Identification Of Delirium Research Articles

Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients.

Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium. The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70). UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.

Predictors and outcomes of delirium in the emergency department during the first wave of the COVID-19 pandemic in Milan

BackgroundRespiratory infections can be complicated by acute brain failure. We assessed delirium prevalence, predictors and outcomes in COVID-19 ED patients.MethodsThis was a retrospective observational study conducted at the San Raffaele...

Evaluation of Education and Patient Screening for Delirium Among Patients With Stroke: Knowledge, Confidence, and Patient Outcomes.

Clinical staff showed a knowledge deficit with identifying and managing delirium. The effect of a validated assessment tool and delirium education on staff knowledge and confidence and patient outcomes was analyzed. A descriptive qualitative and quantitative pre- and postintervention study analyzed the demographics of patients with stroke and clinical outcomes pre- and postimplementation of an assessment tool and delirium staff education. Early and frequent delirium assessments, use of an assessment tool, a delirium order set, and education for clinical staff resulted in increased knowledge and confidence with identifying and managing patients with stroke, an increase in the number of patients with stroke discharged home, and decreased incidence of hospital-acquired urinary tract infection and pneumonia. Delirium education positively impacts staff knowledge and confidence with the identification and management of delirium. Patients with an acute stroke may benefit from early and frequent delirium assessments. Staff education, structured assessment frequency with a validated assessment tool, and specific interventions affect patient outcomes, such as infection rates and discharge level of care. [J Contin Educ Nurs. 2023;54(2):61-70.].

Delirium education for geriatric patients and their families: A quality improvement initiative✰

Delirium affects up to 50% of hospitalized older adults, contributing to poor outcomes. Family members can be engaged in delirium identification, prevention, and management. Rapid cycle improvement methodology was utilized to create a new educational handout on delirium. Using this handout, we taught family caregivers about delirium in a geriatric preoperative clinic. During the patient's postoperative recovery in the hospital, we evaluated family members’ knowledge about delirium and application of concepts learned in the handout. All participating family members reported applying at least one prevention strategy. We implemented a new delirium educational handout for family members that resulted in robust knowledge of delirium and self-report of strategies taken to prevent delirium. All respondents engaged in at least one delirium prevention strategy. This was used in a preoperative setting, but it could also be implemented in other situations prior to an event that might lead to increased delirium risk.

The Effect of Consultation‐Liaison Psychiatry on Postoperative Delirium in Elderly Hip Fracture Patients in the General Hospital

The low recognition rate of postoperative delirium has gradually aroused clinical attention in China. The present study was to investigate the impact of consultation-liaison psychiatry on postoperative delirium in elderly hip fracture patients. From March 2012 to September 2013, 89 patients with hip fractures hospitalized in Wuhan Mental Health Center were included in this prospective study as the consultation-liaison group. A total of 81 patients selected from August 2010 to February 2012 were defined as the conventional group. The delirium was evaluated using the confusion assessment method (CAM) recommended by the American Psychiatric Association guidelines. There was no difference of sex, age, trauma, surgical methods, and anesthesia between two groups (p > 0.05). The consultation rate of consultation-liaison group was significantly higher than that of conventional group (37.07% vs 17.28%, p < 0.05). After the consultation, there were 26 cases (78%) and nine cases (64%) of delirium in the consultation-liaison and conventional group, respectively (p > 0.05). In the consultation-liaison group, three patients (9.09%) were diagnosed with anxiety and three patients (9.09%) were diagnosed with depression, while in the conventional group, three patients (21.42%) were diagnosed with communication and one patient (7.14%) was diagnosed with depression. In addition, this study showed the incidence of delirium in consultation-liaison group was significantly higher than that of conventional group (29.21% vs 11.11%, p < 0.05). The average hospital stay in consultation-liaison group was significantly lower than that of conventional group (11.42 ± 2.63 vs. 15.17 ± 2.38 days, p < 0.01). Consultation-liaison psychiatry could improve the recognition rate of postoperative delirium in elderly hip fracture patients, shorten hospitalization time. The training of mental health knowledge for non-psychiatrists could improve the ability of early identification and treatment of delirium.

