Management Of Delirium In Patients Research Articles

Association Between Hypernatremia and Delirium After Cardiac Surgery: A Nested Case-Control Study.

BackgroundThe association between hypernatremia and delirium after cardiac surgery has rarely been investigated. This study aimed to determine whether hypernatremia increases the risk of delirium after exposure.Materials and MethodsFrom April 2016 to June 2021, 7,831 consecutive patients receiving cardiac surgery were screened for potential enrollment. The primary outcome was postoperative delirium (POD). For the respective case of delirium, 10 controls were matched according to the index date within the nested case-control design. Hypernatremia exposure was defined as serum sodium > 145 mmol/L within 7 days before the index date. A generalized estimation equation was performed to assess excess risks for POD associated with hypernatremia, adjusted for demographics and clinical variables.ResultsAbout 7,277 patients were included in the final analyses. About 669 (9.2%) patients with POD were assigned to the case group, and 6,690 controls were identified from the whole population. About 66.5% of the cases and 36.3% of the controls had hypernatremia exposure. After being adjusted to certain well-recognized confounding factors, hypernatremia showed a significant correlation with increased risk of delirium after cardiac surgery (adjusted OR, 1.73; 95% CI, 1.41~2.12). An e-value analysis suggested the robustness to unmeasured confounding.ConclusionsHypernatremia was associated with an increased risk of delirium after cardiac surgery. This finding could have implications for risk stratification, early detection, and management of delirium in patients receiving cardiac surgery.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice.

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population.In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes.There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Reduced activity in a liaison psychiatry service during the peak of the COVID-19 pandemic: Comparison with 2019 data and characterisation of the SARS-COV-2 positive cohort

IntroductionThe COVID-19 pandemic led to changes in how healthcare was accessed and delivered. It was suggested that COVID-19 will lead to an increased delirium burden in its acute phase, with variable effect on mental health in the longer term. Despite this, there are limited data on the direct effects of the pandemic on psychiatric care.Objectives 1) describe the mental health presentations of a diverse acute inpatient population, 2) compare findings with the same period in 2019, 3) characterise the SARS-CoV-2 positive cohort of patients.MethodsWe present a descriptive summary of the referrals to a UK psychiatric liaison department during the exponential phase of the pandemic, and compare this to the same period in 2019.Resultsshow a 40.3% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for delirium and psychosis. One third (28%) of referred patients tested positive for COVID-19 during their admission, with 39.7% of these presenting with delirium as a consequence of their COVID-19 illness. Our data indicate decreased clinical activity for our service during the pandemic’s peak. There was a marked increase in delirium, though in no other psychiatric presentations.ConclusionsIn preparation for further exponential rises in COVID-19 cases, we would expect seamless integration of liaison psychiatry teams in general hospital wards to optimise delirium management in patients with COVID-19. Further consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the potentially increasing number of people reluctant to visit the emergency department.

120 Improving Delirium Recognition and Management Through In-Situ Simulation

Abstract Introduction Delirium is a common condition that is often associated with increased morbidity and mortality, longer hospital admission, and discharge to a residential or nursing home. By improving our ability to recognise and manage these patients we can intervene early to help reduce the likelihood of these outcomes. Method We organised several in-situ simulation scenarios with junior staff working on the Elderly Care Unit. The research team designed a scenario to re-create a typical delirious patient on the ward. Participants had to recognise the patient was delirious and instigate a management plan. Participants completed a pre and post-intervention questionnaire to ascertain whether they felt the simulation had improved their confidence. Additionally we performed an audit to investigate whether our intervention led to an improvement in the recognition and management of delirium in patients on the ward. Results The questionnaires showed an increase in participants’ confidence and knowledge when managing a delirious patient on the ward. From reviewing patient notes pre-intervention we identified that 24 patients were delirious during admission,14 of which were accurately diagnosed with delirium. The remaining 10 patients were diagnosed with “Acute Confusion”. On reviewing these 10 patients’ notes, they were all likely to have a diagnosis of delirium. Post-intervention there were 14 patients identified as delirious during their admission. All these patients were correctly documented as having delirium with no inaccurate use of terminology. The data also showed increasing use of tools such as AMTS and 4AT to diagnose delirium. Conclusions From the data gathered, we can see participants are better at recognising and diagnosing delirium. However, our sample sizes are too small to test statistical significance between data points. To improve the project we would include a larger sample size to determine whether the simulation produces a statistically significant improvement in confidence levels.

