Early Recognition Of Delirium Research Articles

Development of a Prediction Model for Delirium in Hospitalized Patients with Advanced Cancer.

Delirium is a common neurocognitive disorder in patients with advanced cancer and is associated with poor clinical outcomes. As a potentially reversible phenomenon, early recognition of delirium by identifying the risk factors demands attention. To develop a model to predict the occurrence of delirium in hospitalized patients with advanced cancer. This retrospective study included patients with advanced cancer admitted to the oncology ward of four tertiary cancer centers in Korea for supportive cares and excluded those discharged due to death. The primary endpoint was occurrence of delirium. Sociodemographic characteristics, clinical characteristics, laboratory findings, and concomitant medication were investigated for associating variables. The predictive model developed using multivariate logistic regression was internally validated by bootstrapping. From January 2019 to December 2020, 2,152 patients were enrolled. The median age of patients was 64 years, and 58.4% were male. A total of 127 patients (5.9%) developed delirium during hospitalization. In multivariate logistic regression, age, body mass index, hearing impairment, previous delirium history, length of hospitalization, chemotherapy during hospitalization, blood urea nitrogen and calcium levels, and concomitant anti-depressant use were significantly associated with the occurrence of delirium. The predictive model combining all four categorized variables showed the best performance among the developed models (area under the curve 0.831, sensitivity 80.3%, and specificity 72.0%). The calibration plot showed optimal agreement between predicted and actual probabilities through internal validation of the final model. We proposed a successful predictive model for the risk of delirium in hospitalized patients with advanced cancer.

Non-pharmacological Management of Postoperative Delirium

Postoperative delirium is common especially in the elderly and is associated with high rates of morbidity and mortality. Non-pharmacological multicomponent interventions are effective in reducing the incidence and to a degree the duration of postoperative delirium and are recommended in international guidelines on postoperative delirium as first line intervention for management of delirium. Non-pharmacological management of postoperative delirium consists of strategies for risk stratification, risk reduction by non-pharmacological bundle interventions, early recognition of delirium by screening protocols and immediate therapy of underlying causes of delirium and continuation of non-pharmacological bundles. Non-pharmacological bundle interventions address common perioperative risk factors. Bundles comprise strategies for oxygenation, mobilization, hydration and nutrition, sensory and cognitive stimulation, reorientation, modifications of environmental factors such as design aspects and noise reduction, adequate analgesia, management of agitation and anxiety, protecting circadian rhythms for example by adequate light exposure during daytime, family involvement and timely reduction of unnecessary catheters and anticholinergic drugs. The article aims at providing an overview of non-pharmacological management of postoperative delirium in the hospital.

Inclusion of frailty improved performance of delirium prediction for elderly patients in the cardiac intensive care unit (D-FRAIL): A prospective derivation and external validation study