Identification of delirium from real-world electronic health record clinical notes.

We tested the ability of our natural language processing (NLP) algorithm to identify delirium episodes in a large-scale study using real-world clinical notes. We used the Rochester Epidemiology Project to identify persons ≥ 65 years who were hospitalized between 2011 and 2017. We identified all persons with an International Classification of Diseases code for delirium within ±14 days of a hospitalization. We independently applied our NLP algorithm to all clinical notes for this same population. We calculated rates using number of delirium episodes as the numerator and number of hospitalizations as the denominator. Rates were estimated overall, by demographic characteristics, and by year of episode, and differences were tested using Poisson regression. In total, 14,255 persons had 37,554 hospitalizations between 2011 and 2017. The code-based delirium rate was 3.02 per 100 hospitalizations (95% CI: 2.85, 3.20). The NLP-based rate was 7.36 per 100 (95% CI: 7.09, 7.64). Rates increased with age (both p < 0.0001). Code-based rates were higher in men compared to women (p = 0.03), but NLP-based rates were similar by sex (p = 0.89). Code-based rates were similar by race and ethnicity, but NLP-based rates were higher in the White population compared to the Black and Asian populations (p = 0.001). Both types of rates increased significantly over time (both p values < 0.001). The NLP algorithm identified more delirium episodes compared to the ICD code method. However, NLP may still underestimate delirium cases because of limitations in real-world clinical notes, including incomplete documentation, practice changes over time, and missing clinical notes in some time periods.

Boosting Delirium Identification Accuracy With Sentiment-Based Natural Language Processing: Mixed Methods Study.

Delirium is an acute neurocognitive disorder that affects up to half of older hospitalized medical patients and can lead to dementia, longer hospital stays, increased health costs, and death. Although delirium can be prevented and treated, it is difficult to identify and predict. This study aimed to improve machine learning models that retrospectively identify the presence of delirium during hospital stays (eg, to measure the effectiveness of delirium prevention interventions) by using the natural language processing (NLP) technique of sentiment analysis (in this case a feature that identifies sentiment toward, or away from, a delirium diagnosis). Using data from the General Medicine Inpatient Initiative, a Canadian hospital data and analytics network, a detailed manual review of medical records was conducted from nearly 4000 admissions at 6 Toronto area hospitals. Furthermore, 25.74% (994/3862) of the eligible hospital admissions were labeled as having delirium. Using the data set collected from this study, we developed machine learning models with, and without, the benefit of NLP methods applied to diagnostic imaging reports, and we asked the question "can NLP improve machine learning identification of delirium?" Among the eligible 3862 hospital admissions, 994 (25.74%) admissions were labeled as having delirium. Identification and calibration of the models were satisfactory. The accuracy and area under the receiver operating characteristic curve of the main model with NLP in the independent testing data set were 0.807 and 0.930, respectively. The accuracy and area under the receiver operating characteristic curve of the main model without NLP in the independent testing data set were 0.811 and 0.869, respectively. Model performance was also found to be stable over the 5-year period used in the experiment, with identification for a likely future holdout test set being no worse than identification for retrospective holdout test sets. Our machine learning model that included NLP (ie, sentiment analysis in medical image description text mining) produced valid identification of delirium with the sentiment analysis, providing significant additional benefit over the model without NLP.

Quality Improvement in Delirium Health Literacy in Older Adult Patients and Their Caregivers Attending a Geriatric Clinic.

Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention. We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2-3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults. The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p<0.01) recognizing signs and symptoms (77% vs 94%, p<0.05), complications (76% vs 100%, p<0.01) and identifying the etiological factors associated with delirium. The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.

