Occurrence Of Delirium In Patients Research Articles

Opioid use and subsequent delirium risk in patients with advanced cancer in palliative care: a multicenter registry study

The prevalent use of opioids for pain management in patients with advanced cancer underscores the need for research on their neuropsychiatric impacts, particularly delirium. Therefore, we aimed to investigate the potential association between opioid use and the risk of delirium in patients with advanced cancer admitted to the acute palliative care unit. We conducted a retrospective observational study utilizing a multicenter, patient-based registry cohort by collecting the data from January 1, 2019, to December 31, 2020, in South Korea. All data regarding exposures, outcomes, and covariates were obtained through retrospective chart reviews by a team of specialized medical professionals with expertise in oncology. Full unmatched and 1:1 propensity-score matched cohorts were formed, and stratification analysis was conducted. The primary outcome, delirium, was defined and diagnosed by the DSM-IV. Of the 2,066 patients with advanced cancer, we identified 42.8% (mean [SD] age, 64.4 [13.3] years; 60.8% male) non-opioid users and 57.2% (62.8 [12.5] years; 55.9% male) opioid users, respectively. Opioid use was significantly associated with an increased occurrence of delirium in patients with advanced cancer (OR, 2.02 [95% CI 1.22–3.35]). The risk of delirium in patients with advanced cancer showed increasing trends in a dose-dependent manner. High-dose opioid users showed an increased risk of delirium in patients with advanced cancer compared to non-opioid users (low-dose user: OR, 2.21 [95% CI 1.27–3.84]; high-dose user: OR, 5.75 [95% CI 2.81–11.77]; ratio of OR, 2.60 [95% CI 1.05–6.44]). Patients with old age, male sex, absence of chemotherapy during hospitalization, and non-obese status were more susceptible to increased risk of delirium in patients with cancer. In this multicenter patient-based registry cohort study, we found a significant, dose-dependent association between opioid use and increased risk of delirium in patients with advanced cancer. We also identified specific patient groups more susceptible to delirium. These findings highlight the importance of opioid prescription in these patients with advanced cancer, balancing effective doses for pain management and adverse dose-inducing delirium.

Identification of risk factors for the onset of delirium associated with COVID-19 by mining nursing records.

COVID-19 has a range of complications, from no symptoms to severe pneumonia. It can also affect multiple organs including the nervous system. COVID-19 affects the brain, leading to neurological symptoms such as delirium. Delirium, a sudden change in consciousness, can increase the risk of death and prolong the hospital stay. However, research on delirium prediction in patients with COVID-19 is insufficient. This study aimed to identify new risk factors that could predict the onset of delirium in patients with COVID-19 using machine learning (ML) applied to nursing records. This retrospective cohort study used natural language processing and ML to develop a model for classifying the nursing records of patients with delirium. We extracted the features of each word from the model and grouped similar words. To evaluate the usefulness of word groups in predicting the occurrence of delirium in patients with COVID-19, we analyzed the temporal changes in the frequency of occurrence of these word groups before and after the onset of delirium. Moreover, the sensitivity, specificity, and odds ratios were calculated. We identified (1) elimination-related behaviors and conditions and (2) abnormal patient behavior and conditions as risk factors for delirium. Group 1 had the highest sensitivity (0.603), whereas group 2 had the highest specificity and odds ratio (0.938 and 6.903, respectively). These results suggest that these parameters may be useful in predicting delirium in these patients. The risk factors for COVID-19-associated delirium identified in this study were more specific but less sensitive than the ICDSC (Intensive Care Delirium Screening Checklist) and CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). However, they are superior to the ICDSC and CAM-ICU because they can predict delirium without medical staff and at no cost.

