Episode Of Delirium Research Articles

Quantitative Electroencephalographic Markers of Delirium in the Pediatric Intensive Care Unit: Insights From a Heterogenous Convenience Sample.

Little is known about the underlying neurophysiology of pediatric delirium. In adult patients, the sensitivity of EEG to clinical symptoms of delirium has been noted, with a slowing of background activity (alpha) and an increase in slow-wave activity (delta-theta). In this pilot study, the authors extended this investigation to a pediatric cohort. In a convenience sample, 23 critically ill children were screened for delirium, using the Cornell Assessment for Pediatric Delirium (CAPD), every 12 hours throughout their pediatric intensive care unit stay as part of standard intensive care unit procedure, and EEGs were performed as part of their clinical care. After hospital discharge, EEGs were reviewed using quantitative analysis, and the maximum delta-alpha ratio (DAR; eyes closed) was derived for each 12-hour period. DAR values were compared between delirious and nondelirious episodes, and the linear relationship between DAR and CAPD was assessed. Higher DARs were associated with episodes of delirium. The DAR also positively correlated with CAPD assessments, with higher DARs relating to higher delirium scores. Future prospective studies may further investigate this relationship in a more homogeneous and larger sample, and the DAR should be considered to track delirium and assess the effectiveness of therapeutic interventions.

Ankle-Brachial Index Is a Predictor of In-Hospital Functional Status but Not of Complications in Hospitalized Elderly Patients

Introduction: Atherosclerosis causes a chronic reduction of vascularization with consequent impairment of the performance of organs, like the brain or muscles, which determines the functional and cognitive decline of the elderly and their ability to respond to acute stressful condition. Therefore, our aim was to evaluate if ankle brachial index (ABI) could effectively be a determinant of in-hospital functional status and complications in elderly hospitalized patients. Methods: This is a monocentric cross-sectional study of 189 patients aged 65 years or older. The study was undertaken at the Internal Medicine ward of Niguarda Hospital in Milan. ABI (BOSO ABY-System 100) and in-hospital status (activities of daily living, ADL and instrumental activities of daily living, IADL) were collected on the second day of hospitalization. Complications (falls and delirium episodes) were also recorded during the whole hospitalization period. Results: The average age of patients was 79.3 ± 6.9 years. Among outcomes, only ADL (r = 0.192, p = 0.007) and IADL score (r = 0.200, p = 0.005) showed significant correlation with ABI. Moreover, during the subsequent logistic regression, ABI remained among the statistically significant determinants of both scores (β = 0.231, p = 0.013 and β = 0.314, p = 0.001, respectively). Conclusions: The main result of our study is the finding of ABI as a significant determinant of acute in-hospital functional impairment (evaluated as ADL and IADL scores). The continuous exposure of the brain and muscles to the reduced perfusions induced by vascular atherosclerosis, probably determined the reduced ability to respond to stressful conditions.

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery

Study objectiveOur goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing’. DesignThis was a retrospective study that used a database from a five-center randomized trial. SettingPostoperative cardiothoracic ICU and surgical wards. ParticipantAdults scheduled for elective coronary artery bypass and/or valve surgery. Intervention and measurementsPostoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1–5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions. Main resultsA total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium. ConclusionsPostoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.

P0041 / #511: EVALUATION OF DELIRIUM IN THE PEDIATRIC INTENSIVE CARE UNIT OF HOSPITAL ITALIANO DE BUENOS AIRES. INTERIM ANALYSIS.

