Symptoms Of Delirium Research Articles

Socio-demographic characteristics and pharmacological treatment options in patients with delirium

IntroductionDelirium is common in hospital settings, with approximately 3% to 45% of older patients in hospitals developing delirium during their stay. Among the elderly and those with severe or advanced medical conditions, the reported percentage of patients with delirium is over 56%. The three motor subtypes of delirium are hyperactive, hypoactive, and mixed. Another way to characterize delirium is based on whether it is reversible, irreversible, or terminal.ObjectivesIdentifying appropriate pharmacological treatment options among antipsychotics and their correlation with various precipitating and predisposing factors in the in-hospital contextMethodsThis was a retrospective, cross-sectional, observational study that utilized a database created by the psychiatry department at the National Medical Center 20 de Noviembre, with data collected from April 2021 to April 2022. The database contains anonymized administrative and clinical data of patients who were seen in the psychiatry department for the diagnosis of any type of delirium, using the CAM scale for classification. The database includes records and data of hospitalized patients, encompassing all specialties at this medical centerResultsA total of 139 patients were included in the study, of which 39% were female and 61% were male, with a mean age of 67 and a median age of 68 years. It was observed that the average duration of delirium symptoms, from receiving the consultation to remission, was approximately 6 days (p <0.005) (OR 5.12-6.62), and the average length of hospital stay was approximately 20 days (OR 17.3-22.09). Among the patients, 50.39% were overweight, 63% had hypertension (HTA), 29% had chronic kidney injury, 24% had a history of delirium, and 73% had recent surgical interventions. Patients with diabetes mellitus had a 3.1 times higher risk, those with HTA had a 2.8 times higher risk, and those with kidney injury had a 3.8 times higher risk of having a positive CAM result. It was observed that haloperidol, used in 84% of the patients, showed the highest percentage reduction in CAM scoresImage:Image 2:ConclusionsThe results of this study emphasize the importance of identifying risk factors associated with delirium and implementing effective treatment for this condition. It was observed that the average duration of delirium symptoms was approximately 6 days, which is relevant for understanding the course and management of this illness. Furthermore, it was found that the average hospital stay was 20 days, underscoring the burden that delirium can place on healthcare systems.In conclusion, this study highlights the importance of identifying risk factors and providing appropriate treatment, such as the use of haloperidol, to improve outcomes in patients with delirium.Disclosure of InterestNone Declared

Anticholinergic Toxidrome due to Thorn Apple Seed Ingestion in an Elderly Couple.

Sudden onset of reduced consciousness, psychomotor agitation and mydriasis are all indicative of an anticholinergic toxidrome. It is important to note that numerous drugs, as well as certain herbs and plants, possess anticholinergic properties. An 84-year-old female patient had sudden nocturnal onset of uncoordinated hand movements and altered mental status. Shortly after, the patient's 83-year-old husband developed symptoms of dysarthria, gait ataxia, vertigo, and delirium. Anticholinergic syndrome consists of a combination of central and peripheral anticholinergic symptoms. Physostigmine given intravenously resulted in rapid reversal of symptoms. Thorn apple seeds had been accidentally ingested and were identified as the cause. The clinical presentation of an anticholinergic toxidrome includes both central and peripheral symptoms such as altered consciousness, mydriasis, dry mucous membranes and skin, and tachycardia.Prompt recognition of anticholinergic toxidrome and the administration of physostigmine can lead to rapid reversal of symptoms and improved patient outcomes.Treatment with physostigmine is indicated when a patient with an agitated delirium does not respond adequately to titrated benzodiazepines.

The Health Outcomes of a Telegeriatrics Follow-Up Model on Dementia Patients and Their Caregivers in Cairo.

