180 matched controls (35.4 ± 30.0 nmol/L vs. 45.9 ± 34.5 nmol/L, p = 0.035). Increased 25OHD concentration was associated with a decrease in delirium prevalence (OR = 0.99 [95CI: 0.98–0.99] per nmol/L of 25OHD, p = 0.038). The concentration distinguishing between cases and controls with the best sensitivity-specificity was found between 29.5 and 30.5 nmol/L. The regression models showed that delirium was associated with hypovitaminosis D defined either as 25OHD ≤ 50 nmol/L (OR = 2.37 [95CI: 1.07–5.25], p = 0.034) or as 25OHD ≤ 30 nmol/L (OR = 2.66 [95 CI: 1.30–5.45], p = 0.008).Conclusions: Decreased serum 25OHD concentrations were associated with delirium among acute geriatric inpatients. The threshold concentration to differentiate between cases and controls was around 30 nmol/L.

Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement.

BackgroundDelirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction.ObjectiveTo examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level.DesignProspective cohort, 2014–2017.SettingSingle academic center.SubjectsA total of 187 patients undergoing SAVR (n=77) or TAVR (n=110).MethodsThe Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0–12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium.ResultsDelirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10–12 (28.2%), 7–9 (34.5%), 4–6 (37.5%) and 0–3 (44.1%) (p-for-trend=0.001). A model that included gait speed <0.46 meter/second (OR, 2.7; 95% CI, 1.2–6.4), chair stands time ≥11.2 seconds (OR, 3.5; 95% CI, 1.0–12.4), MMSE <24 points (OR, 2.9; 95% CI, 1.3–6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1–13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5–45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035).ConclusionAssessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.

Sleep and Delirium in Older Adults.

Purpose of ReviewPoor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management.Recent FindingsSleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management.SummaryPoor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.

Preventing Delirium in Older Adults in Institutional Long-Term Care.

Editor's note: The mission of Cochrane Nursing is to provide an international evidence base for nurses involved in delivering, leading, or researching nursing care. Cochrane Corner provides summaries of recent systematic reviews from the Cochrane Library. For more information, see https://nursing.cochrane.org.

READINGS IN GERIATRIC PSYCHIATRY: A QUALITATIVE RETROSPECTIVE ANALYSIS OF A STRUCTURED LITERATURE REVIEW COURSE

READINGS IN GERIATRIC PSYCHIATRY: A QUALITATIVE RETROSPECTIVE ANALYSIS OF A STRUCTURED LITERATURE REVIEW COURSE

A CASE SERIES ON LATE-ONSET CATATONIA MISDIAGNOSED AS DELIRIUM

Introduction Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral and autonomic signs. It is associated with psychiatric disorders, neurologic disorders and general medical conditions. However, the literature on the occurrence of catatonia in older adults is limited, Methods We present three cases of late-onset catatonia in older adults diagnosed with major depressive disorder initially diagnosed as delirium. Case 1 is a 66-year -old male with a past medical history of sclerosing cholangitis, ulcerative colitis, cerebrovascular disease presented with gradually progressive symptoms of one-month duration of mutism, staring, immobility, withdrawal, depression and delusions of infidelity following the surgery of a hepatic nodule. Case 2 is a 68-year-old female with a past history of chronic kidney disease presented with a one-year history of general deterioration of health along with decreased psychomotor activity, talk, social interaction decreased food, auditory hallucinations and persecutory delusions along with staring, posturing, mutism, rigidity, negativism and immobility. Case 3 is a 66-year-old female with a past history of major depressive disorder and gradually declining cognitive functions suggestive of major neurocognitive disorder presented with gradually progressive symptoms of mutism, staring, withdrawal, negativism and depressive symptoms of two months duration. On admission, the Bush Francis Catatonia Rating Scale Scores for the cases were 15/69, 15/69 and 13/69, respectively. All the cases had a past psychiatric history of major depressive disorder. They had been initially admitted to the medicine unit for assessment of delirium which was later ruled out by the consultation-liaison psychiatry team. Results Case 1 was treated with an adequate trial of oral citalopram, lorazepam, olanzapine and later with a trial of oral venlafaxine, aripiprazole and mirtazapine without any improvement in symptoms. The course of treatment was complicated by chronic hyponatremia. His catatonic and depressive symptoms resolved after 13 sessions of electroconvulsive therapy (ECT) along with oral venlafaxine 225mg daily and oral aripiprazole 10mg QHS (total days of inpatient hospitalization=60 days) . Case 2 was treated with oral lorazepam 1?mg twice daily for catatonia along with oral fluoxetine 20?mg daily for depression. The course of treatment was complicated by a urinary tract infection (UTI), which was treated with antibiotics. The dose of oral lorazepam was gradually increased to 1.5mg BID, following which the catatonic symptoms subsequently improved. The patient was discharged after lorazepam was gradually tapered and stopped. However, the patient was readmitted after two days due to a relapse of catatonic symptoms. Oral fluoxetine was continued at the same dose and oral lorazepam 1.5mg BID was restarted. The catatonic symptoms gradually subsided and 10 outpatient sessions of ECT was provided following which the depressive symptoms improved in the same medications (total days of inpatient hospitalization=67 days). Case 2, after relevant investigations, was treated with oral sertraline 100mg daily and oral lorazepam 3?mg three times a day following which her depressive and catatonic symptoms resolved(total days of inpatient hospitalization=7 days). Conclusions Our case series demonstrates catatonia can present in older patients and can be initially misdiagnosed with hypoactive delirium due to the sharing of common characteristics like stupor, agitation and decreased psychomotor activity. Medical disorders followed by mood disorders are implicated in the common causes of catatonia in older adults. The treatment of the cause along with benzodiazepenes remains the mainstay of treatment. ECT has been found to effective in medication refractory cases evidenced in two of the above -mentioned cases with literature demonstrating a delaying in diagnosis leading to a refractory response to ECT. Discontinuation of lorazepam can lead to a relapse of symptoms, as evidenced in case 2. Medical problems in older patients can complicate the treatment course while catatonia can also lead to medical complications like hyponatremia and UTI which have occurred in our cases. Catatonia can lead to increased duration high-risk complications in the elderly like myocardial infarction, pulmonary embolism and thrombosis requiring prompt identification and management, preferably in an interdisciplinary hospital setting. Thus, the prompt diagnosis of catatonia is important and to be differentiated from delirium in older adults as the management differs in both conditions. In this context, consultation-liaison or geriatric psychiatry services becomes essential in a general hospital setting for identification and care of such cases. This research was funded by: Not applicable