Aims & Objectives: Delirium is a frequent and serious complication of certain critical illnesses. The goal of this study is to evaluate the incidence of delirium in critically ill patients under invasive mechanical ventilation (IMV) for more than 48 hours and to explore associated risk factors. Methods: An interim analysis of a prospective observational study was performed. All patients who were over six months of age, were admitted to the pediatric intensive care unit (PICU) between October 2018 and December 2019 and required invasive mechanical ventilation (IMV) for more than 48 hours consecutively entered the study. Children were screened for delirium using the pCAM-ICU and psCAM-ICU and were evaluated for 5 consecutive days after extubation. Results: Forty-two children were included up until December 31st, 2019. Two were eliminated from the analysis due to missing data (Figure 1). From the 40 children included, 16 (40%) suffered delirium (Table 1). Most cases of delirium belonged to the hypoactive subtype (81.25%); only 18.75% of delirium episodes were characterized as hyperactive delirium. There was no statistically significant relationship between opioid exposure, days of mechanical ventilation, or probability of mortality score on the development of delirium. Univariate analysis revealed that the occurrence of delirium was significantly associated with benzodiazepine exposure, OR 1.34 (IC 95% 1.04 - 1.74, p = 0.024).Conclusions: The incidence of delirium observed in this cohort so far was similar to that reported in the literature. Benzodiazepine exposure was associated with the development of delirium.

The diagnostic threshold of Cornell assessment of pediatric delirium in detection of postoperative delirium in pediatric surgical patients

BackgroundCornell assessment of pediatric delirium (CAPD) showed advantage in diagnosis of pediatric delirium in Chinese critically ill patients. But its performance in surgical patients is still unclear. The present study was designed to validate the diagnostic performance of CAPD in surgical pediatric patients.MethodsThis is a prospective validation study. Pediatric patients who underwent selective surgery and general anesthesia were enrolled. Primary outcome was the incidence of delirium within postoperative three days. CAPD Chinese version was used to evaluate if the patient had delirium one time per day. At the meantime, a psychiatrist employed Diagnostic and Statistical Manual of Mental Disorders fifth edition to diagnose delirium, which was the “gold standard”, and the result was considered as reference standard. Sensitivity, specificity and area under receiver operating characteristic (ROC) curve were calculated to investigate the performance of CAPD.ResultsA total of 170 patients were enrolled. Median age was 4 years old. As diagnosed by psychiatrist, 23 (13.5 %) patients experienced at least one episode of delirium during the follow-up period. When diagnostic threshold was set at 9, CAPD showed the optimal sensitivity (87.0 %, 95 %CI 65.3 %-96.6 %) and specificity (98.0 %, 95 %CI 93.7 %-99.5 %) in comparison with other diagnostic thresholds. ROC analysis showed that CAPD was a good delirium assessment instrument with area under curve of 0.911 (95 % CI 0.812 to 1.000, P < 0.001). Agreement between CAPD and reference standard was 0.849 (Kappa coefficient, P < 0.001).ConclusionsThis study found that Cornell assessment of pediatric delirium could be used as an effective instrument in diagnosis of delirium in pediatric surgical patients.Trial registrationwww.chictr.org.cn Identifier: ChiCTR-DDD-17,012,231, August 3, 2017.

A prospective observational cohort pilot study of the association between midazolam use and delirium in elderly endoscopy patients

BackgroundMidazolam is a benzodiazepine commonly used in procedural sedation and general anaesthesia. Current anaesthetic guidelines advise the avoidance of benzodiazepines in elderly patients due to concerns of an increased risk of delirium. Delirium is associated with significant patient morbidity and mortality, while also increasing health costs. Despite this, midazolam is often used in elderly patients undergoing low risk procedures due to the benefits of rapid onset, anxiolysis and haemodynamic stability compared to other sedatives. To date, studies describing the relationship between midazolam use and delirium in elderly patients undergoing low risk procedures, such as endoscopy, are limited.MethodThis was a prospective observational cohort pilot study identifying the prevalence of delirium pre-procedure and incidence of delirium post-procedure in elderly endoscopy patients receiving midazolam. The study population was elderly patients greater than 65 years of age, without underlying cognitive dysfunction, undergoing elective endoscopy. Electronic databases were used for collection of demographic and clinical information. Delirium was identified through the administration of the Family Confusion Assessment Method survey; this was administered to carers of the study population 24–48 h pre and post procedure to categorically identify the presence or absence of delirium.ResultsFifty-eight participants were recruited for this study and eighteen were subsequently excluded based upon additional exclusion criteria. Forty patients were included in the final results. American Society of Anaesthesiology Classification (ASA) of patients were as follows: 1 (9 patients), 2 (12 Patients), 3 (16 Patients) and 4 (3 patients). Patients underwent gastroscopy, colonoscopy or combined gastroscopy and colonoscopy. This study identified no cases of delirium in elderly patients after administration of midazolam for elective endoscopy procedures 24–48 h post-procedure. Additionally, a high proportion of elderly patients were found to have received midazolam.ConclusionNo episodes of delirium were identified in this study. This finding runs counter to current guideline recommendations regarding midazolam use in the elderly patient and that elderly patients undergoing elective endoscopy represent a significantly different patient population compared to those previously studied. This study suggests that in the study population that the risk of delirium in patients exposed to midazolam in elective endoscopy was not demonstrated and that it may be safe to perform experimental studies to elucidate the safety of midazolam in larger studies.