BackgroundThe elderly patients admitted to cardiac intensive care unit (CICU) are at relatively high risk for developing delirium. A simple and reliable predictive model can benefit them from early recognition of delirium followed by timely and appropriate preventive strategies. ObjectiveTo explore the role of frailty in delirium prediction and develop and validate a delirium predictive model including frailty for elderly patients in CICU. DesignA prospective, observational cohort study. SettingsCICU at China–Japan Friendship Hospital from March 1, 2022 to August 25, 2022 (derivation cohort); CICU at Beijing Anzhen Hospital affiliated to Capital Medical University from March 14, 2023 to May 8, 2023 (external validation cohort). ParticipantsA total of 236 and 90 participants were enrolled in the derivation and external validation cohorts, respectively. Participants in the derivation cohort were assigned into either the delirium (n = 70) or non-delirium group (n = 166) based on the occurrence of delirium. MethodsThe simplified Chinese version of the Confusion Assessment Method for the Diagnosis of Delirium in the Intensive Care Unit was used to assess delirium twice a day at 8:00–10:00 and 18:00–20:00 until the onset of delirium or discharge from the CICU. Frailty was assessed using the FRAIL scale during the first 24 h in the CICU. Other possible risk factors were collected prospectively through patient interviews and medical records review. After processing missing data via multiple imputations, univariate analysis and bootstrapped forward stepwise logistic regression were performed to select optimal predictors and develop the models. The models were internally validated using bootstrapping and evaluated comprehensively via discrimination, calibration, and clinical utility in both the derivation and external validation cohorts. ResultsThe study developed D-FRAIL predictive model using FRAIL score, hearing impairment, Acute Physiology and Chronic Health Evaluation-II score, and fibrinogen. The area under the receiver operating characteristic curve (AUC) was 0.937 (95% confidence interval [CI]: 0.907–0.967) and 0.889 (95%CI: 0.840–0.938) even after bootstrapping in the derivation cohort. Inclusion of frailty was demonstrated to improve the model performance greatly with the AUC increased from 0.851 to 0.937 (p < 0.001). In the external validation cohort, the AUC of D-FRAIL model was 0.866 (95%CI: 0.782–0.907). Calibration plots and decision curve analysis suggested good calibration and clinical utility of the D-FRAIL model in both the derivation and external validation cohorts. ConclusionsFor elderly patients in the CICU, FRAIL score is an independent delirium predictor and the D-FRAIL model demonstrates superior performance in predicting delirium.

‘It’s tough. It is hard’: A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

Background: Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. Aim(s): To explore hospice staff and volunteers’ practice, its influences and what may need to change to improve hospice delirium care. Design: Qualitative interview study using behaviour change theory from a critical realist stance. Setting/participants: Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. Results: We found that participants’ practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers’ emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. Conclusions: Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff’s emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

Abstract 14220: Incidence of Delirium After Transcatheter Aortic Valve Replacement

Introduction: Patients who undergo transcatheter aortic valve replacement (TAVR) often are elderly, frail and with comorbid conditions. Delirium is frequently encountered in older adults and is associated with increased morbidity and mortality. Hypothesis: The purpose of this study is to determine the clinical significance of postoperative delirium in patients with aortic stenosis undergoing TAVR. Methods: The National Inpatient Sample was queried from 2011-2019 for relevant ICD-9 and ICD-10 codes to identify patients who underwent TAVR. Baseline characteristics and in-hospital outcomes between patients with and without delirium were compared. Logistic regression was performed to adjust for pre-specified co-variates for mortality and other in-hospital outcomes. p-value was considered significant when &lt;0.001. Results: We identified a weighted sample of 270,178 patients who underwent TAVR, of which 5,059 (1.9%) had a diagnosis of delirium. Baseline characteristics are shown in Table 1. Patients who had delirium after TAVR had a higher mortality risk (3% vs 1.8%), had a longer LOS (median 7 vs 3 days) and higher expenditures (median $220,046 vs $179,166, p&lt;0.001 for all). When adjusted for significant comorbidities, the odds ratio (OR) for mortality was 1.303 (CI [1.1-1.5]) with a LOS OR of 1.065 (CI [1.062-1.068], p&lt;0.001 for both. Conclusions: Delirium after TAVR is associated with higher in-hospital mortality, prolonged hospital stay and higher hospital expenditures. A structured approach focused on prevention and early recognition of delirium may be warranted.

Pediatric Delirium: a Review of Current Diagnosis and Management in the Intensive Care Setting

We describe preventative management, current screening tools, and treatment strategies for pediatric intensive care unit (PICU) delirium. While there is ongoing research regarding medication efficacy for the treatment of delirium, there has been an increased emphasis on screening and prevention strategies. PICU delirium is an underappreciated diagnosis that is associated with increased morbidity and increased length of stay. Strategies to minimize risk of delirium, early recognition of delirium, and mitigation strategies combined with education and engagement of both medical staff and families are of utmost importance. Identification of efficacious medications for the treatment of delirium is ongoing.