Background/Purpose: Older patients living with dementia and their caregivers are ideal beneficiaries of telemedicine, cost-effectiveness, caregiver satisfaction, and physician acceptance. The aim is to study the effect of a telemedicine dementia enabled program on the health outcome of dementia patients and their caregivers, as regard the patient outcome, caregiver stress, and caregiver satisfaction. Methods: Ninety-seven (n = 97) elderly subjects were recruited from the outpatient clinics and inpatient ward of Geriatrics Hospital, Ain Shams University Hospitals. Seventy subjects completed 6 months of follow-up using a telegeriatrics model. Patient outcomes (delirium, behavioral and psychological symptoms of dementia [BPSD], and need for home consultations, emergency room [ER] visits, clinic visits, and hospital admissions) were assessed and followed. Caregiver stress was evaluated and monitored using the abridged Arabic version of the Zarit Burden Interview ZBI-A. Caregiver satisfaction was assessed using dedicated satisfaction questionnaire designed by Ain Shams Virtual Hospital. Results: elirium episodes, BPSD episodes, and the need for home consultations, clinic visits, ER visits, and hospital admissions. This was statistically significant after the second, fourth, and sixth months of follow-up (p-value <0.001). In addition, the telegeriatrics follow-up model had a positive effect on both caregiver stress and caregiver satisfaction. Conclusions: The telegeriatrics follow-up model is a useful tool in the improvement of health outcomes of dementia patients, reduction of caregiver stress, and achievement of caregiver satisfaction.

Screening for Delirium During Pediatric Brain Injury Rehabilitation

ObjectiveTo assess feasibility of routine delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) in children admitted for rehabilitation with acquired brain injury (ABI), report on the prevalence of positive delirium screens in this population, and explore longitudinal trends in CAPD scores and their association with rehabilitation outcomes. DesignRetrospective study. SettingPediatric inpatient rehabilitation unit. Participants144 children (median 10.8 years) with ABI (N=144). InterventionsNot applicable. Main Outcome MeasuresPercent compliance with twice daily delirium screening; prevalence of positive delirium screens; trajectories in CAPD scores and their relation with FIM for Children (WeeFIM) scores. ResultsScreening was feasible (mean 75% compliance for each of 144 children). Of 16,136 delirium screens, 29% were positive. 62% of children had ≥1 positive screen. Four primary patterns of CAPD trajectories were identified: Static Encephalopathy (10%), Episodic Delirium (10%), Improving (32%), and No Delirium (48%). Validity of these trajectories was demonstrated through association with WeeFIM and CALS outcomes. Younger age at admission was associated with positive delirium screens, and rehabilitation length of stay was significantly longer for the Improving group. ConclusionsDelirium occurs frequently in children with ABI during inpatient rehabilitation. Routine delirium screening provides clinically relevant information including the potential to facilitate early detection and intervention for medical complications. Longitudinal ratings of delirium symptoms may also have a role in developing a standardized definition for Post Traumatic Confusional State (PTCS) stage of recovery in children.

Comparison of Pharmacological Treatments for Agitated Delirium in the Last Days of Life

ContextAntipsychotics are often used in managing symptoms of terminal delirium, but evidence is limited. ObjectivesTo explore the comparative effectiveness of haloperidol with as-needed benzodiazepines (HPD) vs. chlorpromazine (CPZ) vs. levomepromazine (LPZ) for agitated delirium in the last days. MethodsA prospective observational study was conducted in two palliative care units in Japan. Adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS-PAL) of one or more were included; palliative care specialist physicians determined that the etiology was irreversible; and estimated survival was 3 weeks or less. Patients treated with HPD, CPZ, or LPZ were analyzed. We measured RASS, NuDESC, Agitation Distress Scale (ADS), and Communication Capacity Scale (CCS) on Days 1 and 3. ResultsA total of 277 patients were enrolled, and 214 were analyzed (112 in HPD, 50 in CPZ, and 52 in LPZ). In all groups, the mean RASS-PAL score significantly decreased on Day 3 (1.37 to -1.01, 1.87 to -1.04, 1.79 to -0.62, respectively; P < 0.001); the NuDESC and ADS scores also significantly decreased. The percentages of patients with moderate to severe agitation and those with full communication capacity on Day 3 were not significantly different. The treatments were well-tolerated. While one-fourth of HPD group changed antipsychotics, 88% or more of CPZ and LPZ groups continued the initial antipsychotics. ConclusionHaloperidol with as-needed benzodiazepine, chlorpromazine, or levomepromazine may be effective and safe for terminal agitation. Chlorpromazine and levomepromazine may have an advantage of no need to change medications.