Efficacy of the Administration of Melatonin 5mg in the Prevention of Delirium in Older Adults Hospitalized in the Emergency Department

Efficacy of the Administration of Melatonin 5mg in the Prevention of Delirium in Older Adults Hospitalized in the Emergency Department

Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis

BackgroundOlder surgical patients are at high risk of developing postoperative delirium. Non-pharmacological strategies are recommended for delirium prevention, but no pharmacological agents have compelling evidence to decrease the incidence of delirium. The purpose of this study was to assess whether perioperative melatonin decreases the incidence of delirium in older adults undergoing surgical procedures.MethodsA systematic search using PubMed/Medline, Embase, PsycINFO, CINAHL, and references of identified articles published in English between January 1990 and October 2017 was performed. Two independent reviewers screened titles and abstracts, and then extracted data following a full-text review of included articles with consensus generation and bias assessment. Studies reporting outcomes for melatonin or ramelteon use to prevent delirium in postoperative hospitalized patients (mean age ≥ 50 years) were eligible for inclusion. Data were pooled using a fixed-effects model to generate a forest plot and obtain a summary odds ratio for the outcome of interest (delirium incidence). Cochran’s Q and I2 values were used to investigate heterogeneity.ResultsOf 335 records screened, 6 studies were selected for the qualitative analysis and 6 were included in the meta-analysis (n = 1155). The mean age of patients in included studies ranged from 59 to 84 years. Patients in intervention groups typically received melatonin or ramelteon at daily doses of two to eight milligrams around cardiothoracic, orthopedic, or hepatic surgeries for one to nine days, starting on the evening before or the day of surgery. The incidence of delirium ranged from 0 to 30% in the intervention groups versus 4–33% in the comparator groups, and was significantly reduced in the melatonin group, with a summary effect of the meta-analysis yielding an odds ratio of 0.63 (95% CI 0.46 to 0.87; 0.006; I2 = 72.1%). A one study removed analysis reduced overall odds ratio to 0.310 (95% CI 0.19 to 0.50), while reducing heterogeneity (Cochran’s Q = 0.798, I2 = 0.000).ConclusionPerioperative melatonin reduced the incidence of delirium in older adults in the included studies. While optimal dosing remains an unanswered question, the potential benefit of melatonin and melatonin receptor agonists may make them a reasonable option to use for delirium prevention in older adults undergoing surgical procedures.

The Caregiver Burden of Delirium in Older Adults With Alzheimer Disease and Related Disorders.