First Person Account COVID 19 Delirium in a Doctor: When Death Stalks the Mind.

Previous studies reported that 20–30% of COVID-19 patients will develop delirium during the hospitalization, achieving 70% in cases of severe illness. The risks factors and the consequences of delirium are well-documented in the literature; however, little is known about the personal experience of delirium. Delirium burden is common and tends to be distressing even after the delirium episode has resolved. Taking this in mind, the present work provides a first-person account of a doctor who acquired Covid-19 and developed bilateral pneumonia and had delirium and a complicate course of illness. During the course of his delirium, the patient recalled experiences of reality and unreality, complete disorientation, lack of control, strong emotions, and intense fear of dying which was significantly distressing. We anticipate that delirium burden will be common on these patients and family members and clinicians should be aware of this phenomenon in order to evaluate the neuropsychiatric consequences of this condition.

Follow-up services for delirium after COVID-19-where now?

Delirium is a common presentation in older inpatients with coronavirus disease 2019 (COVID-19), and a risk factor for cognitive decline at discharge. The glaring gaps in the service provision in delirium care, regardless of aetiology, after a hospital admission pre-existed the pandemic, but the pandemic arguably offers an opportunity now to address them. Whilst a delirium episode in itself is not a long-term condition, the context of it may well be, and therefore patients might benefit from personalised care and support planning. There is no reason to believe that the delirium following COVID-19 is fundamentally different from any other delirium. We propose that the needs of older patients who have experienced delirium including from COVID-19 could be addressed through a new model of post-acute delirium care that combines early supported discharge, including discharge-to-assess, with community-based follow-up to assess for persistent delirium and early new long-term cognitive impairment. Such a drive could be structurally integrated with existing memory clinic services. To succeed, such an ambition has to be flexible, adaptable and person-centred. To understand the impact on resource and service utilisation, techniques of quality improvement should be implemented, and appropriate metrics reflecting both process and outcome will be essential to underpin robust and sustainable business cases to support implementation of delirium care as a long-term solution.

At the nexus of music and medicine, some see treatments for disease

When physician Babar Khan started studying delirium seven years ago, he set out to find a drug that could sooth the agitation, inattention, and hallucinations that characterize the disorder. Delirium is common in the intensive care units (ICUs) where Khan works, most recently as an ICU physician at Indiana University School of Medicine and a researcher at Regenstrief Institute, both in Indianapolis. Some 70–80% of ventilated patients in the ICU experience episodes of delirium that not only prolong their stay in hospital but can also lead to long-term cognitive decline. Neurologists, cognitive neuroscientists, and clinicians are coming together to study the therapeutic potential of music. Image credit: Shutterstock/agsandrew. In the mid-2000s, Khan led two antipsychotic drug trials, neither of which worked for delirium. “So I started looking into more holistic interventions,” he says. He recalled seeing some evidence, drawn from assessments of anxiety and sedative exposure in hospital patients, suggesting that music can not only ease anxiety in the ICU but can help with pain management (1). The music-related findings would spur Khan to start investigating music as an alternative to pharmaceuticals. He recently co-led a 2020 pilot trial using music to alleviate delirium in mechanically ventilated ICU patients. Encouragingly, he found that relaxing, slow-tempo classical music reduced patients’ number of delirium days (2). That study is one of many new projects seeking evidence for music as a medical therapy. Cultures have used music in healing for centuries. Although the evidence is still limited, a growing body of research offers increasing promise for music’s health benefits. And the field is seeing a new injection of funding. Based on his pilot trial, Khan secured funding for a confirmatory trial through the Sound Health initiative, a partnership between the the National Institutes of Health (NIH) and the Washington, DC-based John F. …

Brain MRI after critical care admission: A longitudinal imaging study.

