Organic Brain Syndrome Scale Research Articles

Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting

BackgroundDelirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection.MethodThis diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients’ and the health care professionals’ experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted.ResultsBy reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51–0.84) and specificity 0.92 (95% CI 0.87–0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50–0.93), specificity 0.93 (95% CI 0.87–0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct.ConclusionThe Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.

Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium

The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB). Prospective observational study. Heart Centre, University Hospital. The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB. Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale. Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium. The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

Validation of the confusion assessment method in detecting postoperative delirium in cardiac surgery patients.

Early detection, prevention, and treatment of delirium after cardiac surgery are important for quick postoperative recovery. The Confusion Assessment Method (CAM) may be an easy-to-use instrument for detecting delirium in clinical practice. To compare the congruent validity of the CAM with the results from repeated assessments by using a combination of the Organic Brain Syndrome Scale and the Mini-Mental State Examination according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for delirium. Patients aged 70 years or older undergoing cardiac surgery were assessed on postoperative days 1 and 4, and the 2 diagnostic methods were compared. The sensitivity and specificity of the CAM were examined. The reference method allowed categorization of delirium into subgroups of psychomotor activities and psychiatric symptom profiles, which were compared with the CAM results. Postoperative delirium was diagnosed in 78 of 141 patients (55.3%). According to the CAM, 59 patients (41.8%) were categorized as delirious, 53 correctly. Thus, the sensitivity was 68% and the specificity was 90%, indicating false-negative rather than false-positive observations. Patients with psychomotor hyperactivity and mixed psychotic-emotional symptoms were more likely to have delirium detected via the CAM than were patients with less obvious clinical manifestations of delirium. Repetitive cognitive testing and psychogeriatric experience are probably necessary to improve the results obtained with the CAM.

EComment. Delirium after cardiac surgery: incidence and risk factors

Smulter et al. provide a very detailed study on an important postoperative issue following cardiac surgery, that is associated with increased morbidity and mortality [1]. Their work, however, raises a number of issues. Smulter et al. identified maximum temperature in the intensive care unit as a risk factor for delirium. As hyperpyrexia is caused by an excessive inflammatory response, this finding is not unexpected. However, no mention is made of the rate of rewarming and the maximum temperature at the end of cardiopulmonary bypass (CPB). Both the rate and the final temperature are known risk factors post-CPB for cerebral damage [2]. A difference exists with regard to cerebral embolic load and whether a cardiac procedure is open (valve replacement), or closed [coronary artery bypass surgery (CABG)]. No mention is made about whether open or closed procedures were utilised as independent covariates in their analysis. We would recommend that isolated CABG should be separately analysed from isolated valve procedures, as they are fundamentally different operations with regard to neurological risk [3]. The identification of sodium as an independent risk factor for postoperative delirium confirms previous work [4]. Valve replacement patients are more likely to suffer from this complication secondary to diuretic therapy. Unfortunately, preoperative sodium levels were not reported. Identification of volume loading during surgery as being a significant risk factor raises the possibility of reduced oxygen delivery being an issue. Quantifying reduced oxygen delivery is difficult, and may involve epoch analysis [5]. The finding of gastritis and peptic ulcer history as a significant risk factor is difficult to interpret, as pointed out by Smulter et al. No comment on an interaction analysis with other covariates was mentioned. In our practice, urgent (not emergency) CABG patients have a high incidence of gastric issues secondary to intense dual antiplatelet therapy. Urgent CABG is a known risk factor for neurological issues. As the Mini-Mental State Examination (MMSE) and the Organic Brain Syndrome Scale (OBS) used are linear scales, and delirium is not a binary issue, it would be interesting if multiple linear regression analysis would reveal the same risk factors as logistic regression, as used by Smulter et al. With regard to the logistic regression, it is customary to use a maximum of 10 events per covariate. In this study, this would limit covariate numbers to a maximum of 8, however, 18 variables from univariate analysis were utilised to develop their final model of 7 variables. Conflict of interest: none declared