Inhibition of RXRA-mediated PLA2G2A improves delirium in COPD mice by regulating endoplasmic reticulum stress pathway and inhibiting cell apoptosis.

Delirium is a common psychiatric complication of chronic obstructive pulmonary disease (COPD). The relief of delirium is considered one of the beneficial ways to treat COPD. However, there are currently no specific drugs that alleviate delirium in COPD patients. Our research aimed to elucidate the specific mechanisms underlying delirium in COPD mice, while also seeking more effective therapeutic targets. In our study, bioinformatics analysis and qRT PCR were used to identify key factors in the development of delirium in COPD animal models. Open field and elevated plus maze tests were used to detect delirium in mice. Tunel staining and HE staining were used to analyze the apoptosis of mouse hippocampus cells. EdU and CCK-8 experiments were used to analyze PC-12 cells vitality and proliferation. JASPAR online database, dual luciferase reporting experiments, ChIP experiments, and IF staining were used to analyze the interaction between RXRA and PLA2G2A. RXRA is highly expressed in the brain tissue of COPD mice with delirium symptoms. The downregulation of RXRA inhibits the delirium state in COPD mice. This is mainly due to the reduction of endoplasmic reticulum stress and cell apoptosis by inhibiting the expression of RXRA. In addition, we also confirmed that RXRA is a transcription factor of PLA2G2A. RXRA has an inhibitory effect on the expression of PLA2G2A. In vitro experiments have confirmed that inhibition of the RXRA/PLA2G2A axis reduces cell apoptosis, thereby alleviating the occurrence and development of delirium in COPD mice. Inhibition of the RXRA/PLA2G2A axis reduces endoplasmic reticulum stress and cell apoptosis. This process alleviates the development of delirium in COPD mice.

Levofloxacin-Related Delirium: Uncommon Psychiatric Manifestations in Throat Infection Treatment

We report a case of a 55-year-old man who had a history of ischemic stroke 6 years back and was on follow-up medications. He got a throat infection for which he took levofloxacin 250mg BD as prescribed by the doctor. After taking levofloxacin, the patient developed delirium and symptoms of acute psychosis such as social withdrawal and suspiciousness within 12-24 hours. The symptoms subsided 1 day after the discontinuation of levofloxacin. It can therefore be suspected that Levofloxacin directly contributed to the episode of delirium and acute psychosis witnessed in the patient. This is one of the rare cases of levofloxacin-induced delirium and acute psychosis symptoms seen up till now since the use of levofloxacin by patients. We, therefore, recommend that levofloxacin should be carefully used in patients with underlying psychiatric disorders and patients on levofloxacin should be regularly followed up to notice any such case of levofloxacin-induced delirium and acute psychosis.

Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium.

Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). Data were from five independent study cohorts (N=1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.

Exploring the Documentation of Delirium in Patients After Cardiac Surgery: A Retrospective Patient Record Study.

Delirium is a common disorder for patients after cardiac surgery. Its manifestation and care can be examined through EHRs. The aim of this retrospective, comparative, and descriptive patient record study was to describe the documentation of delirium symptoms in the EHRs of patients who have undergone cardiac surgery and to explore how the documentation evolved between two periods (2005-2009 and 2015-2020). Randomly selected care episodes were annotated with a template, including delirium symptoms, treatment methods, and adverse events. The patients were then manually classified into two groups: nondelirious (n = 257) and possibly delirious (n = 172). The data were analyzed quantitatively and descriptively. According to the data, the documentation of symptoms such as disorientation, memory problems, motoric behavior, and disorganized thinking improved between periods. Yet, the key symptoms of delirium, inattention, and awareness were seldom documented. The professionals did not systematically document the possibility of delirium. Particularly, the way nurses recorded structural information did not facilitate an overall understanding of a patient's condition with respect to delirium. Information about delirium or proposed care was seldom documented in the discharge summaries. Advanced machine learning techniques can augment instruments that facilitate early detection, care planning, and transferring information to follow-up care.

