Science.gov

Sample records for delirium uma perspectiva

  1. Delirium

    MedlinePlus

    ... occur together. Delirium starts suddenly and can cause hallucinations. The symptoms may get better or worse, and ... hand, dementia develops slowly and does not cause hallucinations. The symptoms are stable, and may last for ...

  2. Delirium

    PubMed Central

    Burns, A; Gallagley, A; Byrne, J

    2004-01-01

    Delirium is a common cause of mortality and morbidity in older people in hospital, and indicates severe illness in younger patients. Identification of risk factors, education of professional carers, and a systematic approach to management can improve the outcome of the syndrome. Physicians should be aware that delirium sufferers often have an awareness of their experience, which may be belied by their varying grasp of reality. PMID:14966146

  3. Delirium (PDQ)

    MedlinePlus

    ... of delirium. Possible signs of delirium include sudden personality changes, problems thinking, and unusual anxiety or depression. ... signs of delirium : Agitation . Not cooperating. Changes in personality or behavior. Problems thinking. Problems paying attention. Unusual ...

  4. Postoperative Delirium

    PubMed Central

    Marcantonio, Edward R.

    2013-01-01

    Delirium (acute confusion) complicates 15% to 50% of major operations in older adults and is associated with other major postoperative complications, prolonged length of stay, poor functional recovery, institutionalization, dementia, and death. Importantly, delirium may be predictable and preventable through proactive intervention. Yet clinicians fail to recognize and address postoperative delirium in up to 80% of cases. Using the case of Ms R, a 76-year-old woman who developed delirium first after colectomy with complications and again after routine surgery, the diagnosis, prevention, and treatment of delirium in the postoperative setting is reviewed. The risk of postoperative delirium can be quantified by the sum of predisposing and precipitating factors. Successful strategies for prevention and treatment of delirium include proactive multifactorial intervention targeted to reversible risk factors, limiting use of sedating medications (especially benzodiazepines), effective management of postoperative pain, and, perhaps, judicious use of antipsychotics. PMID:22669559

  5. [Delirium Prevention].

    PubMed

    Restrepo Bernal, Diana; Niño García, Jorge Andrés; Ortiz Estévez, Daniel Eduardo

    2016-01-01

    Delirium is the most prevalent neuropsychiatric syndrome in the general hospital. Its presence is a marker of poor prognosis for patients. Its prevention could be the most effective strategy for reducing its frequency and its complications. To review recent findings and strategies for the prevention of delirium. A non-systematic review of scientific articles published in the last ten years in Spanish and English. A search was made in databases such as MEDLINE, Cochrane, EMBASE, Ovid, and ScienceDirect, for articles that included the terms, delirium and prevention. Identification of predisposing and precipitating factors for delirium and a better understanding of the pathophysiological mechanisms underlying the onset of delirium have enabled the implementation of various pharmacological and non-pharmacological strategies in patients at high risk to develop hospital delirium. The studies to prevent delirium have focused on surgical patients. The current evidence supports the daily implementation of non-pharmacological measures to prevent delirium, as they are easy and cost effective. The available evidence is still limited to recommend the daily use of pharmacological strategies in delirium prophylaxis, and there is a consensus against the modest use of antipsychotic drugs in surgical patients and dexmedetomidine in patients in intensive care. New high-quality clinical trials and studies involving non-surgical patients are needed to provide more evidence about this subject. Copyright © 2015 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España. All rights reserved.

  6. Excited Delirium

    PubMed Central

    Takeuchi, Asia; Ahern, Terence L.; Henderson, Sean O.

    2011-01-01

    Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium. PMID:21691475

  7. What to Ask: Delirium

    MedlinePlus

    ... Join our e-newsletter! Resources What to Ask: Delirium Tools and Tips Under recognition of delirium is a major problem. It is important to ... questions you can ask your healthcare professional about delirium. What is delirium? What are its symptoms? How ...

  8. Delirium Tremens.

    PubMed

    Mehta, S R; Prabhu, Hra; Swamy, A J; Dhaliwal, Harinder; Prasad, Dinesh

    2004-01-01

    The varied clinical manifestations and management of 14 male patients with delirium tremens (DT) have been studied. Eight patients were initially hospitalised for diseases unrelated to ethanol abuse i.e. 2 each for gun shot wound, myocardial infarction and stroke, and one each for pneumonia and gastroenteritis. One patient was going through withdrawal because of prodrome of viral hepatitis before he was hospitalised for uncontrolled agitation and delirium. Two known cases of mild essential hypertension on dietary therapy reported for agitation, abnormal behaviour, a single episode of tonic clonic seizure and hypertensive encephalopathy as they could not/did not get alcohol for 3 days. Three patients presented denovo with DT without concomitant illness. The other features besides delirium and hallucinations were tremulousness in 10, tachycardia in 12, fever in 3, diaphoresis in 2 and tonic clonic seizures in 4 patients. The symptoms fluctuated markedly at short intervals and 2 patients did not have any features of sympathetic overactivity. Altered hepatic biochemical parameters and ketonuria with normal blood sugar were noted in 4 and one patients respectively. Other biochemical parameters including serum electrolytes were normal. CT scan brain done for 5 patients revealed subdural haematoma in one. Cerebro spinal fluid (CSF) and EEG findings were noncontributory. All made good recovery with heavy doses of intravenous vitamin B complex, glucose and oral benzodiazepine. Short course of haloperidol was used in 2 patients. Two patients developed pancreatitis during follow up. All patients made complete recovery, and 8 patients have been followed for 8 to 12 months without relapse. The reason for hospitalisation in such cases is often unrelated to alcohol abuse; hence a detailed history of alcoholism is mandatory to identify those at risk as well as for prompt treatment and decreasing the mortality.

  9. Delirium: a review.

    PubMed

    Gofton, Teneille Emma

    2011-09-01

    Delirium affects a diverse patient population, may present with highly variable clinical features, is a source of distress for patients and their caregivers, prolongs hospital stays and may herald a poor prognosis. Many cases of delirium are reversible and therefore a full history, physical examination and investigations should be performed. Ahigh degree of suspicion is required for detecting delirium and thorough investigations are necessary in order to determine the underlying etiology and to maximize the potential for reversibility. The following review outlines important aspects of a clinical approach to delirium, the differential diagnosis of delirium, investigation of a patient presenting with delirium, management of delirium, the pathophysiology of delirium and the prognosis accompanying delirium.

  10. Delirium Superimposed on Dementia

    PubMed Central

    Steis, Melinda R.; Fick, Donna M.

    2012-01-01

    Delirium is an acute, fluctuating confusional state that results in poor outcomes for older adults. Dementia causes a more convoluted course when coexisting with delirium. This study examined 128 days of documentation to describe what nurses document when caring for patients with dementia who experience delirium. Nurses did not document that they recognized delirium. Common descriptive terms included words and phrases indicating fluctuating mental status, lethargy, confusion, negative behavior, delusions, and restlessness. Delirium is a medical emergency. Nurses are in need of education coupled with clinical and decisional support to facilitate recognition and treatment of underlying causes of delirium in individuals with dementia. PMID:21761816

  11. Side Effects - Delirium

    Cancer.gov

    Delirium is a confused mental state. Symptoms may include changes in thinking and sleeping. In cancer patients, it may be caused by medicine, dehydration, or happen at the end of life. Delirium may be mistaken for depression or dementia.

  12. Delirium in older adults.

    PubMed

    Popeo, Dennis M

    2011-01-01

    Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis, and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and nonpharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and nonpharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research. © 2011 Mount Sinai School of Medicine.

  13. DELIRIUM IN OLDER ADULTS

    PubMed Central

    Popeo, Dennis M.

    2011-01-01

    Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and non-pharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and non-pharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research. PMID:21748745

  14. Delirium in hospitalized older patients.

    PubMed

    Inouye, S K

    1998-11-01

    Delirium is a common, serious problem for hospitalized older patients. Recognition of delirium poses challenges requiring cognitive assessment and knowledge of the clinical course. Delirium often is of multiple causes and is associated with a poor long-term prognosis. Nonpharmacologic approaches for delirium management are recommended; pharmacologic management should be reserved for patients who pose a danger to themselves or others. Importantly, delirium and its complications may be preventable through a targeted risk factor approach.

  15. Delirium and its treatment.

    PubMed

    Attard, Azizah; Ranjith, Gopinath; Taylor, David

    2008-01-01

    Delirium occurs at rates ranging from 10% to 30% of all hospital admissions. It is a negative prognostic indicator, often leading to longer hospital stays and higher mortality. The aetiology of delirium is multifactorial and many causes have been suggested. The stress-diathesis model, which posits an interaction between the underlying vulnerability and the nature of the precipitating factor, is useful in understanding delirium. Preventing delirium is the most effective strategy for reducing its frequency and complications. Environmental strategies are valuable but are often underutilized, while remedial treatment is usually aimed at specific symptoms of delirium. Antipsychotics are the mainstay of pharmacological treatment and have been shown to be effective in treating symptoms of both hyperactive and hypoactive delirium, as well as generally improving cognition. Haloperidol is considered to be first-line treatment as it can be administered via many routes, has fewer active metabolites, limited anticholinergic effects and has a lower propensity for sedative or hypotensive effects compared with many other antipsychotics. Potential benefits of atypical compared with typical antipsychotics include the lower propensity to cause over-sedation and movement disorder. Of the second-generation antipsychotics investigated in delirium, most data support the use of risperidone and olanzapine. Other drugs (e.g. aripiprazole, quetiapine, donepezil and flumazenil) have been evaluated but data are limited. Benzodiazepines are the drugs of choice (in addition to antipsychotics) for delirium that is not controlled with an antipsychotic (and can be used alone for the treatment of alcohol and sedative hypnotic withdrawal-related delirium). Lorazepam is the benzodiazepine of choice as it has a rapid onset and shorter duration of action, a low risk of accumulation, no major active metabolites and its bioavailability is more predictable when it is administered both orally and

  16. Zolpidem withdrawal delirium

    PubMed Central

    Mattoo, Surendra K.; Gaur, Navendu; Das, Partha P.

    2011-01-01

    The Z-category hypnotics are promoted for their relative safety. However, this view is challenged by the emerging clinical evidence in the form of zolpidem related intoxication delirium and seizures, and dependence and complicated withdrawal. We report the case of a zolpidem-naive alcohol-dependent inpatient that, while undergoing alcohol de-addiction, was prescribed zolpidem for insomnia and developed delirium during taper-off. He was successfully detoxified for alcohol, treated for delirium and put on disulfiram prophylaxis. The case highlights the need for being cautious while using zolpidem for insomnia in alcohol dependent subjects. PMID:22144786

  17. Delirium in elderly people

    PubMed Central

    Inouye, Sharon K.; Westendorp, Rudi G. J.; Saczynski, Jane S.

    2014-01-01

    Delirium, an acute disorder of attention and cognition, is a common, serious, costly, under-recognized and often fatal condition for seniors. Its diagnosis requires a formal cognitive assessment and history of acute onset of symptoms. Given its typically complex multifactorial etiology, multicomponent nonpharmacologic risk factor approaches have proven to be the most effective strategy for prevention. To date, there is no convincing evidence that pharmacologic prevention or treatment is effective. Drug reduction for sedation and analgesia combined with nonpharmacologic approaches are recommended. Delirium may provide a window to elucidate brain pathophysiology, serving both as a marker of brain vulnerability with decreased reserve and a potential mechanism for permanent cognitive damage. As a potent patient safety indicator, delirium provides a target for system-wide process improvements. Public health priorities will include improvements in coding and reimbursement, improved research funding, and widespread education for clinicians and the public about the importance of delirium. PMID:23992774

  18. [Delirium and dementia].

    PubMed

    Marín Carmona, José Manuel

    2008-01-01

    Delirium and dementia are highly prevalent neurocognitive syndromes in the elderly. These syndromes are defined by level of consciousness, clinical onset, and potential reversibility, etc. Frequently, both syndromes coincide in the elderly patient and share many epidemiologic, pathogenic and clinical features, which are reviewed in this article. There is no solid scientific evidence that explains the association between delirium and dementia. The present article proposes a change of paradigm in the diagnostic, preventive and therapeutic approach to delirium in the elderly that recognizes the inherent complexity of this geriatric syndrome and, unlike dichotomic models, explores the complex interrelations between both geriatric syndromes. Delirium is viewed as an important model to investigate cognitive disorders and dementia.

  19. Delirium in palliative care.

    PubMed

    Friedlander, Miriam M; Brayman, Yanina; Breitbart, William S

    2004-10-01

    Delirium is highly prevalent in cancer patients with advanced disease. Frequently a preterminal event, the condition is a sign of significant physiologic disturbance, typically involving multiple medical etiologies including infection, organ failure, adverse medication effects, and in rare situations, paraneoplastic syndromes. Unfortunately, delirium is frequently unrecognized or misdiagnosed and, therefore, inappropriately treated or untreated in terminally ill patients. The clinical features of delirium are numerous and encompass a variety of neuropsychiatric symptoms common to other psychiatric disorders. Three clinical subtypes of delirium, based on arousal disturbance and psychomotor behavior, have been described: hyperactive, hypoactive, and mixed. The differential diagnosis for delirium includes depression, mania, psychosis, and dementia. Numerous instruments have been developed to aid the clinician in rapidly screening for the disorder. Standard management requires an investigation of the etiologies, correction of the contributing factors, and management of symptoms. Symptomatic and supportive therapies, including numerous pharmacologic approaches, are important, but several aspects of the use of neuroleptics and other agents in the management of delirium in the dying patient remain controversial.

  20. [Delirium in patients with cancer].

    PubMed

    Staniszewska, Agnieszka; Kłoszewska, Iwona

    2007-01-01

    Delirium is a frequent complication of cancer. It is the cause of patients' suffering and due to worsening of communication, the impediment to clinical assessment. It lowers the quality of life of family caregivers as well. Instant diagnosis and therapy of delirium are essential in clinical practice. In this review etiology, prevalence, clinical features and management of delirium in cancer patients are described.

  1. Thiamine Deficiency and Delirium

    PubMed Central

    Ali, Shahid; Freeman, C.; Barker, Narviar C.; Jabeen, Shagufta; Maitra, Sarbani; Olagbemiro, Yetunde; Richie, William; Bailey, Rahn K.

    2013-01-01

    Thiamine is an essential vitamin that plays an important role in cellular production of energy from ingested food and enhances normal neuronal actives. Deficiency of this vitamin leads to a very serious clinical condition known as delirium. Studies performed in the United States and other parts of the world have established the link between thiamine deficiency and delirium. This literature review examines the physiology, pathophysiology, predisposing factors, clinical manifestations (e.g., Wernicke’s encephalopathy, Wernicke-Korsakoff syndrome, structural and functional brain injuries) and diagnosis of thiamine deficiency and delirium. Current treatment practices are also discussed that may improve patient outcome, which ultimately may result in a reduction in healthcare costs. PMID:23696956

  2. Delirium in critically ill patients.

    PubMed

    Slooter, A J C; Van De Leur, R R; Zaal, I J

    2017-01-01

    Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence. © 2017 Elsevier B.V. All rights reserved.

  3. Testamentary capacity and delirium.

    PubMed

    Liptzin, Benjamin; Peisah, Carmelle; Shulman, Kenneth; Finkel, Sanford

    2010-09-01

    With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature. A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium. The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a "lucid interval" when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion? This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

  4. Delirium recall - an integrative review.

    PubMed

    Fuller, Valerie

    2016-06-01

    The aim of this article is to review and synthesise the empirical literature on patient recall of delirium episodes and to provide a direction for future research. Delirium is a common and costly condition seen in hospitalised and institutionalised patients. Much of the existing literature focuses on delirium detection, risk factors, aetiologies and treatment. Few studies describe the patient experience of delirium recall. A literature search was conducted using the databases of the National Library of Medicine (PubMed/MEDLINE/OVID), the Cumulative Index of Nursing and Allied Health Literature and the American Psychological Association (PsycINFO). Articles were restricted to the English language and from the years 1980-2014. An integrative review of 12 selected studies on delirium recall was performed. The majority of participants recalled their delirious episodes and during these episodes experienced both perceptual disturbances and psychological distress. Common themes from the qualitative data included incomprehensible experiences, strong emotional feelings and fear. Delirium recall is common, is distressing and warrants further investigation. Future studies should employ standardised delirium detection tools and a systematic examination of factors that may predict delirium recall. Understanding delirium recall may help nurses mitigate the psychological morbidity and distress associated with the phenomenon and generate new theories to improve care. © 2016 John Wiley & Sons Ltd.