Early Recognition of Delirium and Delirium Biomarkers in Adults After Cardiac Surgery.

Early Recognition of Delirium and Delirium Biomarkers in Adults After Cardiac Surgery.

Prevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines.

Delirium is an acute, confusional state characterized by altered consciousness and a reduced ability to focus, sustain, or shift attention. It is associated with a number of complex underlying medical conditions and can be difficult to recognize. Many critically ill patients (e.g., up to 80% of patients in the intensive care unit [ICU]) experience delirium due to underlying medical or surgical health problems, recent surgical or other invasive procedures, medications, or various noxious stimuli (e.g., underlying psychological stressors, mechanical ventilation, noise, light, patient care interactions, and drug-induced sleep disruption or deprivation). Delirium is associated with a longer duration of mechanical ventilation and ICU admittance as well as an increased risk of death, disability, and long-term cognitive dysfunction. Therefore, the early recognition of delirium is important and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management. This review presents a brief overview of delirium and an update of the literature with reference to the 2018 Society of Critical Care Medicine Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Delirium? What Does This Have to Do With Preop or PACU? Increasing Perianesthesia Nursing Role Awareness to Increase Prevention and Early Recognition of Delirium in the Geriatric Surgical Patient

Delirium? What Does This Have to Do With Preop or PACU? Increasing Perianesthesia Nursing Role Awareness to Increase Prevention and Early Recognition of Delirium in the Geriatric Surgical Patient

Early Delirium Assessment for Hospitalized Older People in Indonesia: A Systematic Review

Background : Due to the increasing risk of getting co-morbidity and frailty, older people tend to be prone to hospitalization. Hospitalization in older people brings many adverse effects. Moreover, when these elderly get delirium, the mortality and morbidity will increase. The risk of getting deterioration and worsening condition because of delirium would also increase. In fact, delirium assessment is not a high priority in taking care older people during hospitalization because the focus of care is treating the disease.Delirium screening as an early recognition of delirium in the hospitalized elderly inIndonesia remains unreported and even do not well evaluated. Therefore, delirium as a preventable problem or causing problems remains unrecognized. Purpose : This paper aims to review the current evidence of early assessment of delirium in hospitalized older people. Methods : A systematic review was conducted from four databases yielding to 4 articles which met the inclusion and exclusion criteria. Results : There are four focuses on the result, namely delirium screening tools, patient characteristics, identified early delirium assessment, and outcomes affected by early delirium assessment. Confusion Assessment Method (CAM) was used as the delirium screening tool in the hospital. Establishing the care team involving many disciplines will give a better way to improve the integrated care and collaborative care. Conclusion : Performing CAM integrated into comprehensive geriatric assessment can be the most important thing to be undertaken when looking after the hospitalized elderly.

Early Delirium Assessment for Hospitalized Older People in Indonesia: A Systematic Review

Background : Due to the increasing risk of getting co-morbidity and frailty, older people tend to be prone to hospitalization. Hospitalization in older people brings many adverse effects. Moreover, when these elderly get delirium, the mortality and morbidity will increase. The risk of getting deterioration and worsening condition because of delirium would also increase. In fact, delirium assessment is not a high priority in taking care older people during hospitalization because the focus of care is treating the disease.Delirium screening as an early recognition of delirium in the hospitalized elderly inIndonesia remains unreported and even do not well evaluated. Therefore, delirium as a preventable problem or causing problems remains unrecognized. Purpose : This paper aims to review the current evidence of early assessment of delirium in hospitalized older people. Methods : A systematic review was conducted from four databases yielding to 4 articles which met the inclusion and exclusion criteria. Results : There are four focuses on the result, namely delirium screening tools, patient characteristics, identified early delirium assessment, and outcomes affected by early delirium assessment. Confusion Assessment Method (CAM) was used as the delirium screening tool in the hospital. Establishing the care team involving many disciplines will give a better way to improve the integrated care and collaborative care. Conclusion : Performing CAM integrated into comprehensive geriatric assessment can be the most important thing to be undertaken when looking after the hospitalized elderly.