NCI-Delirium Model: Co-caring to decrease the incidence of delirium among hospitalized older adults.

Delirium negatively impacts the health and wellbeing of older adults and their family carers and contributes to unnecessary high healthcare costs, estimated at $8.8 billion per year in Australia. Improvements to clinical practice are urgently needed, particularly now, as the COVID-19 pandemic is placing an enormous burden on our hospitals. &#x0D; Innovative strategies that support partnerships with family carers have been reported as key to improved patient outcomes and satisfaction with care, particularly for older adults unable to participate in their own care. This is because carers have intimate knowledge of a family member’s cognitive state to identify early subtle changes others might not. Carers also provide valuable reassurance and familiarity to the older adults during their treatment and can orient them to place and time. &#x0D; Founded on our clinical observations, informed by a scoping review of the literature (in press) and co-designed with carers, consumers, clinicians and policy analysts, we developed a new model of delirium care: NCI-Delirium. NCI-Delirium is a validated, scalable, low risk model that values the lived experience of older adults and carers. NCI-Delirium supports the integration of carers as partners in the care of the older adult from admission into the acute care setting. To support the integration of carers as partners, they are offered a web-based Delirium Toolkit that contains: an education package to build awareness and skill development (e.g., delirium risk factors, therapeutic and preventive strategies and non-pharmacological interventions to manage the reorientation of the hospitalised older adult); a 7-item psychometrically tested screening tool designed for carers to identify delirium symptoms and people at risk of delirium; access to support resources (e.g., counselling, social prescriptions, peer-support); and a co-designed discharge plan with the health team. &#x0D; Preliminary results suggest that NCI-Delirium improves health service delirium outcomes. Carer involvement in this research, and the introduction of their perspectives, has elevated carers’ key relationships with clinicians. Our co-designed solution to support the integration of carers as partners in delirium management has improved carers’ caregiving burden, psychological wellbeing and knowledge of delirium. This translatable co-designed model of care provides the much needed rich and robust clinical, implementation and economic evidence, to address the risk factors associated with the prevalence of delirium in hospitalised older adults. It is anticipated that the model will transform how we integrate carers as partners in care to improve clinical practice, patient and carer experiences; and reduce caregiving burden.&#x0D; Globally, the identification and management of risk for delirium is imperative. Delirium is a potentially life-threatening condition, and not well detected in the acute or community care setting. If carers are integrated and supported as partners in care, the capacity to identify symptoms and support the diagnosis of delirium should increase, potentially reducing functional decline, transition to residential aged care facilities and mortality rates. The next steps are to evaluate this co-designed web-based delirium model of care for use by carers in the community and residential aged care setting.&#x0D;

Nursing diagnoses as factors associated with delirium among intensive care unit patients with sepsis: A retrospective correlational study.