  5. Delirium in Pediatric Critical Care.

    PubMed

    Patel, Anita K; Bell, Michael J; Traube, Chani

    2017-10-01

    Delirium occurs frequently in the critically ill child. It is a syndrome characterized by an acute onset and fluctuating course, with behaviors that reflect a disturbance in awareness and cognition. Delirium represents global cerebral dysfunction due to the direct physiologic effects of an underlying medical illness or its treatment. Pediatric delirium is strongly associated with poor outcomes, including increased mortality, prolonged intensive care unit length of stay, longer time on mechanical ventilation, and increased cost of care. With heightened awareness, the pediatric intensivist can detect, treat, and prevent delirium in at-risk children. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. Assessing severity of delirium by the Delirium Observation Screening Scale.

    PubMed

    Scheffer, Alice C; van Munster, Barbara C; Schuurmans, Marieke J; de Rooij, Sophia E

    2011-03-01

    Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. Assessment of the severity of delirium is important for adjusting medication. The minimal dose of medication is preferable to prevent side effects. Only few nurse based severity measures are available. The aim of this study was to validate a scale developed to assess symptoms of delirium during regular nursing care, the Delirium Observation Screening (DOS) Scale, for monitoring severity of delirium. Delirious patients of 65 years and older were included. Delirium was diagnosed according to DSM-IV criteria and the Confusion Assessment Method. The DOS Scale was compared to the Dutch version of the Delirium Rating Scale-Revised-98 (DRS-R-98). Global cognitive functioning was assessed by the Informant Questionnaire Cognitive Decline in the Elderly-Short Form (IQCODE-SF) and the KATZ-ADL Scale was used for functional impairment. Ninety seven delirious patients were included: 41 hip fracture patients and 56 medical patients. The correlation between total DRS-R-98 scores and DOS Scale scores was 0.67 (p=0.01). For the cognitive impaired group (IQCODE-SF ≥3.9) this correlation was 0.61 (p=0.01); for the group with no global cognitive impairment, this correlation was 0.67 (p=0.01). Correlations between DRS-R-98 and DOS Scale for hypoactive, hyperactive and mixed delirium subtype were 0.40 (p=0.32), 0.44 (p=0.01) and 0.69 (p=0.05), respectively. The DOS Scale is able to measure severity of delirium. In routine daily clinical practice, the DOS Scale is a time-efficient, easy to use and reliable method for measuring and monitoring severity of delirium by nurses. Copyright © 2010 John Wiley & Sons, Ltd.

  7. Delirium diagnosis, screening and management

    PubMed Central

    Lawlor, Peter G.; Bush, Shirley H.

    2014-01-01

    Purpose of review Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care. Recent findings Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation. Summary Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting. PMID:25004177

  8. Aripiprazole in the treatment of delirium.

    PubMed

    Alao, Adekola O; Soderberg, Maureen; Pohl, Elyssa L; Koss, Marvin

    2005-01-01

    Delirium is a common condition frequently seen in consultation-liaison psychiatry. It is especially common among medically compromised patients, and is an indicator of the severity of the medical illness. In addition, it is associated with a higher morbidity, mortality, and longer hospitalization. Traditionally, haloperidol has been used to treat agitation as it may occur in delirium. However, atypical antipsychotics are being increasingly used to treat delirium. In this article, we will describe two cases of delirium successfully treated with aripiprazole. Both patients had significant improvement in their delirium as measured by the delirium rating scale. Aripiprazole appears to be effective in reducing the symptoms of delirium.

  9. What does delirium cost? An economic evaluation of hyperactive delirium.

    PubMed

    Weinrebe, W; Johannsdottir, E; Karaman, M; Füsgen, I

    2016-01-01

    Demographic changes have resulted in an increase in the number of older (> 75 years) multimorbid patients in clinics. In addition to the primary acute diagnoses that lead to hospitalization, this group of patients often has cognitive dysfunctions, such as delirium. According to clinical experience, delirium patients are more time-consuming for clinicians and their function is often poor. The costs caused by delirium patients are currently unknown. In the present study, a retrospective examination of a database was carried out to calculate the costs that arise during the clinical treatment of documented delirium patients. The purpose of this retrospective analysis was to collect information recorded by nursing personnel trained in the treatment of delirium and information from a manual documentation matrix for additional time expenditure. In the database analysis anonymous data of previously discharged patients for a time window of 3 months were analyzed. Documented additional expenditure for patients with hyperactive delirium at hospitalization were analyzed by personnel. Material costs, the duration of hospitalization by main diagnosis and age clusters during hospitalization until discharge were also examined. The analysis was performed in a hospital with internal wards. Data for 82 hyperactive delirium patients were examined and an average of approximately 240 min of additional personnel expenditure for these patients was found. These patients were approximately 10 years older (p < 0.01) and were hospitalized for an average of 4.2 days longer (p < 0.01) than non-delirium patients. Hyperactive delirium usually developed within the first 5 days of hospitalization and lasted 1.6 days on average. Patients for whom hyperactive delirium was detected early were hospitalized for significantly less time than those for whom it was detected late (6.85 versus 13.61 days, p = 0.002). Additionally, calculated personnel and material costs, including costs affecting the

  10. Delirium from the gliocentric perspective

    PubMed Central

    Sfera, Adonis; Osorio, Carolina; Price, Amy I.; Gradini, Roberto; Cummings, Michael

    2015-01-01

    Delirium is an acute state marked by disturbances in cognition, attention, memory, perception, and sleep-wake cycle which is common in elderly. Others have shown an association between delirium and increased mortality, length of hospitalization, cost, and discharge to extended stay facilities. Until recently it was not known that after an episode of delirium in elderly, there is a 63% probability of developing dementia at 48 months compared to 8% in patients without delirium. Currently there are no preventive therapies for delirium, thus elucidation of cellular and molecular underpinnings of this condition may lead to the development of early interventions and thus prevent permanent cognitive damage. In this article we make the case for the role of glia in the pathophysiology of delirium and describe an astrocyte-dependent central and peripheral cholinergic anti-inflammatory shield which may be disabled by astrocytic pathology, leading to neuroinflammation and delirium. We also touch on the role of glia in information processing and neuroimaging. PMID:26029046

  11. Delirium in the intensive care unit

    PubMed Central

    2013-01-01

    Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner. PMID:24101952

  12. Cognitive Trajectories after Postoperative Delirium

    PubMed Central

    Saczynski, Jane S.; Marcantonio, Edward R.; Quach, Lien; Fong, Tamara G.; Gross, Alden; Inouye, Sharon K.; Jones, Richard N.

    2012-01-01

    BACKGROUND Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac surgery. METHODS We enrolled 225 patients 60 years of age or older who were planning to undergo coronary-artery bypass grafting or valve replacement. Patients were assessed preoperatively, daily during hospitalization beginning on postoperative day 2, and at 1, 6, and 12 months after surgery. Cognitive function was assessed with the use of the Mini–Mental State Examination (MMSE; score range, 0 to 30, with lower scores indicating poorer performance). Delirium was diagnosed with the use of the Confusion Assessment Method. We examined performance on the MMSE in the first year after surgery, controlling for demographic characteristics, coexisting conditions, hospital, and surgery type. RESULTS The 103 participants (46%) in whom delirium developed postoperatively had lower pre-operative mean MMSE scores than those in whom delirium did not develop (25.8 vs. 26.9, P<0.001). In adjusted models, those with delirium had a larger drop in cognitive function (as measured by the MMSE score) 2 days after surgery than did those without delirium (7.7 points vs. 2.1, P<0.001) and had significantly lower postoperative cognitive function than those without delirium, both at 1 month (mean MMSE score, 24.1 vs. 27.4; P<0.001) and at 1 year (25.2 vs. 27.2, P<0.001) after surgery. With adjustment for baseline differences, the between-group difference in mean MMSE scores was significant 30 days after surgery (P<0.001) but not at 6 or 12 months (P = 0.056 for both). A higher percentage of patients with delirium than those without delirium had not returned to their preoperative baseline level at 6 months (40% vs. 24%, P = 0.01), but the difference was not significant at 12 months (31% vs. 20%, P = 0.055). CONCLUSIONS Delirium is associated with a significant decline in

  13. Delirium: a disorder of consciousness?

    PubMed

    Eeles, E M; Pandy, S; Ray, J L

    2013-04-01

    Delirium is recognised as a disorder of consciousness, however, no evidence has been previously generated to specifically address this premise. In order to evaluate this established notion, we have attempted to review consciousness, the components of consciousness and the emerging evidence for neuroanatomical correlates and then relate this to the recognized features of delirium. We have established that the level of awareness is modulated by alertness and arousal, focused by attention and has the ability to switch between the personal resonances of the experience to the precision of cognition. We have discussed consciousness's relationship with delirium and how the degree of integration of CNS function is mandatory for realisation of higher order function and this has implications for the conceptualisation and management of delirium. We have explored the understanding of downstream, components of consciousness as not giving rise to the full condition of delirium but as a subsyndromal state. We have argued that there is a need for future diagnostic criteria, such as DSM-V, to operationalize disturbance of consciousness together with non-cognitive manifestations of delirium. Intervention studies in delirium have focussed on drugs that improve memory (cholinesterase inhibitors). If memory is only one element of consciousness then we reason instead on evaluating the determinants of consciousness that may be modifiable, such as awareness. Reinforcement of environmental awareness by managing a patient within a low stimulus or familiar surrounding may therefore offer a therapeutic intervention. Overall there seemed support for, or no evidence against, the belief that delirium is a disorder of consciousness. From Descartes 'I think therefore I am' we can say 'I am aware not therefore delirious I am'.

  14. Treatment characteristics of delirium superimposed on dementia.

    PubMed

    Boettger, Soenke; Passik, Steven; Breitbart, William

    2011-12-01

    The course of delirium in patients with dementia who are undergoing management of delirium with antipsychotics has not previously been studied. In order to investigate the treatment characteristics of patients with delirium superimposed on dementia in contrast to delirium in the absence of dementia we performed a secondary analysis of our delirium database. We collected sociodemographic data and medical variables in addition to using the systematic rating scales of the Memorial Delirium Assessment Scale (MDAS) and Karnofsky Scale of Performance Status (KPS). These data were recorded in the delirium database. For this analysis we extracted all data pertaining to patients with delirium and dementia (DD) and compared them to those with delirium without dementia (i.e. non-demented with delirium; NDD). Out of 111 cases with a diagnosis of delirium we acquired 22 cases with a diagnosis of DD and 89 cases with NDD. The mean age was significantly different with 77.1 years for DD and 62.7 years for NDD. The MDAS scores at baseline were significantly higher in DD (21.1) compared to NDD (17.6). Over the course of treatment, MDAS scores were significantly higher in DD with 11.7 at T3 compared with 7.0 in NDD. After three days of management, delirium resolution rates were significantly lower in DD with 18.2% compared to 53.9% in NDD, and at seven days delirium resolution rates were 50% and 83% respectively. At the endpoint of the observation period, DD had a significantly more pronounced disturbance of consciousness and impairment in the cognitive domain. KPS scores were not significantly different between DD and NDD. In our sample of patients with delirium superimposed on dementia the delirium resolution rates were lower than in patients without dementia at one week of treatment. The data suggest that when delirium is superimposed on dementia the delirium may resolve at a slower rate.

  15. Delirium in advanced age and dementia: A prolonged refractory course of delirium and lower functional status.

    PubMed

    Boettger, Soenke; Jenewein, Josef; Breitbart, William

    2015-08-01

    The factors associated with persistent delirium, in contrast to resolved delirium, have not been studied well. The aim of our present study was to identify the factors associated with delirium resolution as measured by the Memorial Delirium Assessment Scale (MDAS) and functional improvement as measured by the Karnofsky Performance Status (KPS) scale. All subjects were recruited from psychiatric referrals at the Memorial Sloan Kettering Cancer Center (MSKCC). The two study instruments were performed at baseline (T1), at 2-3 days (T2), and at 4-7 days (T3). Subjects with persistent delirium were compared to those with resolved delirium in respect to sociodemographic and medical variables. Overall, 26 out of 111 patients had persistent delirium. These patients were older, predominantly male, and had more frequently preexisting comorbid dementia. Among cancer diagnoses and stage of illness, brain cancer and terminal illness contributed to persistent delirium or late response, whereas gastrointestinal cancer was associated with resolved delirium. Among etiologies, infection responded late to delirium management, usually at one week. Furthermore, delirium was more severe in patients with persistent delirium from baseline through one week. At baseline, MDAS scores were 20.1 in persistent delirium compared to 17 to 18.8 in resolved delirium (T2 and T3), and at one week of management (T3), MDAS scores were 15.2 and 4.7 to 7.4, respectively. At one week of management, persistent delirium manifested in more severe impairment in the domains of consciousness, cognition, organization, perception, psychomotor behavior, and sleep-wake cycle. In addition, persistent delirium caused more severe functional impairment. In this delirium sample, advanced age and preexisting dementia, as well as brain cancer, terminal illness, infection, and delirium severity contributed to persistent delirium or late response, indicating a prolonged and refractory course of delirium, in addition to more

  16. Delirium in advanced age and dementia: A prolonged refractory course of delirium and lower functional status

    PubMed Central

    BOETTGER, SOENKE; JENEWEIN, JOSEF; BREITBART, WILLIAM

    2017-01-01

    Objective The factors associated with persistent delirium, in contrast to resolved delirium, have not been studied well. The aim of our present study was to identify the factors associated with delirium resolution as measured by the Memorial Delirium Assessment Scale (MDAS) and functional improvement as measured by the Karnofsky Performance Status (KPS) scale. Method All subjects were recruited from psychiatric referrals at the Memorial Sloan Kettering Cancer Center (MSKCC). The two study instruments were performed at baseline (T1), at 2–3 days (T2), and at 4–7 days (T3). Subjects with persistent delirium were compared to those with resolved delirium in respect to sociodemographic and medical variables. Results Overall, 26 out of 111 patients had persistent delirium. These patients were older, predominantly male, and had more frequently preexisting comorbid dementia. Among cancer diagnoses and stage of illness, brain cancer and terminal illness contributed to persistent delirium or late response, whereas gastrointestinal cancer was associated with resolved delirium. Among etiologies, infection responded late to delirium management, usually at one week. Furthermore, delirium was more severe in patients with persistent delirium from baseline through one week. At baseline, MDAS scores were 20.1 in persistent delirium compared to 17 to 18.8 in resolved delirium (T2 and T3), and at one week of management (T3), MDAS scores were 15.2 and 4.7 to 7.4, respectively. At one week of management, persistent delirium manifested in more severe impairment in the domains of consciousness, cognition, organization, perception, psychomotor behavior, and sleep–wake cycle. In addition, persistent delirium caused more severe functional impairment. Significance of results In this delirium sample, advanced age and preexisting dementia, as well as brain cancer, terminal illness, infection, and delirium severity contributed to persistent delirium or late response, indicating a prolonged

  17. Delirium and sedation in the ICU.

    PubMed

    Frontera, Jennifer A

    2011-06-01

    Delirium is defined by a fluctuating level of attentiveness and has been associated with increased ICU mortality and poor cognitive outcomes in both general ICU and neurocritical care populations. Sedation use in the ICU can contribute to delirium. Limiting ICU sedation allows for the diagnosis of underlying acute neurological insults associated with delirium and leads to shorter mechanical ventilation time, shorter length of stay, and improved 1 year mortality rates. Identifying the underlying etiology of delirium is critical to developing treatment paradigms.

  18. A case of nicotine withdrawal delirium.

    PubMed

    Bishnoi, Ram Jeevan; Baig, Muhammad Rais; Brown, Frederick William

    2015-03-01

    Nicotine withdrawal is not a well recognized cause of delirium. A few published cases are on post-operative, terminally ill cancer or neuro-intensive care unit patients. Because of the high incidence of morbidity and mortality of delirium it is important to identify and treat delirium promptly and effectively. We report a case of delirium after sudden cessation of smoking in a heavy smoker, with schizophrenia, hospitalized for stabilization of psychiatric illness.

  19. Opium Withdrawal Delirium: Two Case Reports

    PubMed Central

    Sharma, Ravi C.; Kumar, Ramesh; Sharma, Dinesh Dutt; Kanwar, Pankaj

    2017-01-01

    Two patients with opium dependence developed delirium during abstinence. The delirium resolved completely within 48–58 hours of appropriate treatment. Caution needs to be exercised during opioid detoxification in timely detecting and treating potentially life-threatening condition like delirium. PMID:28138205

  20. Patterns of Postoperative Delirium in Children.

    PubMed

    Meyburg, Jochen; Dill, Mona-Lisa; Traube, Chani; Silver, Gabrielle; von Haken, Rebecca

    2017-02-01

    Intensive care delirium is a substantial problem in adults. Intensive care delirium is increasingly recognized in pediatrics in parallel with the development of specific scoring systems for children. However, little is known about the fluctuating course of intensive care delirium in children after surgery and possible implications on diagnostic and therapeutic strategies. Patients that needed treatment in the PICU following elective surgery were screened for intensive care delirium with the Cornell Assessment of Pediatric Delirium. When the patients were awake (Richmond Agitation and Sedation Score > -3), two trained investigators conducted the Cornell Assessment of Pediatric Delirium twice daily for five consecutive days. Ninety-three patients aged 0 to 17 years. Eight hundred forty-five assessments completed. Of the 845 scores, 230 were consistent with delirium (27.2%). Sixty-one patients (65.5%) were diagnosed with intensive care delirium. Half of these patients (n = 30; 32.2%) had a short-lasting delirium that resolved within 24 hours, and half (n = 31; 33.3%) had delirium of longer duration. Delirium could be clearly distinguished from sedation by analysis of individual test items of the Cornell Assessment of Pediatric Delirium. Time spent delirious had a measurable effect on outcome variables, including hospital length of stay. Most postoperative PICU patients develop intensive care delirium. Some have a short-lasting course, which underlines the need for early screening. Our findings support the view of delirium as a continuum of acute neurocognitive disorder. Further research is needed to investigate prophylactic and treatment approaches for intensive care delirium.

