Delirium Index Research Articles

Prevalence of deviations in hematological and biochemical parameters in patients with Delirium Tremens

Introduction: Delirium Tremens (DTs) is an acute and severe form of alcohol withdrawal which if left untreated could lead to significant mortality. Identification of parameters which may lead to the progression of alcohol withdrawal to delirium tremens will aid in early initiation of appropriate treatment which in turn may help reduce the mortality rates. This study was undertaken to assess the prevalence of haematological and biochemical deviations in Delirium tremens and to assess the corelation between these deviations and severity of delirium tremens. Materials and Methods: A cross-sectional research was carried out at a Tertiary Care Centre over 6 months. Confusion Assessment Method (CAM) tool was applied as a delirium screening tool for patient selection. After gaining consent, 89 patients who met the criteria for inclusion were enrolled. Demographic and clinical data of the patient was collected and laboratory investigations were recorded. Delirium Index (DI) was applied in conjunction with the Modified Mini-Mental State (3MS) Test as a cognitive screening tool. SPSS-PC -25 version was used for data analysis. The Shapiro-Wilk test was used to investigate normal distribution. The difference in means between the groups was investigated using student t-test or Mann-Whitney U-test. Qualitative data were expressed in frequency and percentage. Spearman correlation coefficient was used to see correlation between different quantitative parameters. Statistics were deemed significant at a P <0.05. Results: Male gender, older age, unemployment, anemia, thrombocytopenia, hyponatremia, hyperbilirubinemia and raised SGOT were identified as potential risk factors for developing Delirium tremens. Anemia, hyponatremia, hyperbilirubinemia, and raised SGOT and ALP levels were identified as potential risk factors for worsening the severity of delirium Conclusions: Assessment of demographic details and deviations in laboratory parameters helps in identification of risk factors for developing Delirium tremens aiding in early intervention which prevents the worsening of the severity of delirium.

The Strain of Care for Delirium Index: Validity and Reliability Study

The Strain of Care for Delirium Index: Validity and Reliability Study

A Novel Preoperative Electroencephalogram-Derived Index to Predict Early Postoperative Delirium in Elderly Patients After Hip Fracture Surgeries: Development of a Prediction Model.

It is appealing to accurately predict postoperative delirium (POD) before surgeries. In this study, it was hypothesized that a novel electroencephalogram-derived index, the delirium index (DELi), could extract latent information regarding the predisposing factors of POD preoperatively. This study was aimed at developing a concise model that incorporated this DELi score to predict the early POD of elderly patients after hip surgeries. Elderly patients scheduled for elective hip fracture surgeries were prospectively enrolled in a tertiary care hospital from November 2020 to June 2022. DELi scores and patient characteristics (age, sex, types of fracture and surgery, the time interval between fracture and surgery, cognitive function assessed using the Montreal Cognitive Assessment (MoCA), and frailty status assessed using the FRAIL scale) were collected preoperatively as candidate predictors. POD diagnosed using the confusion assessment method (CAM) was the outcome. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to select predictors. Then, these predictors were entered into a backward logistical regression analysis to develop a prediction model. Discrimination, calibration and clinical utility were validated using the bootstrapping method. All data (144 qualified patients of 170) were used for development. POD was observed in 71 patients (49.3%). Preoperative DELi scores predicted early POD (the area under the curve (AUC) = .786, 95% confidence interval (CI): .712, .860, in internal validation). A nomogram with MoCA, FRAIL scale and DELi score was constructed with excellent discrimination (AUC = .920, 95% CI: .876, .963, in internal validation), accredited calibration (P = .733, Hosmer‒Lemeshow test), and a wide range of threshold probabilities (5% to 95%). Preoperative DELi scores predicted the early POD of elderly patients after hip surgeries. A concise prediction model was developed and demonstrated excellent discrimination.