To examine whether nursing diagnoses were associated with delirium in patients with sepsis. Nursing diagnosis is a nurse's clinical judgement about clients' current or potential health conditions. Delirium is regarded as an important nurse-sensitive outcome. Nonetheless, nursing diagnoses associated with delirium have not yet been identified. Retrospective correlational study. This study was carried out from December 2021 to January 2023. We analysed electronic health records of patients with sepsis admitted to the intensive care units (ICUs) of a tertiary hospital in Seoul, South Korea. Delirium was defined based on the Intensive Care Delirium Screening Checklist score. Nursing diagnoses established within 24 h of admission to the ICU were included and were based on the North American Nursing Diagnosis Association diagnostic classification. The data were analysed using logistic regression. Demographics, comorbidities, procedures and physiological measures were adjusted. Regression model was evaluated via receiver operating characteristic curve, Nagelkerke R2, accuracy and F1 score. The prevalence of delirium in patients with sepsis was 51.8%. Ineffective breathing patterns, decreased cardiac output and impaired skin integrity were significant nursing diagnoses related to delirium. Age ≥ 65 years, Acute Physiology and Chronic Health Evaluation II score, mechanical ventilation, continuous renal replacement therapy, physical restraint and comatose state were also associated with delirium in patients with sepsis. The area under the receiver operating characteristic curve was 0.806. Ineffective breathing patterns, decreased cardiac output and impaired skin integrity could manifest as prodromal symptoms of delirium among patients with sepsis. The prodromal symptoms of delirium revealed through nursing diagnoses can be efficiently used to identify high-risk groups for delirium. The use of nursing diagnosis system should be recommended in clinical practice caring for sepsis patients. STROBE checklist. No patient or public involvement.

EXPLORING THE POTENTIAL OF CHATGPT FOR ASSESSING DELIRIUM SYMPTOMS IN OLDER ADULTS WITH COGNITIVE IMPAIRMENT

Abstract Delirium is a common and serious geriatric syndrome, especially in older adults with cognitive impairment. Accurate caregiver assessment and reporting of delirium in community-dwelling older adults can help healthcare providers diagnose and treat delirium more effectively. Yet, caregivers often lack confidence in their ability to accurately assess and report delirium. An automated method to detect the presence and symptoms of delirium could potentially boost caregiver confidence and assist with more accurate delirium assessment and reporting. This study explored the use of ChatGPT, a generative AI based on the Large Language Model (LLM), to detect the presence and symptoms of delirium. We trained ChatGPT using a series of prompts specifically designed to enhance its understanding of the domain knowledge and the scoring mechanism of a caregiver-centered, seven-item delirium assessment, the Sour Seven. The trained ChatGPT model was asked to identify and score various delirium symptoms in five previously validated geriatric case vignettes using the Sour Seven scale. Each case was repeated three times to test for reliability. The ChatGPT assessment results were compared against those of human experts. The preliminary analysis showed that items 3, 6 and 7 were scored correctly in all cases, but mixed results were found on items 1, 2, 4, and 5, mostly because the AI applied a single symptom statement to multiple items. Overall, the results indicate that generative AI has the potential to accurately capture and represent complex delirium symptoms in natural language, which could assist caregivers in accurately identifying and reporting delirium symptoms.

IMPROVING HOSPITAL AND POST-ACUTE OUTCOMES AND EXPERIENCES OF DYADS LIVING WITH DEMENTIA: RESULTS OF THE FAM-FFC TRIAL

Abstract Hospitalizations of persons living with dementia are associated with protracted functional decline, delirium, and behavioral symptoms of distress as well as increased care partner stress. This symposium presents findings from the Family-centered Function -focused Care (Fam-FFC) trial. In Fam-FFC, nurses purposefully empower family care partners in the assessment, decision-making, care delivery, and evaluation of function-focused care during hospitalization and the 60-day post-acute period. The goal is to improve the functional recovery of the patient while increasing family preparedness for caregiving, bridging hospital to post-acute setting. This cluster randomized controlled trial tested the impact of Fam-FFC in 455 dyads of diverse persons living with dementia and their care partners. The first presentation will compare Fam-FFC outcomes for patients and care partners to the attention control group outcomes at discharge, two and six months. The second presentation will report the impact of Fam-FFC upon adverse patient events (falls, emergency department transfers, hospital admissions) in the two arms. Next, the presenter will utilize Fam-FFC data to describe the patient and care partner characteristics that contribute to care partner distress at the time of hospital discharge. The fourth presentation will focus on staff-patient interactions in the Fam-FFC trial, including the influence of clinical factors upon the quality of the interaction. The final paper will report on the trajectory of behavioral symptoms of distress, and associated outcomes, from hospital admission to six-month follow-up. Our discussant, Karen Rose will lead a discussion of unanswered questions, next steps, and implications of this work for policy and practice.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms.

Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Pediatric Delirium Educational Tool Development With Intensive Care Unit Clinicians and Caregivers in Canada: Focus Group Study.

Pediatric intensive care unit (PICU)-associated delirium contributes to a decline in postdischarge quality of life, with worse outcomes for individuals with delayed identification. As delirium screening rates remain low within PICUs, caregivers may be able to assist with early detection, for which they need more education, as awareness of pediatric delirium among caregivers remains limited. This study aimed to develop an educational tool for caregivers to identify potential delirium symptoms during their child's PICU stay, educate them on how to best support their child if they experience delirium, and guide them to relevant family resources. Web-based focus groups were conducted at a tertiary pediatric hospital with expected end users of the tool (ie, PICU health care professionals and caregivers of children with an expected PICU length of stay of over 48 h) to identify potential educational information for inclusion in a family resource guide and to identify strategies for effective implementation. Data were analyzed thematically to generate requirements to inform prototype development. Participants then provided critical feedback on the initial prototype, which guided the final design. In all, 24 participants (18 health care professionals and 6 caregivers) attended 7 focus groups. Participants identified five informational sections for inclusion: (1) delirium definition, (2) key features of delirium (signs and symptoms), (3) postdischarge outcomes associated with delirium, (4) tips to inform family-centered care, and (5) education or supportive resources. Participants identified seven design requirements: information should (1) be presented in an order that resembles the structure of the clinical discussion around delirium; (2) increase accessibility, recall, and preparedness by providing multiple formats; (3) aim to reduce stress by implementing positive framing; (4) minimize cognitive load to ensure adequate information processing; (5) provide supplemental electronic resources via QR codes; (6) emphasize collaboration between caregivers and the health care team; and (7) use prompting questions to act as a call to action for caregivers. Key design requirements derived from end-user feedback were established and guided the development of a novel pediatric delirium education tool. Implementing this tool into regular practice has the potential to reduce distress and assist in the early recognition and treatment of delirium in the PICU domain. Future evaluation of its clinical utility is necessary.

Delirium and Pseudoparkinsonism in a Bipolar Patient: Case Report

Background Bipolar patients are at higher risk of delirium, in comparison to other psychiatric patients, regardless of being under lithium treatment. Indeed, lithium and antipsychotics are the mainstay drugs in the management of bipolar disorder. In clinical practice, the combinations of these drugs are commonly used in the management of acute phase of mania. Despite rare previous cases of olanzapine-associated delirium and cases of delirium with extrapyramidal signs due to a lithium-olanzapine combination therapy, these are mainly reported in elderly or severely ill patients. Case Presentation This case report illustrates a complex neuropsychiatric syndrome characterized by olanzapine-associated delirium alongside parkinsonism induced by aripiprazole, during a severe manic episode, in an antipsychotic-naïve young adult bipolar patient, under lithium maintenance treatment. Conclusions This case highlights the need for caution regarding delirium and extrapyramidal symptoms when treating antipsychotic-naïve bipolar patients under lithium maintenance therapy. The risk factors and the underlying physiopathology of this iatrogenic neuropsychiatric syndrome are discussed. We hypothesise a central cholinergic antagonism in the pathophysiology for delirium, and both pharmacokinetic and pharmacodynamic mechanisms for Parkinsonism, namely a putative flaw functioning of CYP2D6 or CYP3A4 cytochromes, bringing about a failure in metabolising aripiprazole at a normal rate, and a synergistic effect of lithium and antipsychotics on dopaminergic blockade.

