Hypoactive Subtype Research Articles

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

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

Post-operative delirium in different age groups and subtypes: a systematic review of case reports.

To explore the clinical presentations and outcomes among different ages and subtypes of post-operative delirium patients. Systematic review of Published Cases. We comprehensively searched PubMed, EMBASE, and MEDLINE for published case reports of post-operative delirium up to April 2023. The systematic review has been registered with PROSPERO. Two researchers independently conducted unblinded reviews of the full-text articles. This study included 116 patients with post-operative delirium. Compared to post-operative delirium patients aged 65 and above, those between 18 and 65 years old have lower rates of a history of hypertension, cardiovascular disease and urinary system disorder comorbidities, as well as higher usage rates of fentanyl analogs and lorazepam. Additionally, these patients exhibit lower incidences of anemia and renal failure, along with a lower mortality rate. Compared to post-operative delirium patients aged 65 and above, those under 18 years old have a higher rate of fentanyl analog usage and a higher incidence of post-operative delirium following neurological surgeries. Among the hypoactive, hyperactive, and mixed subtypes, the reasons for surgery, such as cardiovascular diseases, reproductive system diseases, and neurological disorders, significantly varied among these three subtypes. Furthermore, substance abuse history and medication usage patterns also significantly varied among these three subtypes. Our investigation has revealed noteworthy insights into post-operative delirium in different patient populations. Notably, age emerged as a pivotal factor. Compared to elderly patients (≥65 years), those aged 18 to 65 demonstrate better prognosis. Additionally, patients younger than 18 years with post-operative delirium have a higher incidence of delirium following neurosurgical procedures compared to those elderly patients. Additionally, a strong association was found between a history of substance abuse and hyperactive delirium. Variations in drug use patterns were observed across different subtypes. Importantly, post-operative delirium patients younger than 18 years, as well as those aged 18 to 65 with mixed-subtype delirium, exhibited similar high mortality rates as elderly patients. This underscores the need for increased attention to post-operative delirium patients under 65 and highlights the necessity of rapid identification and early intervention for these populations at risk of poor outcomes. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023473383, Identifier [Registration ID: CRD 42023473383].

Factors Associated with Improvement in Activities of Daily Living during Hospitalization: A Retrospective Study of Older Patients with Hip Fractures.

In this study, we aimed to examine the changes in delirium during hospitalization of patients and its association with behavioral and psychological symptoms of dementia (BPSD), as well as improvements in activities of daily living (ADL). A longitudinal, retrospective cohort study was conducted involving 83 older adults (≥65 years) with hip fractures. We collected Mini-Mental State Examination (MMSE) and Functional Independence Measure-motor domain (m-FIM) assessment results from the medical charts at two time points: baseline (first week of hospitalization) and pre-discharge (final week before discharge). Additionally, we collected data on delirium and BPSD at three points: baseline, week 2 post-admission, and pre-discharge. We performed univariate logistic regression analysis using changes in m-FIM scores as the dependent variable and MMSE and m-FIM scores at baseline and pre-discharge, along with delirium and BPSD subtypes at baseline, week 2 post-admission, and pre-discharge, as the explanatory variables. Finally, we performed a multivariate logistic regression analysis incorporating the significant variables from the univariate analysis to identify factors associated with ADL improvement during hospitalization. We observed significant correlations between ADL improvement during hospitalization and baseline m-FIM and MMSE scores, hypoactive delirium state, and BPSD subtype pre-discharge. Notably, all participants with hypoactive symptoms before discharge exhibited some subtype of delirium and BPSD at baseline. Besides ADL ability and cognitive function at admission, the presence of hypoactive delirium and BPSD subtype before discharge may hinder ADL improvement during hospitalization.