To investigate the association between episodes of critical care hospitalizations and delirium with structural brain changes in older adults. We included Mayo Clinic Study of Aging participants ≥60years old at the time of study enrollment (October 29, 2004, through September 11, 2017) with available brain MRI and 'amyloid' positron emission tomography (PET) scans. We tested the hypothesis that a) intensive care unit (ICU) admission is associated with greater cortical thinning and atrophy in entorhinal cortex, inferior temporal cortex, middle temporal cortex, and fusiform cortex (Alzheimer''s disease-signature regions); b) atrophy in hippocampus and corpus callosum; c) delirium accelerates these changes; and d) ICU admission is not associated with increased deposition of cortical amyloid. ICU admission was associated with cortical thinning in temporal, frontal, and parietal cortices, and decreases in hippocampal/corpus callosum volumes, but not Alzheimer''s disease-signature regions. For hippocampal volume, and 10 of 14 cortical thickness measurements, the change following ICU admission was significantly more pronounced for those who experienced delirium. ICU admission was not associated with an increased amyloid burden. Critical care hospitalization is associated with accelerated brain atrophy in selected brain regions, without increases in amyloid deposition, suggesting a pathogenesis based on neurodegeneration unrelated to Alzheimer''s pathway.

Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review

Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence. Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool. Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4). Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.

Application of Multicomponent Nursing Intervention to Controlling Delirium and Duration of ICU Stay among Critically Ill Older Adult Patient

Background Few studies have investigated delirium in a respiratory intensive care unit (RICU) population, thus knowledge is limited regarding it. Aim, the present study aimed to investigate the effectiveness of application of multicomponent nursing intervention to controlling delirium among critically ill older adult patients. Quasi-experimental research design was carried out to meet the aim of this study. A purposive sample included 60 old age critically ill patients taken from respiratory intensive care in Aswan University Hospital. Tool 1, Patient assessment sheet was used for collecting data, which included two parts: bio demographic data and medical data, Tool2, intensive care delirium screening checklist to detection and monitoring delirium include eight screening area Each feature that manifests are given one point and zero point if not manifests Ascore ≥ 4 indicated delirium.Tool3, Richmond Agitation Sedation Scale (RASS) to predicted type of delirium. Tool4 Multiple nursing intervention for controlling delirium. Results: Delirium was frequent in patients in the standard care group compared with our intervention group (p = 0.04), however no substantial differences between both groups regarding types, duration or delirium severity (P≥ 0.05), respectively. Moreover, the duration of ICU stay was lowered in our intervention group (P= 0.001). Age was a substantial risk element for delirium development by multiple regression analysis. Conclusion: the delirium episodes during RICU stay were established to all critically older adults with respiratory illnesses, as anticipated, after application of a multicomponent nursing intervention, the incidence of these adverse consequences was reduced. Recommendation: replication of these study on the large sample size in other ICU that provide care for critically ill older adult patients to decrease incidence of delirium within critical care setting.

Linking electronic dementia care records to national inpatient data in dementia with Lewy bodies: Frequency, duration and cost implications of hospitalization and recording of delirium episodes