Diagnosis of behavioral symptoms as a predictor of institutionalization among Medicaid patients with dementia

ObjectivesBehavioral symptoms are commonly observed in the course of dementia. This study aimed to assess the association of the diagnosis of a cluster of behavioral symptoms (e.g., agitation, aggression, psychotic symptoms, and delirium/wandering) with the likelihood of subsequent institutionalization.MethodsA retrospective cohort study of adults aged 65 and above diagnosed with dementia identified in the IBM® MarketScan® Multistate Medicaid database between October 01, 2015, and September 30, 2019, was conducted. The index date was defined as the first diagnosis date of dementia. The presence or absence of behavioral symptoms was identified in the 6 months prior to the index date (baseline). Institutionalization was evaluated 12 months (follow-up) post the index date. The association between diagnosed behavioral symptoms during the baseline period and institutionalization in the follow-up period was assessed using a multivariable logistic regression, adjusting for baseline sociodemographic and clinical characteristics.ResultsThe study cohort included 40,714 patients with dementia. A diagnosis of behavioral symptoms was found among 2,067 (5.1%) patients during the baseline period. An increased likelihood of institutionalization was found during the follow-up among patients with agitation and aggression in baseline (OR = 1.51 (95% CI: 1.18–1.92)) compared to patients without these symptoms at baseline. Patients with psychotic symptoms in baseline had significantly higher odds of getting institutionalized during the follow-up compared to patients without psychotic symptoms in baseline (OR = 1.36 (95% CI: 1.20–1.54)). Similarly, patients with symptoms of delirium and wandering in baseline had a higher likelihood of institutionalization than patients without these symptoms at baseline (OR = 1.61 (95% CI: 1.30–1.99)).ConclusionSeveral diagnosed behavioral symptoms were associated with a higher risk of institutionalization among older adults with dementia and should be considered when planning treatment strategies for the effective management of the condition.

Extremes of baseline cognitive function determine the severity and outcomes of delirium: findings from a prospective longitudinal cohort study

AbstractBackgroundEpidemiological studies have shown the bidirectional relationship between dementia and delirium to be complex and non‐linear. This has implications for mechanistic studies investigating the extent to which any pathophysiology might be specific to delirium, or shared with dementia. While delirium is associated with long‐term dementia risk and cognitive decline, this association may be independent of classical Alzheimer’s pathology in oldest‐old patients.MethodThe Delirium and Population Health informatics (DELPHIC) study prospectively followed a population‐representative sample of 1510 individuals aged ≥70 years living in London, UK. We performed cognitive assessments at baseline, two years, and ascertained delirium symptoms during incident hospitalisation in 209 participants across 371 episodes.ResultBetter baseline cognitive function was generally associated with a lower likelihood of delirium. However, during delirium episodes, there was a U‐shaped relationship between baseline cognition and delirium symptom severity; participants with the lowest and highest baseline cognition experienced the most severe delirium and arousal deficits (baseline z‐score ‐2: mean MDAS 15; baseline z‐score +2: mean MDAS 11). At follow‐up, we observed the largest cognitive decline in participants with better baseline cognition experiencing delirium (2.2SD decline vs 0.8SD without delirium).ConclusionThese findings imply that delirium pathophysiology research should take into account differences in baseline cognition, for example by defining pre‐existing subclinical dementia pathology. We suggest the need for prospective, serial pathophysiological studies to consider the temporal sequence of delirium‐related neural damage. In this way, we could differentiate which mechanisms are unique to delirium, and which might interact with pre‐existing dementia pathophysiology to result in long‐term cognitive deficits.