Automated phenotyping of postoperative delirium-like behaviour in mice reveals the therapeutic efficacy of dexmedetomidine

Postoperative delirium (POD) is a complicated and harmful clinical syndrome. Traditional behaviour analysis mostly focuses on static parameters. However, animal behaviour is a bottom-up and hierarchical organizational structure composed of time-varying posture dynamics. Spontaneous and task-driven behaviours are used to conduct comprehensive profiling of behavioural data of various aspects of model animals. A machine-learning based method is used to assess the effect of dexmedetomidine. Fourteen statistically different spontaneous behaviours are used to distinguish the non-POD group from the POD group. In the task-driven behaviour, the non-POD group has greater deep versus shallow investigation preference, with no significant preference in the POD group. Hyperactive and hypoactive subtypes can be distinguished through pose evaluation. Dexmedetomidine at a dose of 25 μg kg−1 reduces the severity and incidence of POD. Here we propose a multi-scaled clustering analysis framework that includes pose, behaviour and action sequence evaluation. This may represent the hierarchical dynamics of delirium-like behaviours.

Altered Tryptophan-Kynurenine Pathway in Delirium: A Review of the Current Literature.

Delirium, a common form of acute brain dysfunction, is associated with increased morbidity and mortality, especially in older patients. The underlying pathophysiology of delirium is not clearly understood, but acute systemic inflammation is known to drive delirium in cases of acute illnesses, such as sepsis, trauma, and surgery. Based on psychomotor presentations, delirium has three main subtypes, such as hypoactive, hyperactive, and mixed subtype. There are similarities in the initial presentation of delirium with depression and dementia, especially in the hypoactive subtype. Hence, patients with hypoactive delirium are frequently misdiagnosed. The altered kynurenine pathway (KP) is a promising molecular pathway implicated in the pathogenesis of delirium. The KP is highly regulated in the immune system and influences neurological functions. The activation of indoleamine 2,3-dioxygenase, and specific KP neuroactive metabolites, such as quinolinic acid and kynurenic acid, could play a role in the event of delirium. Here, we collectively describe the roles of the KP and speculate on its relevance in delirium.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit.

Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU. Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Hypoactive delirium

Delirium (or Acute Confusional State) refers to an acute alteration of attention, consciousness, and cognitive performance. Particularly the hypoactive subtype of delirium represents a diagnostic and clinical challenge. As symptoms of hypoactive delirium may overlap with the clinical picture present in dementia and depression, correct diagnostic differentiation can be challenging. In the absence of timely diagnosis and treatment, hypoactive delirium can last for several weeks. Apart from the health consequences for the patient, such a long course can stress caregivers and the family to their very limit. In this article, we will address the particularities of hypoactive delirium in hospital practice, the neurobiological bases of this disorder, the challenges it represents at the diagnostic level as well as its recommended management according to current literature.

Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention.

The assessment of prevalence of delirium in advanced cancer patients admitted in hospice centre and outcome after palliative intervention. The possible related risk factors for development of delirium. This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019 - July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion criteria (all patient admitted to hospice centre above 18 years, with advance cancer disease and on best supportive care) and exclusion criteria (Lack of informed consent, Inability to participate in study due to mentally retard or coma). The following information were collected: age, gender, address, type of cancer, comorbidities, history of substance abuse, history of (h/o) palliative chemotherapy or radiotherapy within last 3month, general condition, ESAS (Edmonton symptom assessment scale), ECOG (Eastern cooperative oncology group), PaP score (palliative prognostic score), medication including opioids, NSAIDs (Non-steroidal anti-inflammatory drugs), steroids, antibiotic, adjuvant analgesic, PPI (Proton pump inhibitor), anti-emetic etc. Delirium diagnosis was based on diagnostic criterion of DSM-IV text revised and MDAS. In our study we found prevalence of delirium was 31.29% in advanced cancer patients admitted to hospice centre. We found most common type of delirium is hypoactive (34.7%) and mixed subtype (34.7%) followed by hyperactive (30.4%) delirium. Resolution of delirium was higher among hyperactive delirium (78.57%) followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%) followed by mixed (43.75%) and hyperactive delirium (14.28%). An identification and assessment of delirium is vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalization, expanded time on a ventilator, and by and large more prominent medical services costs. Clinicians should utilize one of a few approved delirium assessment tools to help evaluate and archive cognitive function. Prevention and recognizing the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium. The study results demonstrate that multi component delirium management or projects are generally proficient to lessen the prevalence and negative outcomes of delirium. It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.

How do predisposing factors differ between delirium motor subtypes? A systematic review and meta-analysis.