  1. Aripiprazole in the treatment of delirium.

    PubMed

    Straker, David A; Shapiro, Peter A; Muskin, Philip R

    2006-01-01

    Antipsychotic drugs are the primary treatment for symptoms of delirium, but their side effects can be problematic. Treatment of delirium with aripiprazole has yet to be evaluated. The authors report on 14 patients with delirium treated with aripiprazole. Twelve patients had a >or=50% reduction in Delirium Rating Scale, Revised-98 scores, and 13 showed improvement on Clinical Global Impression scale scores. There was a low rate of adverse side effects. Aripiprazole may be an appropriate first-line agent for the treatment of delirium because of its minimal effect on QTc interval, weight, lipids, and glucose levels. Controlled comparison studies should be performed to confirm this impression.

  2. Delirium in Children After Cardiac Bypass Surgery.

    PubMed

    Patel, Anita K; Biagas, Katherine V; Clarke, Eunice C; Gerber, Linda M; Mauer, Elizabeth; Silver, Gabrielle; Chai, Paul; Corda, Rozelle; Traube, Chani

    2017-02-01

    To describe the incidence of delirium in pediatric patients after cardiac bypass surgery and explore associated risk factors and effect of delirium on in-hospital outcomes. Prospective observational single-center study. Fourteen-bed pediatric cardiothoracic ICU. One hundred ninety-four consecutive admissions following cardiac bypass surgery, 1 day to 21 years old. Subjects were screened for delirium daily using the Cornell Assessment of Pediatric Delirium. Incidence of delirium in this sample was 49%. Delirium most often lasted 1-2 days and developed within the first 1-3 days after surgery. Age less than 2 years, developmental delay, higher Risk Adjustment for Congenital Heart Surgery 1 score, cyanotic disease, and albumin less than three were all independently associated with development of delirium in a multivariable model (all p < 0.03). Delirium was an independent predictor of prolonged ICU length of stay, with patients who were ever delirious having a 60% increase in ICU days compared with patients who were never delirious (p < 0.01). In our institution, delirium is a frequent problem in children after cardiac bypass surgery, with identifiable risk factors. Our study suggests that cardiac bypass surgery significantly increases children's susceptibility to delirium. This highlights the need for heightened, targeted delirium screening in all pediatric cardiothoracic ICUs to potentially improve outcomes in this vulnerable patient population.

  3. Diagnosis and Treatment of Delirium

    PubMed Central

    Henry, W. Desmond; Mann, Alan M.

    1965-01-01

    Delirium is not a clinical entity but a symptom-complex of manifold etiology. Its presence signifies acute cerebral insufficiency and often represents a medical and/or psychiatric emergency. Though some forms of delirium have distinctive features, the fundamental phenomena are common to all, with clouding of consciousness the sine qua non. The condition has two major components: (1) the basic “acute brain syndrome” and (2) associated release phenomena. Clinicians must first make the vital differentiation between delirium and “functional” mental disorder, then proceed with the elucidation of the underlying diagnosis and the concurrent organization of symptomatic and etiologic treatment. Proper treatment combines management of the acute brain syndrome with general and specific procedures for control of the underlying condition. Dealing with the symptom-complex itself involves the principles and practice of sedation, hydration, and nutrition, nursing care and supportive measures. Provided the basic organic condition is treatable, the prognosis today is usually good. PMID:5844423

  4. Where next for delirium research?

    PubMed

    Harwood, Rowan H; Teale, Elizabeth

    2017-03-08

    Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress. Copyright © 2017 John Wiley & Sons, Ltd.

  5. Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium.

    PubMed

    Traube, Chani; Silver, Gabrielle; Gerber, Linda M; Kaur, Savneet; Mauer, Elizabeth A; Kerson, Abigail; Joyce, Christine; Greenwald, Bruce M

    2017-05-01

    Delirium occurs frequently in adults and is an independent predictor of mortality. However, the epidemiology and outcomes of pediatric delirium are not well-characterized. The primary objectives of this study were to describe the frequency of delirium in critically ill children, its duration, associated risk factors, and effect on in-hospital outcomes, including mortality. Secondary objectives included determination of delirium subtype, and effect of delirium on duration of mechanical ventilation, and length of hospital stay. Prospective, longitudinal cohort study. Urban academic tertiary care PICU. All consecutive admissions from September 2014 through August 2015. Children were screened for delirium twice daily throughout their ICU stay. Of 1,547 consecutive patients, delirium was diagnosed in 267 (17%) and lasted a median of 2 days (interquartile range, 1-5). Seventy-eight percent of children with delirium developed it within the first 3 PICU days. Most cases of delirium were of the hypoactive (46%) and mixed (45%) subtypes; only 8% of delirium episodes were characterized as hyperactive delirium. In multivariable analysis, independent predictors of delirium included age less than or equal to 2 years old, developmental delay, severity of illness, prior coma, mechanical ventilation, and receipt of benzodiazepines and anticholinergics. PICU length of stay was increased in children with delirium (adjusted relative length of stay, 2.3; CI = 2.1-2.5; p < 0.001), as was duration of mechanical ventilation (median, 4 vs 1 d; p < 0.001). Delirium was a strong and independent predictor of mortality (adjusted odds ratio, 4.39; CI = 1.96-9.99; p < 0.001). Delirium occurs frequently in critically ill children and is independently associated with mortality. Some in-hospital risk factors for delirium development are modifiable. Interventional studies are needed to determine best practices to limit delirium exposure in at-risk children.

  6. Delirium in the ICU: an overview.

    PubMed

    Cavallazzi, Rodrigo; Saad, Mohamed; Marik, Paul E

    2012-12-27

    Delirium is characterized by a disturbance of consciousness with accompanying change in cognition. Delirium typically manifests as a constellation of symptoms with an acute onset and a fluctuating course. Delirium is extremely common in the intensive care unit (ICU) especially amongst mechanically ventilated patients. Three subtypes have been recognized: hyperactive, hypoactive, and mixed. Delirium is frequently undiagnosed unless specific diagnostic instruments are used. The CAM-ICU is the most widely studied and validated diagnostic instrument. However, the accuracy of this tool may be less than ideal without adequate training of the providers applying it. The presence of delirium has important prognostic implications; in mechanically ventilated patients it is associated with a 2.5-fold increase in short-term mortality and a 3.2-fold increase in 6-month mortality. Nonpharmacological approaches, such as physical and occupational therapy, decrease the duration of delirium and should be encouraged. Pharmacological treatment for delirium traditionally includes haloperidol; however, more data for haloperidol are needed given the paucity of placebo-controlled trials testing its efficacy to treat delirium in the ICU. Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and they may have a better safety profile. Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU.

  7. Delirium in the ICU: an overview

    PubMed Central

    2012-01-01

    Delirium is characterized by a disturbance of consciousness with accompanying change in cognition. Delirium typically manifests as a constellation of symptoms with an acute onset and a fluctuating course. Delirium is extremely common in the intensive care unit (ICU) especially amongst mechanically ventilated patients. Three subtypes have been recognized: hyperactive, hypoactive, and mixed. Delirium is frequently undiagnosed unless specific diagnostic instruments are used. The CAM-ICU is the most widely studied and validated diagnostic instrument. However, the accuracy of this tool may be less than ideal without adequate training of the providers applying it. The presence of delirium has important prognostic implications; in mechanically ventilated patients it is associated with a 2.5-fold increase in short-term mortality and a 3.2-fold increase in 6-month mortality. Nonpharmacological approaches, such as physical and occupational therapy, decrease the duration of delirium and should be encouraged. Pharmacological treatment for delirium traditionally includes haloperidol; however, more data for haloperidol are needed given the paucity of placebo-controlled trials testing its efficacy to treat delirium in the ICU. Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and they may have a better safety profile. Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU. PMID:23270646

  8. Delirium in the intensive care unit.

    PubMed

    Girard, Timothy D; Pandharipande, Pratik P; Ely, E Wesley

    2008-01-01

    Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to 80% of the sickest intensive care unit (ICU) populations. Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continues to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument. Patients with delirium have longer hospital stays and lower 6-month survival than do patients without delirium, and preliminary research suggests that delirium may be associated with cognitive impairment that persists months to years after discharge. Little evidence exists regarding the prevention and treatment of delirium in the ICU, but multicomponent interventions reduce the incidence of delirium in non-ICU studies. Strategies for the prevention and treatment of ICU delirium are the subjects of multiple ongoing investigations.

  9. Delirium: An Emerging Frontier in Management of Critically Ill Children

    PubMed Central

    Smith, Heidi A.B.; Fuchs, D. Catherine; Pandharipande, Pratik P.; Barr, Frederick E.; Ely, E. Wesley

    2009-01-01

    OBJECTIVES Introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations. Understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics. Understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population. Discuss the pathophysiology of delirium as currently understood. Provide general management guidelines for delirium. PMID:19576533

  10. Delirium and hospitalized older adults: a review of nonpharmacologic treatment.

    PubMed

    Aguirre, Eric

    2010-04-01

    Delirium is a common and debilitating disorder that affects primarily the elderly in acute care settings. This column reviews the assessment, etiology, complications, and nonpharmacologic treatment of delirium.

  11. Intensive care nurses' experiences and perceptions of delirium and delirium care.

    PubMed

    Zamoscik, Katarzyna; Godbold, Rosemary; Freeman, Pauline

    2017-06-01

    To explore nurses' experiences and perceptions of delirium, managing delirious patients, and screening for delirium, five years after introduction of the Confusion Assessment Method for Intensive Care into standard practice. Twelve nurses from a medical-surgical intensive care unit in a large teaching hospital attended two focus group sessions. The collected qualitative data was thematically analysed using Braun and Clarke's framework (2006). The analysis identified seven themes: (1) Delirium as a Secondary Matter (2) Unpleasant Nature of Delirium (3) Scepticism About Delirium Assessment (4) Distrust in Delirium Management (5) Value of Communication (6) Non-pharmacological Therapy (7) Need for Reviewed Delirium Policy. Nurses described perceiving delirium as a low priority matter and linked it to work culture within the intensive care specialty. Simultaneously, they expressed their readiness to challenge this culture and to promote the notion of providing high-quality delirium care. Nurses discussed their frustrations related to lack of confidence in assessing delirium, as well as lack of effective therapies in managing this group of patients. They declared their appreciation for non-pharmacological interventions in treatment of delirium, suggested improvements to current delirium approach and proposed introducing psychological support for nurses dealing with delirious patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

  12. Using Standardized Case Vignettes to Evaluate Nursing Home Staff Recognition of Delirium and Delirium Superimposed on Dementia

    PubMed Central

    Fick, Donna M.; Kolanowski, Ann M.; Hill, Nikki L.; Yevchak, Andrea; DiMeglio, Brittney; Mulhall, Paula M.

    2014-01-01

    The purpose of this study is to describe nursing home staff knowledge regarding delirium detection and the most common causes of delirium. Specific aims that guided this study include identifying the rate of nurse recognition of delirium and delirium superimposed on dementia (DSD), including different motoric subtypes of delirium, using standardized case vignettes, and exploring what nursing home staff describe as the potential causes of delirium. The study showed overall poor recognition of delirium and DSD, which did not improve over time. Interventions have the potential to increase the early detection of delirium and DSD by the staff and warrant development. PMID:25400513

  13. Quantitative proteomics of delirium cerebrospinal fluid

    PubMed Central

    Poljak, A; Hill, M; Hall, R J; MacLullich, A M; Raftery, M J; Tai, J; Yan, S; Caplan, G A

    2014-01-01

    Delirium is a common cause and complication of hospitalization in older people, being associated with higher risk of future dementia and progression of existing dementia. However relatively little data are available on which biochemical pathways are dysregulated in the brain during delirium episodes, whether there are protein expression changes common among delirium subjects and whether there are any changes which correlate with the severity of delirium. We now present the first proteomic analysis of delirium cerebrospinal fluid (CSF), and one of few studies exploring protein expression changes in delirium. More than 270 proteins were identified in two delirium cohorts, 16 of which were dysregulated in at least 8 of 17 delirium subjects compared with a mild Alzheimer's disease neurological control group, and 31 proteins were significantly correlated with cognitive scores (mini-mental state exam and acute physiology and chronic health evaluation III). Bioinformatics analyses revealed expression changes in several protein family groups, including apolipoproteins, secretogranins/chromogranins, clotting/fibrinolysis factors, serine protease inhibitors and acute-phase response elements. These data not only provide confirmatory evidence that the inflammatory response is a component of delirium, but also reveal dysregulation of protein expression in a number of novel and unexpected clusters of proteins, in particular the granins. Another surprising outcome of this work is the level of similarity of CSF protein profiles in delirium patients, given the diversity of causes of this syndrome. These data provide additional elements for consideration in the pathophysiology of delirium as well as potential biomarker candidates for delirium diagnosis. PMID:25369144

  14. Diagnosing and managing delirium in the elderly.

    PubMed Central

    Conn, D. K.; Lieff, S.

    2001-01-01

    OBJECTIVE: To outline current approaches to diagnosing and managing delirium in the elderly. QUALITY OF EVIDENCE: A literature review was based on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used as the basis for discussion of diagnosis and etiology. We planned to include all published randomized controlled trials regarding management but found only two. Consequently, we also used review articles and recent practice guidelines for delirium published by the American Psychiatric Association. MAIN FINDINGS: Clinical diagnosis of delirium can be aided by using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method. Management must include investigation and treatment of underlying causes and general supportive measures. Providing optimal levels of stimulation, reorienting patients, education, and supporting families are important. Pharmacologic management of delirium should be considered only for specific symptoms or behaviours, e.g., aggression, severe agitation, or psychosis. Only one randomized controlled trial of tranquilizer use for delirium in medically ill people has been published. Findings support the current belief that neuroleptics are superior to benzodiazepines in most cases of delirium. Most authorities still consider haloperidol the neuroleptic of choice. Controlled trials of the new atypical neuroleptics for treating delirium are not yet available. Benzodiazepines with relatively short half-lives, such as lorazepam, are the drugs of choice for withdrawal symptoms. CONCLUSION: Delirium is frequently underdiagnosed in clinical practice. It should be suspected with acute changes in behaviour. Careful investigation of the underlying cause permits appropriate management. PMID:11212421

  15. Blonanserin in the treatment of delirium.

    PubMed

    Kato, Koji; Yamada, Keigo; Maehara, Mizuki; Akama, Fumiaki; Kimoto, Keitaro; Saito, Mai; Yano, Hiroshi; Ichimura, Atsushi; Matsumoto, Hideo

    2011-06-01

    The purpose of the present study was to provide preliminary data on the usefulness and safety of blonanserin for patients with delirium in the intensive care unit (ICU). The charts of 32 consecutive patients with delirium in the ICU were retrospectively reviewed. These patients were treated with blonanserin. A total of 96.6% had reduction in Memorial Delirium Assessment Scale score. The proportion of patients with side-effects was 24.1%. Blonanserin may be effective and safe in the treatment of delirium in the ICU. © 2011 The Authors. Psychiatry and Clinical Neurosciences © 2011 Japanese Society of Psychiatry and Neurology.

  16. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses.

    PubMed

    Breitbart, William; Gibson, Christopher; Tremblay, Annie

    2002-01-01

    We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.

  17. Postoperative delirium and cognitive dysfunction.

    PubMed

    Deiner, S; Silverstein, J H

    2009-12-01

    Postoperative delirium and cognitive dysfunction (POCD) are topics of special importance in the geriatric surgical population. They are separate entities, whose relationship has yet to be fully elucidated. Although not limited to geriatric patients, the incidence and impact of both are more profound in geriatric patients. Delirium has been shown to be associated with longer and more costly hospital course and higher likelihood of death within 6 months or postoperative institutionalization. POCD has been associated with increased mortality, risk of leaving the labour market prematurely, and dependency on social transfer payments. Here, we review their definitions and aetiology, and discuss treatment and prevention in elderly patients undergoing major non-cardiac surgery. Good basic care demands identification of at-risk patients, awareness of common perioperative aggravating factors, simple prevention interventions, recognition of the disease states, and basic treatments for patients with severe hyperactive manifestations.