To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs). Prospective, observational cohort. Inpatient hospital and study participants' homes. A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study. Delirium burden was measured using the DEL-B instrument (range = 0-40, with higher scores indicating greater burden) in caregivers (DEL-B-C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM-Severity [CAM-S]) were measured during hospitalization and at 1-month follow-up. ADRD diagnosis was determined by a clinical consensus process. For patients with (n = 56) and without (n = 211) ADRD, both DEL-B instruments had good internal consistency. DEL-B-C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5-15) and 5 (1-11), respectively (P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = -.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = -0.18; P = .01). Patients with ADRD who developed delirium self-reported less burden than those without ADRD (β[delirium × ADRD] = -.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = -0.18; P = .005) and correlated with the CAM-S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = -0.07; P = .61). Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587-2592, 2019.

Diagnosis of postoperative delirium in older adults using the Confusion Assessment Method for the intensive care unit in non-intensive care unit settings: A test modification might improve its diagnostic performance.

To evaluate the diagnostic performance of the Confusion Assessment Method for the intensive care unit (CAM-ICU) among postoperative older patients in non-ICU settings. The CAM-ICU was used by trained staff to prospectively evaluate postoperative patients for delirium. The patients were aged ≥60 years, were in general wards and had no critical illnesses. The assessments occurred for 7 consecutive days after surgery. The results were compared with delirium diagnoses obtained by geriatricians using Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria as the reference standard. The sensitivity of delirium detection for the CAM-ICU was 31.6% (95% confidence interval [CI] 12.6-56.6), while the specificity was 97.6% (95% CI 94.9-99.1), positive predictive value was 50.0% (95% CI 26.3-73.7) and negative predictive value was 95.0% (95% CI 93.3-96.3). Feature 4 (disorganized thinking) yielded the highest sensitivity (60%; 95% CI 14.7-94.7), whereas feature 2 (inattention) had low sensitivity (36.8%; 95% CI 16.3-61.6). Further analyses to explore the highest sensitive criteria showed that if CAM-ICU diagnoses were made by the presence of any two out of feature 1 (acute change or fluctuation of cognition), feature 3 (altered level of consciousness) or feature 4, the sensitivity increased substantially to 80.0% (95% CI 28.4-99.5), with a reasonably high specificity of 81.8% (95% CI 48.2-97.7). Modification of the flow of delirium diagnosis using the CAM-ICU appears to offer a better sensitivity for detecting delirium in non-ICU settings. Furthermore, changing feature 2 to evaluate patients' attention levels over a longer period of time might yield a better diagnostic performance. Geriatr Gerontol Int 2019; 19: 762-767.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery.

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

The impact of the Hospital Elder Life Program on the treatment of asymptomatic bacteriuria: An unexpected benefit

Delirium in older adults is often inappropriately attributed to presumed urinary tract infections (UTIs) leading to unnecessary prescribing of antibiotics for asymptomatic bacteriuria. We sought to examine whether implementation of the Hospital Elder Life Program (HELP), a delirium prevention program, reduced the inappropriate treatment of asymptomatic bacteriuria. We conducted a secondary data analysis of administrative data and electronic health records on a descriptive study in which HELP was implemented at an academic community hospital. Patients aged 70 and older admitted before HELP was implemented (n = 687) were compared to the intervention group after HELP implementation (n = 637). HELP intervention participants, compared to pre-intervention patients, were less likely to receive inappropriate treatment for asymptomatic bacteriuria (3.0% versus 6.7%, adjusted odds ratio=0.46, 95% confidence interval=0.26–0.79, P = 0.005). HELP was associated with a reduction in the treatment of asymptomatic bacteriuria. Therefore, HELP may decrease adverse events and costs related to unnecessary exposure to antibiotics.

Association of Duration of Surgery With Postoperative Delirium Among Patients Receiving Hip Fracture Repair

Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks. To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium. This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019. Surgery duration, measured as the total time in the operating room. A diagnosis of postoperative delirium during hospitalization. Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01). Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.

Recent advances in non-surgical management of cancer in the elderly.

This article summarizes the seminal publications from mid-2016 through 2017 in the area of medical care for older adults with cancer. Areas addressed include chemotherapy tolerance and efficacy in the aged, geriatric fitness assessments, and advancements in palliative and supportive care. The practice-changing finding from this past year’s publications is that antipsychotics should not be used in the management of terminal delirium in older adults receiving palliative care. The other trials demonstrated an improved understanding of the utility of geriatric assessments in patients with cancer, developed the body of information about which chemotherapy agents are safe and effective in older adults (and which are not), and expanded our understanding of good palliative and supportive care.

Exploration of Relationships Between Postoperative Pain and Subsyndromal Delirium in Older Adults.