BackgroundDelirium is a common neurocognitive disorder in hospitalised older adults with vast negative consequences. The predominant method of subtyping delirium is by motor activity profile into hypoactive, hyperactive and mixed groups.ObjectiveThis systematic review and meta-analysis investigated how predisposing factors differ between delirium motor subtypes.MethodsDatabases (Medline, PsycINFO, Embase) were systematically searched for studies reporting predisposing factors (prior to delirium) for delirium motor subtypes. A total of 61 studies met inclusion criteria (N = 14,407, mean age 73.63 years). Random-effects meta-analyses synthesised differences between delirium motor subtypes relative to 22 factors.ResultsHypoactive cases were older, had poorer cognition and higher physical risk scores than hyperactive cases and were more likely to be women, living in care homes, taking more medications, with worse functional performance and history of cerebrovascular disease than all remaining subtypes. Hyperactive cases were younger than hypoactive and mixed subtypes and were more likely to be men, with better cognition and lower physical risk scores than all other subtypes. Those with no motor subtype (unable to be classified) were more likely to be women and have better functional performance. Effect sizes were small.ConclusionsImportant differences in those who develop motor subtypes of delirium were shown prior to delirium occurrence. We provide robust quantitative evidence for a common clinical assumption that indices of frailty (institutional living, cognitive and functional impairment) are seen more in hypoactive patients. Motor subtypes should be measured across delirium research. Motor subtyping has great potential to improve the clinical risk assessment and management of delirium.

De-prescribing strategy in a case of Delirium in the elderly

Introduction Iatrogenic factors, such as polypharmacy and prescription cascade, are some of the main causes of delirium in the elderly. We present a case of delirium of months of evolution that improved after applying a pharmacological de-prescription strategy.ObjectivesTo report a case and review the available literature on the concepts of prescription cascade and de-prescription in delirium in the elderly.MethodsA 92-year-old woman with a history of cerebrovascular accidents and no psychiatric history or dementia was admitted to a psychogeriatric clinic due to disorientation, delusions of harm and gait apraxia. Several months earlier she had required admission to the general hospital for agitation. In view of the suspicion of delirium, an exhaustive examination and complementary tests were performed, including a neuropsychological assessment and a brain scan (Image 1).ResultsThe patient had previously received multiple high-dose psychotropic drugs (Gabapentin, trazodone, Zolpidem, Quetiapine), which had reduced the agitation but had not resolved the problem. Organic causes were treated in a multidisciplinary team (pressure ulcers), together with a gradual tapering of medication. Although underlying vascular dementia was diagnosed, the patient’s gait and cognitive status improved, with a significant impact on her autonomy and quality of life.ConclusionsDespite an extensive literature on the subject, delirium in the elderly remains an under-diagnosed medical condition, especially the hypoactive subtype, just as cascade prescribing remains common. It is important to raise awareness among specialists in training to prevent and diagnose it.DisclosureNo significant relationships.

Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article.

BackgroundPostoperative delirium is the highest prevalence and life-threatening complication following geriatric surgery. The overall incidence rate varies from 5% to 52% of hospitalized surgical patients based on the type of surgery that often began in the postanesthesia care unit and continues up to 5 days post-surgery. Postoperative delirium manifests as a hypoactive, hyperactive and mixed subtype. The mechanism of delirium development is not clear, but it is accepted that delirium is a result of the patient’s underlying vulnerabilities or risk factors combined with an outside stressor such as infection or surgery.ObjectiveTo develop evidence-based recommendations for the prevention, diagnosis, and treatment of postoperative delirium.MethodsLiterature was searched from PubMed, CINAH, Google Scholar, and Cochrane databases that are published from 2010 to 2021 by formulating inclusion and exclusion criteria. Filtering was made depending on methodological quality, outcome, and data on population. Finally, 11 meta-analysis, 11 systematic reviews, 7 interventional studies, 11 observational studies, and recommendations of the previous clinical practice guideline developed by the American and European are included in this review.ResultsA total of 43 studies were considered in this evaluation. The development of this guideline was based on nine studies on risk stratification for postoperative delirium, eighteen studies on risk minimization and prevention for postoperative delirium, five studies on diagnosis for postoperative delirium, and eleven studies on treatments for postoperative delirium.ConclusionPostoperative delirium management can be categorized into risk assessment, risk minimization, early diagnosis, and treatment. Early diagnosis is critical to trigger focused and effective treatment. Non-pharmacological interventions are the first-line management for both hypoactive and hyperactive postoperative with considering contributory factors and underlying causes. Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves. Current evidence suggested that dexmedetomidine can be used as a treatment option for postoperative delirium.