  18. PREDICTORS FOR POST- STROKE DELIRIUM OUTCOME

    PubMed Central

    Dostovic, Zikrija; Dostovic, Ernestina; Smajlovic, Dzevdet; Ibrahimagic, Omer C.; Avdic, Leila; Becirovic, Elvir

    2016-01-01

    Background: There have been only a small number of studies that have evaluated the outcome of post-stroke delirium. Objectives: To evaluate the effects of gender, age, stroke localization, delirium severity, previous illnesses, associated medical complications on delirium outcome as well as, to determine effects of delirium on cognitive functioning one year after stroke. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glazgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Patients who developed post-stroke delirium had significantly more complications (p = 0.0005). Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The strongest predictor of outcome was age, mean age ≥ 65 years with a odds ratio (OR) 4.9. Cox’s regression survival was conducted to assess the impact of multiple factors on survival. The accompanying medical complications were the strongest predictor of respondents poore outcome with Hazard-risk 3.3. Cognitive assessments including Mini Mental State score have showen that post-stroke delirium patients had significant cognitive impairment, three (p = 0.0005), six months (p = 0.0005) and one year (p = 0.0005) after stroke, compared to patients without delirium. Conclusion: Patient gender, age, localization of stroke, severity of delirium, chronic diseases and emerging complications significantly affect the outcome of post- stroke delirium. Delirium significantly reduced cognitive functioning of after stroke patients. PMID:27999490

  19. Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients.

    PubMed

    De, Jayita; Wand, Anne P F

    2015-12-01

    Delirium occurs commonly in hospitalized older patients but is poorly recognized. Although there are a plethora of validated delirium screening tools, it is unclear which tool best suits particular populations. To evaluate validation studies of delirium screening tools in non-critically ill hospital inpatients and provide guidance on the choice of screening tool. The MEDLINE, CINAHL, and PsychInfo databases were searched for studies comparing delirium bedside screening tools with either the Diagnostic and Statistical Manual or International Classification of Diseases defined diagnosis of delirium in hospital inpatients. Information was also drawn from conference proceedings and discussion with delirium researchers. Thirty-one studies describing 21 delirium screening tools were included in the systematic review. The majority of studies were conducted across a broad range of inpatient settings internationally in elderly inpatients, including patients with dementia but most excluded nonnative language speakers. The Confusion Assessment Method was the most widely used instrument to identify delirium, however, specific training is required to ensure optimum performance. The Delirium Rating Scale and its revised version performed best in the psychogeriatric population but requires an operator with psychiatric training. The Nurses' Delirium Screening Checklist appears best suited to the surgical and recovery room setting. The Single Question in Delirium shows promise in oncology patients. The Memorial Delirium Assessment Scale, while demonstrating good measures of validity in the surgical and palliative care setting, may be better used a measure of delirium severity. The 4As Test performed well when delirium was superimposed on dementia, but it requires further study. © The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  20. Future Directions of Delirium Research and Management

    PubMed Central

    Hughes, Christopher G.; Brummel, Nathan E.; Vasilevskis, Eduard E.; Girard, Timothy D.; Pandharipande, Pratik P.

    2013-01-01

    Delirium is a prevalent organ dysfunction in critically ill patients associated with significant morbidity and mortality, requiring advancements in the clinical and research realms to improve patient outcomes. Increased clinical recognition and utilization of delirium assessment tools, along with clarification of specific risk factors and presentations in varying patient populations, will be necessary in the future. To improve predictive models for outcomes, the continued development and implementation of delirium assessment tools and severity scoring systems will be required. The interplay between the pathophysiological pathways implicated in delirium and resulting clinical presentations and outcomes will need to guide the development of appropriate prevention and treatment protocols. Multicenter randomized controlled trials of interventional therapies will then need to be performed to test their ability to improve clinical outcomes. Physical and cognitive rehabilitation measures need to be further examined as additional means of improving outcomes from delirium in the hospital setting. PMID:23040289

  1. Delirium in the Intensive Care Unit

    PubMed Central

    Arumugam, Suresh; El-Menyar, Ayman; Al-Hassani, Ammar; Strandvik, Gustav; Asim, Mohammad; Mekkodithal, Ahammed; Mudali, Insolvisagan; Al-Thani, Hassan

    2017-01-01

    Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings. PMID:28243012

  2. Vulnerability: the crossroads of frailty and delirium.

    PubMed

    Quinlan, Nicky; Marcantonio, Edward R; Inouye, Sharon K; Gill, Thomas M; Kamholz, Barbara; Rudolph, James L

    2011-11-01

    Frailty and delirium, although seemingly distinct syndromes, both result in significant negative health outcomes in older adults. Frailty and delirium may be different clinical expressions of a shared vulnerability to stress in older adults, and future research will determine whether this vulnerability is age related, pathological, genetic, environmental, or most likely, a combination of all of these factors. This article explores the clinical overlap of frailty and delirium, describes possible pathophysiological mechanisms linking the two, and proposes research opportunities to further knowledge of the interrelationships between these important geriatric syndromes. Frailty, a diminished ability to compensate for stressors, is generally viewed as a chronic condition, whereas delirium is an acute change in attention and cognition, but there is a developing literature on transitions in frailty status around acute events, as well as on delirium as a chronic, persistent condition. If frailty predisposes an individual to delirium, and delirium delays recovery from a stressor, then both syndromes may contribute to a downward spiral of declining function, increasing risk, and negative outcomes. In addition, frailty and delirium may have shared pathophysiology, such as inflammation, atherosclerosis, and chronic nutritional deficiencies, which will require further investigation. The fields of frailty and delirium are rapidly evolving, and future research may help to better define the interrelationship of these common and morbid geriatric syndromes. Because of the heterogeneous pathophysiology and presentation associated with frailty and delirium, typical of all geriatric syndromes, multicomponent prevention and treatment strategies are most likely to be effective and should be developed and tested. © 2011, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.

  3. Delirium and older people: repositioning nursing care.

    PubMed

    Neville, Stephen

    2006-06-01

    Aims.  To critically examine the nursing care offered to older people who have been delirious. Background.  Delirium occurs as a result of physiological imbalances resulting in an alteration in consciousness and cognitive impairment. Delirium is a prevalent and serious cognitive disorder experienced by older people. While there is a vast number of studies published utilizing quantitative methods, there remains a dearth of research relating to delirium in older people from a qualitative perspective. Design.  A qualitative research design that utilized a critical gerontological framework underpinned this study. This framework drew on aspects of postmodernism and Foucault's understanding of discourse. Methods.  Data sources included published documents on delirium, semi-structured taped interviews with people over the age of 65 years who had been delirious (as well as their clinical notes), family members, Registered Nurses and a hospital doctor. A postmodern discourse analytic approach was used to interrogate the 20 sets of data collected. Findings.  Textual analysis revealed the presence of two major discourses impacting on being an older person with delirium. These were identified as a nursing discourse of delirium and a personal discourse of delirium. A nursing discourse of delirium was largely focussed on the biomedical processes that resulted in a delirious episode. Conversely, a personal discourse of delirium highlights that there are other ways of 'knowing' about delirium through considering the narratives of older adults, and their families, when offering a nursing service to this group of people. Relevance to clinical practice.  Nursing needs to critically examine all aspects of nursing care as it applies to older people who have delirium to ensure the rhetorical claims of the profession become the reality for consumers of health services. The use of critical gerontology provides nurses with the tools to challenge the status quo and uncover the

  4. Preoperative Sleep Disruption and Postoperative Delirium

    PubMed Central

    Leung, Jacqueline M.; Sands, Laura P.; Newman, Stacey; Meckler, Gabriela; Xie, Yimeng; Gay, Caryl; Lee, Kathryn

    2015-01-01

    Study Objectives: To describe preoperative and postoperative sleep disruption and its relationship to postoperative delirium. Design: Prospective cohort study with 6 time points (3 nights pre-hospitalization and 3 nights post-surgery). Setting: University medical center. Patients: The sample consisted of 50 English-speaking patients ≥ 40 years of age scheduled for major non-cardiac surgery, with an anticipated hospital stay ≥ 3 days. Interventions: None. Measurements and results: Sleep was measured before and after surgery for a total of 6 days using a wrist actigraph to quantify movement in a continuous fashion. Postoperative delirium was measured by a structured interview using the Confusion Assessment Method. Sleep variables for patients with (n = 7) and without (n = 43) postoperative delirium were compared using the unpaired Student t-tests or χ2 tests. Repeated measures analysis of variance for the 6 days was used to examine within-subject changes over time and between group differences. The mean age of the patients was 66 ± 11 years (range 43–91 years), and it was not associated with sleep variables or postoperative delirium. The incidence of postoperative delirium observed during any of the 3 postoperative days was 14%. For the 7 patients who subsequently developed postoperative delirium, wake after sleep onset (WASO) as a percentage of total sleep time was significantly higher (44% ± 22%) during the night before surgery compared to the patients who did not subsequently developed delirium (21% ± 20%, p = 0.012). This sleep disruption continued postoperatively, and to a greater extent, for the first 2 nights after surgery. Patients with WASO < 10% did not experience postoperative delirium. Self-reported sleep disturbance did not differ between patients with vs. without postoperative delirium. Conclusions: In this pilot study of adults over 40 years of age, sleep disruption was more severe before surgery in the patients who experienced postoperative

  5. Interventions for preventing delirium in hospitalised patients.

    PubMed

    Siddiqi, N; Stockdale, R; Britton, A M; Holmes, J

    2007-04-18

    Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients. Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings. We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 28th September, 2005. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials. Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients. Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus. Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer. Only one study of 126 hip fracture patients comparing proactive

  6. [Psychopharmalogical treatment of delirium in the elderly].

    PubMed

    Drach, Lutz M

    2014-04-01

    Delirium is frequent in hospitalized elderly. Treatment of the medical problems causing delirium is paramount. Mostly antipsychotics are used for treatment of psychological and behavioral symptoms in delirium. Increased mortality of elderly and demented patients receiving antipsychotics suggests caution in prescribing antipsychotics for delirium. Standard treatment is low-dose haloperidol. If more sedation is needed, melperone or pipamperone can be used. In delirious Parkinsonian patients or if dementia with Lewy-bodies is suspected quetiapine is better tolerated. Other sedating antipsychotics like prothipendyl, promethazine or levomepromazin are considered inappropriate medication in the elderly due to their anticholinergic and orthostatic side effects. Cholinesterase inhibitors are not effective in delirium, except physostigmine for treatment of anticholinergic intoxication confined to intensive care. Benzodiazepines are effective in alcohol- und benzodiazepine-withdrawal, but may induce delirium (paradox reaction). Clomethiazole is contraindicated in frequent pulmonal conditions in the elderly like COPD. Chloral hydrate is considered inappropriate medication in the elderly due to QTc-prolongation. On intensive care units clonidine and recently dexmedetomidine are useful. At the moment there are no data indicating melatonin being effective for treatment of delirium.

  7. Delirium in older persons: evaluation and management.

    PubMed

    Kalish, Virginia B; Gillham, Joseph E; Unwin, Brian K

    2014-08-01

    Delirium is defined as an acute, fluctuating syndrome of altered attention, awareness, and cognition. It is common in older persons in the hospital and long-term care facilities and may indicate a life-threatening condition. Assessment for and prevention of delirium should occur at admission and continue throughout a hospital stay. Caregivers should be educated on preventive measures, as well as signs and symptoms of delirium and conditions that would indicate the need for immediate evaluation. Certain medications, sensory impairments, cognitive impairment, and various medical conditions are a few of the risk factors associated with delirium. Preventive interventions such as frequent reorientation, early and recurrent mobilization, pain management, adequate nutrition and hydration, reducing sensory impairments, and ensuring proper sleep patterns have all been shown to reduce the incidence of delirium, regardless of the care environment. Treatment of delirium should focus on identifying and managing the causative medical conditions, providing supportive care, preventing complications, and reinforcing preventive interventions. Pharmacologic interventions should be reserved for patients who are a threat to their own safety or the safety of others and those patients nearing death. In older persons, delirium increases the risk of functional decline, institutionalization, and death.

  8. Advancing the Neurophysiological Understanding of Delirium.

    PubMed

    Shafi, Mouhsin M; Santarnecchi, Emiliano; Fong, Tamara G; Jones, Richard N; Marcantonio, Edward R; Pascual-Leone, Alvaro; Inouye, Sharon K

    2017-06-01

    Delirium is a common problem associated with substantial morbidity and increased mortality. However, the brain dysfunction that leads some individuals to develop delirium in response to stressors is unclear. In this article, we briefly review the neurophysiologic literature characterizing the changes in brain function that occur in delirium, and in other cognitive disorders such as Alzheimer's disease. Based on this literature, we propose a conceptual model for delirium. We propose that delirium results from a breakdown of brain function in individuals with impairments in brain connectivity and brain plasticity exposed to a stressor. The validity of this conceptual model can be tested using Transcranial Magnetic Stimulation in combination with Electroencephalography, and, if accurate, could lead to the development of biomarkers for delirium risk in individual patients. This model could also be used to guide interventions to decrease the risk of cerebral dysfunction in patients preoperatively, and facilitate recovery in patients during or after an episode of delirium. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  9. Delirium in the Critically Ill Child.

    PubMed

    Norman, Sharon; Taha, Asma A; Turner, Helen N

    The purposes of this article are to describe the scientific literature on assessment, prevention, and management of delirium in critically ill children and to articulate the implications for clinical nurse specialists, in translating the evidence into practice. A literature search was conducted in 4 databases-OvidMEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, and Web of Science-using the terms "delirium," "child," and "critically ill" for the period of 2006 to 2016. The scientific literature included articles on diagnosis, prevalence, risk factors, adverse outcomes, screening tools, prevention, and management. The prevalence of delirium in critically ill children is up to 30%. Risk factors include age, developmental delay, severity of illness, and mechanical ventilation. Adverse outcomes include increased mortality, hospital length of stay, and cost for the critically ill child with delirium. Valid and reliable delirium screening tools are available for critically ill children. Prevention and management strategies include interventions to address environmental triggers, sleep disruption, integrated family care, and mobilization. Delirium is a common occurrence for the critically ill child. The clinical nurse specialist is accountable for leading the implementation of practice changes that are based on evidence to improve patient outcomes. Screening and early intervention for delirium are key to mitigating adverse outcomes for critically ill children.

  10. Do nutrients play a role in delirium?

    PubMed

    Sanford, Angela M; Flaherty, Joseph H

    2014-01-01

    This study will review the biologic roles of thiamine, niacin, folic acid, cobalamin, antioxidants, lipids, glucose, and water and their implications as contributors or causal agents in the development of delirium, particularly if deficiencies or excesses exist. Knowledge on how overall nutritional status and individual nutrients predispose or directly lead to the development of delirium is currently very limited. Most studies in the area of nutrition and cognition still describe mental status changes using the term dementia and do not specifically address nutrition and delirium. However, as the brain pathophysiology that accompanies delirium has been furthered elucidated, it has become clear that nutritional imbalances can lead to these same physiologic changes in neuronal tissue. Delirium, characterized by an acute change in mental status along with diminished awareness and attention and disturbances in memory, language, or perception, confers high rates of morbidity and mortality and can be difficult to both diagnose and treat. Although the cause of delirium is often multifactorial, nutritional status and nutrients may play a role in predisposing or directly causing this acute cognitive dysfunction. Many nutritional deficiencies or excesses (i.e., B vitamins, antioxidants, glucose, water, lipids) have been shown to alter the way one thinks and restoring the balance in many of these nutrients can lead to resolution of delirium.

  11. Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management.

    PubMed

    Oosterhouse, Kimberly J; Vincent, Catherine; Foreman, Marquis D; Gruss, Valerie A; Corte, Colleen; Berger, Barbara

    2016-10-01

    Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.

  12. Delirium superimposed on dementia. Assessment and intervention.

    PubMed

    Flanagan, Nina M; Fick, Donna M

    2010-11-01

    Delirium remains a significant risk for hospitalized older adults and has been shown to be a persistent risk posthospitalization as well. Dementia is a risk factor for delirium. The prevalence of delirium superimposed on dementia (DSD) ranges from 22% to 89% in hospitalized and community-dwelling individuals 65 and older. Individuals with DSD have been found to have accelerated decline in cognitive and functional abilities, greater need for institutionalization, greater rehospitalization risk, and increased mortality. The purpose of this article is to define and describe DSD, outline assessment tools for its identification, and provide appropriate nursing interventions.

  13. Neuroblastoma and pediatric delirium: a case series.

    PubMed

    Traube, Chani; Augenstein, Julie; Greenwald, Bruce; LaQuaglia, Michael; Silver, Gabrielle

    2014-06-01

    Delirium occurs frequently in critically ill children, and children with neuroblastoma may be at particular risk. Early diagnosis and treatment may improve short- and long-term outcomes. In this case series, we present four critically ill children with neuroblastoma who were diagnosed with delirium in the post-operative period. In all four patients, the diagnosis of delirium facilitated targeted intervention and improvement. Heightened awareness by pediatric oncologists, surgeons, and intensivists may lead to earlier diagnosis and improvement in clinical outcomes. © 2013 Wiley Periodicals, Inc.