AbstractBackgroundIncreased hospitalization is a major component of dementia impact on individuals and cost but has rarely been studied in dementia with Lewy bodies (DLB). In particular episodes of delirium and related hospitalizations have been described as a prodrome of dementia with Lewy bodies. Our aims were to harness a novel linkage between dementia/mental health care records and national hospitalization data in England to (1) describe risk and duration of hospital admissions in patients with DLB and (2) to assess the incidence of delirium recording before and after a diagnosis of dementia is established in patients with DLB and compare findings to a matched cohort of patients with Alzheimer’s disease (AD).MethodIn a large database of mental health and dementia care in South London we identified 194 patients with DLB and 1:4 matched these with 776 patients diagnosed with AD on age, gender, and cognitive status.ResultRates of hospital admissions in the year after dementia diagnosis were significantly higher in patients with DLB compared to patients with AD or the catchment population. Patients with DLB had on average almost four additional hospital days per person‐year than patients with AD and incurred higher hospitalization‐related costs. Further, patients with DLB had significantly more episodes of delirium recorded in the year before dementia diagnosis than patients with AD. Whereas the incidence of recording of delirium episodes reduced substantially in patients with DLB after dementia diagnosis, it remained significantly higher than in patients with AD.ConclusionPatients with DLB are more frequently admitted to general hospital and utilize inpatient care to a substantially higher degree than patients with AD. Establishing a diagnosis of dementia reduces episodes classified as delirium in patients with DLB and might lead to fewer potentially harmful interventions as hospitalization or use of antipsychotic medication. These data highlight an opportunity to reduce hospital days and episodes classified (and treated) as delirium by identifying DLB earlier and providing more targeted care focused on the specific triggers for hospitalization and associations of prolonged stay.

Effects of COVID-19 Pandemic Confinement in Patients With Cognitive Impairment.

Introduction: State of emergency caused by COVID-19 pandemic and subsequent lockdown hit Spain on 14th March 2020 and lasted until 21st June 2020. Social isolation measures were applied. Medical attention was focused on COVID-19. Primary and social care were mainly performed by telephone. This exceptional situation may affect especially vulnerable patients such as people living with dementia. Our aim was to describe the influence of restrictive measures on patients living with mild cognitive decline and dementia evaluating SARS-CoV2 infection, changes in routines, cognitive decline stage, neuropsychiatric symptoms, delirium, falls, caregiver stress, and access to sanitary care.Materials and Methods: We gathered MCI and dementia patients with clinical follow-up before and after confinement from DegMar registry (Hospital del Mar). A telephone ad-hoc questionnaire was administered. Global status was assessed using CDR scale. Changes in neuropsychiatric symptoms were assessed by Neuropsychiatric Inventory (NPI) and retrospective interview for pre-confinement base characteristics.Results: We contacted a total of 60 patients, age 75.4 years ± 5,192. 53.3% were women. Alzheimer's Disease (41.7%) and Mild Cognitive Impairment (25%) were the most prevalent diagnosis. Remaining cases included different dementia disorders. A total of 10% of patients had been diagnosed with SARS-CoV-2. During confinement 70% of patients abandoned previous daily activities, 60% had cognitive worsening reported by relatives/caretakers, 15% presented delirium episodes, and 13% suffered increased incidence of falls. Caregivers reported an increased burden in 41% cases and burnout in 11% cases. 16% reported difficulties accessing medical care, 33% received medical phone assistance, 20% needed emergency care and 21% had changes in psychopharmacological therapies. Neuropsychiatric profile globally worsened (p < 0.000), also in particular items like agitation (p = 0.003), depression (p < 0.000), anxiety (p < 0.000) and changes in appetite (p = 0.004).Conclusion: SARS-CoV2-related lockdown resulted in an important effect over social and cognitive spheres and worsening of neuropsychiatric traits in patients living with mild cognitive decline and dementia. Although the uncertainty regarding the evolution of the pandemic makes strategy difficult, we need to reach patients and caregivers and develop adequate strategies to reinforce and adapt social and health care.

Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic.

Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic. A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6months following the delirium episode. Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management. This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.

Cystocerebral Syndrome: An Updated Review and a New Proposed Mechanism for an Often Forgotten Cause of Delirium.