Distribution of delirium motor subtypes in the intensive care unit: a systematic scoping review

BackgroundDelirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.MethodsThis systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model.ResultsWe included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0–54.7]), followed by mixed delirium (27.7% [95% CI 24.1–31.3]) and hyperactive delirium (22.7% [95% CI 19.0–26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium.ConclusionsHypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted.

Incidencia del Síndrome Confusional (delirio) en un Hospital Universitario Latinoamericano

BackgroundLittle is known about the incidence of delirium and its subtypes in patients admitted to different departments of university hospitals in Latin America. ObjectiveTo determine the incidence of delirium and the frequency of its subtypes, as well as its associated factors, in patients admitted to different departments of a university hospital in Bogotá, Colombia. MethodsA cohort of patients over 18 years of age admitted to the internal medicine (IM), geriatrics (GU), general surgery (GSU), orthopaedics (OU) and intensive care unit (ICU) services of a university hospital was followed up between January and June 2018. To detect the presence of delirium, we used the CAM (Confusion Assessment Method) and the CAM-ICU if the patient had decreased communication skills. The delirium subtype was characterised using the RASS (Richmond Agitation and Sedation Scale). Patients were assessed on their admission date and then every two days until discharged from the hospital. Those in whom delirium was identified were referred for specialised intra-institutional interdisciplinary management. ResultsA total of 531 patients admitted during the period were assessed. The overall incidence of delirium was 12% (95% CI, 0.3-14.8). They represented 31.8% of patients in the GU, 15.6% in the ICU, 8.7% in IM, 5.1% in the OU, and 3.9% in the GSU. The most frequent clinical display was the mixed subtype, at 60.9%, followed by the normoactive subtype (34.4%) and the hypoactive subtype (4.7%). The factors most associated with delirium were age (adjusted RR=1.07; 95% CI, 1.05-1.09), the presence of four or more comorbidities (adjusted RR=2.04; 95% CI, 1.31-3.20), and being a patient in the ICU (adjusted RR=2.02; 95% CI, 1.22-3.35). ConclusionsThe incidence of delirium is heterogeneous in the different departments of the university hospital. The highest incidence occurred in patients that were admitted to the GU. The mixed subtype was the most frequent one, and the main associated factors were age, the presence of four or more comorbidities, and being an ICU patient.

Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study.

Background: A significant proportion of patients with coronavirus disease 2019 (COVID-19) suffer from delirium during hospitalization. This single-center observational study investigates the occurrence of delirium, the associated risk factors and its impact on in-hospital mortality in an Italian cohort of COVID 19 inpatients. Methods: Data were collected in the COVID units of a general medical hospital in the South of Italy. Socio-demographic, clinical and pharmacological features were collected. Diagnosis of delirium was based on a two-step approach according to 4AT criteria and DSM5 criteria. Outcomes were: dates of hospital discharge, Intensive Care Unit (ICU) admission, or death, whichever came first. Univariable and multivariable proportional hazards Cox regression models were estimated, and risks were reported as hazard ratios (HR) along with their 95% confidence intervals (95% CI). Results: A total of 47/214 patients (22%) were diagnosed with delirium (21 hypoactive, 15 hyperactive, and 11 mixed). In the multivariable model, four independent variables were independently associated with the presence of delirium: dementia, followed by age at admission, C-reactive protein (CRP), and Glasgow Coma Scale. In turn, delirium was the strongest independent predictor of death/admission to ICU (composite outcome), followed by Charlson Index (not including dementia), CRP, and neutrophil-to-lymphocyte ratio. The probability of reaching the composite outcome was higher for patients with the hypoactive subtype than for those with the hyperactive subtype. Conclusions: Delirium was the strongest predictor of poor outcome in COVID-19 patients, especially in the hypoactive subtype. Several clinical features and inflammatory markers were associated with the increased risk of its occurrence. The early recognition of these factors may help clinicians to select patients who would benefit from both non-pharmacological and pharmacological interventions in order to prevent delirium, and in turn, reduce the risk of admission to ICU or death.