A multicentre point prevalence study of delirium assessment and management in patients admitted to Australian and New Zealand intensive care units

Objective: To characterise the assessment and management of delirium in patients admitted to intensive care units (ICUs) in Australia and New Zealand. Methods: We conducted a multicentre observational point prevalence study across 44 adult Australian and New Zealand ICUs. Data were extracted for all patients in the ICU in terms of assessment and treatment of delirium. ICU-level data were collected regarding the use of explicit protocols related to delirium. Results: We studied 627 patients, with 54% (336/627) having at least one delirium screening assessment performed. The Confusion Assessment Method for the ICU (CAM-ICU) was the most frequently used tool (88%, 296/336). Of patients assessed, 20% (68) were identified to have delirium. Eighteen per cent (111) of patients were administered a drug to manage delirium, with 41% (46) of those receiving a drug having no recorded assessment for delirium on that day. Of the drugs used to treat delirium, quetiapine was the most frequently administered. Physical restraints were applied to 8% (48/626) of patients, but only 17% (8/48) of such patients had been diagnosed with delirium. Most physically restrained patients either did not have delirium diagnosed (31%, 15/48) or had no formal assessment recorded (52%, 25/48) on that day. Conclusions: On the study day, more than 50% of patients had a delirium screening assessment performed, with 20% of screened patients deemed to have delirium. Drugs that are prescribed to treat delirium and physical restraints were frequently used in the absence of delirium or the formal assessment for its presence.

Shifting the focus: A QI project to improve the management of delirium in patients with hip fracture

Delirium is common in the perioperative setting, particularly in those admitted with a neck of femur fracture. It is associated with poorer outcomes, including increasing mortality, morbidity and prolonged hospital stay. It is often poorly recognised and under diagnosed. An urban district general hospital. A steering group was set up and used 'plan, do, study, act' methodology to develop a diagnostic pathway and educational programme for all staff working with patients admitted with neck of femur fracture. There was an increase in the multidisciplinary teams use of the 4AT delirium screening tool by 26% (p=0.0008). Staff surveys indicated an increase in the knowledge of delirium and confidence at explaining it to patients. By increasing staff confidence and use of recognised screening tools it is hoped that accurate diagnosis of this perioperative complication is improved, leading to improved management of these complex patients.

Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

PurposeTo characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure. Materials and methodsInternational, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine. ResultsRespondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04). ConclusionsMost respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.

Prevention, recognition and management of delirium in patients who are critically ill.

Delirium is common in patients who are critically ill, often resulting in extended hospital stays and increased mortality and morbidity. There are several subtypes of delirium, which are often undiagnosed and untreated, resulting in suboptimal patient outcomes. This article examines delirium in patients in the intensive care unit, including its signs and symptoms, incidence, causes and subtypes. It outlines the assessment of delirium and the pharmacological and non-pharmacological interventions that can be used to manage the condition, as well as describing the optimal prevention measures.

An integrative literature review exploring the clinical management of delirium in patients with advanced cancer.

To present the findings of an integrative literature review of the evidence for the clinical management of delirium in patients with advanced cancer. Patients with advanced cancer frequently experience delirium which can be distressing for both patients and their families. Current guidelines recommend that underlying causes of the delirium be addressed and a course of antipsychotics considered. However, the research into the effectiveness of treatments for delirium in people with advanced cancer is limited. Integrative literature review. Systematic searches of the MEDLINE, CINAHL, ProQuest Nursing and Allied Health and PsychInfo databases were conducted in April 2016 to include papers published in 2000 and later. The returns were screened using inclusion and exclusion criteria, and the seven studies found to be suitable were subject to review. Findings of the seven papers were extracted, appraised critically and reviewed using a narrative approach. A number of interventions, including the use of atypical antipsychotics, opioid rotation, methylphenidate hydrochloride and coeliac plexus block, were reported; however, there was limited evidence of their effectiveness. One study reported the use of exercise therapy as a nonpharmacological intervention. A variety of interventions to treat delirium in patients with advanced cancer have been tested through nonblinded, nonrandomised trials which have not produced a clear evidence base for practice. The clinical management of delirium in patients with advanced cancer is poorly understood and remains a clinical issue which requires further research (particularity randomized control trials) in order to determine more effective treatments and management strategies.

Neuroleptics in the management of delirium in patients with advanced cancer.

Delirium is the most common and distressing neuropsychiatric syndrome in cancer patients. Few evidence-based treatment options are available due to the paucity of high quality of studies. In this review, we shall examine the literature on the use of neuroleptics to treat delirium in patients with advanced cancer. Specifically, we will discuss the randomized controlled trials that examined neuroleptics in the front line setting, and studies that explore second-line options for patients with persistent agitation. Contemporary management of delirium includes identification and management of any potentially reversible causes, coupled with nonpharmacological approaches. For patients who do not respond adequately to these measures, pharmacologic measures may be required. Haloperidol is often recommended as the first-line treatment option, and other neuroleptics such as olanzapine, risperidone, and quetiapine represent potential alternatives. For patients with persistent delirium despite first-line neuroleptics, the treatment strategies include escalating the dose of the same neuroleptic, rotation to another neuroleptic, or combination therapy (i.e., the addition of a second neuroleptic or other agent). We will discuss the advantages and disadvantages of each approach, and the available evidence to support each strategy. Adequately powered, randomized trials involving proper control interventions are urgently needed to define the optimal treatment strategies for delirium in the oncology setting.

Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium in Patients with Advanced Cancer.

PurposeThe response to haloperidol as a first-line neuroleptic and the pattern of neuroleptic rotation after haloperidol failure have not been well defined in palliative care. The purpose of this study was to determine the efficacy of haloperidol as a first-line neuroleptic and the predictors associated with the need to rotate to a second neuroleptic.Materials and MethodsWe conducted a retrospective review of the charts of advanced cancer patients admitted to our acute palliative care unit between January 2012 and March 2013. Inclusion criteria were a diagnosis of delirium and first-line treatment with haloperidol.ResultsAmong 167 patients with delirium, 128 (77%) received only haloperidol and 39 (23%) received a second neuroleptic. Ninety-one patients (71%) who received haloperidol alone improved and were discharged alive. The median initial haloperidol dose was 5 mg (interquartile ranges [IQR], 3 to 7 mg) and the median duration was 5 days (IQR, 3 to 7 days). The median final haloperidol dose was 6 mg (IQR, 5 to 7 mg). A lack of treatment efficacy was the most common reason for neuroleptic rotation (87%). Significant factors associated with neuroleptic rotation were inpatient mortality (59% vs. 29%, p=0.001), and being Caucasian (87% vs. 62%, p=0.014). Chlorpromazine was administered to 37 patients (95%) who were not treated successfully by haloperidol. The median initial chlorpromazine dose was 150 mg (IQR, 100 to 150 mg) and the median duration was 3 days (IQR, 2 to 6 days). Thirteen patients (33%) showed reduced symptoms after the second neuroleptic.ConclusionNeuroleptic rotation from haloperidol was only required in 23% of patients with delirium and was associated with inpatient mortality and white race.

Intravenous Patient-controlled Analgesia Has a Positive Effect on the Prognosis of Delirium in Patients Undergoing Orthopedic Surgery.

BackgroundPostoperative delirium is relatively common. However, the relationship between intravenous patient-controlled analgesia (IV-PCA) and delirium has not been thoroughly investigated. The aim of this study was to evaluate the effects of IV-PCA on the prognosis of postoperative delirium in patients undergoing orthopedic surgery.MethodsMedical records of 129 patients with postoperative delirium were reviewed. Patients were divided into two groups according to whether they used IV-PCA with fentanyl and ketorolac. The IV-PCA group consisted of 73 patients who were managed with IV-PCA; the NO-PCA group consisted of 56 patients who were managed without PCA.ResultsIncidences of multiple psychiatric consultations and prolonged delirium were significantly lower in patients using IV-PCA with fentanyl and ketorolac than in those without PCA.ConclusionsWe recommend the use of IV-PCA for pain control and management of delirium in patients with postoperative delirium.

Neuroleptic Dose in the Management of Delirium in Patients with Advanced Cancer

Neuroleptics are commonly used in the management of delirium. Limited information is available regarding the dosage requirements and efficacy of neuroleptics in the palliative care setting. We determined the type and dose of neuroleptic use by delirium subtype. The medical records of 99 inpatients with advanced cancer were reviewed retrospectively. The doses of different neuroleptics, expressed as haloperidol equivalent daily doses (HEDDs), were correlated with delirium recall, recalled delirium symptom frequency, and associated distress from the patients', family caregivers', nurses' and palliative care specialists' perspectives. Subtypes of delirium included hypoactive in 20 (20%), mixed in 66 (67%), and hyperactive in 13 (13%). The median HEDD was 2.5mg, interquartile range (Q1-Q3) 1-4.7 mg (mean 4.0+/-5.9 mg), and it was significantly higher in agitated and mixed delirium as compared with hypoactive delirium (P=0.008). The neuroleptic dose was low and appeared to be ineffective in preventing patient delirium recall, with 73 (74%) patients remembering their episode of delirium as distressing. HEDD did not correlate with delirium recall, recalled symptom frequency, or distress for patients and family caregivers. However, HEDD increased with nurses' distress related to patients' symptoms (disorientation to place P=0.002, disorientation to time P=0.008, delusions P=0.041, and agitation P<0.001), and palliative care specialists' distress related to patients' hallucinatory symptoms (P=0.006) and agitation (P=0.006). In this study, the administered neuroleptic dose was influenced more by health care professional distress than by delirium symptom frequency. Future studies should examine the efficacy of neuroleptic dose according to individual delirium symptoms.

Haloperidol Dose in the Management of Delirium in Patients with Advanced Cancer (411-A)

Haloperidol Dose in the Management of Delirium in Patients with Advanced Cancer (411-A)

Delirium in Acute Stroke: A Review

Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation. Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke. This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.

The cause of delirium in patients with hip fracture.

To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture. Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached. The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge. Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.