Delirium after cardiac surgery: incidence and risk factors

Delirium after cardiac surgery is a problem with consequences for patients and healthcare. Preventive strategies from known risk factors may reduce the incidence and severity of delirium. The present aim was to explore risk factors behind delirium in older patients undergoing cardiac surgery with cardiopulmonary bypass. Patients (≥70 years) scheduled for routine cardiac surgery were included (n = 142). The patients were assessed and monitored pre-/postoperatively, and delirium was diagnosed from repeated assessments with the Mini-Mental State Examination and the Organic Brain Syndrome Scale, using the DSM-IV-TR criteria. Variables were analysed by uni-/multivariable logistic regression, including both preoperative variables (predisposing) and those extracted during surgery and in the early postoperative period (precipitating). Delirium was diagnosed in 78 patients (54.9%). Delirium was independently associated with both predisposing and precipitating factors (P-value, odds ratio, upper/lower confidence interval): age (0.036, 1.1, 1.0/1.2), diabetes (0.032, 3.5, 1.1/11.0), gastritis/ulcer problems (0.050, 4.0, 1.0/16.1), volume load during operation (0.001, 2.8, 1.5/5.1), ventilator time in ICU (0.042, 1.2, 1.0/1.4), highest temperature recorded in ICU (0.044, 2.2, 1.0/4.8) and sodium concentration in ICU (0.038, 1.2, 1.0/1.4). Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to delirium. When combined, the predictive strength of the model improved. Preventive strategies may be considered, in particular among the precipitating factors. Of interest, delirium was strongly associated with an increased volume load during surgery.

Thirty-day prevalence of delirium among very old people: A population-based study of very old people living at home and in institutions

Delirium has mainly been studied in various patient samples and in people living in institutions. The present study investigates the 30-day prevalence of delirium in a population-based sample of very old people in northern Sweden and Finland. Seven hundred and eight persons aged 85 years and older from the GErontological Regional DAtabase (GERDA) were assessed. Information was also collected from relatives, carers and medical records. Assessments performed were among others the Organic Brain Syndrome (OBS) scale, the Mini Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15). Delirium, depression and dementia diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The prevalence of delirium was 17% among 85 year-olds, 21% among 90 year-olds and 39% among participants aged 95 years and older (p<0.001). Delirium prevalence among individuals without dementia was lower than among those with dementia (5% vs. 52%, p<0.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression (Odds Ratio (OR)=2.0, 95% Confidence Interval (CI)=1.2–3.3), heart failure (OR=2.1, 95% CI=1.2–3.7), institutional living (OR 4.4, 95% CI=2.4–8.2) and prescribed antipsychotics (OR=3.0, 95% CI=1.5–6.0).Delirium is highly prevalent among very old people with dementia. Depression, heart failure, institutional living and prescribed antipsychotic medication seem to be associated with delirium.

The prevalence of stroke and the association between stroke and depression among a very old population

There are few studies comparing those who have had and have not had a stroke among those aged 80 years and over, the very old. The aim of this paper was to investigate the prevalence of stroke and the association between stroke and depression in a very old population. This paper is based on cross-sectional data from a population-based study performed between 2005 and 2007. Half of those aged 85 years, all 90-, and 95-year-olds and older in eight urban and rural municipalities in northern Sweden and Finland were invited to participate. A sample of 601 individuals who participated fully in the study was selected. Data were collected through assessments, structured interviews and investigation of medical charts. A specialist in geriatric medicine determined disease status for depression based on medical records and results from the Geriatric Depression Scale (GDS)-15, the Montgomery Åsberg Depression Rating Scale (MADRS) and the Organic Brain Syndrome (OBS) scale, and for stroke based on medical records and reported disease. The prevalence of stroke was 21.5%. The prevalence of depression was 50.4% among those with stroke compared to 34.3% among those without stroke (OR 1.944, p<0.001). In a logistic regression model adjusted for several demographic variables, diseases and functional level, stroke was independently associated with depression (OR 1.644, p=0.038). A large proportion of those with depression, both with and without stroke, were not receiving antidepressant medication. In conclusion, the stroke prevalence was high and stroke showed a strong association with depression among very old people.

