Delirium Rating Research Articles

Serum Biomarkers in Postoperative Delirium After Esophagectomy

BackgroundEsophagectomy is associated with postoperative delirium, but its pathophysiology is not well defined. We conducted this study to measure the relationship among serum biomarkers of inflammation and neuronal injury and delirium incidence and severity in a cohort of esophagectomy patients. MethodsBlood samples were obtained from patients preoperatively and on postoperative days 1 and 3 and were analyzed for S100 calcium-binding protein B, C-reactive protein (CRP), interleukin (IL) 8 and IL-10, tumor necrosis factor-α, and insulin-like growth factor 1. Delirium was assessed twice daily using the Richmond Agitation Sedation Scale and Confusion Assessment Method for Intensive Care Unit. Delirium severity was assessed once daily with the Delirium Rating Scale–Revised-98. ResultsSamples from 71 patients were included. Preoperative biomarker concentrations were not associated with postoperative delirium. Significant differences in change in concentrations from preoperatively to postoperative day 1 were seen in IL-8 (delirium, 38.6; interquartile range [IQR], 29.3-69.8; no delirium, 24.8; IQR, 16.0-41.7, P = .022), and IL-10 (delirium, 26.1; IQR, 13.9-36.7; no delirium, 12.4; IQR, 7.7-25.7; P = .025). Greater postoperative increase in S100 calcium-binding protein B (Spearman r = 0.289, P = .020) and lower levels of insulin-like growth factor 1 were correlated with greater delirium severity (Spearman r = −0.27, P = .040). Greater CRP change quartiles were associated with higher delirium incidence adjusting for severity of illness (odds ratio, 1.68; 95% confidence interval, 1.03-2.75; P = .037) or comorbidities (odds ratio, 1.70; 95% confidence interval, 1.05-2.76, P = .030). ConclusionsDifferences in change in serum CRP, IL-8, and IL-10 concentrations were associated with postoperative delirium, suggesting biomarker measurement early in the postoperative course is associated with delirium.

The effect of multi-component interventions on the incidence rate, severity, and duration of post open heart surgery delirium among hospitalized patients

BackgroundDelirium is one of the prevalent complications of post open heart surgery. The present research aimed to assess the effect of multi-component interventions on the incidence rate, severity, and duration of post open heart surgery delirium among hospitalized patients.MethodsIn this quasi-experimental study, 96 patients under open heart surgery were selected using convenience sampling and divided into a control and an intervention group. The interventions included the patients’ preoperative education, nurses’ education, and in-ward environmental interventions. The demographic information and Mini-Mental State Examination (MMSE) questionnaires were completed a day before surgery. The patients in both groups were also surveyed after extubation until the fourth day post operation using Delirium Observation Screening (DOS) scale considering the incidence, severity, and duration of delirium. The data were analyzed using the SPSS statistical software, version 20.ResultsThe incidence rate of delirium was 14.6 and 6.2% in the control and intervention groups, respectively (p > 0.05). Besides, the mean severity of delirium was 0.53 in the control group and 0.40 in the intervention group (p > 0.05). Finally, the mean duration of delirium was 4.5 and 3.25 h in the two groups, respectively (p > 0.05).ConclusionsSince prevention of delirium can play a considerable role in the patients’ recovery after heart surgery, it is necessary to carry out some measures to prevent such complications. Even though the interventions performed in this study did not cause significant changes in this regard, the results suggested that prevention interventions should be performed with stronger and more integrated planning for achieving better outcomes.

Factors associated with the severity of delirium.

Various factors affecting the development of delirium have been identified. However, the associations between the severity of delirium and potentially related factors have not been adequately investigated. The aim of the present study was to explore factors associated with the severity of delirium and to identify the reversible contributing factors. A total of 577 patients with delirium referred to the Department of Psychiatry during the 5 years from May 2015 to April 2020 at a general hospital were included. The Delirium Rating Scale-revised-98 (DRS-R-98) was used to measure the severity of delirium. Multiple regression analysis was used to determine whether individual factors were associated with the severity of delirium. Intensive care unit admission (p=0.003), use of benzodiazepines (p=0.01), dementia (p=0.02), and older age (p=0.045) were all positively associated the severity of delirium, while use of β-blockers (p=0.001) was negatively associated with the severity of delirium. Reversible contributing factors, that is use of benzodiazepines, should be avoided as much as possible, especially in elderly patients or patients with dementia or patients who need critical care in ICU. Reducing the dose of benzodiazepines or switching them to other drugs should be a priority.