A Study of Old Age Delirium and Quality of Life of Family Caregivers

Objectives: To study the aetiology of patients of delirium in old age, to study the severity of delirium in old age and to study the quality of life of family caregivers of delirium patients. Design: Prospective, observational, and cross sectional. Setting: Inpatient tertiary care hospital setting. Participants: Subjects with the diagnosis of Delirium qualifying according to ICD-10 (international classification of disease-10) and confirmed with CAM scale aged >60 years and Patient or patient’s family members willing to give consent. Measurements: Socio-demographic questionnaire, Confusion assessment method, Delirium index, Delirium aetiology check list, ICD -10 DCR, WHO QOL BREF and the Barthel index. Results: There is no significant association between delirium severity and WHOQoL. There is no significant association between Barthel index and WHOQoL. There is no significant association between WHOQoL and delirium aetiologies. There is no significant association between gender and WHOQoL. There is no significant association between marital status and WHOQoL. There is no significant association between religion and WHOQoL. There is no significant association between WHOQol and education. There is significant association between WHOQoL and occupation. Emloyed subjects have better quality of life than unemployed. There is no significant association between WHO QoL and residence. There is no significant association between WHOQoL and duration of delirium. There is no significant association between WHOQoL and medical comorbidities. There is no significant association between WHOQoL and substance use. There is no significant association between medical comorbidities and delirium aetiology. There is significant association between delirium severity and duration of delirium. As duration of delirium increases severity of delirium increases. There is no significant association between duration of delirium and delirium aetiology. There is no significant association between delirium severity and medical comorbidities. Conclusions: In this study results showed that there is significant association between delirium is an acute illness with sudden onset with maximum percentage of duration 2-4 weeks, delirium is more in males than females, majority of the care givers are spouses and parents, multiple aetiologies, diminished psychological QoL are associated with increased care giver burden. Family history of delirium is associated with better care giver burden. Employed subjects with delirium have better overall QoL. As duration of delirium increases, delirium severity increases.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BackgroundDelirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention. ObjectivesThe aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity. MethodsWe based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test–retest reliability. ResultsExploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68–.87) and test–retest reliability (intraclass correlation coefficients = .46–.62) were confirmed. ConclusionWe developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Ultrasound-guided Multiple Nerve Blocks: A Safe and Effective Anesthetic Modality in Geriatric Hip Fracture Patients.

The aim was to compare the feasibility of ultrasound-guided multiple nerve blocks (fascia iliaca compartment block+sacral plexus block+superior cluneal nerve block) with general anesthesia in geriatric hip fracture patients. Ninety-four patients were randomly divided into 2 groups: group N received ultrasound-guided multiple nerve blocks and group G received general anesthesia. Primary outcome measures included perioperative Pain Threshold Index (PTI) and Numerical Rating Scale. Secondary outcome measures comprised the following: (1) perioperative Delirium Index and Short Portable Mental Status Questionnaire; (2) perioperative Comfort Index; (3) perioperative opioid consumption (within 72 hours postoperatively); and (4) postoperative side effects (within 72 h postoperatively). Eighty-seven patients completed the study. Baseline PTI was comparable between the groups. However, intraoperative PTI was significantly lower in group N than in group G. Preoperative and postoperative Comfort Index scores were comparable between the groups. Moderate delirium (24 to 72 h postoperatively) was significantly higher than the baseline in group G. Early moderate delirium (24 h postoperatively) was significantly higher in group G than in group N. Severe delirium was comparable between the groups and within each group. High intraoperative PTI was associated with high opioid consumption. The intravenous sufentanil dose in group G was twice of that in group N. Incidence of nausea and vomiting was similar between the groups. Ultrasound-guided multiple nerve blockade may be an alternative to the common anesthetic procedures used for geriatric hip fracture patients. It provided satisfactory intraoperative pain management and reduced early postoperative cognitive disorders.

Subjective strain of care experienced by pulmonary and critical care medical nurses when caring for patients with delirium: a cross-sectional study