  14. Delirium: a guide for the general physician.

    PubMed

    Todd, Oliver M; Teale, Elizabeth A

    2016-12-01

    Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.

  15. [Delirium, depression, dementia: solving the 3D's].

    PubMed

    Schuerch, M; Farag, L; Deom, S

    2012-01-01

    As there is no consensus in the specialized literature, it is often difficult to recognize the ties existing between dementia, delirium and depression. Depression preceding dementia is well-documented. Depressive symptoms during the process of dementia are less well-known. So are the close relationships between dementia and delirium as well as between delirium and depression. The commonality of symptoms between the three often causes diagnostic dilemmas. Unfortunately, elderly patients can often present two, or even three, of the "3 D's" simultaneously. Untangling the 3 D's has been the subject of several articles. We propose a synthesis as well as our thoughts on the subject from a clinical psychogeriatric standpoint.

  16. Development of the Vanderbilt Assessment for Delirium in Infants and Children to Standardize Pediatric Delirium Assessment By Psychiatrists.

    PubMed

    Gangopadhyay, Maalobeeka; Smith, Heidi; Pao, Maryland; Silver, Gabrielle; Deepmala, Deepmala; De Souza, Claire; Garcia, Georgina; Giles, Lisa; Denton, Danica; Jacobowski, Natalie; Pandharipande, Pratik; Fuchs, Catherine

    Pediatric delirium assessment is complicated by variations in baseline language and cognitive skills, impairment during illness, and absence of pediatric-specific modifiers within the Diagnostic and Statistical Manual of Mental Disorders delirium criterion. To develop a standardized approach to pediatric delirium assessment by psychiatrists. A multidisciplinary group of clinicians used Diagnostic and Statistical Manual criterion as the foundation for the Vanderbilt Assessment for Delirium in Infants and Children (VADIC). Pediatric-specific modifiers were integrated into the delirium criterion, including key developmental and assessment variations for children. The VADIC was used in clinical practice to prospectively assess critically ill infants and children. The VADIC was assessed for content validity by the American Academy of Child and Adolescent Psychiatry Delirium Special Interest Group. The American Academy of Child and Adolescent Psychiatry-Delirium Special Interest Group determined that the VADIC demonstrated high content validity. The VADIC (1) preserved the core Diagnostic and Statistical Manual delirium criterion, (2) appropriately paired interactive assessments with key criterion based on development, and (3) addressed confounders for delirium. A cohort of 300 patients with a median age of 20 months was assessed for delirium using the VADIC. Delirium prevalence was 47%. The VADIC provides a comprehensive framework to standardize pediatric delirium assessment by psychiatrists. The need for consistency in both delirium education and diagnosis is highlighted given the high prevalence of pediatric delirium. Copyright © 2016 The Academy of Psychosomatic Medicine. All rights reserved.

  17. Southwestern Internal Medicine Conference. Etiology and management of delirium.

    PubMed

    Roche, Vivyenne

    2003-01-01

    Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.

  18. A rare cause of hypoactive delirium

    PubMed Central

    Kosari, S A; Amiruddin, A; Shorakae, S; Kane, R

    2014-01-01

    A 90-year-old man was transferred to a geriatric evaluation and management (GEM) unit for management of hypoactive delirium following a pneumonia and acute myocardial infarction complicated by septic shock. He was found to have central hypothyroidism and hypoadrenalism leading to the diagnosis of hypopituitarism. Cerebral imaging confirmed this was secondary to a pituitary haemorrhage. This case illustrates the complexity of assessment of delirium and its aetiologies. Hypoactive forms of delirium in particular can be difficult to detect and therefore remain undiagnosed. While this patient's delirium was likely multifactorial, his hypopituitary state explained much of his hypoactivity. His drowsiness, bradycardia, hypotension and electrolyte imbalance provided clinical clues to the diagnosis. PMID:25331146

  19. Guideline urges healthcare staff to 'think delirium'.

    PubMed

    Duffin, Christian

    2010-08-26

    Healthcare professionals must improve their skills in assessing, preventing and treating delirium because patients are developing the condition unnecessarily, the National Institute for Health and Clinical Excellence (NICE) has said.

  20. Cognitive Issues: Decline, Delirium, Depression, Dementia.

    PubMed

    Harris, Melodee

    2017-09-01

    Cognitive decline in older persons can be pathologic or occur as a part of the normal aging process. Delirium, depression, and dementia are geriatric syndromes and neurocognitive disorders that are the result of cognitive decline associated with pathology. This overview is a brief guide on cognitive decline and how to identify, manage, and treat associated neurocognitive disorders, including delirium, depression, and dementia. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. Perioperative delirium and its relationship to dementia

    PubMed Central

    Silverstein, Jeffrey H.; Deiner, Stacie G.

    2013-01-01

    A number of serious clinical cognitive syndromes occur following surgery and anesthesia. Postoperative delirium is a behavioral syndrome that occurs in the perioperative period. It is diagnosed through observation and characterized by a fluctuating loss of orientation and confusion. A distinct syndrome that requires formalized neurocognitive testing is frequently referred to as postoperative cognitive dysfunction (POCD). There are serious concerns as to whether either postoperative delirium or postoperative cognitive dysfunction lead to dementia. These concerns are reviewed in this article. PMID:23220565

  2. Postoperative Delirium in the Geriatric Patient

    PubMed Central

    Schenning, Katie J.; Deiner, Stacie G.

    2015-01-01

    SYNOPSIS Postoperative delirium, a common complication in older surgical patients, is independently associated with increased morbidity and mortality. Patients over the age of 65 years receive greater than 1/3 of the over 40 million anesthetics delivered yearly in the United States. This number is expected to increase with the aging of the population. Thus, it is increasingly important that perioperative clinicians who care for geriatric patients have an understanding of the complex syndrome of postoperative delirium. PMID:26315635

  3. Care of the patient in excited delirium.

    PubMed

    Gordon, Cheryl; Schmelzer, Marilee

    2013-03-01

    Patients with excited delirium present a challenge to both law enforcement and health care personnel because handcuffs, the traditional method used to keep persons from harming themselves and others, may be fatal. The patient's survival depends upon rapid recognition and treatment, including chemical sedation, decreased environmental stimulation, intravenous fluids, and other supportive interventions. Excited delirium protocols should be established to ensure rapid and appropriate treatment to ensure patient survival and the safety of those caring for them.

  4. Delirium in the Cardiac Surgical Intensive Care Unit

    PubMed Central

    Brown, Charles H

    2014-01-01

    Purpose Evidence is emerging that delirium is associated with both short- and long-term morbidity and mortality. This review highlights the epidemiology, outcomes, prevention and treatment strategies associated with delirium after cardiac surgery. Recent findings The incidence of delirium after cardiac surgery is estimated to be 26-52%, with a significant percentage being hypoactive delirium. It is clear that without an appropriate structured test for delirium, the incidence of delirium will be under-recognized clinically. Delirium after cardiac surgery is associated with poor outcomes including increased long-term mortality, increased risk of stroke, poor functional status, increased hospital readmissions, and substantial cognitive dysfunction for 1-year following surgery. The effectiveness of prophylactic antipsychotics to reduce the risk of delirium is controversial, with data from recent small studies in non-cardiac surgery potentially showing a benefit. Although anti-psychotic medications are often used to treat delirium, the evidence that anti-psychotics in cardiac surgery patients reduce duration of delirium or improve long-term outcomes following delirium is poor. Summary Clinicians in the ICU must recognize the impact of delirium in predicting long-term outcomes for patients. Further research is needed in determining interventions that will be effective in preventing and treating delirium in cardiac surgical setting. PMID:24514034

  5. Delirium in Critically Ill Children: An International Point Prevalence Study.

    PubMed

    Traube, Chani; Silver, Gabrielle; Reeder, Ron W; Doyle, Hannah; Hegel, Emily; Wolfe, Heather A; Schneller, Christopher; Chung, Melissa G; Dervan, Leslie A; DiGennaro, Jane L; Buttram, Sandra D W; Kudchadkar, Sapna R; Madden, Kate; Hartman, Mary E; deAlmeida, Mary L; Walson, Karen; Ista, Erwin; Baarslag, Manuel A; Salonia, Rosanne; Beca, John; Long, Debbie; Kawai, Yu; Cheifetz, Ira M; Gelvez, Javier; Truemper, Edward J; Smith, Rebecca L; Peters, Megan E; O'Meara, A M Iqbal; Murphy, Sarah; Bokhary, Abdulmohsen; Greenwald, Bruce M; Bell, Michael J

    2017-04-01

    To determine prevalence of delirium in critically ill children and explore associated risk factors. Multi-institutional point prevalence study. Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia. All children admitted to the pediatric critical care units on designated study days (n = 994). Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected. Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics. Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

  6. Postoperative Delirium: Acute Change with Long-Term Implications

    PubMed Central

    Rudolph, James L.; Marcantonio, Edward R.

    2011-01-01

    Delirium is an acute change in cognition and attention, which may include alterations in consciousness and disorganized thinking. While delirium may affect any age group, it is most common in older patients, especially those with preexisting cognitive impairment. Patients with delirium after surgery recover more slowly than those without delirium and, as a result, have increased length of stay and hospital costs. The measured incidence of postoperative delirium varies with the type of surgery, the urgency of surgery, and the type and sensitivity of the delirium assessment. While generally considered a short-term condition, delirium can persist for months and is associated with poor cognitive and functional outcomes beyond the immediate postoperative period. In this article we will provide a guide to assess delirium risk preoperatively, and to prevent, diagnose, and treat this common and morbid condition. Care improvements such as identifying delirium risk preoperatively; training surgeons, anesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols may reduce the risk of delirium and its associated morbidity. PMID:21474660

  7. Pediatric delirium: evaluating the gold standard.

    PubMed

    Silver, Gabrielle; Kearney, Julia; Traube, Chani; Atkinson, Thomas M; Wyka, Katarzyna E; Walkup, John

    2015-06-01

    Our aim was to evaluate interrater reliability for the diagnosis of pediatric delirium by child psychiatrists. Critically ill patients (N = 17), 0-21 years old, including 7 infants, 5 children with developmental delay, and 7 intubated children, were assessed for delirium using the Diagnostic and Statistical Manual-IV (DSM-IV) (comparable to DSM-V) criteria. Delirium assessments were completed by two psychiatrists, each blinded to the other's diagnosis, and interrater reliability was measured using Cohen's κ coefficient along with its 95% confidence interval. Interrater reliability for the psychiatric assessment was high (Cohen's κ = 0.94, CI [0.83, 1.00]). Delirium diagnosis showed excellent interrater reliability regardless of age, developmental delay, or intubation status (Cohen's κ range 0.81-1.00). In our study cohort, the psychiatric interview and exam, long considered the "gold standard" in the diagnosis of delirium, was highly reliable, even in extremely young, critically ill, and developmentally delayed children. A developmental approach to diagnosing delirium in this challenging population is recommended.

  8. Does preoperative risk for delirium moderate the effects of postoperative pain and opiate use on postoperative delirium?

    PubMed Central

    Leung, Jacqueline M.; Sands, Laura P.; Lim, Eunjung; Tsai, Tiffany L.; Kinjo, Sakura

    2013-01-01

    Objectives To investigate whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on the development of postoperative delirium. Design Prospective cohort study Setting University medical center Participants Patients ≥ 65 years of age scheduled for major noncardiac surgery Measurements A structured interview was conducted pre- and post-operatively to determine the presence of delirium, defined using the Confusion Assessment Method. We first developed a prediction model to determine which patients were at high vs. low risk for the development of delirium based on preoperative patient data. We then computed a logistic regression model to determine whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on incident delirium. Results Of 581 patients, 40% developed delirium on days 1 or 2 after surgery. Independent preoperative predictors of postoperative delirium included lower cognitive status, a history of central nervous system disease, high surgical risk, and major spine and joint arthroplasty surgery. Compared to the patients at low preoperative risk for developing delirium, the relative risk for postoperative delirium for those in the high preoperative risk group was 2.38 (95% CI = 1.67–3.40). A significant three-way interaction indicates that preoperative risk for delirium significantly moderated the effect of postoperative pain and opioid use on the development of delirium. Among patients at high preoperative risk for development of delirium who also had high postoperative pain and received high opioid doses, the incidence of delirium was 72%, compared to 20% among patients with low preoperative risk, low postoperative pain and received low opioid doses. Conclusions High levels of postoperative pain and using high opioid doses increased risk for postoperative delirium for all patients. However, the highest incidence of delirium was among patients who had high preoperative risk for

  9. Hospital-Related Delirium May Help Worsen Dementia

    MedlinePlus

    ... medlineplus.gov/news/fullstory_163123.html Hospital-Related Delirium May Help Worsen Dementia But disorienting condition can ... WEDNESDAY, Jan. 18, 2017 (HealthDay News) -- Hospitalization-related delirium may speed mental decline in patients with dementia, ...

  10. [Non-withdrawal-related delirium : Evidence on prevention and therapy].

    PubMed

    Haussmann, R; Bauer, M; Donix, M

    2016-05-01

    Delirium is a severe and common yet under-diagnosed disorder in the clinical routine. Multiple factors may contribute to the development of delirium, which is associated with increased mortality and high healthcare costs. Treatment of delirium is often provided with delay and limited to pharmacological interventions. This article summarizes the key symptoms for delirium as well as risk factors and highlights the pharmacological and non-pharmacological options for treatment and prevention.

  11. Screening and Management of Delirium in Critically Ill Patients

    PubMed Central

    Farina, Nicholas; Smithburger, Pamela

    2015-01-01

    Delirium is highly prevalent in the critically ill population and has been associated with numerous negative outcomes including increased mortality. The presentation of a delirious patient in the intensive care unit (ICU) is characterized by a fluctuating cognitive status and inattention that varies dramatically among patients. Delirium can present in 3 different motoric subtypes: hyperactive, hypoactive, and mixed. Two tools, the Intensive Care Delirium Screening Checklist and Confusion Assessment ICU, are validated and recommended for the detection of delirium in critically ill patients. The identification of delirium in a critically ill patient should be facilitated using one of these tools. An intermediate form of delirium known as subsyndromal delirium also exists, although the significance of this syndrome is largely unknown. Another phenomenon known as sedation-related delirium has been recently described, although more research is needed to understand its significance. Patients in the ICU are exposed to many risk factors for developing delirium; controlling these risk factors is essential for preventing delirium development in critically ill patients. Nonpharmacologic interventions have been shown to prevent patients from developing delirium. Prevention is crucial because once delirium develops pharmacologic therapy is limited. PMID:26715799

  12. The Impact of Delirium | NIH MedlinePlus the Magazine

    MedlinePlus

    ... of this page please turn JavaScript on. Feature: Delirium Research The Impact of Delirium Past Issues / Fall 2015 Table of Contents Ill ... hospitalized older people can experience sudden episodes of delirium, a state of confusion and disorientation that can ...

  13. Postoperative delirium. part 2: detection, prevention and treatment.

    PubMed

    Steiner, Luzius A

    2011-10-01

    To target pharmacological prevention, instruments giving an approximation of an individual patient's risk of developing postoperative delirium are available. In view of the variable clinical presentation, identifying patients in whom prophylaxis has failed (that is, who develop delirium) remains a challenge. Several bedside instruments are available for the routine ward and ICU setting. Several have been shown to have a high specificity and sensitivity when compared with the standard definitions according to DSM-IV-TR and ICD-10. The Confusion Assessment Method (CAM) and a version specifically developed for the intensive care setting (CAM-ICU) have emerged as a standard. However, alternatives allowing grading of the severity of delirium are also available. In many units, the approach to delirium follows a three-step strategy. Initially, non-pharmacological multicomponent strategies are used for primary prevention. As a second step, pharmacological prophylaxis may be added. Perioperative administration of haloperidol has been shown to reduce the severity, but not the incidence, of delirium. Perioperative administration of atypical antipsychotics has been shown to reduce the incidence of delirium in specific groups of patients. In patients with delirium, both symptomatic and causal treatment of delirium need to be considered. So far symptomatic treatment of delirium is primarily based on antipsychotics. Currently, cholinesterase inhibitors cannot be recommended and the data on dexmedetomidine are inconclusive. With the exception of alcohol-withdrawal delirium, there is no role for benzodiazepines in the treatment of delirium. It is unclear whether treating delirium prevents long-term sequelae.