Effects of molecular targeting agents and immune-checkpoint inhibitors in patients with advanced cancer who are near the end of life.

In recent years, the use of both molecular targeting agents (MTAs) and immune-checkpoint inhibitors (ICIs) tend to occupy important positions in systemic anticancer therapy (SACT). The objective of this study is to describe the predictors of SACT include both MTAs and ICIs near the end of life (EOL) and the effect on EOL care in patients with advanced cancer. We analyzed all patients who died of advanced cancer from August 2016 to August 2019, and we analyzed the survival time of patients who underwent anticancer agents excluded due to the loss of information about the last administration of SACT. The primary endpoint of this study was to identify predictors during the last administration of SACT near EOL. In a multivariate analysis, the Eastern Cooperative Oncology Group performance status (ECOG-PS) (ORs 33.781) was significantly related factors within 14 days of death from the last administration of SACT. Age (ORs 0.412), ECOG-PS (ORs 11.533), primary cancer site of upper GI cancers (ORs 2.205), the number of comorbidities (ORs 0.207), MTAs (ORs 3.139), and ICIs (ORs 3.592) were significantly related factors within 30 days of death. The median survival time (MST) of patients with PS 3-4 was 29 days, while that of patients with both PS 0-2 was 76 days. The prevalence rate of delirium with MTAs was 17.5%, which was significantly lower than that of patients without it (31.8%). The prevalence rate of the mean dose of opioids in patients with ICIs was 97.9 mg/day, which was significantly higher than that of patients without it (44.9 mg/day). Age, ECOG-PS, primary cancer site, the number of comorbidities, MTAs, and ICIs use were significant associated with SACT near EOL. Information on these factors may aid clinical decision making in referral to palliative care institutes.

Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon.

An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.

Preoperative Cerebrospinal Fluid Cortisol and the Risk of Postoperative Delirium: A Prospective Study of Older Hip Fracture Patients

Background: Ageing, depression, and neurodegenerative disease are common risk factors for delirium in the elderly. These risk factors are associated with dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in higher levels of cortisol under normal and stressed conditions and a slower return to baseline. Objectives: We investigated whether elevated preoperative cerebrospinal fluid (CSF) cortisol levels are associated with the onset of postoperative delirium. Methods: In a prospective cohort study CSF samples were collected after cannulation for the introduction of spinal anesthesia of 75 patients aged 75 years and older admitted for surgical repair of acute hip fracture. Delirium was assessed with the confusion assessment method (CAM) and the Delirium Rating Scale-Revised-98 (DRS-R98). Because the CAM and DRS-R98 were available for time of admission and 5 postoperative days, we used generalized estimating equations and linear mixed modeling to examine the association between preoperative CSF cortisol levels and the onset of postoperative delirium. Results: Mean age was 83.5 (SD 5.06) years, and prefracture cognitive decline was present in one-third of the patients (24 [33%]). Postoperative delirium developed in 27 (36%) patients. We found no association between preoperative CSF cortisol levels and onset or severity of postoperative delirium. Conclusions: These findings do not support the hypothesis that higher preoperative CSF cortisol levels are associated with the onset of postoperative delirium in elderly hip fracture patients.

Effectiveness of a Delirium Prevention Initiative on an Inpatient Neuroscience Unit.

BACKGROUND: Delirium frequently develops in hospitalized patients and results in increased mortality, longer length of stay, and need for transitional care. Neurological patients are at an increased risk for developing delirium. There is a paucity of research on effective prevention strategies for this population. PURPOSE: The objectives of this project were to improve nurses' knowledge and confidence in delirium prevention, design a delirium volunteer program, and establish ongoing monitoring for continued improvement. METHODS: This study is a quality improvement project using a pretest-posttest design to examine the benefits of refocusing care from delirium management to delirium prevention. The sample included 304 patients pre and 332 post intervention. The interventions included delirium education for nurses and the recruitment of trained volunteers to implement nonpharmacological, multicomponent delirium prevention interventions. RESULTS: Forty-eight nurses completed delirium education, and 11 volunteers were recruited and trained. There was a significant increase in nursing knowledge (z = 3.967, P < .0005) and confidence (z = 3.989, P < .0005). Volunteers visited 54 patients and implemented 99 interventions post implementation. CONCLUSION: This pre-post improvement project provides beginning evidence that nursing education increased nurses' knowledge and confidence in preventing and treating delirium. Trained volunteers supported using nonpharmacological delirium prevention interventions, but ongoing evaluation is needed to determine the impact of volunteers on delirium rates.

Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study.

Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors. This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission. Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium. In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.

Does implementation of a tailored intervention increase adherence to a National Safety and Quality Standard? A study to improve delirium care.

Delirium is commonly detected in older people after hip fracture. Delirium is considered to be a multifactorial disorder that is often seen post-operatively (incidence ranging from 35% to 65%). Hospitals in Australia are required to meet eight standards including the comprehensive care standard to be able to maintain their accreditation. The standard includes actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care. Delirium prevention was identified as an area for improvement in our Orthopaedic unit in a Level 1 University Trauma Centre in Australia. This implementation research project aimed to understand the efficacy of a delirium prevention intervention within an existing orthopaedic speciality care system. Implementation of the tailored intervention will increase adherence to National Safety and Quality Health Service Standards, thereby reducing rate of delirium. In this study, we used an interrupted time series design to examine changes in practice over time in people admitted to hospital with a hip fracture. Clinical staff caring for patients with hip fracture in an acute care setting in Adelaide, South Australia, participated in the project. In brief, intervention included education, environmental restructuring, change champions, infographics and audit feedback reports. The primary outcome of interest was rate of delirium. The secondary outcome was compliance with the use of delirium 4AT screening tool, duration of delirium and hospital length of stay. The rate of change per month in patients with delirium decreased significantly by 19.2%. There was no significant change observed in trend for duration of delirium and length of hospital stay between pre-intervention and post-intervention phases. A significant increase in the use of screening tool was observed from 4.7% in the pre-intervention phase to 33.6% in the post-intervention phase. Translation of evidence-based intervention model incorporating well-considered implementation strategies had a mixed impact on decreasing the rate of delirium. The scheduled hospital accreditation enhanced the use of validated screening tool to recognize delirium. This project highlights the importance of aligning implementation goals with the wider goals of the organization as well as making clinicians accountable by consistent auditing.

Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis.

Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes thatcan lastlong term. Therefore, the importance of prevention is undeniable andadoptingnew models of carefor at-risk patients should be prioritised. This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium inacutely unwellhospitalised patients. MEDLINE, EMBASE,PsycINFO,OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO. A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies).Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio=0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention(risk ratio=0.29, 95% CI: 0.09 to 0.87). Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.

Frailty, Complexity, and Priorities in the Use of Advanced Palliative Care Resources in Nursing Homes.

Background and objectives: This study aimed to determine the frailty, prognosis, complexity, and palliative care complexity of nursing home residents with palliative care needs and define the characteristics of the cases eligible for receiving advanced palliative care according to the resources available at each nursing home. Materials and Methods: In this multi-centre, descriptive, and cross-sectional study, trained nurses from eight nursing homes in southern Spain selected 149 residents with palliative care needs. The following instruments were used: the Frail-VIG index, the case complexity index (CCI), the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal), the palliative prognosis index, the Barthel index (dependency), Pfeiffer’s test (cognitive impairment), and the Charlson comorbidity index. A consensus was reached on the complexity criteria of the Diagnostic Instrument of Complexity in Palliative Care that could be addressed in the nursing home (no priority) and those that required a one-off (priority 2) or full (priority 1) intervention of advanced palliative care resources. Non-parametric tests were used to compare non-priority patients and patients with some kind of priority. Results: A high percentage of residents presented frailty (80.6%), clinical complexity (80.5%), and palliative care complexity (65.8%). A lower percentage of residents had a poor prognosis (10.1%) and an extremely poor prognosis (2%). Twelve priority 1 and 14 priority 2 elements were identified as not matching the palliative care complexity elements that had been previously identified. Of the studied cases, 20.1% had priority 1 status and 38.3% had priority 2 status. Residents with some kind of priority had greater levels of dependency (p < 0.001), cognitive impairment (p < 0.001), and poorer prognoses (p < 0.001). Priority 1 patients exhibited higher rates of refractory delirium (p = 0.003), skin ulcers (p = 0.041), and dyspnoea (p = 0.020). Conclusions: The results indicate that there are high levels of frailty, clinical complexity, and palliative care complexity in nursing homes. The resources available at each nursing home must be considered to determine when advanced palliative care resources are required.