Early recognition of delirium in trauma patients

Evaluate change in practice and beliefs regarding delirium among nurses, pharmacists, respiratory therapists and physicians in a trauma intensive care unit. Descriptive pre and post-design at a Level One Trauma Center. Education on causes of delirium, risk factors, strategies to prevent delirium and routine screening. Change in practice and beliefs regarding delirium. McNemars test measured the differences between pre- and post-questionnaires comparing the proportion of staff changed their responses in one direction to those who went in the opposite direction. Changes in "Delirium is largely preventable", were statistically significant (p=0.035). Haldol was the medication of choice for treating delirium, with an increase in use (p=0.062) post-intervention. The majority of participants believed a high percentage of patients experience delirium in a trauma intensive care. The two most frequent medical complications associated with delirium pre-questionnaire was over sedation 8 (22%) and falls 9 (24%) and in post-questionnaire, over sedation 12 (26%) and falls 13 (28%). An educational intervention emphasising the importance of screening for delirium, risk factors for delirium and approaches to decrease the incidence of delirium can improve identifying and correctly treating delirium in a critical care setting. An educational program had concrete results in respondents' knowledge about delirium.

Family Caregivers' Knowledge of Delirium and Preferred Modalities for Receipt of Information.

Delirium is a life-threatening, frequently reversible condition that is often a sign of an underlying health problem. In-hospital mortality alone for older adults with delirium ranges from 25% to 33%. Early recognition of delirium is critical because prolonged duration poses a greater risk of poor functional outcomes for older adults. Family caregivers, who are familiar with the older adult's usual behaviors, are most likely to recognize delirium symptoms but might dismiss them as due to aging. It is important to learn what family caregivers know about delirium to ascertain their need for education. The aims of this study were to describe family caregivers' knowledge of delirium and preferred modalities for receipt of information about delirium. A cross-sectional design was used for this study and a survey distributed to family caregivers for older adults. Analysis of 134 usable surveys indicated that family caregivers need and want information about delirium. The preferred modalities for receipt of information included Internet, in-person classes, and newsletters.

Educational Interventions to Improve Recognition of Delirium: A Systematic Review

Delirium is a common and serious condition that is underrecognized in older adults in a variety of healthcare settings. It is poorly recognized because of deficiencies in provider knowledge and its atypical presentation. Early recognition of delirium is warranted to better manage the disease and prevent the adverse outcomes associated with it. The purpose of this article is to review the literature concerning educational interventions focusing on recognition of delirium. The Medline and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases were searched for studies with specific educational focus in the recognition of delirium, and 26 studies with various designs were identified. The types of interventions used were classified according to the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, and outcomes were sorted according to Kirkpatrick's hierarchy. Educational strategies combining predisposing, enabling, and reinforcing factors achieved better results than strategies that included one or two of these components. Studies using predisposing, enabling, and reinforcing strategies together were more often effective in producing changes in staff behavior and participant outcomes. Based on this review, improvements in knowledge and skill alone seem insufficient to favorably influence recognition of delirium. Educational interventions to recognize delirium are most effective when formal teaching is interactive and is combined with strategies including engaging leadership and using clinical pathways and assessment tools. The goal of the current study was to systematically review the published literature to determine the effect of educational interventions on recognition of delirium.