  14. Attention! A good bedside test for delirium?

    PubMed Central

    O'Regan, Niamh A; Ryan, Daniel J; Boland, Eve; Connolly, Warren; McGlade, Ciara; Leonard, Maeve; Clare, Josie; Eustace, Joseph A; Meagher, David; Timmons, Suzanne

    2014-01-01

    Background Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective ‘confusion’. Methods We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method. Results 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity. Conclusions Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people. PMID:24569688

  15. Phenomenology of the subtypes of delirium: phenomenological differences between hyperactive and hypoactive delirium.

    PubMed

    Boettger, Soenke; Breitbart, William

    2011-06-01

    The purpose of this study was to examine the differences in phenomenology between hypoactive and hyperactive subtypes of delirium, and specifically to determine the comparative prevalence of perceptual disturbances (e.g., hallucinations) and delusions in these two subtypes of delirium. We conducted an analysis of Memorial Delirium Assessment Scale (MDAS) items in a set of 100 delirium cases evaluated and treated at Memorial Sloan-Kettering Cancer Center (MSKCC) utilizing an MSKCC Institutional Review Board (IRB) approved Clinical Delirium Database. Individual MDAS items, reflecting the phenomenology of delirium, were compared in delirious patients classified as to motoric subtype (hypoactive versus hyperactive based on MDAS item no. 9, psychomotor activity). Particular attention was paid to differences between subtypes as to the prevalence of perceptual disturbances (MDAS item no. 7) and delusions (MDAS item no. 8). Significant differences were found between hyperactive and hypoactive subtypes of delirium for the presence and severity of perceptual disturbances and delusions; with perceptual disturbances (e.g., hallucinations) and delusions being significantly more prevalent in hyperactive than in hypoactive delirium. The prevalence of perceptual disturbances was 50.9% and the prevalence of delusions was 43.4% in patients with hypoactive delirium. In patients with hyperactive delirium, the prevalence of perceptual disturbances was 70.2% and the prevalence of delusions was 78.7%. The prevalence of perceptual disturbances and delusions in both subtypes of delirium was significantly correlated with the presence of moderate-to-severe disturbance of consciousness/arousal (MDAS item no. 1) and attention impairment (MDAS item no. 5), but was not correlated with the presence of moderate-to-severe cognitive impairment (MDAS item nos. 2-4). Contrary to earlier studies, which indicated extremely low prevalence rates of perceptual disturbances (e.g., hallucinations) and

  16. Delirium

    MedlinePlus

    ... alert at night) Changes in feeling (sensation) and perception Changes in level of consciousness or awareness Changes ... Joseph V. Campellone, MD, Division of Neurology, Cooper University Hospital, Camden, NJ. Review provided by VeriMed Healthcare ...

  17. Delirium

    MedlinePlus

    ... to drain urine from the bladder) Dehydration Prolonged sleep deprivation Sensory deprivation (including being socially isolated or not ... are not wearing their glasses or hearing aid Sleep deprivation Stress (any type) Use of a bladder catheter ( ...

  18. Review of delirium in patients with Parkinson's disease.

    PubMed

    Vardy, Emma R L C; Teodorczuk, Andrew; Yarnall, Alison J

    2015-11-01

    Parkinson's disease (PD) is common and has a number of associated neuropsychiatric disturbances. Of these, delirium has historically been under-recognised. Delirium is an acute disturbance of attention and awareness that fluctuates, and is accompanied by an additional disturbance of cognition. As delirium is known to carry a particularly poor prognosis in terms of morbidity and mortality, and the relationship between delirium and dementia is becoming better defined, we completed a literature review of delirium in the context of PD. A literature search was completed using the databases PubMed, Embase and Ovid Medline. PubMed (1945-2014) was searched in September 2014; Embase (1974-2014); and Ovid Medline (1946-2014) in October 2014. The search terms 'delirium' and 'Parkinsons' in combination were used. Large studies using a robust definition of delirium were lacking in PD. There is the suggestion that PD is a risk factor for delirium and that delirium negatively impacts upon the motor symptom trajectory. Deficits in the neurotransmitters dopamine and acetylcholine are implicated in the pathophysiology of delirium in PD. Systemic inflammation also appears to have a role. Treatment of delirium in PD should include medication review and cautious use of atypical antipsychotics where pharmacological treatment is indicated. Of the atypical antipsychotics studied, quetiapine has the least extrapyramidal side effects. Evidence suggests a specific link between delirium and PD but well-designed clinical studies to evaluate the prevalence, impact and treatment of delirium in PD are required. Given the potential to improve outcomes through delirium prevention we conclude that delirium in PD is an area worthy of further study.

  19. Preventing delirium in dementia: Managing risk factors.

    PubMed

    Ford, Andrew H

    2016-10-01

    Delirium is a common, disabling medical condition that is associated with numerous adverse outcomes. A number of inter-related factors, including pre-existing cognitive impairment, usually contribute to the development of delirium in a particular susceptible individual. Non-pharmacological approaches to prevention typically target multiple risk factors in a systematic manner (multicomponent interventions). There is generally good evidence that multicomponent interventions reduce the incidence of delirium in hospital populations but there are limited data in people with dementia and those living in the community. It is likely that there is a differential effect of specific interventions in those with cognitive impairment (e.g. people with dementia may respond better to simpler, more pragmatic interventions rather than complex procedures) but this cannot be determined from the existing data. Targeted interventions focussed on hydration, medication rationalization and sleep promotion may also be effective in reducing the incidence of delirium, as well as the active involvement of family members in the care of the elderly hospitalized patient. Hospitalization itself is a potential risk factor for delirium and promising data are emerging of the benefits of home-based care as an alternative to hospitalization but this is restricted to specific sub-populations of patients and is reliant on these services being available. Crown Copyright © 2016. Published by Elsevier Ireland Ltd. All rights reserved.

  20. Melatonin deficiency hypothesis in delirium: a synthesis of current evidence.

    PubMed

    de Rooij, Sophia E; van Munster, Barbara C

    2013-08-01

    The pineal hormone melatonin plays a major role in circadian sleep-wake rhythm in many mammals, including humans. Patients with acute confusional state or delirium, especially those with underlying cognitive impairment, frequently suffer from sleep disturbances and disturbed circadian rhythm. In this review, an overview is given of delirium and delirium symptoms that correspond with symptoms in dementia, such as sundowning, followed by a presentation of the circadian rhythm disorders in delirium in relation to melatonin deficiency. Finally, this review examines the therapeutic benefit of melatonin treatment in disorders related to delirium and dementia, including the placebo-controlled randomized clinical trials addressing this topic.

  1. Comprehensive Approaches to Managing Delirium in Patients with Advanced Cancer

    PubMed Central

    Kang, Jung Hun; Shin, Seong Hoon; Bruera, Eduardo

    2013-01-01

    Delirium is a frequently under-recognized complication in patients with advanced cancer. Uncontrolled delirium eventually leads to significant distress to patients and their families. However, delirium episodes can be reversed in half of these patients by eliminating precipitating factors and using appropriate interventions. The purpose of this narrative review is to discuss the most recent updates in the literature on the management of delirium in patients with advanced cancer. This article addresses the epidemiology, cause, pathophysiology, clinical characteristics, and assessment of delirium as well as various treatment options, including nonpharmacologic intervention and palliative sedation. PMID:22959227

  2. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*.

    PubMed

    Traube, Chani; Silver, Gabrielle; Kearney, Julia; Patel, Anita; Atkinson, Thomas M; Yoon, Margaret J; Halpert, Sari; Augenstein, Julie; Sickles, Laura E; Li, Chunshan; Greenwald, Bruce

    2014-03-01

    To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012. One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. Two hundred forty-eight paired assessments completed. The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in

  3. Cornell Assessment of Pediatric Delirium: A Valid, Rapid, Observational Tool for Screening Delirium in the PICU*

    PubMed Central

    Traube, Chani; Silver, Gabrielle; Kearney, Julia; Patel, Anita; Atkinson, Thomas M.; Yoon, Margaret J.; Halpert, Sari; Augenstein, Julie; Sickles, Laura E.; Li, Chunshan; Greenwald, Bruce

    2017-01-01

    Objective To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. Design Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the “gold standard” for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. Setting Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March–May 2012. Patients One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. Intervention Two hundred forty-eight paired assessments completed. Measurements and Main Results The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8–98.8%) and specificity of 79.2% (95% CI, 73.5–84.9%). Overall Cronbach’s α of 0.90 was observed, with a range of 0.87–0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68–0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7–98.3%) and specificity was 86.5% (95% CI, 75.4–97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7–77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5–100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete

  4. Bedside coaching to improve nurses' recognition of delirium.

    PubMed

    Gordon, Susan Jean; Melillo, Karen Devereaux; Nannini, Angela; Lakatos, Barbara E

    2013-10-01

    Delirium is a widespread complication of hospitalization and is frequently unrecognized by nurses and other healthcare professionals. Patients with neuroscience diagnoses are at increased risk for delirium as compared with other patients. The aims of this quality improvement project were to (1) increase neuroscience nurses' knowledge of delirium, (2) integrate coaching into evidence-based practice, and (3) evaluate the effectiveness of this combined approach to improve nurses' recognition of delirium on a neuroscience unit. Institutional review board approval was obtained. A retrospective chart review of randomly selected patients admitted before the intervention was completed. The (modified) Nurse's Knowledge of Delirium Tool was electronically administered to nursing staff (n = 47), followed within 2 weeks by a didactic presentation on delirium. Bedside coaching was performed over a period of 4 weeks. The (modified) Nurses Knowledge of Delirium Tool was electronically readministered to nurses 4 weeks later to determine the change in aggregate knowledge. A postintervention chart review was conducted. SPSS software was used to analyze descriptive statistics with regard to chart reviews, documentation, and change in questionnaire scores. Findings reveal that neuroscience nurses recognize the absence of delirium 94.4% of the time and the presence of delirium 100% of the time after a didactic session and coaching. The postintervention chart review showed a statistically significant increase (p = .000) in the documentation of delirium screening results. Expert coaching at the bedside may be a reliable method for teaching nurses to use evidence-based screening tools to detect delirium in patients with neuroscience diagnoses.

  5. The intensive care delirium research agenda: a multinational, interprofessional perspective.

    PubMed

    Pandharipande, Pratik P; Ely, E Wesley; Arora, Rakesh C; Balas, Michele C; Boustani, Malaz A; La Calle, Gabriel Heras; Cunningham, Colm; Devlin, John W; Elefante, Julius; Han, Jin H; MacLullich, Alasdair M; Maldonado, José R; Morandi, Alessandro; Needham, Dale M; Page, Valerie J; Rose, Louise; Salluh, Jorge I F; Sharshar, Tarek; Shehabi, Yahya; Skrobik, Yoanna; Slooter, Arjen J C; Smith, Heidi A B

    2017-06-13

    Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

  6. Outcomes associated with postoperative delirium after cardiac surgery.

    PubMed

    Mangusan, Ralph Francis; Hooper, Vallire; Denslow, Sheri A; Travis, Lucille

    2015-03-01

    Delirium after surgery is a common condition that leads to poor outcomes. Few studies have examined the effect of postoperative delirium on outcomes after cardiac surgery. To assess the relationship between delirium after cardiac surgery and the following outcomes: length of stay after surgery, prevalence of falls, discharge to a nursing facility, discharge to home with home health services, and use of inpatient physical therapy. Electronic medical records of 656 cardiac surgery patients were reviewed retrospectively. Postoperative delirium occurred in 161 patients (24.5%). Patients with postoperative delirium had significantly longer stays (P < .001) and greater prevalence of falls (P < .001) than did patients without delirium. Patients with delirium also had a significantly greater likelihood for discharge to a nursing facility (P < .001) and need for home health services if discharged to home (P < .001) and a significantly higher need for inpatient physical therapy (P < .001). Compared with patients without postoperative delirium, patients who had this complication were more likely to have received zolpidem and benzodiazepines postoperatively and to have a history of arrhythmias, renal disease, and congestive heart failure. Patients who have delirium after cardiac surgery have poorer outcomes than do similar patients without this complication. Development and implementation of an extensive care plan to address postoperative delirium is necessary for cardiac surgery patients who are at risk for or have delirium after the surgery. ©2015 American Association of Critical-Care Nurses.

  7. A prospective study of delirium in hospitalized elderly.

    PubMed

    Francis, J; Martin, D; Kapoor, W N

    1990-02-23

    The prevalence, risk factors, and outcomes of delirium were studied in 229 elderly patients. Fifty patients (22%) met criteria for delirium; nondelirious elderly constituted the control group. Abnormal sodium levels, illness severity, dementia, fever or hypothermia, psychoactive drug use, and azotemia were associated with risk of delirium. Patients with three or more risk factors had a 60% rate of delirium. Delirious patients stayed 12.1 days in the hospital vs 7.2 days for controls and were more likely to die (8% vs 1%) or be institutionalized (16% vs 3%). Illness severity predicted 6-month mortality, but the effect of delirium was not significant. Delirium occurs commonly in hospitalized elderly, is associated with chronic and acute problems, and identifies elderly at risk for death, longer hospitalization, and institutionalization. The increased mortality associated with delirium appears to be explained by greater severity of illness.

  8. Multicomponent delirium prevention: not as effective as NICE suggest?

    PubMed

    Teale, Elizabeth; Young, John

    2015-11-01

    Multicomponent delirium prevention strategies have been shown in intervention studies consistently to reduce the occurrence of delirium. Based on this convincing evidence base, the National Institute for Health and Care Excellence has advocated the widespread adoption of multicomponent delirium prevention interventions into the routine inpatient care of older people. However, despite successful reductions in incident delirium of about a third, anticipated reductions in mortality or admissions to long-term care--both clinically important endpoints statistically correlated with the occurrence of delirium--have not been conclusively observed. We hypothesise that the reasons for this disconnection are partly methodological, due to difficulties in delirium detection and blinding of study personnel to the intervention, but predominantly due to the underlying relationship between delirium and the abnormal health state of frailty; the interaction between these two geriatric syndromes is currently poorly understood.

  9. The Interface of Delirium and Dementia in Older Persons

    PubMed Central

    Fong, Tamara G.; Davis, Daniel; Growdon, Matthew E.; Albuquerque, Asha; Inouye, Sharon K.

    2015-01-01

    Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelationship remains poorly understood. Previous studies have documented that dementia is the leading risk factor for delirium; and delirium is an independent risk factor for subsequent dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the impact of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, it is likely that all of these hypotheses are true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies provide support for a strong interrelationship and for both shared and distinct pathological mechanisms. Targeting delirium for new preventive and therapeutic approaches may offer the sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing. PMID:26139023

  10. An approach to drug induced delirium in the elderly

    PubMed Central

    Alagiakrishnan, K; Wiens, C

    2004-01-01

    Drugs have been associated with the development of delirium in the elderly. Successful treatment of delirium depends on identifying the reversible contributing factors, and drugs are the most common reversible cause of delirium. Anticholinergic medications, benzodiazepines, and narcotics in high doses are common causes of drug induced delirium. This article provides an approach for clinicians to prevent, recognise, and manage drug induced delirium. It also reviews the mechanisms for this condition, especially the neurotransmitter imbalances involving acetylcholine, dopamine, and gamma aminobutyric acid and discusses the age related changes that may contribute to altered pharmacological effects which have a role in delirium. Specific interventions for high risk elderly with the goal of preventing drug induced delirium are discussed. PMID:15254302

  11. The Epidemiology of Delirium: Challenges and Opportunities for Population Studies

    PubMed Central

    Davis, Daniel H.J.; Kreisel, Stefan H.; Muniz Terrera, Graciela; Hall, Andrew J.; Morandi, Alessandro; Boustani, Malaz; Neufeld, Karin J.; Lee, Hochang Benjamin; MacLullich, Alasdair M.J.; Brayne, Carol

    2013-01-01

    Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective. PMID:23907068

  12. Paraneoplastic neuropsychiatric syndrome presenting as delirium.

    PubMed

    Roldan Urgoiti, Gloria; Sinnarajah, Aynharan; Hussain, Seema; Hao, Desiree

    2016-07-28

    Delirium in patients with cancer is associated with poor outcomes, but reversible causes need to be ruled out. We report the case of a 59-year-old woman who was presented with behavioural and cognitive changes over 2 weeks. She was non-verbal and combative, requiring involuntary admission and declaration of incompetence to make healthcare treatment decisions. Infectious and metabolic investigations and initial brain imaging were unremarkable. She was diagnosed with limited-stage small cell lung cancer and a paraneoplastic neuropsychiatric syndrome. Owing to the patient's delirium, chemotherapy delivery required pharmacological and physical restraints. After 2 cycles of chemotherapy, she could participate in the decision process and was discharged home. She completed radical chemo-radiotherapy and has remained free of disease progression for 18 months. Paraneoplastic neuropsychiatric syndromes, although rare, are potentially treatable and need to be excluded as a cause of delirium.