Quantitative EEG signatures of delirium and coma in mechanically ventilated ICU patients

ObjectiveTo identify quantitative electroencephalography (EEG)-based indicators of delirium or coma in mechanically ventilated patients. MethodsWe prospectively enrolled 28 mechanically ventilated intensive care unit (ICU) patients to undergo 24-hour continuous EEG, 25 of whom completed the study. We assessed patients twice daily using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU). We evaluated the spectral profile, regional connectivity and complexity of 5-minute EEG segments after each assessment. We used penalized regression to select EEG metrics associated with delirium or coma, and compared mixed-effects models predicting delirium with and without the selected EEG metrics. ResultsDelta variability, high-beta variability, relative theta power, and relative alpha power contributed independently to EEG-based identification of delirium or coma. A model with these metrics achieved better prediction of delirium or coma than a model with clinical variables alone (Akaike Information Criterion: 36 vs 43, p = 0.006 by likelihood ratio test). The area under the receiver operating characteristic curve for an ad hoc hypothetical delirium score using these metrics was 0.94 (95%CI 0.83–0.99). ConclusionsWe identified four EEG metrics that, in combination, provided excellent discrimination between delirious/comatose and non-delirious mechanically ventilated ICU patients. SignificanceOur findings give insight to neurophysiologic changes underlying delirium and provide a basis for pragmatic, EEG-based delirium monitoring technology.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan

ObjectivesDelirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we...

Using Multiple Strategies to Reduce the Incidence of Delirium in Older Adult Patients Receiving Surgery

Older adult patients receiving surgery experience a relatively high rate of developing acute delirium due to factors related to the environment, surgery and anesthesia, pain, and indwelling line, which puts these patients at higher risk of patient safety incidents. The incidence of delirium among older patients receiving surgery in our ward was 12.3%. Moreover, in our ward, delirium-attributed self-extraction accounted for 84.2% of the "tubing events" reported via the Taiwan Patient-safety Reporting System and delirium-attributed falls accounted for 33.3% of the "fall events". Thus, delirium in this patient population had a serious effect on patient safety and increased medical expenses. Reduce the incidence of delirium in older adult patients receiving surgery from 12.3% to 6.6%. Strategies used included providing delirium care education and training to improve the delivery of delirium preventive treatments and the care implementation rate by care teams; formulating a surgical delirium high-risk factor assessment scale for the early screening of high-risk patients; adopting the "RADAR" delirium identification method for the rapid identification of cognition changes; establishing delirium prevention and treatment care guidelines for quality-of-care improvement; introducing bedside exercise equipment to increase patient mobility; and designating a dedicated delirium ward for these patients to provide high-quality delirium care services. The incidence rate of delirium in older adult patients receiving surgery was reduced to 6.5%. In addition, the implementation rate of delirium prevention treatment was increased to 98% in physicians and 100% in nurses. This project resulted in significantly improved outcomes and was expanded to the other surgical wards. The innovative concept of incorporating a designated delirium ward for older patients receiving surgery into other wards may be referenced in future ward planning and strategies for improving the quality of medical care.

Examination of the Presence of COVID-19 Encephalopathy on Inpatient Acute Rehabilitation Outcomes and Disability