Comparison of the Effectiveness of Haloperidol Injection and Oral Quetiapine to Control Delirium in Patients in the Emergency Department and Intensive Care Unit – A Randomized Clinical Trial

Background: Delirium is a psychiatric syndrome observed among patients with critical psychiatric disorders. Haloperidol is now one of the first-line drugs for the treatment of delirium. However, quetiapine can be considered as an appropriate substitute in patients with a high risk of extrapyramidal symptoms or long QT syndrome. Objectives: This study aimed to compare the effectiveness of intramuscular haloperidol and oral quetiapine to control delirium in patients in the emergency department and intensive care unit. Methods: This randomized clinical trial was performed during 2017-2018 on patients with delirium who were referred to the emergency department and intensive care unit of Imam Reza Hospital (referral center), Mashhad, Iran. Patients were divided into two groups of 100 patients per group through a random allocation technique . In this study, 5 mg of intramuscular haloperidol every 12 hours and 25 mg of oral quetiapine were prescribed daily for the patients in the control and intervention groups, respectively. The delirium severity score of each patient was evaluated before and three days after the intervention through Delirium Rating Scale-Revised-98. Results: In this study, the mean±SD age of participants was 60.2±14.1 years. The findings indicated that no significant difference was observed between haloperidol (22.7±1.9) and quetiapine (22.7±2.2) groups in terms of the baseline delirium severity score (P=0.95). The mean delirium severity scores of patients in haloperidol and quetiapine groups were 25.6±2.1 and 25.2±2.5, respectively. Based on the obtained results, the difference between the delirium severity scores of both groups was not statistically significant (P=0.24). Conclusion: Based on the results, oral quetiapine has a similar effect as intramuscular haloperidol and can be used as a substitute to this medicine for controlling the symptoms of patients with delirium.

A Geriatric Hip Fracture Care Pathway: An Operational Approach to Quality Improvement

Introduction: Geriatric hip fractures are a devastating injury that decrease patient independence, increase morbidity and mortality, and have a significant economic impact. Although early operative intervention decreases mortality, hospitals often do not meet these benchmarks. The purpose of this study was to use a methodological approach to optimize the care and outcomes of patients sustaining geriatric hip fractures at a single level I trauma center by minimizing time to surgery and length of stay (LOS). Methods: A process map that outlined the paths that a hip fracture patient could take through our system from the time of injury to discharge was created. Classical operations management tactics known as Lean Synchronization and Six Sigma were used to identify bottlenecks in the system that led to delays in time to surgery or discharge. The pathway was systematically revised to address additional inefficiencies. Results: The initial process map revealed that time to surgery was increased by extensive preoperative testing and LOS was increased by admission to a non-orthopaedics service. By creating a standardized protocol for risk stratification and admitting all hip fracture patients to the orthopaedics service, improvements were seen within 6 months, including reductions in time to surgery (32.4 vs 17.5 hours), LOS (7.1 vs 5.6 days), 30-day readmissions (14.29% to 8.33%), and in-hospital mortality (2.79% vs 0%). Additional areas for improvement were later identified to reduce delirium rates and cost of care. Discussion: We conclude that the use of an operational management approach to address the inefficiencies in a clinical care pathway produced substantial and sustainable improvements in relevant outcome measures in patients sustaining geriatric hip fractures. By systematically identifying the bottlenecks in the system, we generated an ideal state pathway, which has allowed us to deliver higher quality care to our patients while simultaneously decreasing cost of care.

Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic.