Cystocerebral syndrome is an often forgotten cause of delirium in elderly males, which is quite easily treated. We reviewed the current body of literature documenting cystocerebral syndrome and proposed a new mechanism of action explaining why all patients identified thus far have been male.Data was obtained from articles describing cases of cystocerebral syndrome, urinary retention, and confusion in addition to delirium via a PubMed database search. We reviewed all articles describing cases of cystocerebral syndrome via the PubMed database using the Medical Subject Headings (MeSH) keywords of "cystocerebral syndrome,” urinary retention and confusion," and "delirium and urinary retention or cystocerebral syndrome," and identified eight cases of cystocerebral syndrome including the original publication by Blackburn and Dunn.We found that all patients reported in the literature were males older than 70 years and often with concomitant benign prostatic hypertrophy (BPH) who presented with acute episodes of delirium that rapidly responded to bladder decompression.The authors seek to update the medical community regarding this uncommon phenomenon of delirium in elderly male patients. We also propose that the lack of female patients in the literature is reflective of their decreased intraurethral flow resistance as is currently being described in other avenues of research in the field of urodynamics.

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study

BackgroundClinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care.MethodsThis study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored.ResultsDuring the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63–79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1–42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (adjRR) = 1.71, 95% confidence interval (CI) 1.20–2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1–7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, adjRR = 2.54, 95% CI 1.72–3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU.ConclusionFrailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

Efectividad de la aplicación de medidas no farmacológicas para la prevención de delirium en pacientes no ventilados ingresados en una Unidad de Cuidados Intensivos nivel ii

Frame of referenceDelirium is one of the most frequent clinical conditions in Intensive Care Units (ICU), which has been associated with an increase in mortality. The present study aims to demonstrate whether the application of non-pharmacological measures reduces the appearance of this entity in non-ventilated adult patients admitted to a level II ICU. It was found that the application of non-pharmacological measures was associated with a reduction in the risk of developing delirium in clinical, although not statistical, terms. We recommend studies with a larger sample size. IntroductionDelirium is a predictor of mortality and one of the most frequent syndromes in ICUs. ObjectivesTo determine the effectiveness of the application of non-pharmacological measures vs. standard care in reducing delirium in non-ventilated adult patients admitted to the ICU of the Las Lajas Clinic between June 2015 and March 2016. DesignClinical trial with random distribution, blinded to the investigator. ScopeThe study was carried out in a level II ICU, where both patients with medical and surgical illnesses are admitted. ParticipantsEligible patients were adult patients admitted to the Las Lajas Clinic ICU (over 18 years of age), with an expectation of stay in the unit greater than 24 h and Glasgow coma scale ≥ 13, patients who filled out informed consent. Patients who used sedatives, with dementia, delirium or confusion and patients without Medical prognosis were excluded. 168 patients were eligible, of which 145 patients participated in the study. InterventionIn the intervention group, non-pharmacological measures were applied (putting on a mask, ear plugs and an early mobilization protocol was applied), the control group was conventional management continued (no mask placement, no earplugs, and physical therapy was continued as indicated by the treating physician 1 to 2 times a day). The duration of the intervention was during the time they remained in the unit or until the outcome occurred. Main variables of interestPresentation of delirium, patient mortality at 7 days, length of stay in the ICU. ResultsThe population median age was 62 years and the median age in the group that developed delirium was 81 years. The proportion of patients who developed delirium in the control group it was 10.3%, while the intervention group was 3.0%. Applying these measures was associated with a reduction in the risk of developing delirium (RR = 0.29, 95% CI 0.06-1.32 p = 0.107). Likewise, it was found that the number needed to treat to avoid an episode of delirium was 13. ConclusionsIn our study, the application of non-pharmacological measures was not associated with a decrease in the appearance of delirium. Studies with a sample size are recommended.

Low Vitamin D Levels and Risk of Incident Delirium in 351,000 Older UK Biobank Participants.