Urinary tract infection in very old women is associated with delirium

The aim of the study was to investigate whether urinary tract infection (UTI) in a representative sample of 85-, 90- and ≥95-year-old women is associated with delirium. In 504 out of 643 women (78.4%) it was possible to evaluate UTI and delirium. Assessments such as the Organic Brain Syndrome (OBS) Scale, the Geriatric Depression Scale-15 (GDS-15) and the Mini-mental State Examination (MMSE) were performed during home visits. Delirium, dementia and depression were diagnosed according to the DSM-IV criteria. A diagnosed, symptomatic UTI with or without ongoing treatment, documented in medical records or detected in association with the assessments, was registered. Eighty-seven of 504 women (17.2%), were diagnosed as having a UTI with or without ongoing treatment when they were assessed, and almost half of them (44.8%) were diagnosed to be delirious or having had episodes of delirium during the past month. One hundred and thirty-seven of the 504 women (27.2%) were delirious or had had episodes of delirium during the past month and 39 (28.5%) of them were diagnosed to have a UTI. In a multivariate logistic regression model, delirium was significantly associated with Alzheimer's disease (OR = 5.8), multi-infarct dementia (OR = 5.4), depression (OR = 3.1), heart failure (OR = 2.3) and urinary tract infection (OR = 1.9). A large proportion of very old women with UTI suffered from delirium which might indicate that UTI is a common cause of delirium. There should be more focus on detecting, preventing and treating UTI to avoid unnecessary suffering among old women.

Reducing delirium in elderly patients with hip fracture: a multi‐factorial intervention study

There is an evident need for improved management of elderly patients with trauma in order to avoid common and troublesome complications such as delirium. The aim of this study was to investigate whether an implementation of a multi-factorial program including intensified pre-hospital and perioperative treatment and care could reduce the incidence of delirium in elderly patients with hip fracture, cognitively intact at admission to the hospital. In addition, we explored the factors that characterize patients who developed delirium. A prospective, quasi-experimental design was used. A total of 263 patients with hip fracture (> or = 65 years), cognitively intact at admission, were consecutively included between April 2003 and April 2004. On 1 October 2003, a new program was introduced. All patients were screened for cognitive impairment within 30 min after admission to the emergency department using The Short Portable Mental Status Questionnaire (SPMSQ). To screen for delirium, patients were tested within 4 h of admission and thereafter daily, using the Organic Brain Syndrome scale. The number of patients who developed delirium during hospitalization was 74 (28.1%), with a decrease from 34% (45 of 132) in the control group to 22% (29 of 131) in the intervention group (P=0.031). Patients who developed delirium were statistically older, more often had > 4 prescribed drugs at admission and scored less well in the SPMSQ test. The use of a multi-factorial intervention program in elderly hip fracture patients, lucid at admission, reduced the incidence of delirium during hospitalization by 35%.

Depression in relation to purpose in life among a very old population: A five-year follow-up study

Objectives: To investigate the relationship between purpose in life and depression and, in a five-year follow-up investigate whether purpose in life, adjusted for different background characteristics, can prevent very old men and women from developing depression. Methods: A cross-sectional study included 189 participants (120 women and 69 men) 85–103 years of age living in a county in northern Sweden. Those who had not been diagnosed as depressed at baseline were included in the five-year follow-up study (n = 78). Depression was assessed using the Geriatric Depression Scale-15, the Organic Brain Syndrome scale, the Montgomery–Åsberg Depression Rating Scale, and Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Purpose in life was assessed with the Purpose in Life (PIL) scale. Results: In the cross-sectional study, 40 participants out of 189 (21.2%) were depressed, and those with depression had significantly lower PIL scores (mean score 107 vs. 99, p = 0.014). In the follow-up study, 78 persons were available for the assessment of depression. Of those, 21 (26.9%) were diagnosed as depressed and their mean PIL score at baseline was 106 (SD = 17.4) versus 108 (SD = 16.0, p = 0.750) among those not depressed. Using multivariate logistic regression analysis controlling for possible confounders, we found no association between purpose in life and the risk of developing depression after five years (OR = 1.0, 95% CI 0.97–1.03). Conclusions: The results show a significant inverse relationship between purpose in life and depression in the cross-sectional study; however, a high PIL score does not seem to serve very old people as a protection against the risk of developing depression.

Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study

Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028). Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.

Delirium in Older Patients Admitted to General Internal Medicine

Delirium on the day of admission to general internal medicine wards was studied in 400 consecutive patients aged 70 years and above regarding occurrence, associated factors, clinical profile, length of hospital stay, and mortality. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination, and delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day of admission occurred in 31.3% of the patients and was independently associated with old age, fever on the day of admission (> or = 38 degrees C), treatment with neuroleptics, impaired vision, male sex, and previous stroke. Delirious patients had longer hospital stay (15.4 vs 9.5 days, P < .001), a higher mortality rate during hospitalization (11/125 vs 5/275, P < .001), and a higher 1-year mortality rate (45/125 vs 55/275, P = .001). Delirium is a common complication with often easily identified causes, and it has a serious impact on outcome for older medical patients.

