Delirium Research Articles

Infectious Pneumonitis Revealing an Anal Imperforation with Recto-Vaginal Fistula: A Case of Late Discovery in a 70-Year-Old Woman

Introduction: Anorectal malformations concern all anomalies of the terminal part of the digestive tract often diagnosed in the perinatal period. We report a clinical case of anorectal malformation discovered incidentally and very late at 70 years, following complications from the infectious syndrome. Observation: 70-year-old female patient, housewife, uneducated was referred to the hospital for acute febrile, cough, and mental confusion associated with chronic pelvic pain. The genito-anal examination showed an anal imperforation associated with a recto-vaginal fistula complicated by cervico-vaginitis. The evolution during hospitalization was favorable, but the patient died at home, 3 weeks after discharge. Conclusion: The discovery of anorectal malformation in adults is rare and exceptional in an elderly subject. This case demonstrates once again the challenges encountered in developing countries on the socio-economic and health levels.

Cerebral vasculopathy after COVID-19 infection in the central region of Saudi Arabia: a case report

Background: The most common symptoms of coronavirus disease 2019 (COVID-19) are dyspnea, fever, cough, headache, diarrhea, and myalgia. Case Presentation: We report a case of peripheral cortical borderline cerebral vasculopathy associated with COVID-19 infection in a young female patient who presented with seizures and a history of acute confusion and generalized tonic-clonic seizure. She was diagnosed with COVID-19 disease 1 week ago before the presentation. Her illness was mild and did not require hospitalization. The magnetic resonance imaging study revealed cerebral vasculopathy. COVID-19 infection and other risk factors can increase the risk of cerebral vasculopathy. To our knowledge, no other case of peripheral cortical borderline cerebral vasculopathy associated with COVID-19 infection has been reported in Saudi Arabia. Conclusion: This report highlights the importance of considering seizures and cerebral vasculopathy as manifestations of COVID-19 disease. Physicians should consider seizures due to cerebral vasculopathy among the expected neurological complications of COVID-19 to aid early detection and management of COVID-19- associated complications.

From dementia to delirium: The role of infections in cognitive decline – A case report

Delirium is an acute confusional state characterized by inattention, cognitive impairment and an altered level of consciousness, often precipitated by infections or surgery. In contrast, dementia manifests as a gradual, chronic and progressive decline in cognitive function that was previously acquired. Delirium superposed on dementia is a prevalent condition in older adults, representing a significant diagnostic challenge for clinicians due to the lack of tools specifically designed for its detection. Early detection and effective management are essential for minimizing associated morbidity, mortality and distress for patients and their caregivers. We present the case of a 70-year-old woman admitted to a psychiatric ward for an acute onset of persecutory delusions and visual hallucinations. Upon the third day of admission, the patient presented difficulty breathing, drowsiness, impaired response to verbal and painful stimuli, oxygen saturation of 81% and elevated blood pressure measuring 210/120 mmHg. Following the presented symptomatology, the patient was transferred to an infectious disease hospital for left lower lobe pneumonia. Ten days after being discharged, she was readmitted to the emergency department in a hypoglycemic coma and diagnosed with a urinary infection caused by Klebsiella pneumoniae. During her hospitalization, she presented typical symptoms of delirium and reported experiencing retrograde amnesia related to the episode of confusion.

Melatonin for Insomnia in Medical Inpatients: A Narrative Review

In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.

DELIRIUM SUPERIMPOSED ON DEMENTIA IN POST-ACUTE CARE: NURSE DOCUMENTATION OF SYMPTOMS AND INTERVENTIONS

Abstract Delirium is common in older adults and across settings of care, including post-acute care (PAC). Nurses have an important role in identifying, preventing and managing delirium. Even though best practice guidelines highlight the need to accurately document delirium and to deliver non-pharmacological, nurse-driven interventions, it is unclear how this is done in PAC. The aim of this research was two-fold: 1) to describe how nurses document DSD symptoms in PAC nursing notes and 2) to determine if appropriate non-pharmacological nursing interventions are included in their documentation when DSD is present. The sample (N=281) was drawn from a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve-DSD) across 8 facilities. Participants tended to be white, female, and had a high-school education. A total of 115 participants (40.6%) had full delirium per the CAM upon admission to PAC, while the remainder 168 (59.4%) had subsyndromal delirium. All had a baseline of dementia. Symptoms of ‘Confusion or Acute Confusion’ were reported for more than 50% of patients. Approximately 90% of had the symptom ‘Confusion or Acute Confusion’ documented and this was also the most commonly documented symptom for which a nursing-driven intervention was provided. Overall delirium symptoms and interventions were poorly documented by nurses. Implications for future research and practice include understanding how the pandemic and subsequent resource deprivations impacted delirium documentation and intervention in this setting. Also there is a need for expanded nurse and other healthcare provider education.