Delirium is common in older adults, especially following hospitalization. Because low vitamin D levels may be associated with increased delirium risk, we aimed to determine the prognostic value of blood vitamin D levels, extending our previous genetic analyses of this relationship. Prospective cohort analysis. Community-based cohort study of adults from 22 cities across the United Kingdom (the UK Biobank). Adults aged 60 and older by the end of follow-up in the linked hospital inpatient admissions data, up to 14 years after baseline (n = 351,320). At baseline, serum vitamin D (25-OH-D) levels were measured. We used time-to-event models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between vitamin D deficiency and incident hospital-diagnosed delirium, adjusted for age, sex, assessment month, assessment center, and ethnicity. We performed Mendelian randomization genetic analysis in European participants to further investigate vitamin D and delirium risk. A total of 3,634 (1.03%) participants had at least one incident hospital-diagnosed delirium episode. Vitamin D deficiency (<25 nmol/L) predicted a large incidence in delirium (HR = 2.49; 95% CI = 2.24-2.76; P = 3*10-68 , compared with >50 nmol/L). Increased risk was not limited to the deficient group: insufficient levels (25-50 nmol/L) were also at increased risk (HR = 1.38; 95% CI = 1.28-1.49; P = 4*10-18 ). The association was independent of calcium levels, hospital-diagnosed fractures, dementia, and other relevant cofactors. In genetic analysis, participants carrying more vitamin D-increasing variants had a reduced likelihood of incident delirium diagnosis (HR = .80 per standard deviation increase in genetically instrumented vitamin D: .73-.87; P = 2*10-7 ). Progressively lower vitamin D levels predicted increased risks of incident hospital-diagnosed delirium, and genetic evidence supports a shared causal pathway. Because low vitamin D levels are simple to detect and inexpensive and safe to correct, an intervention trial to confirm these results is urgently needed.

DIALYSIS DISEQUILIBRIUM SYNDROME: A RARE CAUSE OF DELIRIUM IN THE ICU

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Delirium is common in the hospital setting with rates up to 70% in the medical intensive care unit. It can be due to multiple etiologies. Here we describe a case of dialysis disequilibrium syndrome (DDS) associated with hemodialysis for acute hyperkalemia. CASE PRESENTATION: A 55 year-old male with past medical history of heart failure, diabetes mellitus and end-stage renal disease presented to the emergency room after a mechanical fall. His last hemodialysis was 2 days prior. On examination, he was alert and oriented to time, place, and person without headache, nausea or vomiting. Laboratory values were notable for a sodium of 140 mEq/L, potassium of 7.3 mEq/L, BUN 114 mg/dL. EKG showed peaked T waves. He was admitted to the MICU for acute hyperkalemia and urgent hemodialysis at a blood flow rate of 400ml/minute for 3.5 hours with 1.6L of ultrafiltration. Three hours after completion of dialysis, he became confused and delirious. Over the next few hours, he became more agitated with incomprehensible speech and inability to answer questions appropriately. Repeat labs showed a sodium of 136 mEq/L, BUN of 25 mg/dL, Ammonia of 36 umol/L and glucose of 125 mg/dl. CT head was performed to rule out subdural hematoma in the setting of a fall, however, it was normal. Toxicology screen as well as infectious work up were negative. Given the acute onset of mental status changes after hemodialysis with a drastic decrease in BUN, and excluding all possible causes, a working diagnosis of Dialysis Disequilibrium Syndrome was made. Dialysis was held for one day with improvement in patient's mental status. He was able to follow commands without any delirium. BUN showed a steady increase from 25 to 64 mg/dL. Hemodialysis was re-initiated at a slower blood flow rate of 200 ml/minute which the patient tolerated without any complications and no further episodes of delirium. DISCUSSION: DDS is caused by water movement into the brain due to a transient osmotic gradient from the rapid removal of small solutes such as urea, which causes cerebral edema. It is generally seen in patients undergoing dialysis for the first time or if they are undergoing dialysis after a long period of time. Most of the symptoms are self-limited. However, one must be cautious to restart hemodialysis at a slower flow rate since there have been cases that resulted in death. CONCLUSIONS: DDS is an increasingly rare syndrome and one must consider this after excluding all other causes of acute delirium. Early detection and management is associated with favorable outcomes. Reference #1: Mistry K. Dialysis disequilibrium syndrome prevention and management. Int J Nephrol Renovasc Dis. 2019;12:69-77 DISCLOSURES: No relevant relationships by Hung-I Liao, source=Web Response No relevant relationships by Avantika Nathani, source=Web Response