BackgroundDelirium, a disorder of consciousness, often occurs for a period of time during hospitalisation. It is characterised by a disturbance of attention or awareness. Hyperactive delirium may lead to accidental removal of medical equipment, while hypoactive delirium may inhibit patients from participating in nursing interventions, medical treatment, and physical therapy. However, there are limited relevant studies of the strain of care of nurses in China when caring for patients with delirium. This study, thus, aimed to investigate the subjective level of the strain of care experienced by pulmonary and critical care nurses when caring for patients with delirium.MethodsThis was a descriptive, cross-sectional study. A survey was conducted with 100 nurses in the Chinese pulmonary and critical care medical (PCCM) department in 2018. The Strain of Care for Delirium Index (SCDI) was used to measure nurses’ strain of care. Participants were instructed to rate the degree of perceived difficulty in managing patients who displayed the behaviours listed in the SCDI, on a scale from 1 (quite easy) to 4 (very difficult). The mean ± standard deviation (SD) scores of the ranked difficulty scores were calculated.ResultsIn our sample, 47 % of the nurses had received delirium-related training previously. The three wards with the highest strain of care scores when caring for patients with delirium were the chronic obstructive pulmonary disease ward (3.29 ± 0.72), interstitial lung disease ward (3.11 ± 1.31), and respiratory intensive care unit (3.02 ± 0.78). The three types of patient behaviours associated with the highest degree of nursing strain of care were being uncooperative and difficult to manage (3.37 ± 0.84), pulling out tubes and tearing out dressings (3.33 ± 0.98), and irritability (3.22 ± 0.95).ConclusionsThis study is the first to focus on nurses’ subjective strain of care when caring for patients with delirium in PCCM departments in China. The findings suggest the need to pay more attention to the working status of Chinese nurses. Further trials with large samples assessing relevant outcomes of patients with delirium are warranted.

Cardiac Delirium Index for Predicting the Occurrence of Postoperative Delirium in Adult Patients After Coronary Artery Bypass Grafting.

BackgroundPostoperative delirium (POD) is a serious complication of cardiac surgery. It is an acute neuropsychiatric syndrome. The aim of this study was to analyze the CARDEL Index, composed of advancing age, preoperative glycated hemoglobin and the platelet-to-WBC ratio (PWR) previously described and calculated, using a different patient database, to assess its usefulness as a marker for predicting postoperative delirium after coronary artery by-pass grafting (CABG).MethodsA retrospective analysis of 1098 patients who underwent, isolated CABG procedures between 2017 and 2019 was performed.ResultsWithin the study group, 164/1098 (14.93%) patients were diagnosed with delirium. Preoperative inflammatory parameters were elevated in patients with delirium: White Blood Cell count (p=0.003), Neutrophil count (p=0.016) and C-reactive protein (p<0.001). A decrease in preoperative PWR was shown in patients with delirium (p=0.008). Delirious patients spent more time mechanically ventilated (p<0.001) and had longer hospitalization times (p=0.002). Mortality at 1 year was significantly higher in patients with POD (p<0.001). The CARDEL Index in this study group for POD detection has the largest area under the curve (AUC) of 0.664 (p<0.001) and a cut-off value of 8.08.ConclusionCARDEL Index may be treated as a potentially valuable tool for delirium prediction in patients after CABG.

The effects of interactive E-learning on delirium recognition ability and delirium-related strain of care among critical care nurses.

Nursing care for patients with delirium is very complex and stressful and is associated with considerable care strain for nurses. Delirium recognition is the first step to the prevention and management of delirium and reduction of strain of care. Education is one of the strategies for improving nurses' delirium recognition ability. This study aimed to evaluate the effects of interactive E-learning on delirium recognition ability and delirium-related strain of care among critical care nurses. This quasi-experimental study was conducted in 2019 using a two-group pretest-posttest design. Participants were 98 critical care nurses recruited through a census from two hospitals in Iran. They were non-randomly allocated to an intervention and a control group. Study intervention was an interactive E-learning program with four parts on delirium, its prevention, its treatment, and its diagnostic and screening procedures. The program was uploaded on a website and its link was provided to participants in the intervention group. Before and two months after the intervention, data were collected using the Strain of Care for Delirium Index and five case vignettes. For data analysis, the Chi-square, Fisher's exact, independent-sample t, and paired-sample t tests were performed usingthe SPSS software (v. 16.0). Groups did not significantly differ from each other regarding the pretest mean scores of delirium recognition ability and strain of care. After the intervention, the mean score of delirium recognition ability in the intervention group was significantly greater and the mean score of strain of care was significantly lower than the control group (P < 0.05). Interactive E-learning is effective in significantly improving critical care nurses' delirium recognition ability and reducing their strain of care. As nurses' heavy workload and limited free time are among the main barriers to their participation in face-to-face educational programs, interactive E-learning can be used for in-service education.