<h3>Research Objectives</h3> The objective of the current study was to investigate the impact of COVID-19 encephalopathy on acute inpatient rehabilitation outcome. <h3>Design</h3> This retrospective study assessed functional ability pre-intervention (admission) and post-intervention (discharge) among COVID-19 patients who received acute inpatient rehabilitation between April 2020 and March 2021. <h3>Setting</h3> Participants received care in a dedicated COVID unit at a freestanding acute inpatient rehabilitation facility. <h3>Participants</h3> 161 inpatients were divided into two groups according to COVID-encephalopathy status: 87 negative (CE-) and 74 positive (CE+). Encephalopathy status was determined based on Chart-Based Delirium Identification Instrument using electronic medical records. The sample was 61% male / 39% female, 62% White, 14% Black, 8% Hispanic, 4% Asian, 12% Other/declined. Mean age was 62 (SD=15.2) and mean education was 13 years (SD=3.9). <h3>Interventions</h3> Rehabilitation interventions utilized a medically-based, multidisciplinary approach. All participants received a minimum of three hours of physical, occupational and/or speech therapy five days / week during inpatient stay. <h3>Main Outcome Measures</h3> The total raw score from the self-care and mobility section of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) was used to assess overall functional ability at admission and discharge. The Brief Interview for Mental Status was utilized to assess orientation. <h3>Results</h3> At admission, encephalopathy groups did not differ in overall ability. In contrast, at discharge overall ability was significantly higher with encephalopathy and IRF-PAI change per day trended higher with encephalopathy. Finally, at discharge orientation was associated with overall ability in the CE+ group. <h3>Conclusions</h3> Following inpatient rehabilitation CE+ patients had less overall disability than CE- patients but residual problems with cognitive functioning were associated with severe overall disability in the CE+ group. Findings highlight the complexity of COVID-19 symptom manifestation and persistent physical and cognitive deficits during the course of a COVID-19 infection and recovery. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest to declare nor any financial or non-financial interests to disclose.

170 DELIRIUM SCREENING CONCURRENT AUDIT UTILISING THE 4AT ASSESSMENT TOOL IN THE EMERGENCY DEPARTMENT

Abstract Background Delirium is an acute onset of clinical serious conditions associated with poor outcomes, seen in older patients in Emergency Department (ED). Despite its seriousness, delirium can be missed by 57-83% and 25% with unrecognised delirium discharged from ED. The audit aim is to improve delirium screening for older people in ED using the 4AT assessment tool. Methods Criteria included patients over 75 and under 75 with complaints of new confusion, history of dementia and cognitive impairment presented to ED over 20 day period in January 2022. Exclusion criteria included patients with alcohol and drug withdrawal, trauma and critically ill. Data collection through concurrent chart review using self-designed tool performed by two auditors. 30 patient charts gathered through consecutive sampling accessed in IMS Maxims (electronic patient record system) for 3 random days approved by Assistant Director of Nursing and data collected with respect and in accordance with General Data Protection Regulation. Algorithm of Early Identification and Management of Delirium in ED/AMAU (HSE 2021) and ED Delirium Screening Bundle (University Limerick Hospital Group 2021) were standards used. Results 70% were screened using the 4AT tool and 4 cases identified with delirium. 9 patients were not screened implying 30% variance against the national standard. 100% expected level of compliance but 50% failed compliance standard. Results discussed at staff meeting, daily huddles and poster presentation in ED information board. Conclusion The audit shows satisfactory results on the awareness and importance of delirium screening and moderately poor compliance on documentation. Strategies to improve practice and maintain sustainability include staff re-education, increase awareness in triage by adding blue-colored sticker “Screen me with 4AT” and rewarding staff with Delirium Champion of the Day to promote use.

253 DELIRIUM IDENTIFICATION AT INITIAL TRIAGE IN AN IRISH EMERGENCY DEPARTMENT SETTING

Abstract Background Over 10% of older adults are affected by delirium on presentation to Emergency Departments (ED), with many more developing it during a prolonged ED stay. Early detection is key to delirium management, but the diagnosis is often missed, with over 50% of delirium going undetected in the ED. In 2019 the HSE guideline on Early Identification and Management of Delirium in the ED recommended that all those over 65 years be screened on presentation to ED using the 4AT, a validated instrument in delirium screening. Through our ED’s delirium working group, we conducted a baseline audit on current rates of screening for delirium, ahead of a quality improvement project on management of patients with, or at risk of delirium in our ED. Methods A retrospective review was conducted of consecutive patients &amp;gt;65yrs who presented to ED in one month with the following terms mentioned in the presenting complaint at triage: confusion/delirium/memory/speech/language disturbance/agitation i.e. terms that could indicate possible delirium as considered by the triage practitioner. We also recorded whether a 4AT was recorded. An additional 50 charts from the consecutive series were randomly selected and examined for probable delirium on presentation which was not captured at triage. Results n=23/1,597 (&amp;lt;1%) had possible delirium recorded at triage as per our criteria. In-depth case note review supported the diagnosis of delirium in 20 of the 23 initially identified at triage. Only 5 of these had a documented 4AT score. Of the additional 50 charts screened, a further 6 had likely delirium of whom n=3 had a 4AT score completed. N=16 required hospital admission. Conclusion Delirium screening and detection rates at ED triage are less than expected, and below the 2019 national screening recommendations. Implementing same in any busy ED is challenging. We are developing a multifaceted educational program to address this and plan a repeat audit following implementation.