Implementing the best available evidence in early delirium identification in elderly hip surgery patients

Delirium is a frequent complication in the surgical experience of elderly hip surgery patients. Its impact can be severe and may even include death. Implementation of a delirium predictor tool might focus attention on early recognition of delirium, thereby potentially decreasing its impact. A related aim is to evaluate best practices in implementation strategies in this project. After an exhaustive search of the literature, no consensus was found regarding delirium predictors for the elderly hip surgery patient. A local research study was implemented to determine factors that may predict delirium in this population. With evidence secured, a multidisciplinary implementation project augmented by ongoing audit was instituted. A variety of social diffusion and education tools were used. Implementation was guided by the use of the Promoting Action on Research Implementation in Health Services framework assessment tool and the Alberta Context Tool, as well as traditional performance improvement tools, such as fishbone charting. Audit identified the rate of use of the predictor tool and pre- and post-rates of delirium. This project was part of the Joanna Briggs Institute Signature Project, an implementation project consisting of six teams, each representing a different organisation. This overall project was supported by experts in the field of translation and implementation science internationally. Initial compliance to the use of the predictor tool was assessed at 54% within 3 months of implementation and increased to 56% in the ensuing months. Before the study use of the predictor tool, the delirium rate was 10.4% (12 of 115 patients). An interim analysis 4 months after implementation identified a 20% delirium rate (18 of 70 patients) and an updated analysis 8 months into the project showed a 16.3% delirium rate. Delirium predictor tool use was associated with a lower delirium rate (9/76, 11.84%) than no delirium predictor tool (13/60, 21.67%), but the difference was not statistically significant with a sample size of 133 (P = 0.122). The delirium predictor tool shows promise as a prompt for best practices in prevention of delirium. This study showed a change in delirium rates as a result of its use. Although the results were not statistically significant, they may be clinically meaningful. Comprehensive assessment and implementation planning by a multidisciplinary team contributed to only 56% compliance in use. Despite this low rate, delirium identification rates were higher.

Diagnostic Accuracy of a Rapid Checklist to Identify Delirium in Older Patients Transported by EMS

Background. The presence of delirium in elderly patients is common and has been identified as an independent marker for increased mortality and hospital-acquired complications, yet it is poorly recognized by health care providers. Early recognition of delirium in the prehospital setting has the potential to improve outcomes, but is not feasible without valid assessment tools. Objective. To determine whether use of a rapid delirium checklist by prehospital providers is a valid way to identify cases of delirium compared with a criterion standard and whether the checklist is better at identifying delirium than the Glasgow Coma Score (GCS). Methods. We conducted a prospective study at two academic, tertiary-care emergency departments (EDs) where a convenience sample of matched dyads of emergency medical services providers and elderly patients (age ≥65 years) were enrolled. Prehospital providers reported limited demographics and work history about themselves. They also reported vital signs and GCS for each patient and completed the checklist asking about presence of the four features of delirium. The patient then underwent a cognitive assessment using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by a trained investigator, which was used as the criterion standard. Criterion validity and concurrent validity of the delirium checklist and abnormal GCS were evaluated using sensitivity and specificity. Results. Two hundred fifty-nine matched dyads were studied. Delirium occurred in 24 (9%) of the elderly patients sampled. Prehospital providers’ recognition of any delirium symptom resulted in a sensitivity of 0.63 (95% confidence interval [CI] 0.43–0.79) and a specificity of 0.74 (95% CI 0.73–0.84). Prehospital report of a GCS <15 has a sensitivity of 0.67 (95% CI 0.47–0.82) and a specificity of 0.85 (95% CI 0.80–0.89). Conclusions. A rapid delirium checklist can identify 63% of patients with delirium, but performed no better than the GCS. Future research should determine whether a rapid test of cognition improves early identification of elderly patients with delirium. Key words: elderly; delirium; checklist; emergency medical services