The Practical Use of White Cell Inflammatory Biomarkers in Prediction of Postoperative Delirium after Cardiac Surgery.

Introduction: Postoperative delirium (POD) is associated with unfavorable outcomes. It may result from neuroinflammation and oxidative stress. The aim of this study was to evaluate the role of routinely available inflammatory markers derived from white blood cell count (WBC), for prognostic value in diagnosing delirium after cardiac surgery. Methods: We performed an analysis of data collected from patients undergoing planned coronary artery bypass grafting (CABG). Differential WBC and CRP (C-reactive protein) concentration were evaluated preoperatively (T0) and postoperatively at day 1 (T1), 3 (T3), 5 (T5) after CABG. Differences in neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and platelet-to-WBC ratio (PWR) between patients with (Del +) and without delirium (Del −) were evaluated. Patients were screened using CAM-ICU. Results: We included 968 patients in the study. Incidence of delirium was 13.3%. In the group with POD, the majority of patients were men (87/129, 67.44%), and the mean age was 72 years. Preoperative WBC (8.21 ± 3.04 G/l vs. 7.55 ± 1.86 G/l, p = 0.029) were higher and mean platelet count was lower (217.7 ± 69.07 G/l vs. 227.44 ± 59.31 G/l, p = 0.031) in patients with POD. Lower pre-operative PLR values (109.87 ± 46.38 vs. 120.36 ± 52.98, p = 0.026) and PWR values (27.69 ± 7.50 vs. 31.32 ± 9.88 p < 0.001) were found in patients with POD. Association was strongest for PWR and remained significant at T1 (p < 0.001), T3 (p < 0.001) and T5 (p < 0.001). Basing on coefficients of logistic regression a model for optimal prediction of POD was calculated: CARDEL Index (CARdiac DELirium Index) = 0.108 × Age + 0.341 × HBA1C − 0.049 × PWR with AUC of 0.742 (p < 0.001). Conclusions: The results of this study show that lower pre-operative levels of PLR and PWR were associated with POD after cardiac surgery. Pre-operative PWR showed strongest correlation with POD and may be a potential new biomarker associated with postoperative delirium. CARDEL prognosis index composed of age, HbA1c and PWR is good at predicting development of delirium after CABG.

Unrecognized Incident Delirium in Older Emergency Department Patients.

It is documented that health professionals from various settings fail to detect>50% of delirium cases. This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60days regarding 1) unplanned consultations and 2) functional and cognitive decline. This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65years who tested negative for delirium on the initial interview with an ED stay ≥ 8h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not. The main study reported a positive CAM in 68 patients. Three patients' medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p=0.03) and female (p=0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p=0.01) and they experienced a more important functional decline at 60days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function. This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60days.

LO14: Unrecognized delirium in a cohort of older ED patients assessed at a tertiary care center: signs of improvement?

Introduction: BACKGROUND: Recognition rates of delirium in older ED patients were reported between 13 to 25% in studies conducted in the U.S in the 1990's. Recently, there has been increased attention to delirium in Emergency Medicine, with the development of Geriatric curriculums in Canada specifically focused on delirium. However rates of delirium recognition have not been reassessed in Canadian ED's. OBJECTIVES: To assess the rate of delirium recognition by ED staff in a cohort of older ED patients assessed at a tertiary care Canadian ED. Methods: STUDY DESIGN: Prospective observational cohort study at a Canadian teaching ED. PARTICIPANTS: Eligible patients were aged ≥70 years and older who had stayed in the ED for a minimum of 4 hours. We excluded patients who were critically ill, visually impaired or otherwise unable to communicate. DATA COLLECTION: Trained research assistants approached clinical staff prior to approaching patients to confirm that patients were delirium free. They then assessed demographics, ED length of stay (LOS) and cognition using the validated Montreal Cognitive Assessment scale (MOCA), mini-mental status exam (MMSE), delirium index and Richardson Agitation Scale (RASS) at baseline. Delirium was assessed using the validated Confusion Assessment Method (CAM). We report descriptive statistics and 95% confidence intervals (CI) where appropriate. Results: We enrolled 203 patients of which 102 (50.3%) were female. Their mean age was 81.0 years, mean LOS was 16.3 hours, mean MOCA was 23.4 and mean MMSE was 26.7. RA's detected delirium using the CAM in 16/203 patients (7.9%, 95% CI 4.6 to 12.5%). Mean MOCA and MMSE for delirious patients was 13.4 and 18.3 and their mean DI was 6.4. All CAM positive patients were deemed to be delirium free by clinical staff. RA alerted clinical staff in all cases where patients had delirium, but 3/16 were discharged home (18.8%, 95% CI 4.1 to 45.7%). Conclusion: Our findings confirm previous low delirium recognition rates in a Canadian Tertiary ED. Future research should explore barriers and facilitators to recognizing delirium in the ED.