DELIRIUM-LIKE BEHAVIORAL SYMPTOMATOLOGY IN COMMUNITY-DWELLING OLDER ADULTS WITH DEMENTIA

Abstract Delirium, a sudden and acute confusional state, is known to be more prevalent and deleterious in older adults with dementia; yet the literature on estimates of delirium in community-dwelling older adults with dementia is scarce. The aim of this study was to determine the patterns and frequency of delirium-like symptoms in community-dwelling older adults with dementia, as reported by their caregivers (n=50) in a 21-day diary study (n=1389 diaries). Caregiver reports of severity scores of care-recipient behaviors that were one standard deviation above the mean were considered outliers, representing a sudden and acute change. Caregivers that reported outlier scores for two consecutive days were considered delirium-like symptoms. Descriptive statistics were used to determine the number of caregivers who reported delirium-like symptoms and the percentage of days with symptoms present. Additionally, chi-square tests and Independent samples T-test were used to determine the associations between delirium-like symptoms and participant characteristics. Caregivers were predominately White/Caucasian (89%), female (94%), and a son/daughter (60%) of the care-recipient. Caregivers had an average age of 52.6 years and were caregiving an average of 3.9 years. The care-recipients had dementia for an average of 4.3 years. Caregivers reported delirium-like symptoms for 12(24%) care-recipients and this rate was consistent with previous research findings. Caregivers reported delirium-like symptoms, on average, for 6.9 days (33%) of the 21-day diary period. More research is needed to understand the occurrence and patterns of delirium in community-dwelling older adults with dementia to improve home care services, outpatient services, and support for caregivers.

An Atypical Manifestation of Pheochromocytoma Crisis: Acute Delirium

Pheochromocytoma is a rare neuroendocrine tumor presenting with a classical triad of symptoms. In 10% of the cases the presentation can be atypical, and the diagnosis is often missed for several years. Most common neurological manifestations are haemorrhage, seizures, etc., but pheochromocytoma crisis presenting as delirium has been infrequently reported. We present a case of a middle-aged female who presented with hypertensive emergency and acute confusional state. Other causes of delirium were ruled out in the patient and a timely diagnosis of pheochromocytoma was made with CT abdomen showed a large right suprarenal mass which was confirmed on 123I-MIBG scan and supported by elevated plasma metanephrines. She responded to alpha and beta blockers following which her blood pressure spikes were controlled and subsequently her sensorium improved significantly. Patient underwent surgical resection of the tumor and was followed up after 2 weeks with her blood pressure controlled without any medications.

Delirium during COVID‑19: A report of eight cases and a review of the literature

Delirium is an acute confusional state, often associated with long‑term hospitalization, oxygen supplementation, the male sex and an older age. Since the start of the coronavirus disease 2019 (COVID‑19) pandemic, there was an abrupt increase in intensive care unit (ICU) admissions and hospitalization in general, as well as in the need for oxygen therapy and enforced isolation due to the contagion risk. This caused a sudden increase in the episodes of delirium. The diagnosis of delirium, however, remains a difficult task, as it can often be misdiagnosed or confused with underlying dementia, particularly among the elderly. The present study describes present eight cases of patients admitted to hospital due to severe acute respiratory syndrome coronavirus 2 infection, who manifested delirium. Notably, only one of the patients had psychiatric comorbidities prior to hospitalization. The most prevalent sex was the male (7:1) one, the mean age of the patients was 81.7±4 years, and the mean duration of hospitalization was 23.6±6 days. In total, 3 patients had a virological recovery and were discharged, 3 had a clinical recovery and were transferred to a lower intensity COVID‑19 facility and 2 patients did not survive. In the eight cases described herein, the mortality rate was 25%. Delirium was found to be commonly associated with a higher mortality rate and a longer hospitalization period. Therefore, it is imperative to develop protocols and tools with which to rapidly assess delirium and treat it accordingly. In addition, it is fundamental to improve the quality of life of hospitalized patients, supporting behavioral therapy and the environmental factors that can affect patients, to prevent delirium as well.

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis.