Brain metabolism during delirium

AbstractBackgroundAltered cerebral glucose metabolism manifested by increased cerebrospinal fluid (CSF) lactate and decreased neuron specific enolase during delirium has been found in CSF analyses in multiple settings, although without change in CSF or blood glucose. These changes correlate with markers of delirium severity and outcomes of delirium.However, patients with delirium are acutely unwell in hospital and have multiple comorbidities. The contribution of acute illness and dementia have not been excluded.MethodWe studied two groups of acutely unwell older people in hospital after excluding underlying dementia by history and the Informant Questionnaire on Cognitive Decline in the Elderly. The first group had delirium and the second group had no delirium. All patients underwent a 18F‐fluorodeoxyglucose positron emission tomography (FDG‐PET) scan in hospital while unwell, and during delirium for the first group. Confounders on FDG‐PET such as structural brain lesions and medications that affect brain metabolism were excluded.Then we also compared the delirium FDG‐PET scans to a group with Alzheimer’s dementia.ResultPatients with delirium demonstrated a unique, novel pattern of brain hypometabolism that reflected symptoms of delirium. The affected areas included: bilateral thalami; right posterior cingulate cortex (PCC); right superior frontal, right infero‐lateral anterior temporal and left superior parietal cortices. The areas highly negatively correlated with delirium severity scores (Spearman’s rank correlation coefficients between ρ = ‐0.39 and ‐0.71; p values from 0.089 to 0.001) and performance on a range of relevant neuropsychological tests, for example thalami and Trail Making Test B (Spearman’s ρ = ‐0.52; p = 0.028). Direct comparison to AD scans significant thalamic hypometabolism (p&lt;0.01) in delirium, but the PCC was not different.ConclusionIn patients with acute illness but without dementia, delirium is accompanied by regional cerebral hypometabolism in a distribution that is not consistent with any known pattern of dementia. While there is some overlap with AD, thalamic hypometabolism is atypical of AD and consistent with the clinical features of delirium.ReferencesNitchingham AR, Pereira JV‐B, Wegner EA, Oxenham V, Close J Caplan GA. Regional cerebral hypometabolism on 18F‐FDG PET/CT scan in delirium is independent of acute illness and dementia. Alzheimers &amp; Dementia 2022; 1‐10.

Low-dose PLX5622 treatment prevents neuroinflammatory and neurocognitive sequelae after sepsis

BackgroundSepsis-associated encephalopathy (SAE) is characterized by symptoms of delirium including hallucinations, impaired concentration, agitation, or coma and is associated with poor outcome in the early phase of sepsis. In addition, sepsis survivors often suffer from persisting memory deficits and impaired executive functions. Recent studies provide evidence that microglia are involved in the pathophysiology of SAE.MethodsHere, we investigated whether pharmacological depletion of microglia using PLX5622 (1200 ppm or 300 ppm) in the acute phase of sepsis is able to prevent long-term neurocognitive decline in a male mouse model of polymicrobial sepsis or lipopolysaccharide-induced sterile neuroinflammation. Therefore, we performed the novel object recognition test at different time points after sepsis to address hippocampus-dependent learning. To further assess synapse engulfment in microglia, colocalization analysis was performed using high-resolution 3D Airyscan imaging of Iba1 and Homer1. We also investigated the effect of PLX5622 on acute astrocyte and chronic microglia proliferation in the hippocampus after sepsis induction using immunofluorescence staining.ResultsHigh-dose application of the colony stimulating factor 1 receptor (CSF1R) inhibitor PLX5622 (1200 ppm) seven days prior to sepsis induction lead to 70–80% microglia reduction but resulted in fatal outcome of bacterial sepsis or LPS induced inflammation. This is likely caused by severely compromised host immune response upon PLX5622-induced depletion of peripheral monocytes and macrophages. We therefore tested partial microglia depletion using a low-dose of PLX5622 (300 ppm) for seven days prior to sepsis which resulted in an increased survival in comparison to littermates subjected to high-dose CSF1R inhibiton and to a stable microglia reduction of ~ 40%. This partial microglia depletion in the acute stage of sepsis largely prevented the engulfment and microglia-induced stripping of postsynaptic terminals. In addition, PLX5622 low-dose microglia depletion attenuated acute astrogliosis as well as long-term microgliosis and prevented long-term neurocognitive decline after experimental sepsis.ConclusionsWe conclude that partial microglia depletion before the induction of sepsis may be sufficient to attenuate long-term neurocognitive dysfunction. Application of PLX5622 (300 ppm) acts by reducing microglia-induced synaptic attachement/engulfment and preventing chronic microgliosis.