Objectives:To better elucidate how the COVID-19 pandemic has affected the operatively treated geriatric hip fracture population and how the health care system adapted to pandemic dictated procedures.Design:Retrospective cohort study.Setting:A community hospital.Participants:Individuals ≥65 years of age presented with a proximal femoral fracture from a low-energy mechanism undergoing operative treatment from January 17, 2020 to July 2, 2020 (N = 125).Measurements:We defined 3 phases of healthcare system response: pre-COVID-19, acute phase, and subacute phase. Thirty-day mortality, time to operating room (OR), length of stay, time to start physical therapy, perioperative complications, delirium rate, hospice admission rate, discharge dispositions, readmission rate, and the reason of surgery delay were assessed.Results:The number of hip fractures has remained constant during the pandemic. The 30-day mortality rate, time to OR, and length of stay were higher in the pandemic compared to the pre-pandemic. Those who had a longer wait time to OR (≥ 24 hours) had more complications and increased 30-day mortality rates. Some of the surgery delays were related to OR unavailability as a consequence of the COVID-19 pandemic. Surgery was delayed in 3 patients who were on direct oral anticoagulants (DOACs) in pandemic but none for pre-pandemic period.Conclusion:This is the first study to compare the effect of the acute and subacute phases of the pandemic on uninfected hip fracture patients. In the age of COVID-19, to provide the best care for the vulnerable geriatric orthopedic populations, the healthcare system must adopt new protocols. We should still aim to promote prompt surgical care when indicated. It is important to ensure adequate resource availability, such as OR time and staff so that hip fracture patients may continue to receive rapid access to surgery. A multidisciplinary approach remains the key to the management of fragility hip fracture patients during the pandemic.

A PERSPECTIVA DOS ENFERMEIROS SOBRE O ACOMPANHANTE NA UTI EM TEMPOS DE COVID-19

The aim was to know the perspective of nurses in relation to the presence of a companion in the ICU in times of COVID-19. This is an exploratory research with a qualitative approach, carried out in the ICU of a Hospital located in the city of Florianópolis. Eight nurses from the unit participated. Data collection took place online through a semi-structured questionnaire instrument, via Google Forms. It highlights the benefits of the presence of a companion in the ICU and the harm that their absence causes to the hospitalized patient. Difficulties can be found in the implementation of strategies, such as: limited structure, non-compliance with protocols and nurses' work overload. The companion transforms the ICU environment, reduces delirium and depression rates for patients and stress for the nursing staff. Professionals experience a period of pressure, which makes them feel guilty about the patient's pain process without the family's face-to-face assistance at this time. The companion in the ICU brings several benefits to the patient, but it is observed that humanization in the ICU still consists of many taboos and barriers to the creation of strategies and protocols, in relation to the companion's stay. The nurse is extremely important in this process.

Nursing intervention to prevent delirium in critically ill adults.

To determine the effectiveness of a nursing intervention for delirium prevention in critically ill patients. A quasi-experimental study was conducted with a non-equivalent control group and with evaluation before and after the intervention. 157 Patients were part of the intervention group and 134 of the control group. Patients were followed-up until they were discharged from the ICU or died. The incidence of delirium in both groups was compared. Additionally, the effect measures were adjusted for the propensity score. The incidence and incidence rate of delirium in the control group were 20.1% and 33.1 per 1000 person-days (CI 95% 22.7 to 48.3) and in the intervention group was 0.6% and 0.64 per 1000 person-days (CI 95% 0.22 to 11.09), respectively. The crude Hazard Ratio was 0.06 (CI 95% 0,008 to 0,45) and adjusted 0.07 (CI 95% 0,009 to 0,60). The number needed to be treated was six. Low incidence of delirium in critically ill patients intervened demonstrated the effectiveness of interventions. The average intervention time was 4 days with a 15-minutes dedication for each patient.

Evaluation of association of impairment of attention with other symptoms of delirium

Aim: To evaluate the association of impairment of attention with other symptoms of delirium. Methodology: Eighty-six patients with delirium as per the Diagnostic and Statistical Manual, 5th Revision seen in the consultation-liaison psychiatry setup of a tertiary care hospital were cross-sectionally assessed on the short informant questionnaire on cognitive decline in the elderly (Retrospective), montreal cognitive assessment (MoCA), and delirium rating scale revised-98 (DRS-R98) version. Results: The mean age of the study participants was 46.6 (standard deviation [SD] – 16.4) years. All the patients had impairment in attention with the altered sleepwake cycle, acute onset of illness, with the fluctuating course and underlying physical disease. In terms of severity, the severity score was the highest for the item of sleep-wake cycle disturbances, followed by motor agitation. The mean noncognitive symptoms domain of the DRS-R98 domain were more than the mean score of the cognitive symptom domain of DRS-R98. The mean total score on MoCA was 11.9 (SD: 7.5). Higher attention impairment was associated with more severe noncognitive and cognitive symptoms and higher delirium severity as assessed by DRS-R98. Higher severity of attention deficit was also associated with higher impairment in other domains of cognition of MoCA. Cognitive symptoms, as evaluated by DRS-R98, had more significant correlations with various domains of MoCA except for language and abstraction. Conclusion: Attention deficits are the core symptom of delirium and have a significant impact on other cognitive and noncognitive symptoms of delirium.