Factors of delirium in elderly patients with mild cognitive impairment in long-term care facilities: a pilot study

Purpose: This study was conducted to identify factors that affect the occurrence of delirium in patients with mild cognitive impairment hospitalized in long-term care facilities. Methods: This study analyzed data collected from 2 long-term care facilities. A cross-sectional pilot study was conducted with 42 patients aged 65 years or older and mild cognitive impairment. To identify factors influencing the occurrence of delirium, multiple logistic regression analysis including general characteristics, risk-related, and medical characteristics was performed. Results: Delirium occurred in 14 (33.3%) of the participants. Hypoactivity was seen in 6 participants (42.86%), hyperactivity in 7 (50.0%), and a combination of both aspects in 1 (7.14%). The results of multiple logistic regression analysis showed that delirium in patients with mild cognitive impairment in long-term care facilities had a high occurrence in patients wearing diapers. Conclusion: This study identified the occurrence of delirium in patients with mild cognitive impairment hospitalized in long-term care facilities. One of the factors affecting the occurrence of delirium was “wearing diapers.” The findings can be used to train nurses on delirium evaluation and intervention and to help prevent and manage delirium in long-term care facilities. This study suggests that further research is necessary to reduce the incidence of delirium.

Sleep and Stroke-Related Delirium: A Systematic Review

Study objectives: Sleep and circadian rhythms disorders are frequent in the acute stroke. Sleep modifications are likely to contribute to the development of stroke-related delirium, a common neuropsychiatric complication of acute stroke. This systematic review aimed to clarify the association between sleep modifications and the occurrence of delirium in patients with acute stroke. Methods: The current systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The search was performed on PubMed and Scopus databases. Only studies that provided data concerning sleep, or pre-existing sleep disorders, in acute stroke and performed a formal evaluation of delirium were included. Results: The literature search enabled the identification of 15 studies, which exhibited high heterogeneity in terms of study design, settings, sleep assessments, delirium measures, and types of sleep intervention. In the study quality assessment, the majority of the studies were rated as weak or moderate. In most of the cases, sleep was subjectively assessed by the patients or rated by clinicians. None of the studies performed polysomnography for the evaluation of sleep. Only four of the studies assessed the impact of a sleep intervention on delirium, suggesting the potentially protective role of sleep promotion in reducing the prevalence and severity of stroke-related delirium. Conclusions: The evidence arising from the present systematic review supports that sleep disruption is a potential promoting factor for stroke-related delirium. We suggest that a formal sleep assessment and sleep promotion should be included in routine stroke care.

Delirium After Traumatic Brain Injury: Prediction by Location and Size of Brain Lesion.

To examine (1) the location of brain lesion that would predict post-traumatic delirium and (2) the association between volume of brain lesion and occurrence of delirium in patients with traumatic brain injury (TBI). A retrospective study was conducted by reviewing medical records of 68 TBI patients, categorized into two groups: the delirious group (n=38) and non-delirious group (n=30). The location and volume of TBI were investigated with the 3D Slicer software. The TBI region in the delirious group mainly involved the frontal or temporal lobe (p=0.038). All 36 delirious patients had brain injury on the right side (p=0.046). The volume of hemorrhage in the delirious group was larger by about 95 mL compared to the non-delirious group, but this difference was not statistically significant (p=0.382). Patients with delirium after TBI had significantly different injury site and side, but not lesion size compared to patients without delirium.

A simple risk score list can be used to predict the occurrence of delirium in patients admitted to inpatient hospice care: A medical record study.

This study aimed to examine whether the 10-item Risk Score List (RSL) accurately predicts delirium in patients admitted to inpatient hospice care and whether this instrument can be simplified. Determining the risk for developing delirium can help to treat these patients in a timely manner. This was a retrospective medical record study in patients who died in 2019 or 2020 in three hospices. Predictive values were examined using Cox regression analysis, crosstabs, and C-statistic. In total, 240 patients were included. Median age at admission was 78 (IQR 70-84) years. Primary diagnosis most often was cancer (n = 186, 78%); 173 (72%) patients had an increased risk of delirium according to RSL, of whom 120 (69%) developed delirium. Overall, 147 (61%) patients developed delirium. The RSL significantly predicted future delirium (HR 3.25, CI 1.87-5.65, p < 0.01) and had a sensitivity of 85%, a specificity of 43%, positive predictive value of 62%, negative predictive value of 73%, and a C-statistic of 0.64. Simplifying the RSL to four items still significantly predicted future delirium, with similar predictive values. Delirium occurs in more than half of patients admitted to hospice care. The RSL can be simplified to four items, without compromising on predictive accuracy.