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed. The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective. The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases. Surgical wards, surgical intensive care units, and post-anaesthesia care units. A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase. Registered nurses and licensed practical nurses (n=105) participated in the fieldwork phase. In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported. The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care. In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

Using virtual reality to educate healthcare professionals on patients’ experience of delirium

Delirium is an acute onset confusion that has fluctuating consciousness symptoms such as hallucinations, mood changes and distractibility. It is experienced by around 2 in 10 patients within the hospital [1]. Amongst these patients, 96% are older adults and their outcomes are consistently worse due to the delirium alone, including increased mortality rates [2]. It can also be extremely frightening and distressing. Hence, the attitudes and knowledge of healthcare professionals surrounding delirium is an important topic to address in order to aid prevention as well as manage delirium. Despite training, delirium is under reported and generally poorly managed. Studies have found that the use of virtual reality in medical education has improved empathy, depth of knowledge, and self-awareness [3]. Using a 360° camera and virtual reality headsets, an in-patient scenario was created whereby the effects of delirium such as hallucinations and disorientation were depicted. The aim of the project was to establish whether virtual reality can be used to improve healthcare professionals understanding and awareness of patients’ experience of delirium. The virtual reality video and the interviews can be found on YouTube. Eight people were recorded using the VR and five of them were interviewed afterwards. The interviews were conducted using an unstructured approach in which the topics of how the virtual reality tool changed their perception of dementia, what they learnt from the tool, and whether they thought the tool was useful, were discussed. Thematic analysis was carried out retrospectively. The thematic analysis of the qualitative data highlighted four key themes amongst the healthcare professionals’ responses. These themes were education, insight, empathy, and future practice. The most common theme was insight, with comments such as ‘having the virtual reality, it breaks that barrier between you and them,’ ‘you realise how just isolated that person is,’ and how the virtual reality made them feel like they are ‘in the room,’ emphasising this theme. The outcome has been to prove concept and highlight the usefulness of virtual reality as a method of educating healthcare professionals. We have been emboldened by the feedback received. We are looking to incorporate the VR film as part of a broader simulation-based training. The training is already being adopted by local clinical teams and our local university partners. 1. Combined NHS (National Health Service). Delirium Training Video (Virtual Reality). 2022. 2. Royal College of Nursing. Delirium | Older people | Royal College of Nursing. The Royal College of Nursing. 2013. 3. Dyer E, Swartzlander BJ, Gugliucci MR. Using virtual reality in medical education to teach empathy. Journal of the Medical Library Association. 2018;106(4):498–500.

Simulation for preceptee physiotherapists readiness to practise

The COVID-19 pandemic has significantly impacted the clinical placement experiences of undergraduate Physiotherapists [1], many of whom started working as preceptee Physiotherapists shortly after qualifying in 2021. Consequently, it was important to provide training in the key skills required to work within an acute inpatient setting to preceptee Physiotherapists starting at an acute NHS Trust in 2021. A one-day simulation course was developed to expose preceptees to common scenarios occurring in clinical practice to increase their confidence in managing these situations. Six simulation courses were delivered with 22 preceptees each attending a single course. The course started with a group tactical decision exercise to develop caseload management skills. Participants took part in a simulated multidisciplinary team (MDT) ward handover and were provided the opportunity to gather more information from MDT colleagues, simulated medical notes, and admission systems to help them prioritise their simulated caseload. Participants then used this information to make decisions regarding the prioritisation of their simulated workload. The influence of information on participants’ decision-making was then discussed. Participants subsequently undertook five high-fidelity scenarios in pairs; examining themes of discharge planning, managing an unwitnessed fall, the acutely unwell patient, conflict resolution, and acute confusion management. Each scenario was followed by a faculty-led debriefing to facilitate learning through discussion and reflection. Participants completed a self-rating questionnaire based on the 5-point perceived self-efficacy scale before and after course attendance. It evaluated confidence and competence in aspects of inpatient care. Overall self-rated confidence and competence improved post-course in all question categories. Significant differences (R>0.5) were seen for self-rated confidence in managing a ward handover (1.2), prioritising daily workload (0.6), communicating with the multidisciplinary team (0.6), communicating with patients and relatives (0.6), and responding to unpredictable workload and environments (1.2). Significant differences were also seen for self-rated competence in managing a ward handover (0.9), prioritising a daily workload (0.5), and responding to unpredictable workload and environments (0.8). Free text analysis of participants’ course key learning points identified themes surrounding confidence in own abilities, escalation, and communication. Simulation-based training was effective in enhancing confidence for preceptee Physiotherapists in managing aspects of acute inpatient care. Further work is required to establish its utility in addressing competence. The development of preceptee simulation training for multi-professional groups is also required. For 2022, a joint Physiotherapy and Occupational Therapy preceptee induction simulation course is planned. 1. Gough S, Orr R, Stirling A, Raikos A, Schram B, Hing W. Health Sciences and Medicine Education in Lockdown: Lessons Learned During the COVID-19 Global Pandemic. In Nestel D, Reedy G, McKenna L, Gough S. Clinical education for the health professions: theory and practice. Springer; 2021.