222 TOWARDS A DELIRIUM FRIENDLY EMERGENCY DEPARTMENT

Abstract Background Delirium affects approx. 10-30 % of patients over the age of 65. Up to 70% of cases are missed in the Emergency Department (ED). Delirium results in increased morbidity, mortality, increased length of stay and decreased functional status with increased discharges to residential care centres. Delirium in the ED is an independent predictor of death within 6 months. Methods We completed an audit which showed 40% of those &amp;gt; 65 years of age in the ED were delirious and 60% of those had dementia. None of these had been identified as delirious prior to review. We have approx. 5,000 patients &amp;gt;75 years of age attending our ED annually (1/7th of presentations). This audit was used as a catalyst for our quality improvement project. We established a steering group with a small quality improvement sub-committee. We combed the literature, identified areas for improvement and costed our project. We also looked at reliance on 1:1 carers for those with delirium and potential benefits to patient, staff and management. Results We used the SPARK ignite programme as a means to gain momentum and also educate ourselves on business management and change management. We competed in the finals with our “delirium package” – focussing on orientation, stimulation, safety and education. These 4 pillars of delirium care have been shown to prevent delirium, reduce hospital stay for those with delirium and also augment their delirium cycle. Competing and winning a prize highlighted the importance of delirium care and brought our project to a bigger stage. Conclusion Due to our multi-disciplinary team composed of non-consultant hospital doctors, advanced nurse practitioners and occupational therapists, we have been able to introduce the national dementia programme for early identification of delirium in the emergency department. We now have a space for managing those with delirium and have received funding to put our package in place. This can be replicated in hospitals around the country highlighting the non-pharmacological treatments for delirium.

Potential value of cerebrospinal fluid α-synuclein in the identification of postoperative delirium undergoing knee/hip arthroplasty: The perioperative neurocognitive disorder and biomarker lifestyle study.

Postoperative delirium (POD) is a common postoperative complication, which may be associated with α-synuclein (α-syn). The purpose of this study was to explore the association between the expression level of α-syn in cerebrospinal fluid (CSF) and POD. We conducted a prospective observational cohort study, which involved in 740 participants (mean age of 61.86 years, range 40-90 years; 40% female) from the Perioperative Neurocognitive Disorder And Biomarker Lifestyle (PNDABLE) study in the final analysis. POD was diagnosed using the Confusion Assessment Scale (CAM), and its severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immune-sorbent assay (ELISA) was used to detect the concentrations of α-syn, Aβ40, Aβ42, T-tau, and P-tau in CSF. The incidence of POD was 11.22% (83/740). The logistic regression analysis showed that the increased concentrations of CSF α-syn (OR = 1.005, 95%CI 1.004-1.006, P < 0.001), P-tau (OR = 1.093, 95%CI 1.071-1.115, P < 0.001), and T-tau (OR = 1.008, 95%CI 1.006-1.009, P < 0.001) were risk factors of POD. Linear regression showed that CSF α-syn had positive correlations with P-tau (β = 0.480, P < 0.001), T-tau (β = 0.334, P < 0.001), while negative correlations with Aβ40 (β = -0.378 P < 0.001), Aβ42 (β = -0.800, P = 0.001) in POD patients. Mediation analyses showed the association between α-syn and POD was partially mediated by tau pathologies (proportion: 16-17%). CSF α-syn is one of the preoperative risk factors for POD, which may be mediated through tau pathologies. [www.ClinicalTrials.gov], identifier [ChiCTR20 00033439].