Management of psychiatric disorders in patients with cancer.

Management of psychiatric disorders in patients with cancer.

Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery

In adults undergoing hip fracture surgery, regional anesthesia may reduce postoperative delirium, but there is uncertainty about its effectiveness. To investigate, in older adults undergoing surgical repair for hip fracture, the effects of regional anesthesia on the incidence of postoperative delirium compared with general anesthesia. A randomized, allocation-concealed, open-label, multicenter clinical trial of 950 patients, aged 65 years and older, with or without preexisting dementia, and a fragility hip fracture requiring surgical repair from 9 university teaching hospitals in Southeastern China. Participants were enrolled between October 2014 and September 2018; 30-day follow-up ended November 2018. Patients were randomized to receive either regional anesthesia (spinal, epidural, or both techniques combined with no sedation; n = 476) or general anesthesia (intravenous, inhalational, or combined anesthetic agents; n = 474). Primary outcome was incidence of delirium during the first 7 postoperative days. Secondary outcomes analyzed in this article include delirium severity, duration, and subtype; postoperative pain score; length of hospitalization; 30-day all-cause mortality; and complications. Among 950 randomized patients (mean age, 76.5 years; 247 [26.8%] male), 941 were evaluable for the primary outcome (6 canceled surgery and 3 withdrew consent). Postoperative delirium occurred in 29 (6.2%) in the regional anesthesia group vs 24 (5.1%) in the general anesthesia group (unadjusted risk difference [RD], 1.1%; 95% CI, -1.7% to 3.8%; P = .48; unadjusted relative risk [RR], 1.2 [95% CI, 0.7 to 2.0]; P = .57]). Mean severity score of delirium was 23.0 vs 24.1, respectively (unadjusted difference, -1.1; 95% CI, -4.6 to 3.1). A single delirium episode occurred in 16 (3.4%) vs 10 (2.1%) (unadjusted RD, 1.1%; 95% CI, -1.7% to 3.9%; RR, 1.6 [95% CI, 0.7 to 3.5]). Hypoactive subtype in 11 (37.9%) vs 5 (20.8%) (RD, 11.5; 95% CI, -11.0% to 35.7%; RR, 2.2 [95% CI, 0.8 to 6.3]). Median worst pain score was 0 (IQR, 0 to 20) vs 0 (IQR, 0 to 10) (difference 0; 95% CI, 0 to 0). Median length of hospitalization was 7 days (IQR, 5 to 10) vs 7 days (IQR, 6 to 10) (difference 0; 95% CI, 0 to 0). Death occurred in 8 (1.7%) vs 4 (0.9%) (unadjusted RD, -0.8%; 95% CI, -2.2% to 0.7%; RR, 2.0 [95% CI, 0.6 to 6.5]). Adverse events were reported in 106 episodes in the regional anesthesia group and 102 in the general anesthesia group; the most frequently reported adverse events were nausea and vomiting (47 [44.3%] vs 34 [33.3%]) and postoperative hypotension (13 [12.3%] vs 10 [9.8%]). In patients aged 65 years and older undergoing hip fracture surgery, regional anesthesia without sedation did not significantly reduce the incidence of postoperative delirium compared with general anesthesia. ClinicalTrials.gov Identifier: NCT02213380.

Circulating MicroRNAs and Novel Proteins as Potential Biomarkers of Neurological Complications after Heart Bypass Surgery.