  13. Delirium: a diagnostic dilemma. Part 1.

    PubMed

    Hardy, Kersten; Brown, Michelle

    Effective symptom management for a patient with a palliative diagnosis can be challenging. There are some symptoms that may be more difficult to control and understand than others. Delirium, as a symptom, may well prove to be a significant challenge for all involved, leaving family and health professionals perplexed and exhausted. Understanding the predisposing factors and the manifestations may aid the health professional in the assessment and identification of this distressing symptom, facilitating more effective management and care of those who are approaching the end of life. This article attempts to address some of the challenges and offer a number of suggestions that may aid in identifying delirium in patients at the end of life, but also examines some of the dilemmas when attempting to treat delirium.

  14. Delirium: a guide for the general physician.

    PubMed

    Todd, Oliver M; Teale, Elizabeth A

    2017-02-01

    Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types. © Royal College of Physicians 2017. All rights reserved.

  15. Recognition of Delirium in Postoperative Elderly Patients: A Multicenter Study.

    PubMed

    Numan, Tianne; van den Boogaard, Mark; Kamper, Adriaan M; Rood, Paul J T; Peelen, Linda M; Slooter, Arjen J C

    2017-09-01

    To evaluate to what extent delirium experts agree on the diagnosis of delirium when independently assessing exactly the same information and to evaluate the sensitivity of delirium screening tools in routine daily practice of clinical nurses. Prospective observational longitudinal study. Three medical centers in the Netherlands. Elderly postoperative adults (n = 167). A researcher examined participants daily (Postoperative Day 1-3) for delirium using a standardized cognitive assessment and interview including the Delirium Rating Scale Revised-98 as global impression without any cut-off values that was recorded on video. Two delirium experts independently evaluated the videos and clinical information from the last 24 hours in the participants' record and classified each assessment as delirious, possibly delirious, or not delirious. Interrater agreement between the delirium experts was determined using weighted Cohen's kappa. When there was no consensus, a third expert was consulted. Final classification was based on median score and compared with the results of the Confusion Assessment Method for Intensive Care Unit and Delirium Observation Scale that clinical nurses administered. Four hundred twenty-four postoperative assessments of 167 participants were included. The overall kappa was 0.61 (95% confidence interval = 0.53-0.68). There was no agreement between the experts for 89 (21.0%) assessments and a third delirium expert was needed for the final classification. Delirium screening that nurses performed detected 32% of the assessments that the experts diagnosed as (possibly) delirious. There was considerable disagreement in classification of delirium by experts who independently assessed exactly the same information, showing the difficulty of delirium diagnosis. Furthermore, the sensitivity of daily delirium screening by clinical nurses was poor. Future research should focus on development of objective instruments to diagnose delirium. © 2017, Copyright the

  16. Delirium: A Survey of Healthcare Professionals' Knowledge, Beliefs, and Practices.

    PubMed

    Sinvani, Liron; Kozikowski, Andrzej; Pekmezaris, Renee; Akerman, Meredith; Wolf-Klein, Gisele

    2016-12-01

    To evaluate knowledge, beliefs, and practices regarding delirium of physicians, nurse practitioners (NPs), and registered nurses (RNs). Anonymous cross-sectional paper survey. New York metropolitan area tertiary care hospital. RNs, NPs, and physicians (N = 164). The survey assessed knowledge, beliefs, and practices regarding delirium and prior delirium or geriatric training. Of the 200 surveys distributed, 164 were completed (82% response rate). Of these, 61.7% were RNs, 13.6% were NPs, and 20.7% were physicians. Mean participant age was 36.3. The majority (80.1%) were female; 56.5% were white, 18.1% Asian, 8.7% Hispanic, 8.0% black, and 8.7% other. Of the seven potential barriers to delirium screening assessed, the three most frequently reported were lack of conceptual understanding of delirium (48.0%), similarity of delirium and dementia (41.4%), and the fluctuating nature of delirium (38.1%). Physicians were more likely than NPs and RNs to report being confident in identifying delirium (P = .002) and to score higher on the delirium knowledge assessment (P < .001). Participants who received geriatrics training were significantly more likely than those who did not to be confident in identifying delirium (P = .005) and to score higher on overall delirium knowledge assessment (P = .003). Geriatric training is associated with more confidence in delirium screening and higher delirium knowledge scores. There is an urgent need to broaden the approach to delirium education of nurses and physicians caring for hospitalized older adults using comprehensive multidisciplinary geriatric educational models. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  17. Postoperative Delirium in the Geriatric Patient.

    PubMed

    Schenning, Katie J; Deiner, Stacie G

    2015-09-01

    Postoperative delirium, a common complication in older surgical patients, is independently associated with increased morbidity and mortality. Patients older than 65 years receive greater than one-third of the more than 40 million anesthetics delivered yearly in the United States. This number is expected to increase with the aging of the population. Thus, it is increasingly important that perioperative clinicians who care for geriatric patients have an understanding of the complex syndrome of postoperative delirium. Copyright © 2015 Elsevier Inc. All rights reserved.

  18. Perioperative delirium and its relationship to dementia.

    PubMed

    Silverstein, Jeffrey H; Deiner, Stacie G

    2013-06-03

    A number of serious clinical cognitive syndromes occur following surgery and anesthesia. Postoperative delirium is a behavioral syndrome that occurs in the perioperative period. It is diagnosed through observation and characterized by a fluctuating loss of orientation and confusion. A distinct syndrome that requires formalized neurocognitive testing is frequently referred to as postoperative cognitive dysfunction (POCD). There are serious concerns as to whether either postoperative delirium or postoperative cognitive dysfunction leads to dementia. These concerns are reviewed in this article. Copyright © 2012 Elsevier Inc. All rights reserved.

  19. Delirium in elderly vascular surgery patients.

    PubMed

    Cudennec, Tristan; Goëau-Brissonnière, Olivier; Coscas, Raphaël; Capdevila, Clément; Moulias, Sophi; Coggia, Marc; Teillet, Laurent

    2014-04-01

    The elderly represent a large percentage of patients seen in departments of vascular surgery. Delirium is a frequent perioperative complication in this population and contributes to increased morbidity and mortality. Prevention of problems associated with mental confusion rests in identifying comorbidities, their severity, and the risk factors associated with delirium syndrome. The aging of our population implies management of increasing numbers of older patients who often have concomitant pathologies and, consequently, polypharmacy. Optimization of their management rests on collaboration between surgeons, anesthetists, and geriatrists.

  20. Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences.

    PubMed

    Boettger, Soenke; Jenewein, Josef; Breitbart, William

    2015-08-01

    Our aim was to examine the characteristics of delirium in the severely medically ill cancer population on the basis of sociodemographic and medical variables, delirium severity, and phenomenology, as well as severity of medical illness. All subjects in the database were recruited from psychiatric referrals at Memorial Sloan Kettering Cancer Center (MSKCC). Sociodemographic and medical variables, as well as the Karnofsky Performance Status (KPS) scale and Memorial Delirium Assessment Scale (MDAS) scores were recorded at baseline. Subsequently, these variables were analyzed with respect to the severity of the medical illness. Out of 111 patients, 67 qualified as severely medically ill. KPS scores were 19.7 and 30.7 in less severe illness. There were no significant differences with respect to age, history of dementia, and MDAS scores. Although the severity of delirium did not differ, an increased frequency and severity of consciousness disturbance, disorientation, and inability to maintain and shift attention did exist. With respect to etiologies contributing to delirium, hypoxia and infection were commonly associated with severe illness. In contrast, corticosteroid administration was more often associated with less severe illness. There were no differences with respect to opiate administration, dehydration, and CNS disease, including brain metastasis. Delirium in the severely medically ill cancer population has been characterized by an increased disturbance of consciousness, disorientation, and an inability to maintain and shift attention. However, the severity of illness did not predict severity of delirium. Furthermore, hypoxia and infection were etiologies more commonly associated with delirium in severe illness, whereas the administration of corticosteroids was associated with less severe illness.

  1. Delirium superimposed on dementia versus delirium in the absence of dementia: phenomenological differences.

    PubMed

    Boettger, Soenke; Passik, Steven; Breitbart, William

    2009-12-01

    To examine differences in the phenomenological characteristics of delirium superimposed on dementia compared to those observed in delirious patients without dementia, based on the rating items of the Memorial Delirium Assessment Scale (MDAS). We conducted an analysis of a prospectively collected clinical delirium database utilized to record and monitor the care of delirious patients treated at Memorial Sloan-Kettering Cancer Center (MSKCC). Sociodemographic, medical variables, and MDAS total score and individual item ratings were analyzed in respect to differences between delirium in the demented (DD) versus delirium in the nondemented (ND). We were able to examine data collected on 100 delirious patients: 82 ND patients and 18 DD patients. Patients in the DD group, compared to the ND group, had significantly greater levels of disturbance of consciousness and impairments in all cognitive domains (i.e., orientation, short term memory, concentration, organization of thought process). Severe symptoms were more common in the DD group compared to the ND group on all the MDAS cognitive items as well as in disturbance of consciousness. There were no significant differences between the DD and ND groups in terms of presence or severity of hallucinations, delusions, psychomotor behavior, and sleep-wake cycle disturbance. Delirium superimposed on dementia has phenomenological differences compared to delirium in the absence of dementia. There are no significant differences in the severity of hallucinations, delusions, psychomotor behavior, or sleep-wake cycle disturbances. However, level of disturbance in consciousness (arousal and awareness) and impairments in multiple cognitive domains are significantly more severe in patients with delirium superimposed on dementia.

  2. Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences

    PubMed Central

    BOETTGER, SOENKE; JENEWEIN, JOSEF; BREITBART, WILLIAM

    2017-01-01

    Objective Our aim was to examine the characteristics of delirium in the severely medically ill cancer population on the basis of sociodemographic and medical variables, delirium severity, and phenomenology, as well as severity of medical illness. Method All subjects in the database were recruited from psychiatric referrals at Memorial Sloan Kettering Cancer Center (MSKCC). Sociodemographic and medical variables, as well as the Karnofsky Performance Status (KPS) scale and Memorial Delirium Assessment Scale (MDAS) scores were recorded at baseline. Subsequently, these variables were analyzed with respect to the severity of the medical illness. Results Out of 111 patients, 67 qualified as severely medically ill. KPS scores were 19.7 and 30.7 in less severe illness. There were no significant differences with respect to age, history of dementia, and MDAS scores. Although the severity of delirium did not differ, an increased frequency and severity of consciousness disturbance, disorientation, and inability to maintain and shift attention did exist. With respect to etiologies contributing to delirium, hypoxia and infection were commonly associated with severe illness. In contrast, corticosteroid administration was more often associated with less severe illness. There were no differences with respect to opiate administration, dehydration, and CNS disease, including brain metastasis. Significance of Results Delirium in the severely medically ill cancer population has been characterized by an increased disturbance of consciousness, disorientation, and an inability to maintain and shift attention. However, the severity of illness did not predict severity of delirium. Furthermore, hypoxia and infection were etiologies more commonly associated with delirium in severe illness, whereas the administration of corticosteroids was associated with less severe illness. PMID:25191904

  3. Use of nurse-observed symptoms of delirium in long-term care: effects on prevalence and outcomes of delirium.

    PubMed

    McCusker, Jane; Cole, Martin G; Voyer, Philippe; Monette, Johanne; Champoux, Nathalie; Ciampi, Antonio; Vu, Minh; Belzile, Eric

    2011-05-01

    Previous studies have reported that nurse detection of delirium has low sensitivity compared to a research diagnosis. As yet, no study has examined the use of nurse-observed delirium symptoms combined with research-observed delirium symptoms to diagnose delirium. Our specific aims were: (1) to describe the effect of using nurse-observed symptoms on the prevalence of delirium symptoms and diagnoses in long-term care (LTC) facilities, and (2) to compare the predictive validity of delirium diagnoses based on the use of research-observed symptoms alone with those based on research-observed and nurse-observed symptoms. Residents aged 65 years and over of seven LTC facilities were recruited into a prospective study. Using the Confusion Assessment Method (CAM), research assistants (RAs) interviewed residents and nurses to assess delirium symptoms. Delirium symptoms were also abstracted independently from nursing notes. Outcomes measured at five month follow-up were: death, the Hierarchic Dementia Scale (HDS), the Barthel ADL scale, and a composite outcome measure (death, or a 10-point decline in either the HDS or the ADL score). The prevalence of delirium among 235 LTC residents increased from 14.0% (using research-observed symptoms only) to 24.7% (using research- and nurse-observed symptoms). The relative risks (and 95% confidence intervals) for prediction of the composite outcome, after adjustment for covariates, were: 1.43 (0.88, 1.96) for delirium using research-observed symptoms only; 1.77 (1.13, 2.28) for delirium using research- and nurse-observed symptoms, in comparison with no delirium. The inclusion of delirium symptoms observed by nurses not only increases the detection of delirium in LTC facilities but improves the prediction of outcomes.

  4. Digging Into the Mysteries of Delirium | NIH MedlinePlus the Magazine

    MedlinePlus

    ... turn JavaScript on. Feature: Delirium Research Digging Into the Mysteries of Delirium Past Issues / Fall 2015 Table ... by delirium experience its effects for weeks after the first occurrence. Why is this? That's part of ...

  5. Delirium in hospitalized older patients: recognition and risk factors.

    PubMed

    Inouye, S K

    1998-01-01

    Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.

  6. Postoperative delirium. Part 1: pathophysiology and risk factors.

    PubMed

    Steiner, Luzius A

    2011-09-01

    Delirium presents clinically with differing subtypes ranging from hyperactive to hypoactive. The clinical presentation is not clearly linked to specific pathophysiological mechanisms. Nevertheless, there seem to be different mechanisms that lead to delirium; for example the mechanisms leading to alcohol-withdrawal delirium are different from those responsible for postoperative delirium. In many forms of delirium, the brain's reaction to a peripheral inflammatory process is considered to be a pathophysiological key element and the aged brain seems to react more markedly to a peripheral inflammatory stimulus than a younger brain. The effects of inflammatory mediators on the brain include changes in neurotransmission and apoptosis. On a neurotransmitter level, impaired cholinergic transmission and disturbances of the intricate interactions between dopamine, serotonin and acetylcholine seem to play an important role in the development of delirium. The risk factors for delirium are categorised as predisposing or precipitating factors. In the presence of many predisposing factors, even trivial precipitating factors may trigger delirium, whereas in patients without or with only a few predisposing factors, a major precipitating insult is necessary to trigger delirium. Well documented predisposing factors are age, medical comorbidities, cognitive, functional, visual and hearing impairment and institutional residence. Important precipitating factors apart from surgery are admission to an ICU, anticholinergic drugs, alcohol or drug withdrawal, infections, iatrogenic complications, metabolic derangements and pain. Scores to predict the risk of delirium based on four or five risk factors have been validated in surgical patients.

  7. Excited Delirium: A Systematic Review.

    PubMed

    Gonin, Philippe; Beysard, Nicolas; Yersin, Bertrand; Carron, Pierre-Nicolas

    2017-10-09

    We aimed to clarify the definition, epidemiology, and pathophysiology of excited delirium syndrome (ExDS) and to summarize evidence-based treatment recommendations. We conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge, and Cochrane Library for articles published to March 18, 2017. We also searched the grey literature (Google Scholar) and official police or medical expert reports to complete specific epidemiological data. Search results and full-text articles were independently assessed by two investigators and agreements between reviewers assessed with K statistics. We classified articles by study type, setting, and evidence level. After reviewing the title and abstract of 3604 references, we fully reviewed 284 potentially relevant references, from which 66 were selected for final review. Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its pathophysiology, and 27 to its management. The incidence of ExDS varies widely with medical or medico-legal context. Mortality is estimated to be as much as 8.3 to 16.5%. Patients are predominantly male. Male gender, young age, African-American race, and being overweight are independent risk factors. Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases occur with psychostimulant use or among psychiatric patients, or both. Proposed treatments are symptomatic, often with rapid sedation with benzodiazepines or antipsychotic agents. Ketamine is suggested as an alternative. The overall quality of studies was poor. A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity, that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been done to conclude whether one treatment approach is preferable to another in the case

  8. Aripiprazole and haloperidol in the treatment of delirium.

    PubMed

    Boettger, Soenke; Friedlander, Miriam; Breitbart, William; Passik, Steven

    2011-06-01

    To compare the efficacy and tolerability of aripiprazole and haloperidol in the amelioration of distressing symptoms of delirium and its motoric subtypes. At Memorial Sloan-Kettering Cancer Center, we prospectively collected sociodemographic and medical data and systematically rated all patients diagnosed with delirium with the Memorial Delirium Assessment Scale (MDAS), Karnofsky Performance Scale (KPS) and the abbreviated Udvalg Kliniske Undersogelser Side Effect Rating Scale (UKU) at the initial diagnosis of delirium (T1), after 48-72 h (T2) and 7 days later (T3). All collected information was entered into a delirium database. For our analysis, we subsequently extracted data on aripiprazole (ARI) treated patients to compare to case-matched haloperidol (HAL) treated patients. We retrieved 21 patients treated with aripiprazole and 21 case-matched patients treated with haloperidol. Initial MDAS scores did not significantly differ between the groups. Over the course of treatment (T1 to T3), MDAS scores improved from 18.1 to 8.3 for ARI and 19.9 to 6.8 for HAL. The delirium resolution rate was 76.2% for ARI and 76.2% for HAL. For patients with hypoactive delirium, the MDAS scores improved from 15.6 to 5.7 for ARI and 18.8 to 8.1 for HAL. Delirium resolution rates for patients with hypoactive delirium were 100% for ARI and 77.8% for HAL. For patients experiencing hyperactive delirium, the MDAS scores improved from 19.9 to 6.8 for ARI and 20.8 to 5.8 for HAL. Delirium resolution rates for patients with hyperactive delirium were 58.3% for ARI and 75% for HAL. There were no significant differences in treatment results between ARI and HAL. Treatment with HAL caused more extrapyramidal side effects. From our secondary analysis, aripiprazole may be as effective as haloperidol in the management of delirium and its subtypes. Treatment with haloperidol resulted in more side effects.