Implementing a Delirium Risk Stratification Tool and Rounds to Identify and Prevent Delirium in Hospitalized Older Adults.

Up to 40% of delirium cases are preventable, and early identification is key to improve patient outcomes. To implement and evaluate a multidisciplinary delirium intervention program. The delirium intervention program targeted patients at high risk for delirium and included patient and nurse education, risk stratification, multidisciplinary rounds, a nonpharmacological intervention bundle, and a treatment order set. After implementation, there was a reduction in length of stay of 6.3 days ( P = .01), a 24% decrease in disposition to a skilled nursing facility ( P = .05), and increased detection of delirium by nurses. Positive patient outcomes were achieved by employing a multifactorial approach for delirium identification, prevention, and management. The components of this quality improvement project provide guidance to hospitals seeking to develop a delirium intervention program.

Potential value of preoperative fasting blood glucose levels in the identification of postoperative delirium in non-diabetic older patients undergoing total hip replacement: The perioperative neurocognitive disorder and biomarker lifestyle study.

BackgroundPostoperative delirium (POD) is a common complication after total hip replacement. This study aims to explore the relationship between preoperative fasting blood glucose (FBG) levels and POD in non-diabetic older patients undergoing total hip replacement.Materials and methodsThis study included a total of 625 patients undergoing elective total hip replacement under combined spinal and epidural anesthesia from the PNDABLE study. The relationship between POD and preoperative FBG was analyzed by using the logistic regression model. The associations of FBG with individual cerebrospinal fluid (CSF) biomarkers were detected by using the multivariable linear regression model controlling for age, gender, and education level. The mediation effects were explored by mediation analyses with 5,000 bootstrap iterations, while sensitivity analysis was used to test the reliability and stability of the results. The receiver operating characteristic (ROC) curve and the nomogram model were applied to evaluate the efficacy of FBG and POD-related CSF biomarkers in predicting POD. POD assessment was performed two times daily by a trained anesthesiologist at 9:00–10:00 am and 2:00–3:00 pm on postoperative days 1–7 or before the patients were discharged from the hospital. POD was defined by the Confusion Assessment Method (CAM), and POD severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immunosorbent assay (ELISA) was used to measure CSF Aβ40, Aβ42, T-tau, and P-tau levels.ResultsPOD was detected in 10.2% (60/588) of the patients. Logistic regression analysis showed that after adjusting for age and education level, the increased levels of FBG (OR 1.427, 95% CI 1.117–1.824, P = 0.004), CSF P-tau (OR 1.039, 95% CI 1.019–1.060, P < 0.001), and CSF T-tau (OR 1.013, 95% CI 1.009–1.018, P < 0.001) were risk factors for POD, and the increased level of CSF Aβ42 (OR 0.996, 95% CI 0.994–0.998, P = 0.001) was a protective factor for POD. Multivariable linear regression models showed that when adjusting for age, gender, and education level, in the POD group, higher preoperative FBG levels were negatively correlated with the CSF Aβ42 level (β = −0.290, P = 0.028) and positively correlated with CSF P-tau (β = 0.384, P = 0.004) and T-tau (β = 0.447, P < 0.001). In the non-POD group, a higher preoperative FBG was not related to CSF biomarkers. Mediated effect analysis showed that CSF T-tau (proportion = 17.1%) had an apparent mediation effect on the relationship between FBG and POD. Sensitivity analysis revealed that the results from the logistic regression and multivariable linear regression models were consistent with previous results.ConclusionIncreased preoperative FBG was a risk factor for POD in older patients without T2DM, and T-tau might mediate the relationship between FBG and POD.

A quality improvement project addressing the underreporting of delirium in hip fracture patients

IntroductionAfter discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred. MethodsHip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations. ResultsThe incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001). ConclusionsOur institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

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.