Postoperative recovery can be impaired by many conditions, some of which are difficult to diagnose clinically. These include type 2 neurological complications such as hypoactive subtype of postoperative delirium (PD) and early postoperative cognitive dysfunction (ePOCD). Hope for their timely detection may lie with novel biomarkers. Plasma concentrations of microRNA-1-3p, microRNA-21-5p, glial fibrillary acidic protein (GFAP), neuroserpin (NSP), phosphorylated axonal neurofilament subunit H (pNfH) and visinin-like protein 1 (VILIP-1) were investigated in 30 patients undergoing elective off-pump coronary artery bypass grafting. Blood samples were collected at the start and end of a surgery as well as 24 h postoperatively. Associations between the studied biomarkers’ perioperative expression and type 2 neurological complications were analyzed. PD was associated with postoperative expression of GFAP; ePOCD was associated with postoperative expression of microRNA-21-5p and GFAP as well as intraoperative expression of NSP. The predictive accuracy of these molecules was found acceptable, with all their areas under the curve (AUC) values above 0.7. Multivariable regression indicated that microRNA-21-5p, GFAP and NSP were the only significant predictors of ePOCD. Evaluation of a multi-marker model including these three molecules revealed its outstanding predictive accuracy for ePOCD (AUC = 0.95). The use of microRNA-21-5p, GFAP and NSP for monitoring postoperative recovery warrants further research considering their potential to predict PD and ePOCD.

Delirium in neurological practice

Delirium is an acute, usually reversible, fluctuating impairment of the level of consciousness, attention, and cognitive activity resulted from impaired brain metabolism due to a wide range of various neurological and non-neurological diseases, the effects of drugs and other substances. The main manifestations of delirium are acute changes in consciousness, disturbance of attention, perception, often with the development of hallucinations, emotion, sleep-wake cycle, psychomotor and autonomic activity. Delirium is divided into hypoactive and hyperactive subtypes depending on the severity of psychomotor and emotional disturbances. Patients with acute stroke are also often susceptible to episodes of delirium at the risk factors such as age, pre-existing cognitive impairment, pneumonia, urinary tract infections, and right hemispheric stroke. The pathophysiology of delirium has been less known, but there is evidence of the role of cholinergic deficiency. Delirium is a transient condition, but it needs treatment to prevent the development of complications since it is usually associated with poor functional outcomes, longer hospitalization and higher mortality. The strategy for the treatment of patients with delirium should be directed to early identification of its symptoms, elimination of modifiable risk factors and metabolic causes. In patients with severe symptoms of agitation and hallucinations, short-term prescription of antipsychotics for their relief is possible.

Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study.

The temporal association of delirium during critical illness with mortality is unclear, along with the associations of hypoactive and hyperactive motoric subtypes of delirium with mortality. We aimed to evaluate the relationship of delirium during critical illness, including hypoactive and hyperactive motoric subtypes, with mortality in the hospital and after discharge up to 1 year. We analyzed a prospective cohort study of adults with respiratory failure and/or shock admitted to university, community, and Veterans Affairs hospitals. We assessed patients using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the intensive care unit (ICU) and defined the motoric subtype according to the corresponding Richmond Agitation-Sedation Scale if delirium was present. We used Cox proportional hazard models, adjusted for baseline characteristics, coma, and daily hospital events, to determine whether delirium on a given day predicted mortality the following day in patients in the hospital and also to determine whether delirium presence and duration predicted mortality after discharge up to 1 year in patients who survived to hospital discharge. We performed similar analyses for hypoactive and hyperactive subtypes of delirium. Among 1040 critically ill patients, 214 (21%) died in the hospital and 204 (20%) died out-of-hospital by 1 year. Delirium was common, occurring in 740 (71%) patients for a median (interquartile range [IQR]) of 4 (2-7) days. Hypoactive delirium occurred in 733 (70%) patients, and hyperactive occurred in 185 (18%) patients, with a median (IQR) of 3 (2-7) days and 1 (1-2) days, respectively. Delirium on a given day (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.32-6.21; P = .008), in particular the hypoactive subtype (HR, 3.35; 95% CI, 1.51-7.46; P = .003), was independently associated with an increased risk of death the following day in the hospital. Hyperactive delirium was not associated with an increased risk of death in the hospital (HR, 4.00; 95% CI, 0.49-32.51; P = .19). Among hospital survivors, neither delirium presence (HR, 1.01; 95% CI, 0.82-1.24; P = .95) nor duration (HR, 0.99; 95% CI, 0.97-1.01; P = .56), regardless of motoric subtype, was associated with mortality after hospital discharge up to 1 year. Delirium during critical illness is associated with nearly a 3-fold increased risk of death the following day for patients in the hospital but is not associated with mortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients

ObjectivesTo investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology.DesignCross-sectional study.SettingInternational study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and...