LO70: Functional &amp; cognitive decline in older delirious adults after an emergency department visit

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Latent class analysis of the multivariate Delirium Index in long-term care settings.

The multivariate DI was measured weekly for six months in seven LTC facilities, located in Montreal and Quebec City. Data were analyzed using a hidden Markov chain/latent class model (HMC/LC). The analysis sample included 276 LTC residents. Four ordered latent classes were identified: fairly healthy (low "disorientation" and "memory impairment," negligible other DI symptoms), moderately ill (low "inattention" and "disorientation," medium "memory impairment"), clearly sick (low "disorganized thinking" and "altered level of consciousness," medium "inattention," "disorientation," "memory impairment" and "hypoactivity"), and very sick (low "hypoactivity," medium "altered level of consciousness," high "inattention," "disorganized thinking," "disorientation" and "memory impairment"). Four course types were also identified: stable, improvement, worsening, and non-monotone. Class order was associated with increasing cognitive impairment, frequency of both prevalent/incident delirium and dementia, mortality rate, and decreasing performance in ADL. Four ordered latent classes and four course types were found in LTC residents. These results are similar to those reported previously in acute care (AC); however, the proportion of very sick residents at enrolment was larger in LTC residents than in AC patients. In clinical settings, these findings could help identify participants with a chronic clinical disorder. Our HMC/LC approach may help understand coexistent disorders, e.g. delirium and dementia.

MP11: Underreport of incident delirium in elderly patients treated in the emergency department

Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (p&lt;0.05). Other predictive delirium variables, such as cognitive status, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between groups. Conclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.

Effect of an interactive E-learning tool for delirium on patient and nursing outcomes in a geriatric hospital setting: findings of a before-after study

BackgroundEducation of healthcare workers is a core element of multicomponent delirium strategies to improve delirium care and, consequently, patient outcomes. However, traditional educational strategies are notoriously difficult to implement. E-learning is hypothesised to be easier and more cost effective, but research evaluating effectiveness of delirium education through e-learning is scarce at present. Aim is to determine the effect of a nursing e-learning tool for delirium on: (1) in-hospital prevalence, duration and severity of delirium or mortality in hospitalized geriatric patients, and (2) geriatric nurses’ knowledge and recognition regarding delirium.MethodsA before-after study in a sample of patients enrolled pre-intervention (non-intervention cohort (NIC); n = 81) and post-intervention (intervention cohort (IC); n = 79), and nurses (n = 17) of a geriatric ward (university hospital). The intervention included an information session about using the e-learning tool, which consisted of 11 e-modules incorporating development of knowledge and skills in the prevention, detection and management of delirium, and the completion of a delirium e-learning tool during a three-month period. Key patient outcomes included in-hospital prevalence and duration of delirium (Confusion Assessment Method), delirium severity (Delirium Index) and mortality (in-hospital; 12 months post-admission); key nurse outcomes included delirium knowledge (Delirium Knowledge Questionnaire) and recognition (Case vignettes). Logistic regression and linear mixed models were used to analyse patient data; Wilcoxon Signed Rank tests, McNemar’s or paired t-tests for nursing data.ResultsNo significant difference was found between the IC and NIC for in-hospital prevalence (21.5% versus 25.9%; p = 0.51) and duration of delirium (mean 4.2 ± SD 4.8 days versus 4.9 ± SD 4.8 days; p = 0.38). A trend towards a statistically significant lower delirium severity (IC versus NIC: difference estimate − 1.59; p = 0.08) was noted for delirious IC patients in a linear mixed model. No effect on patient mortality and on nurses’ delirium knowledge (p = 0.43) and recognition (p = 1.0) was found.ConclusionOur study, the first in its area to investigate effects of delirium e-learning on patient outcomes, demonstrated no benefits on both geriatric patients and nurses. Further research is needed to determine whether delirium e-learning nested within a larger educational approach inclusive of enabling and reinforcing strategies, would be effective.Trial registrationISRCTN (82,293,702, 27/06/2017).