Mishel's uncertainty in illness theory: Informing nursing diagnoses and care planning.

Patients with glioblastoma multiforme (GBM) face uncertainty during the illness trajectory that decreases their quality of life. Uncertainty manifests as an altered state of mind in patients with GBM and increases the burden of managing their diagnosis. The uncertainty in illness theory (UIT) can be used to guide nursing practice and create care plans to decrease this uncertainty. The UIT and conceptual model were used to pair diagnoses from NANDA-I Nursing Diagnoses to form care plans for patients with GBM. In a stepwise approach, concepts from the UIT were organized and cross-walked into an integrated theory-driven practice framework to enhance care planning. The UIT helps define and identify circumstances of uncertainty in patients experiencing illness, and Nursing Diagnoses provide engagement and outcomes for those uncertainty-based diagnoses. Some examples of the UIT guiding Nursing Diagnoses includes a patient's cognitive level guiding a Nursing Diagnosis care plan of Risk for Acute Confusion. Social Support can guide the care plan of Risk for Loneliness, and appraisal of uncertainty can guide a care plan for Ineffective Individual Coping. Using the UIT to guide theory-driven practice links interventions and outcomes in patients with GBM. The UIT can guide NANDA-I Nursing Diagnoses to assist nurses in creating a nursing care plan for nursing engagement to decrease uncertainty and increase the quality of life in patients with GBM. Theory-driven research defines the application of the UIT in GBM and provides foundational knowledge for theory-driven practice to occur.

Ertapenem-induced neurotoxicity in an end-stage renal disease patient on intermittent haemodialysis: a case report

BackgroundCarbapenem-induced neurotoxicity is an unusual side effect, with seizure being the most commonly reported symptom. Among the carbapenems, imipenem-cilastin is classically associated with the most severe neurotoxicity side effects. Carbapenem is mainly excreted by the kidney and its half-life is significantly increased in patients with chronic kidney disease (CKD). Therefore, dose adjustment is necessary in such patients. Ertapenem-associated neurotoxicity is increasingly being reported in CKD patients, but rarely seen in patients with recommended dose adjustment.Case presentationWe report a case of a 56-year-old male patient with chronic kidney disease 5 on dialysis(CKD 5D). The patient presented with a history of fever, chills and rigours during a session of haemodialysis (HD). He was diagnosed with Enterobacter cloacae catheter-related blood stream infection and was started on ertapenem. After 13 days of ertapenem, he experienced an acute confusional state and progressed to having auditory and visual hallucinations. His blood investigations and imaging results revealed no other alternative diagnosis. Hence a diagnosis of ertapenem-induced neurotoxicity was made. He had complete resolution of symptoms after 10 days’ discontinuation of ertapenem.ConclusionOur case draws attention to the risk of potentially serious toxicity of the central nervous system in HD patients who receive the current recommended dose of ertapenem. It also highlights that renal dosing in CKD 5D patients’ needs to be clinically studied to ensure antibiotic safety.

Rare presentation of Waldenström’s macroglobulinaemia requiring bilateral above-knee amputations: a case report

BackgroundWaldenström’s macroglobulinaemia is a rarely encountered B-lymphocytic malignancy. Waldenström’s macroglobulinaemia-associated paraproteinaemia is linked to an increase in serum viscosity, which results in a hypercoagulable state. Burning bilateral foot pain in a man with alcohol dependence and controlled atrial fibrillation presenting to the emergency department was attributed to peripheral neuropathy, given satisfactory angiographic evidence of bilateral foot arterial blood supply. Subsequently, his presentation as an emergency with acute bilateral critical lower limb ischemia that was managed by bilateral above-knee amputations, prompted a wider search for other etiologies. We present a hitherto unreported case of Waldenström’s macroglobulinaemia-related acute bilateral lower limb ischemia, which required bilateral above-knee amputations.Case presentationA 50-year-old Caucasian man, who was an alcohol dependent heavy smoker, presented with burning pain in his right foot that was deemed to be related to alcoholic neuropathy. A computerized tomographic angiogram demonstrated an occluded right distal anterior tibial artery but a patent posterior tibial artery supplying the foot arch, findings that were associated with noncritical ischemia. After multiple presentations within a week, he was admitted following sudden clinical deterioration with acute confusion, hyponatremia, and bilateral foot pain. Over the course of 24 hours, the patient deteriorated rapidly, with bilateral lower limb ischemia requiring bilateral above-knee amputations. Subsequent investigations revealed a diagnosis of Waldenström’s macroglobulinaemia.ConclusionsTo the best of our knowledge, this is the only reported case of Waldenström’s macroglobulinaemia-induced bilateral lower limb ischemia requiring major bilateral amputations.