Impact of Adjuvant Anticonvulsant Medications on Benzodiazepine Use and Delirium in Alcohol Withdrawal Syndrome.

Objective: To assess the benefits of anticonvulsant medications on benzodiazepine (BZD) use and delirium in patients with alcohol dependence at risk of alcohol withdrawal and admitted to the hospital without delirium.Methods: This was a resident-led retrospective study of prospectively collected data for patients admitted to the monitored unit of a general medical ward between June 2016 and March 2017 for a variety of medical conditions. Patients were assigned to the usual care group (BZD as needed) or the intervention group (scheduled anticonvulsants and BZD as needed) based on admission census and order of arrival. Of 75 patients, 44 were assigned to the usual care group and 31 to the intervention group.Results: Significantly lower BZD dosage (P = .0002) and lower Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised scores were observed in the intervention group. Delirium occurred significantly less in the intervention group (0 versus 7 in the usual care group; P = .037).Conclusions: Adjuvant anticonvulsant medications for alcohol withdrawal were efficacious in reducing BZD use, severity of symptoms of alcohol withdrawal, and occurrence of delirium in patients admitted to the general medical ward without delirium for reasons other than alcohol detoxification.

Estratégias utilizadas por enfermeiras para minimizar a ocorrência de delirium em pacientes críticos

Objetivo: descrever as estratégias utilizadas por enfermeiras para minimizar a ocorrência de delirium em pacientes internados em unidade de terapia intensiva (UTI). Método: estudo exploratório-descritivo, de abordagem qualitativa, desenvolvido em um hospital de ensino, público, de grande porte da cidade de Salvador. Foi realizado nos meses de setembro e outubro de 2018, participaram do estudo 16 enfermeiras. Os dados foram coletados mediante entrevista semiestruturada e analisados por meio da “Técnica de Análise de Conteúdo Temática”. Resultados: da análise dos dados emergiram duas categorias temáticas, denominadas: “Desconhecimento sobre monitorização do delirium em UTI” e “Estratégias das enfermeiras para minimizar a ocorrência de delirium em UTI”. Conclusão: apesar do pouco conhecimento das enfermeiras sobre o delirium existe uma coerência quantos aos métodos de intervenções para preveni-lo. A implementação de protocolos e atividades educativas são imprescindíveis para empoderar o enfermeiro quanto às intervenções realizadas.

Symptom expression in advanced cancer patients admitted to hospice or home care with and without delirium.

The aim of this study is to investigate the relationship between delirium and symptom expression in advanced cancer patients admitted to palliative care services. This is a secondary analysis of a consecutive sample of advanced cancer patients who were admitted to home care and hospices, and prospectively assessed for a period of 10months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after seven days of home care or hospice care (T7). Of the eight hundred and forty-eight patients screened in the period, 585 were not considered in the analysis for various reasons. The mean age was 72.1years (SD 13.7), and 146 patients were males (55.5%). The mean Karnofsky status recorded at T0 is 34.1 (SD = 6.69). The mean duration palliative care assistance is 38.4days (SD = 48, range 2-220). Of 263 patients who had a MDAS available at T0, 110 patients (41.8%) had a diagnosis of delirium. Of them, 167 patients had complete data regarding MDAS measurement, either at T0 and T7. A larger number of patients (n 167, 63.5%) had delirium after a week of palliative care. Patients with delirium are likely to be older, to have a lower Karnofsky level at T0, and to be home care patients. At T0, weakness, nausea, drowsiness, lack of appetite, and well-being are associated with delirium. At T7, weakness, poor appetite, and poor well-being are significantly associated with delirium. 27% of patients who had a normal cognitive status at T0 developed delirium at T7. In patients with delirium, an improvement in the cognitive status corresponds to a significant improvement in weakness, depression, and appetite. Conversely, the occurrence of delirium in patients who had a normal cognitive status at admission significantly increases the level depression, while the level of weakness and appetite decrease. Symptom expression is amplified in patients with delirium admitted to home care or hospices, while patients without delirium can be more responsive to palliative treatments with a significant decrease in intensity of ESAS items.