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.

A post cardiac surgery intervention to manage delirium involving families: a randomized pilot study.

As many delirium manifestations (e.g., hallucinations or fears) are linked to patients' experiences and personality traits, it is suggested that interventions should be tailored to optimize its management. The inclusion of family members, as part of an intervention, has recently emerged as a solution to developing individualised patient care, but has never been assessed in post-cardiac surgery intensive care unit where almost half of patients will present with delirium. To assess the feasibility, acceptability and preliminary efficacy of an nursing intervention involving family caregivers (FC) in delirium management following cardiac surgery. A randomized pilot study. A total of 30 patient/FC dyads were recruited and randomized to usual care (n = 14) or intervention (n = 16). The intervention was based on the Human Caring Theory, a mentoring model, and sources informing self-efficacy. It comprised seven planned encounters spread over 3 days between an intervention nurse and the FC, each including a 30-min visit at the patient's bedside. During this bedside visit, the FC used delirium management strategies, e.g. reorient the person with delirium. The primary indicator of acceptability was to obtain consent from 75% of approached FCs. The preliminary effect of the intervention on patient outcomes was assessed on (1) delirium severity using the Delirium Index, (2) occurrence of complications, such as falls, (3) length of postoperative hospital stay and (4) psycho-functional recovery using the Sickness Impact Profile. The preliminary effect on FC outcomes was assessed on FC anxiety and self-efficacy. Data were analysed using descriptive statistics, ANCOVAs and logistic regressions. The primary indicator of obtaining consent from FC was achieved (77%). Of the 14 dyads, thirteen (93%) dyads received all seven encounters planned in the experimental intervention. Intervention group patients presented better psycho-functional recovery scores when compared with control group patients (p = 0·01). Mean delirium severity scores showed similar trajectories on days 1, 2 and 3 in both groups. The mentoring intervention was acceptable and feasible and shows promising results in improving patients and FC outcomes. Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance.

Longitudinal patterns of delirium severity scores in long-term care settings.

The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents. A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores. During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks. The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

LO023: Association between ED-induced delirium and cognitive &amp; functional decline in seniors

Introduction: Delirium is a common medical complication among seniors in hospital setting. In the emergency department (ED), its prevalence varies between 7 &amp; 14%. Delirium is associated with increased mortality &amp; longer hospital stay. This condition is also associated with functional &amp; cognitive decline in hospitalized seniors and higher risk of institutionalization up to 2 years after their discharge. However, no data is currently available for ED patients. The aim of this study was to evaluate the association between ED-induced delirium and functional &amp; cognitive decline in seniors at 60 days. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay (INDEED) study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED and followed up to 24h after admission. A 60-day follow-up phone assessment was also conducted. Delirium was measured by the validated Confusion Assessment Method &amp; the Delirium Index. Functional status was measured by the validated OARS. Cognitive status was measured using the validated TICS-M. Functional and cognitive decline were obtained by comparing the baseline and 60-days follow-up scores. Results: 380 seniors were recruited and 280 had 60-day follow-up data available. ED-induced delirium was 8.4% of seniors. There was a difference in mean functional decline among seniors with and without ED-induced delirium 2.95(1.23-4.67) vs 1.55(1.20-1.91, pwlicoxon= 0.05] Proportion of seniors showing a decline ≥2 points on the OARS was significantly higher In those with ED-induced delirium (65,0 % vs 40.18 %, p=0.03). Seniors with ED-induced delirium also showed a significant decline in mean TICS scores [3.31 (0,82-5.84) vs -0.01((-.071-0.75)), pwlicoxon =0.009]. There was no significant difference in the proportions of seniors showing a decline ≥ 3 OARS points between those with or without delirium (p=0.06). Conclusion: ED-induced delirium seems to be associated with poor functional and cognitive outcomes in older patients 60 days after discharge from the hospital. Further studies are required to confirm clinical importance ED-induced delirium delayed complication.