ODP015 "Malignant" Hypertension in an Older Male

Abstract Background Malignant hypertension connotates extreme elevation of blood pressure with associated acute target organ injury. Secondary causes of hypertension should always be considered in patients presenting with acute organ dysfunction especially when the hypertension is also resistant. Clinical case: A 66-year-old male was transferred to our hospital after two successive admissions to a local hospital with acute confusion. Importantly, he was noted to have acute kidney injury and hypokalemia in the course of those admissions. On review of his records, it was noted that he had been evaluated recently for chest pain with a contrast enhanced chest CT which incidentally detected a left adrenal mass. Biopsy of the mass had been performed and returned positive for adrenocortical carcinoma. Past history was also notable for chronic hypertension, type 2 diabetes and hypothyroidism for which he was on appropriate therapy. On physical examination, the patient was noted to be hypertensive. Other pertinent findings included facial plethora, extensive bruising and supraclavicular fat pad fullness. Abdominal striae were not seen. Laboratory investigations showed hyperglycemia (glucose: 201 mg/dL), hypokalemia (potassium: 3. 0 mmol/L) and metabolic alkalosis (bicarbonate: 30 mmol/L). Endocrine work up showed suppressed aldosterone (<4. 0 ng/dL, n: <21 ng/dL), total testosterone (31 ng/dL, n: 240-950 ng/dL) and ACTH (<5. 0 pg/mL, n: 7.2-63 pg/mL). Dehydroepiandrosterone (474 mcg/dL, n: 12-227 mcg/dL) and androstenedione (219 ng/dL, n: 40-150 ng/dL) levels were elevated. Cortisol levels did not suppress with overnight dexamethasone suppression test (29.8 mcg/dL). A diagnosis of Cushing's syndrome secondary to adrenocortical carcinoma was made. The patient was initiated on chemotherapy with carboplatin and etoposide. He was planned for mitotane therapy but passed away unexpectedly before the drug could be arranged. Conclusion Adrenocortical carcinoma can present with rapid onset of Cushingoid symptoms as well as sudden decompensation of previously controlled chronic hypertension, both of which were seen in this case. Although relatively uncommon, it remains a treatable and yet deadly cause for secondary hypertension, and should be considered in the appropriate clinical and biochemical settings. Presentation: No date and time listed

Donepezil treatment is associated with improved outcomes in critically ill dementia patients via a reduction in delirium.

During hospital admissions, patients with dementia are at risk for developing delirium, an acute state of brain failure associated with significant morbidity. There are currently no pharmacologic tools to treat or prevent delirium. Decreased cholinergic signaling plays a role in the pathophysiology of both disorders. Whether enhanced pre-hospital cholinergic signaling in patients with dementia improves outcomes during critical illness remains unknown. We utilized the Medical Information Mart for Intensive Care III (MIMIC-III) database to determine whether pre-hospital donepezil use was associated with improved outcomes during critical illness in dementia patients. We identified 2734 subjects with dementia admitted to the intensive care unit (ICU; 447 received donepezil). After adjusting for confounders, patients with dementia who were receiving donepezil had a significantly reduced in-hospital and 90-day mortality, ICU length of stay, and duration of mechanical ventilation. Donepezil use was associated with, and its benefit was mediated by, reduced delirium. Patients with dementia who are treated with donepezil have improved outcomes during critical illness and reductions in delirium. No pharmacologic treatments exist to reduce delirium in patients with dementia. Donepezil improves outcomes during critical illness in patients with dementia. Improved outcomes are mediated by a reduction in hospital delirium. Future studies in patients with dementia should prospectively evaluate donepezil in the prevention of delirium.

Early onset delirium incidence and risk factors in hematology oncology patients admitted to the intensive care unit: A retrospective cohort study.