Effect of dynamic light at the coronary care unit on the length of hospital stay and development of delirium: a retrospective cohort study.

BackgroundDisturbed circadian rhythm is a potential cause of delirium and is linked to disorganisation of the circadian rhythmicity. Dynamic light (DL) could reset the circadian rhythm by activation of the suprachiasmatic nucleus to prevent delirium. Evidence regarding the effects of light therapy is predominantly focused on psychiatric disorders and circadian rhythm sleep disorders. In this study, we investigated the effect of DL on the total hospital length of stay (LOS) and occurrence of delirium in patients admitted to the Coronary Care Unit (CCU).MethodsThis was a retrospective cohort study. Patients older than 18 years, who were hospitalized longer than 12 h at the CCU and had a total hospital LOS for at least 24 h, were included. Patients were assigned to a room with DL (n = 369) or regular lighting conditions (n = 379). DL was administered at the CCU by two ceiling-mounted light panels delivering light with a colour temperature between 2700 and 6500 degrees Kelvin. Reported outcome data were: total hospital LOS, delirium incidence, consultation of a geriatrician and the amount of prescripted antipsychotics.ResultsBetween May 2015 and May 2016, data from 748 patients were collected. Baseline characteristics, including risk factors provoking delirium, were equal in both groups. Median total hospital LOS in the DL group was 100.5 (70.8–186.0) and 101.0 (73.0–176.4) h in the control group (P = 0.935). The incidence of delirium in the DL and control group was 5.4% (20/369) and 5.0% (19/379), respectively (P = 0.802). No significant differences between the DL and control group were observed in secondary endpoints. Subgroup analysis based on age and CCU LOS also showed no differences.ConclusionOur study suggests exposure to DL as an early single approach does not result in a reduction of total hospital LOS or reduced incidence of delirium. When delirium was diagnosed, it was associated with poor hospital outcome.

Virtual Reality and Human Consciousness: The Use of Immersive Environments in Delirium Therapy.

Immersive virtual environments can produce a state of behavior referred to as "presence," during which the individual responds to the virtual environment as if it were real. Presence can be arranged to scientifically evaluate and affect our consciousness within a controlled virtual environment. This phenomenon makes the use of virtual environments amenable to existing and in-development forms of therapy for various conditions. Delirium in the intensive care unit is one such condition for which virtual reality technology has not been evaluated to date. We are currently assessing the feasibility and utility of a delirium prevention and treatment system which implements virtual reality to improve quality of sleep, reduce pain, lower usage of sedatives, and stimulate cognition. The proposed system will consist of 3-axis wearable accelerometers, 6-DOF position trackers, a virtual reality system, and apps designed to promote sleep quality and mindfulness. Our a priori hypothesis is that our virtual reality therapy system would lower the occurrence of delirium in patients admitted to intensive care units.

Association of education with occurrence of delirium in patients from an emergency department.

ABSTRACTBackground: Delirium is a neuropsychiatric syndrome with multiple etiological factors. Evaluation of delirium in different settings, especially the Emergency Department (ED) pertaining to different regions of the world with patients from different cultural and educational backgrounds is needed. Objective: To determine the prevalence of delirium and its association with education in an ED in Brazil during a 6-month period. Methods: Patients aged >18 years were randomly selected from ED admissions. The instruments Confusion Assessment Method (CAM) scale, Mini-Mental State Examination (MMSE), Wechsler Logical Memory (WLM) and Charlson comorbidity score were applied to evaluate delirium, cognitive status, and comorbidities. Results: The prevalence of delirium was10.7%. Delirium patients had significantly lower education, MMSE and WLM (immediate and delayed) scores, with 97.4% presenting episodic memory impairment. Patients with delirium had more history of neurological disorders. Three logistic regression models evaluating the association of variables with delirium were developed. Age and MMSE were retained in the first model, WLM scores in the second, and education in the third. Conclusion: To the best of our knowledge, this is the first study estimating the prevalence of delirium in a Brazilian ED. Lower education was associated with the occurrence of delirium.