The Organic Brain Syndrome (OBS) scale: a systematic review

The Organic Brain Syndrome (OBS) Scale was developed to determine elderly patients' disturbances of awareness and orientation as to time, place and own identity, and assessment of various emotional and behavioural symptoms appearing in delirium, dementia and other organic mental diseases. The aim of the study was to examine the OBS Scale, using the eight criteria and guidelines formulated by the Scientific Advisory Committee of the Medical Outcomes Trust (SAC), and to investigate its relevance and suitability for use in various clinical settings. Systematic search and analysis of papers (30) on the OBS Scale were carried out using the criteria suggested by the SAC. The OBS Scale in many aspects satisfies the requirements suggested by the SAC: conceptual and measurement model, reliability, validity, responsiveness, interpretability, respondent and administrative burden, alternative forms of administration, and cultural and language adaptations, but there is a need for additional evaluation, especially with regard to different forms of reliability, and the translation and adaptation to other languages. The OBS Scale is a sensitive scale which is clinically useful for the description and long-term follow-up of patients showing symptoms of acute confusional state and dementia. Although the OBS Scale has been used in several clinical studies there is need for further evaluation.

A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients

To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients. Prospective intervention study. Department of General Internal Medicine, Sundsvall Hospital, Sweden. Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward. The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03). This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.

Psychotropic drugs in nursing- and old-age homes: relationships between needs of care and mental health status

The aim of the present study was to map out what kind of psychotropic drugs are prescribed for elderly residents in assisted-living homes and how they relate to age, sex, form of living, psychiatric diagnosis, care needs and mental health status, and to identify factors of importance for their use; and to study the indication for treatment and the evaluation of the effects of treatment. The study had a cross-sectional design and included one-third of all patients ( n=175) living in old-age homes or in nursing homes in a municipality in southern Sweden. Data concerning medication was obtained from medical records and included all psychotropic drugs prescribed the day the study started and the previous month. Need of care was assessed using Katz index, and mental health status was assessed using the Organic Brain Syndrome scale. Of the study population, 128 (73%) used one or more psychoactive drug. Prescribed drugs were neuroleptics (16%), anxiolytics (32%), hypnotics, (45%), and anti-depressants (33%). A greater prescription of neuroleptics than anti-depressants was seen for those showing signs of depression, and caution with prescription of benzodiazepines was seen for those showing signs of dementia. An indication and evaluation of treatment was lacking in half of the cases. Treatment with psychiatric drugs existed for approximately 50% of those without a determined psychiatric diagnosis. We have found a frequent use of neuroleptics, anxiolytics and hypnotics in the elderly, but an underprescription of anti-depressants appears to exist. There is a lack of documentation of indications and evaluations of psychotropic medication.

Dementia after delirium in patients with femoral neck fractures.

To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate. A 5-year prospective follow-up study. Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden. Seventy-eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years. The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre- and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini-Mental State Examination in their homes 5 years after the fracture. Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5-year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P <.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P =.001). Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.

Delirium after Coronary Bypass Surgery Evaluated by the Organic Brain Syndrome Protocol

Objective : The aim was to evaluate symptoms of delirium from a psychogeriatric perspective occurring postoperative to coronary bypass surgery. Design : Patients, S 60 years, scheduled for coronary bypass surgery ( n = 52) were enrolled in a prospective descriptive study. The patients were evaluated before and several times after surgery by the Organic Brain Syndrome scale, and delirium was diagnosed according to psychiatric codes. Results : Of the 52 patients, 23% presented delirium. These patients were older than the control group, 73.5 - 4.2 and 69.3 - 5.9 years, respectively (mean - SD, p < 0.01), and had more frequently a history of previous stroke ( p < 0.05). Emotional delirium was seen in 83%, hyperactive delirium in about 40%, and 25% were classified to have a psychotic delirium. A major finding was a 58% frequency of hallucinations and illusions among patients with delirium, and a similar rate among those without delirium. Conclusion : Delirium is common after cardiac surgery in particular in older patients, but is often under-diagnosed. Hallucinations were common in both delirious and non-delirious patients.