The role of acetylcholinesterase and butyrylcholinesterase activity in the development of delirium in acute stroke.

Our study aimed to test whether plasma acetylcholinesterase and butyrylcholinesterase enzyme activity were related to the presence and intensity of delirium in acute stroke patients. We carried out a matched (age and gender) case-control study, in a sample of consecutive patients with an acute infarct or intracerebral haemorrhage (≤7 days). We assessed delirium using the DSM-5 criteria and the Delirium Rating Scale, and we measured plasma acetylcholinesterase and butyrylcholinesterase enzyme activity after the patient's admission in the stroke unit and before hospital discharge. Mantel-Haenszel's chi-square was used to test bivariate associations between cases (delirious patients) and controls (non-delirious patients). At admission in the stroke unit, cases and controls did not present significant differences in plasma acetylcholinesterase or butyrylcholinesterase activity. At hospital discharge (18 cases and 21 controls) patients who have had delirium at admission had higher levels of butyrylcholinesterase activity. Butyrylcholinesterase activity may secondarily increase due to the inflammatory process associated with neuronal dysfunction in delirium patients.

Electronic Health Record Data Can be Used at the Bedside to Identify Older Hospitalized Patients With Delirium

Delirium is a serious condition that is often underrecognized. Several delirium predictive rules can assist in early detection. The coupling of prediction rules with features of the EHR are in their infancy but hold potential. This study aimed to determine variables within the EHR that can be used to identify older hospitalized patients with delirium. This is a prospective study among patients >=65 years admitted to the hospital. Researchers screened daily for delirium using the 3-D CAM. Predictive variables were extracted from the EHR. Basic descriptive statistics were conducted. Chi-squared and Fischer’s exact tests were used to compare differences among those diagnosed with or without delirium as appropriate; binary logistic regression was used for multivariate modeling. Among 408 participants, mean age was 75 years, 61% were female, and 83% were black. The overall rate of delirium was 16.7% (prevalent delirium 10.5%; incident delirium 6.1%). There was no statistical difference in 30-day mortality (2.9% vs. 2.7%) or 30-day readmission (13.2% vs. 14.7%) rates between those with and without delirium (both P>0.05). Even so, patients with delirium were older, more likely to have a diagnosis of infection and/or cognitive impairment, as well as increased severity of illness (all P’s <0.05). Moreover, patients with delirium had a lower Braden score and higher Morse fall score (both P’s <0.01). In multivariate analysis, cognitive impairment (OR 5.49; 95% CI 2.77-10.87) and lower Braden scores (OR 1.29; 95% CI 1.18-1.41) remained significant predictors of delirium. Further research is needed to develop an automated EHR prediction model.

The Harmonization of Four Delirium Instruments

Delirium is a clinical syndrome characterized by acute cognitive dysfunction, which is pervasive in older persons. Delirium affects over 2.6 million Americans over age 65 annually. One major problem in detection of delirium is that over 40 different instruments have been created to identify delirium in different clinical settings. There is no single agreed upon reference standard instrument. In previous work, we performed a systematic review to identify the four most commonly cited and well-validated instruments for delirium identification. The aim of this study is to harmonize these four commonly used instruments: Confusion Assessment Method (CAM), Delirium Observation Screening Scale (DOSS), Delirium Rating Scale-Revised-98 (DRS-R-98), and Memorial Delirium Assessment Scale (MDAS). We used data from three separate sources (N = 1623). Participants were rated by multiple and overlapping instruments across studies, allowing us to apply item response theory linking procedures. We fit generalized structural equation models, and found unidimensional factor models fit well. We found the instruments were highly correlated (all r > 0.9) and kappa statistics for delirium case identification were high (range: 0.89 to 0.95). We generated crosswalks to map sum scores on one instrument to another. Our results suggest the same underlying construct, propensity to delirium, is measured across the four instruments. The crosswalks facilitate comparison and combination for immediate clinical use or for future meta-analyses. In future steps, we will use our results to find the optimal cut-points for use across all instruments to identify delirium.