Triggers and nursing influences on delirium in intensive care units.

Among care providers, nurses have the most influence on the occurrence of delirium in patients. To identify and investigate the risk factors associated with delirium and analyse the nurse's influence on delirium, a secondary data analysis approach was used with clinical data from the electronic medical record and health care provider data from the management information systems of a university hospital. Data of 3284 patients (delirium = 688, non-delirium = 2596) hospitalized in the medical and surgical intensive care units containing 2178 variables were analysed. Donabedian's structure-process-outcome model was applied to categorize the factors for multilevel hierarchical logistic regression analysis. Sixteen factors (10 patient factors, 1 provider factor, 1 environmental factor, 2 nursing intervention factors and 2 medical intervention factors) were identified as significant in the final model. Longer intensive care unit experience of nurses did not decrease the risk of delirium. Greater number of nursing intervention needs and greater use of restraints were associated with an increased risk of delirium. The duration of nursing career did not affect the reduction of the risk of delirium. Nurses should therefore endeavour to acquire nursing experience specific for delirium care and attend training courses for delirium management.

Seasonal variation in the occurrence of delirium in patients admitted to medical units of a general hospital in Italy.

Delirium syndrome is common in the hospitalised population. However, data on its aetiological factors are scarce. Clinical observations suggest a relationship between delirium occurrence and seasons. The aim of study was to determine whether a seasonal variation exists in the occurrence of delirium events in-hospital patients. The study included all admissions to the medical units of the Hospital of Ferrara, Italy, between January 2002 and December 2010. On the basis of date admission, cases have been analysed for seasonal variation (four 3-month intervals by seasons) by means of conventional statistics. Moreover, cases categorised into twelve 1-month intervals were also analysed by means of a validated chronobiologic inferential method (single cosinor) to search for cyclic variability. During the analysed period, the hospital database contained 74 379 records referring to 42 625 subjects (52.7% females). Delirium diagnoses were 1300 (1.7% of total sample), 668 of whom in females (51.4%) and 632 in males (48.6%). Events of delirium were more frequent in winter and autumn (26.6 and 26.5%, respectively) than in spring (23.5%) and summer (23.4%). Chronobiological analysis yielded a significant peak of delirium events in January, when considering both the total raw number of cases and the percent of admissions. The study seems to indicate in patients hospitalised in medical units, a higher rate of occurrence of delirium in autumn-winter, similar to that reported for acute medical diseases. The role of possible underlying favouring or triggering factors deserves further research.

Robust methods for generalized linear models with nonignorable missing covariates

AbstractThe EM algorithm is often used for finding the maximum likelihood estimates in generalized linear models with incomplete data. In this article, the author presents a robust method in the framework of the maximum likelihood estimation for fitting generalized linear models when nonignorable covariates are missing. His robust approach is useful for downweighting any influential observations when estimating the model parameters. To avoid computational problems involving irreducibly high‐dimensional integrals, he adopts a Metropolis‐Hastings algorithm based on a Markov chain sampling method. He carries out simulations to investigate the behaviour of the robust estimates in the presence of outliers and missing covariates; furthermore, he compares these estimates to the classical maximum likelihood estimates. Finally, he illustrates his approach using data on the occurrence of delirium in patients operated on for abdominal aortic aneurysm.

Delirium associated with mianserin

Delirium may develop in vulnerable subjects under normal doses of psychotropic drugs. The occurrence of delirium in patients treated with tricyclic antidepressants is attributed to the anticholinergic activity of these drugs. Mianserin, characterized by low anticholinergic activity, has been recommended for treatment of depression in elderly patients. We report five cases of delirium in elderly patients treated with mianserin. The incidence of organo-mental side effects associated with this drug may be higher than previously reported.