Subsyndromal delirium is associated with serious adverse outcomes of longer lengths of stay, increased long-term care admissions, and higher 6-month mortality rates. Postoperative pain is a risk factor for delirium, but the relationship between pain and the severity of subclinical delirium symptoms is unclear. A better understanding will inform nursing interventions to reduce adverse outcomes associated with delirium symptoms. The purpose of this correlational study was to determine the relationship between pain and subsyndromal delirium in older adults following joint replacement surgery. Delirium assessments were completed on postoperative Days 1, 2, and 3 for 49 adults of ages 65 years or older following joint replacement surgery. Multiple linear regression was used to analyze data for relationships between postoperative pain and subsyndromal delirium and, secondarily, postoperative opioid intake and subsyndromal delirium while accounting for known preoperative risk factors. Increased age, cognitive impairment, current smoking, and higher levels of self-reported pain were significantly related to subsyndromal delirium (p < .001). After accounting for preoperative risk factors of age, cognitive status, smoking status, and opioid intake, pain was significantly related to subsyndromal delirium (β = .28, p < .05); however, opioid intake did not contribute to subsyndromal delirium. Higher pain levels were significantly related to subsyndromal delirium when age, cognitive status, smoking status, and opioid intake were accounted for (p < .05), although opioid intake was not significantly related to subsyndromal delirium after accounting for age, cognitive status, smoking status, and pain. Nurses caring for older adults who undergo joint replacement surgery are encouraged to ensure effective pain management to reduce onset and severity of delirium symptoms.

Frailty and Delirium in Older Adults: A Systematic Review and Meta-Analysis of the Literature.

To evaluate the relationship between frailty and delirium. Systematic review and meta-analysis. MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases were searched for articles on frailty and delirium published on or before October 31, 2017. Individuals aged 65 and older. Two authors independently reviewed all English-language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random-effects or fixed-effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I2 statistics. We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta-analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65-2.91). There was low variability among studies in the measures of association between frailty and delirium (I2 2.24, p-value Q-statistic = .41) but high heterogeneity in the methods used to assess the two conditions. This systematic review and meta-analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.

Electroencephalography-Guided Minimisation of Anaesthetic Administration to Prevent Post-Operative Delirium: A Randomised, Pragmatic Trial

Background: Intraoperative electroencephalogram suppression, suggesting excessive general anaesthesia, predicts postoperative delirium. The primary purpose of this trial was to assess the effectiveness of electroencephalography-guided minimisation of anaesthetic administration and electroencephalogram suppression to prevent postoperative delirium in older adults. Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes [ENGAGES] study enrolled adults older than 60 undergoing major surgery under general anaesthesia at Barnes-Jewish Hospital in Saint Louis. Using a computer-generated randomisation sequence we randomly assigned patients in blocks of 20 in four strata (cardiac or non-cardiac surgery; positive or negative recent fall history) to electroencephalography-guided or usual anaesthetic care. Participants and investigators were blinded to group assignment. Delirium was assessed for 5 postoperative days, using structured chart review and daily Confusion Assessment Method. We analysed by intention-to-treat and assessed adverse events. Findings: Between Jan 16, 2015 and May 7, 2018, 39144 patients were screened, and 1232 patients were randomly assigned, with 614 in the electroencephalography-guided and 618 in the usual care group. Compared with usual care, the guided group had a 14% median decrease in volatile anaesthetic administration, and a 46% reduction in the median [interquartile range] intraoperative time with electroencephalogram suppression (7 [1 to 23] vs 13 [2 to 58] minutes, p<0·001). However, there was no significant difference between groups in delirium incidence: 157/604 in the guided compared with 140/609 in the usual care group (26·0% vs 23·0%; absolute difference 3·0%, 95% CI -2·0 to 8·0, P=0·224). No patients reported intraoperative awareness, but patient movement occurred in 22·3% of patients in the guided and 15·4% in the usual care group (absolute difference 6·9%, 95% CI 2·6 to 11·3, P=0·002). Duration of hypotension and overall occurrence of serious adverse events were similar in the groups. Interpretation: Electroencephalography-guidance of anaesthesia with the aim of minimising suppression and anaesthetic administration is unlikely to prevent postoperative delirium, and might instead promote undesirable patient movement during surgery. Trial Registry Number: The trial is registered with clinicaltrials.gov, number NCT02241655. Funding: This study was funded by a National Institutes of Health grant to support pragmatic trials ((1 UH2 HL125141, 5 UH3 AG050312). This study was also funded by the National Institutes of Health NIDUS Grant (NIA R24AG054259) and the Dr Seymour and Rose T. Brown Endowed Chair at Washington University. Declaration of Interests: The authors have no conflicts of interest to report. Ethical Approval Statement: The ethics committee at Washington University School of Medicine approved the study, and all patients provided written informed consent.

71Evaluating Medical Team Assessment &amp; Documentation of Delirium in Older Adults Admitted to the Hospital via the Emergency Department and AMAU

71Evaluating Medical Team Assessment &amp; Documentation of Delirium in Older Adults Admitted to the Hospital via the Emergency Department and AMAU