Risk Factors of Delirium after Cardiac Surgery: A Systematic Review

Delirium or acute confusion is a temporary mental disorder that occurs frequently among hospitalized elderly patients, but also in younger patients a delirium can develop. Patients who undergo cardiac surgery have an increased risk of developing delirium that is associated with many negative consequences. Therefore, prevention of delirium is essential. Despite the high incidence of delirium, a paucity of data on risk factors for delirium exists. The aim of this study was to summarize the available information concerning these risk factors. A literature research was performed using the PubMed, Cinahl, and Cochrane Library databases and was limited to the last 10 years. Our review revealed 27 risk factors; 12 predisposing and 15 precipitating factors for delirium after cardiac surgery. The most established predisposing risk factors were atrial fibrillation, cognitive impairment, depression, history of stroke, older age, and peripheral vascular disease. The most established precipitating risk factor was a red blood cell transfusion. An abnormal albumin level was reported as the most established precipitating risk factor among blood values tested. A low cardiac output and the use of an Intra Aortic Balloon Pump or inotropic medication seem to be the most relevant risk factors associated with a postoperative delirium. A multifactorial risk model should be applied to identify patients at an increased risk of developing delirium following elective cardiac surgery. In these patients, if possible, preventative interventions can be taken and early recognition of delirium can be realized. This could potentially decrease the incidence of delirium and negative consequences caused by a postoperative delirium.

Promoting Safety in the Cardiac Intensive Care Unit

Patient safety is an overarching theme inherent in hospital care. The aging of the population increases the potential for serious consequences from a lapse in safety. Educating intensive care unit nursing team members in early recognition of delirium and other fall risk factors can improve patient safety outcomes. The geriatric resource nurse model was used to achieve a reduction in falls through standardized delirium screening and implementation of fall prevention strategies.

The Long-Term Cognitive and Functional Outcomes of Postoperative Delirium After Cardiac Surgery

Delirium or acute confusion is a temporary mental disorder, which occurs frequently among hospitalized elderly patients. Patients who undergo cardiac surgery have an increased risk of developing delirium. This is associated with many negative consequences such as prolonged hospital stay, nursing home placement, and reduced cognitive and functional recovery. In this prospective follow-up study, a questionnaire was used 1 to 1.5 years after cardiac surgery in our earlier cohort of 112 patients who underwent elective cardiac surgery, of which 24 patients (21%) developed postoperative delirium as diagnosed by a single psychiatrist. Postoperative delirium after cardiac surgery may be associated with increased mortality (12.5% in patients with delirium versus 4.5% in patients without delirium; p = 0.16), more readmissions to the hospital (47.6% vs 32.6%; p = 0.19), dysfunction in memory (31.6% vs 22.6%; p = 0.39), and concentration problems (36.8% vs 20.2%; p = 0.13); and is associated with sleep disturbance (47.4% vs 23.8%; p = 0.03). Postoperative delirium after cardiac surgery may be associated with increased mortality and readmissions to the hospital, as well as poorer cognitive and functional outcomes. Therefore, prevention and (or) early recognition of delirium must be improved. In addition, patients and caregivers (family and general practitioner) must be better informed about the long-term consequences of delirium and what they can do about it.

Delirium After Cardiac Surgery and Predictive Validity of a Risk Checklist

Delirium or acute confusion is a temporary mental disorder that occurs frequently among hospitalized elderly patients. Patients who undergo cardiac surgery have an increased risk of delirium, which is associated with many negative consequences. Therefore, prevention or early recognition of delirium is essential. In this observational study, a risk checklist for delirium was used during the preoperative outpatient screening in 112 patients who underwent elective cardiac surgery. The Delirium Observation Screening (DOS) scale was used before and after surgery to assess whether delirium had developed in patients. The psychiatrist was consulted to confirm or refute the diagnosis delirium. The incidence of delirium after cardiac surgery was 21%, and the mean duration of delirium was 2.5 days. The time to discharge was 11 days longer for patients with delirium. The delirium risk checklist could accurately predict postoperative delirium in patients who underwent elective cardiac surgery based on a disturbance in the electrolytes sodium and potassium and on EuroSCORE (European System for Cardiac Operative Risk Evaluation). When using a probability of delirium of 50%, the sensitivity of the risk checklist was 25.0% and specificity was 95.5%. The predictive value of a positive test was 60.0%, and the predictive value of a negative test was 82.4%. The area under the receiver-operating characteristic curve was 0.75. With the risk checklist for delirium, patients at an increased risk of delirium after elective cardiac surgery can be identified.