Delirium occurs frequently in intensive care unit (ICU) patients; however, there are limited data evaluating its impact on critically ill hematology-oncology patients. We aimed to determine the incidence and risk factors for early-onset delirium development in hematology-oncology patients admitted to the ICU. This single-center, retrospective cohort study evaluated the primary outcome of incident delirium within 7 days of ICU admission in adults admitted to the hematology-oncology medical or surgical ICU. Patients with delirium (DEL) were compared to those without (No-DEL) for evaluation of secondary endpoints including hospital mortality, ICU, and hospital length of stay (LOS). Multivariable logistic regression modeling was performed to identify independent risk factors for delirium. Delirium occurred in 125 (51.2%) of 244 patients. Inhospital mortality was significantly higher in the DEL vs. No-DEL group (32.8% vs. 15.1%, P = 0.002). Median (1st and 3rd quartiles) ICU and hospital LOS were significantly longer in the delirium group, respectively (6 [4-10] days vs. 3 [2-5] days, P < 0.001, and 21 [14-36] days vs. 12 [8-22] days, P < 0.001). Higher Sequential Organ Failure Assessment score, high-dose corticosteroids, mechanical ventilation (MV), and brain metastases were each independently, associated with an increased delirium risk. Hematology-oncology patients admitted to the ICU frequently develop delirium. Consistent with literature in nonhematology-oncology critically ill patients, identified independent risk factors for delirium were MV and organ dysfunction. Risk factors unique to the critically ill hematology-oncology patient population include high-dose corticosteroids and brain metastases. Further research is needed to evaluate strategies to mitigate delirium development in this population based on risk assessment.

Losing passion and injured self-image: An interpretive description study of troubled conscience among registered nurses caring for older people with delirium in hospital

BackgroundNurses caring for older people with delirium in hospitals often report stressful situations that trouble their conscience and threaten their wellbeing in the workplace. These situations are yet to be explored to gain a deeper understanding of troubled conscience when nurses are involved in care below expected professional standards or their personal values. AimThe purpose of this Interpretive Descriptive study was to explore the troubled conscience amongst nurses caring for older people with delirium in hospital. MethodThe study was conducted at a regional health service with 250 acute in-patient hospital beds in Victoria, Australia. Using Thorne's (2016) approach to Interpretative Description (ID) allowed the results to be authentic and applicable to the nursing profession. To extend the understanding of the data, thematic networks were generated. FindingsThe global theme that illuminated troubled conscience was ‘losing passion and injured self-image.’ The nurses were losing passion and had their self-image compromised because they struggled to hold congruence between their ideal self and their actual self in their workplace. The organising themes were an inability to execute care to personal satisfaction, being incapacitated and constrained by the workplace environment, being involved in negligent care and misconduct, feeling powerless and hopeless and seeking fulfilment and contentment. ConclusionRe-conceiving the meaning of humane caring in nursing, empowering nurses’ voices, avoiding perceived negligent care and misconduct, as well as practising self-care through debriefing and physical exercise potentially reduces troubled conscience. This study is a step towards greater understanding of the phenomenon and interventions to support nurses’ passion, self-image, and integrity in their workplaces.

Этикетная речевая стратегия в испанском дипломатическом дискурсе

The article is devoted to the study of the ethical speech strategy in the Spanish diplomatic discourse. The article deals with the functioning of speech strategy in Spanish diplomatic documents. The relevance of the study is due to the importance of studying of the speech impact on the addressee of the communication. Particular attention is paid to the theoretical aspects. The article gives an overview of the concepts of «speech genre», «speech strategy», «ethical genres». The subject of study are the texts of diplomatic documents of the Spanish Ambassador to Russia, Duke de Liria during the reign of Emperor Peter II and Empress Anna Ioannovna. The Duke de Liria ethical speech strategy involves numerous areas of silence about the most important historical events of Russia during this period, which is evidence of the modality of persuasion of the addressee in the absence of active domestic political life in the country and the formation of public opinion in accordance with the goal, the conclusion of a treaty between Russia and the Holy Roman Empire. The author of the article shows that modern ethical speech strategies of the Spanish diplomatic discourse also exist mainly in the modality of persuasion, today they use a large arsenal of means to achieve this goal, which includes repetition, synonymous series and periphrastic constructions, outdated words and expressions, which gives the right to speak about a high degree of conservatism of ethical speech strategies in the Spanish political discourse. The author of the article concludes that etiquette speech strategies on the one hand reflect global trends, on the other hand, demonstrate a high commitment to national principles of diplomatic documents construction.

Recipe for primary prevention of delirium in hospitalized older patients.

Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.