Delirium before and after operation for femoral neck fracture.

The aim of this study was to investigate the differences between preoperative and postoperative delirium regarding predisposing, precipitating factors and outcome in older patients admitted to hospital with femoral neck fractures. A prospective clinical assessment of patients treated for femoral neck fractures. Department of orthopedic surgery at Umeå University Hospital, Sweden. One hundred one patients, age 65 and older admitted to the hospital for treatment of femoral neck fractures. The Organic Brain Syndrome (OBS) Scale. Thirty patients (29.7%) were delirious before surgery and another 19 (18.8%) developed delirium postoperatively. Of those who were delirious preoperatively, all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, had been treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium, and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and had more postoperative complications such as infections. Male patients were more often delirious both preoperatively and postoperatively. Patients with preoperative delirium were more often discharged to institutional care and had poorer walking ability both on discharge and after 6 months than did patients with postoperative delirium only. Because preoperative and postoperative delirium are associated with different risk factors it is necessary to devise different strategies for their prevention.

Clinical signs of ICU syndrome/delirium: an observational study.

Some clinical signs of the intensive care unit (ICU) syndrome/delirium are probably known, but there may be additional signs that can be observed during the care of ICU patients. The aim of this study was to investigate and describe the clinical signs of the ICU syndrome in relation to patients' reactions and behaviour following the second day of their stay in an ICU. A total of 31 patients were observed during the weaning process and in the days following extubation. Informal dialogues between the patient and the observer, using parts of the questionnaire 'Organic Brain Syndrome Scale' were also carried out. The data was structured in a chronological order and consists of descriptions of patients' behaviour and reactions, together with events, occurrences and environmental circumstances. It was found that the patients showed a great variety of clinical signs that could be related to the ICU syndrome. Such signs were the quality, ability and divergence of speech; talking, movements, bodily position and facial expressions. Several patients also related unreal experiences only occasionally, while others experienced them during longer periods. The clinical signs did not seem to be separate phenomena but were inter-connected and part of a progression, and, therefore must be seen in the overall context and situation. Longer periods of observation and repeated interaction with patients are necessary in order to be aware of onset and clinical signs of the ICU syndrome.

Sleep apnea, delirium, depressed mood, cognition, and ADL ability after stroke.

The incidence of sleep apnea and stroke increases with age. The aim of this study was to investigate the presence of sleep apnea after stroke and its relationship to delirium, depressed mood, cognitive functioning, ability to perform activities of daily living (ADLs), and psychiatric and behavior symptoms. Cross-sectional study. Geriatric stroke rehabilitation unit. 133 patients (78 women and 55 men, mean age 77.1 +/- 7.7 years) consecutively admitted to a geriatric stroke rehabilitation unit. All patients underwent overnight respiratory sleep recordings at 23 +/- 7 days (range 11 to 41 days) after suffering a stroke. The patients were assessed using the Organic Brain Syndrome Scale, Montgomery-Asberg-Depression-Rating Scale, Mini-Mental State Examination (MMSE), and Barthel-ADL Index. Sleep apnea was defined as an apnea-hypopnea index (AHI) of 10 or more. The median of the AHI for the studied sample (N = 133) was 13 (range 0-79; interquartile range 6-28). Fifty-nine percent fulfilled the criteria for sleep apnea; 52% with first-ever stroke had sleep apnea. More patients with sleep apnea than without were delirious, depressed, or more ADL-dependent. Sleep apnea patients also had a higher frequency of ischemic heart disease and had more often suffered from an earlier cerebral infarction. Multivariate analysis showed that obesity, low ADL scores, ischemic heart disease, and depressed mood were independently associated with sleep apnea. Low ADL scores, apnea-related hypoxemia, body mass index < or = 27, and impaired vision were independently associated with delirium. The presence of sleep apnea was not associated with any specific type of stroke or location of the brain lesion. Sleep apnea is common in stroke patients and is associated with delirium, depressed mood, latency in reaction and in response to verbal stimuli, and impaired ADL ability. We suggest a trial investigating whether delirium, depressed mood, and ADL ability improve with nasal continuous positive airway pressure treatment of sleep apnea in stroke patients.