  9. Dementia and delirium, the outcomes in elderly hip fracture patients.

    PubMed

    Mosk, Christina A; Mus, Marnix; Vroemen, Jos Pam; van der Ploeg, Tjeerd; Vos, Dagmar I; Elmans, Leon Hgj; van der Laan, Lijckle

    2017-01-01

    Delirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium. This is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes. Of a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%). Elderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent an episode of delirium were at

  10. Dementia and delirium, the outcomes in elderly hip fracture patients

    PubMed Central

    Mosk, Christina A; Mus, Marnix; Vroemen, Jos PAM; van der Ploeg, Tjeerd; Vos, Dagmar I; Elmans, Leon HGJ; van der Laan, Lijckle

    2017-01-01

    Background Delirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium. Methods This is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes. Results Of a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%). Conclusion Elderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent

  11. Levetiracetam: an unusual cause of delirium.

    PubMed

    Hwang, Eileen S; Siemianowski, Laura A; Sen, Sanchita; Patel, Ritesh

    2014-01-01

    Levetiracetam is a second-generation anticonvulsant that was approved by the Federal Drug Administration in 1999 for the treatment of epilepsy. Recently, levetiracetam has become more popular for the prevention of posttraumatic seizures. Some of the well-known adverse effects of levetiracetam are somnolence, behavioral abnormalities, and less commonly, psychosis. Delirium is not a well-known adverse effect of levetiracetam. Here, we present the case of a 77-year-old Caucasian male who developed disorientation, agitation, and lethargy after initiation of levetiracetam to prevent posttraumatic seizures. Imaging on admission demonstrated a subacute subdural hematoma in the left frontal lobe without mass effect, and the patient was started on levetiracetam 500 mg intravenously twice daily. Less than 24 hours later, the patient began to display a fluctuating level of consciousness, disorientation, an inability to follow commands, and garbled speech. His symptoms continued for 12 days unabated despite episodic treatment with sedatives and antipsychotics. At one point, the patient progressed to aggressive behavior and required restraints. Laboratory tests during this period did not demonstrate signs of infection or metabolic abnormalities. Delirium from levetiracetam was suspected and the drug was discontinued. The patient's mental status improved dramatically within 24 hours after administration of the last dose of levetiracetam and he was discharged home. Based on the Naranjo scale, the episode of delirium was probably related to levetiracetam. Although the other neuropsychiatric effects of levetiracetam are well known, we highlight the first case of delirium without psychotic features associated with levetiracetam.

  12. Delirium associated with baclofen withdrawal: a review of common presentations and management strategies.

    PubMed

    Leo, Raphael J; Baer, Daniel

    2005-01-01

    The authors reviewed 23 published cases of psychiatric symptoms in association with baclofen withdrawal. Delirium, and not other functional psychiatric conditions, arose secondarily from abrupt baclofen cessation. Vulnerability to baclofen-withdrawal delirium appeared to be greater in individuals who received chronic baclofen therapy. Baclofen-withdrawal delirium can be difficult to distinguish from delirium of other etiologies, and unrecognized and inadequately treated baclofen-withdrawal delirium is associated with significant morbidity and mortality. Complete resolution of delirium symptoms was possible with reinstatement of baclofen. The clinical management of patients experiencing baclofen-withdrawal delirium includes supportive interventions to reduce complications of delirium until symptoms resolve.

  13. Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium.

    PubMed

    Silver, Gabrielle; Kearney, Julia; Traube, Chani; Hertzig, Margaret

    2015-08-01

    The recently validated Cornell Assessment for Pediatric Delirium (CAPD) is a new rapid bedside nursing screen for delirium in hospitalized children of all ages. The present manuscript provides a "developmental anchor points" reference chart, which helps ground clinicians' assessment of CAPD symptom domains in a developmental understanding of the presentation of delirium. During the development of this CAPD screening tool, it became clear that clinicians need specific guidance and training to help them draw on their expertise in child development and pediatrics to improve the interpretative reliability of the tool and its accuracy in diagnosing delirium. The developmental anchor points chart was formulated and reviewed by a multidisciplinary panel of experts to evaluate content validity and include consideration of sick behaviors within a hospital setting. The CAPD developmental anchor points for the key ages of newborn, 4 weeks, 6 weeks, 8 weeks, 28 weeks, 1 year, and 2 years served as the basis for training bedside nurses in scoring the CAPD for the validation trial and as a multifaceted bedside reference chart to be implemented within a clinical setting. In the current paper, we discuss the lessons learned during implementation, with particular emphasis on the importance of collaboration with the bedside nurse, the challenges of establishing a developmental baseline, and further questions about delirium diagnosis in children. The CAPD with developmental anchor points provides a validated, structured, and developmentally informed approach to screening and assessment of delirium in children. With minimal training on the use of the tool, bedside nurses and other pediatric practitioners can reliably identify children at risk for delirium.

  14. Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium

    PubMed Central

    SILVER, GABRIELLE; KEARNEY, JULIA; TRAUBE, CHANI; HERTZIG, MARGARET

    2016-01-01

    Objective The recently validated Cornell Assessment for Pediatric Delirium (CAPD) is a new rapid bedside nursing screen for delirium in hospitalized children of all ages. The present manuscript provides a “developmental anchor points” reference chart, which helps ground clinicians’ assessment of CAPD symptom domains in a developmental understanding of the presentation of delirium. Method During the development of this CAPD screening tool, it became clear that clinicians need specific guidance and training to help them draw on their expertise in child development and pediatrics to improve the interpretative reliability of the tool and its accuracy in diagnosing delirium. The developmental anchor points chart was formulated and reviewed by a multidisciplinary panel of experts to evaluate content validity and include consideration of sick behaviors within a hospital setting. Results The CAPD developmental anchor points for the key ages of newborn, 4 weeks, 6 weeks, 8 weeks, 28 weeks, 1 year, and 2 years served as the basis for training bedside nurses in scoring the CAPD for the validation trial and as a multifaceted bedside reference chart to be implemented within a clinical setting. In the current paper, we discuss the lessons learned during implementation, with particular emphasis on the importance of collaboration with the bedside nurse, the challenges of establishing a developmental baseline, and further questions about delirium diagnosis in children. Significance of Results The CAPD with developmental anchor points provides a validated, structured, and developmentally informed approach to screening and assessment of delirium in children. With minimal training on the use of the tool, bedside nurses and other pediatric practitioners can reliably identify children at risk for delirium. PMID:25127028

  15. Identifying and managing patients with delirium in acute care settings.

    PubMed

    Bond, Penny; Goudie, Karen

    2015-11-01

    Delirium is an acute medical emergency affecting about one in eight acute hospital inpatients. It is associated with poor outcomes, is more prevalent in older people and it is estimated that half of all patients receiving intensive care or surgery for a hip fracture will be affected. Despite its prevalence and impact, delirium is not reliably identified or well managed. Improving the identification and management of patients with delirium has been a focus for the national improving older people's acute care work programme in NHS Scotland. A delirium toolkit has been developed, which includes the 4AT rapid assessment test, information for patients and carers and a care bundle for managing delirium based on existing guidance. This toolkit has been tested and implemented by teams from a range of acute care settings to support improvements in the identification and immediate management of delirium.

  16. Delirium: assessment and treatment of patients with cancer. PART 2.

    PubMed

    Brown, Michelle; Hardy, Kersten

    Delirium at the end of life may present significant ethical dilemmas in clinical practice: whether to simply treat it in order to maximise symptom relief, with the resulting side effect being palliative sedation, or to attempt to reverse delirium and risk prolonging suffering. Determining whether the delirium can be reversed involves comprehensive assessment using established tools, which may or may not provide the answer to the question posed. This article examines the evidence surrounding several assessment tools that have been suggested as effective in identifying delirium, and the consequences of various approaches to the management of delirium in a patient with a cancer diagnosis. It also considers the impact delirium may have on the health professional and those close to the patient.

  17. Delirium in elderly patients hospitalized in internal medicine wards.

    PubMed

    Fortini, Alberto; Morettini, Alessandro; Tavernese, Giuseppe; Facchini, Sofia; Tofani, Lorenzo; Pazzi, Maddalena

    2014-06-01

    A prospective observational study was conducted to evaluate the impact of delirium on geriatric inpatients in internal medical wards and to identify predisposing factors for the development of delirium. The study included all patients aged 65 years and older, who were consecutively admitted to the internal medicine wards of two public hospitals in Florence, Italy. On admission, 29 baseline risk factors were examined, cognitive impairment was evaluated by Short Portable Mental Status Questionnaire, and prevalent delirium cases were diagnosed by Confusion Assessment Method (CAM). Enrolled patients were evaluated daily with CAM to detect incident delirium cases. Among the 560 included patients, 19 (3 %) had delirium on admission (prevalent) and 44 (8 %) developed delirium during hospitalization (incident). Prevalent delirium cases were excluded from the statistical analysis. Incident delirium was associated with increased length of hospital stay (p < 0.01) and institutionalization (p < 0.01, OR 3.026). Multivariate analysis found that cognitive impairment on admission (p < 0.0002), diabetes (p < 0.05, OR 1.936), chronic kidney failure (p < 0.05, OR 2.078) and male gender (p < 0.05, OR 2.178) was significantly associated with the development of delirium during hospitalization. Results show that delirium impact is relevant to older patients hospitalized in internal medicine wards. The present study confirms cognitive impairment as a risk factor for incident delirium. The cognitive evaluation proved to be an important instrument to improve identification of patients at high risk for delirium. In this context, our study may contribute to improve application of preventive strategies.

  18. Temperature Variability during Delirium in ICU Patients: An Observational Study

    PubMed Central

    van der Kooi, Arendina W.; Kappen, Teus H.; Raijmakers, Rosa J.; Zaal, Irene J.; Slooter, Arjen J. C.

    2013-01-01

    Introduction Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and –nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature. Methods We included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or –nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores. Results Temperature variability was increased during delirium-days compared to days without delirium (βunadjusted=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (βadjusted=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (βunadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This

  19. Cost Associated With Pediatric Delirium in the ICU.

    PubMed

    Traube, Chani; Mauer, Elizabeth A; Gerber, Linda M; Kaur, Savneet; Joyce, Christine; Kerson, Abigail; Carlo, Charlene; Notterman, Daniel; Worgall, Stefan; Silver, Gabrielle; Greenwald, Bruce M

    2016-12-01

    To determine the costs associated with delirium in critically ill children. Prospective observational study. An urban, academic, tertiary-care PICU in New York city. Four-hundred and sixty-four consecutive PICU admissions between September 2, 2014, and December 12, 2014. None. All children were assessed for delirium daily throughout their PICU stay. Hospital costs were analyzed using cost-to-charge ratios, in 2014 dollars. Median total PICU costs were higher in patients with delirium than in patients who were never delirious ($18,832 vs $4,803; p < 0.0001). Costs increased incrementally with number of days spent delirious (median cost of $9,173 for 1 d with delirium, $19,682 for 2-3 d with delirium, and $75,833 for > 3 d with delirium; p < 0.0001); this remained highly significant even after adjusting for PICU length of stay (p < 0.0001). After controlling for age, gender, severity of illness, and PICU length of stay, delirium was associated with an 85% increase in PICU costs (p < 0.0001). Pediatric delirium is associated with a major increase in PICU costs. Further research directed at prevention and treatment of pediatric delirium is essential to improve outcomes in this population and could lead to substantial healthcare savings.

  20. Frequency of delirium in a neurological emergency room.

    PubMed

    Ramirez-Bermudez, Jesus; Lopez-Gómez, Mario; Sosa Ana, Luisa; Aceves, Sergio; Nader-Kawachi, Juan; Nicolini, Humberto

    2006-01-01

    The authors present a cross-sectional survey designed to evaluate the presence of delirium in patients with neurological emergencies. Two hundred and two patients were included in the study: 14.9% of subjects had delirium; 62.4% had no arousal disturbances; and 22.7% presented a coma or stupor state. Findings revealed that the presence of a cerebral infection, the presence of multiple etiologies, and the location of lesions in the frontal and temporal lobes were all associated with delirium. Results substantiate that delirium is a frequent occurrence in neurological patients and that the presence of multiple etiologies must be investigated in each patient.

  1. Delirium in the older emergency department patient: a quiet epidemic.

    PubMed

    Han, Jin H; Wilson, Amanda; Ely, E Wesley

    2010-08-01

    Delirium is defined as an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. This form of organ dysfunction commonly occurs in older patients in the emergency department (ED) and is associated with a multitude of adverse patient outcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus on searching for the underlying cause. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently. Copyright 2010 Elsevier Inc. All rights reserved.

  2. Aging and delirium: too much or too little pain medication?

    PubMed

    Robinson, Sherry; Vollmer, Charlene; Jirka, Holly; Rich, Catherine; Midiri, Carol; Bisby, Donna

    2008-06-01

    Review of the literature revealed an association of pain and delirium in hip fracture patients. The literature was sparse addressing other types of patients. The purpose of the present study was therefore to examine the association of pain and delirium in medical and surgical patients. A retrospective record review was conducted using records of 100 patients who developed delirium while hospitalized. Data included: age, comorbidities, hospital day when delirium developed, presence of major risk factors for delirium on admission, and amount of medication received in the 24 h before onset of delirium. Descriptive statistics, correlations, and univariate analysis of variance were used to determine association between the variables. The mean age was 76.71 years. The mean number of comorbidities was 2.22. The mean number of risk factors for delirium on admission was 2.26 (range 0 to 5). The mean percentage of total amount of medication ordered that was received was 27.67%. Those individuals admitted with a risk factor of hearing loss received significantly less amount of pain medication than those with other risk factors (p = .023). Nurses should carefully assess pain management in their older patients. If using a PCA pump, the older patient's ability to manage the pump should be reassessed often. If a patient is admitted with risk factors for development of delirium, unmanaged pain might be the additional factor that precipitates delirium.

  3. Detecting delirium in older adults living at home.

    PubMed

    Malenfant, Priscilla; Voyer, Philippe

    2012-01-01

    The aim of this study was to determine whether in-home care nurses had the necessary knowledge to detect delirium in older adults. To this end, 87 home care nurses from 2 sites in the greater Quebec City region in Canada answered a questionnaire. The results showed nurses had limited level of knowledge about the diagnostic criteria for delirium, the main signs and symptoms of delirium, and the tools for its detection. Moreover, 54.4% of the in-home care nurses were able to recognize delirium, from structured clinical vignettes.

  4. Pharmacological interventions for preventing delirium in the elderly.

    PubMed

    Ford, Andrew H; Almeida, Osvaldo P

    2015-06-01

    Delirium is a common occurrence in older hospitalised patients, particularly in the setting of surgical intervention and acute illness. Delirium is associated with a number of adverse clinical and social outcomes with higher financial cost and risk of developing dementia, as well as increased likelihood of need for residential care. Current interventions for the prevention of delirium typically involve recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predispose the individual to delirium. A number of pharmacological strategies for delirium prevention have been tested. Antipsychotic medications are used for treatment of agitation in the setting of delirium when other measures have failed, but their efficacy in prevention is limited by study heterogeneity and concerns about tolerability. Acetylcholinesterase inhibitors are effective in the symptomatic treatment of Alzheimer's disease but do not appear to be effective in preventing delirium. Melatonin and melatonin agonists have a rather benign side effect profile and show promise for prevention of delirium in medically unwell individuals. The alpha-2 agonist, dexmedetomidine may be helpful in the intensive care unit setting but intravenous route of administration and need for close clinical supervision limits its use in the wider hospital environment. Other agents such as benzodiazepines, corticosteroids, statins and gabapentin have been suggested but lack evidence to support their role in delirium prevention. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent although some interventions do show promise. Larger, well-designed, placebo-controlled clinical trials are needed.

  5. Intensive care unit environment may affect the course of delirium.

    PubMed

    Zaal, Irene J; Spruyt, Carolina F; Peelen, Linda M; van Eijk, Maarten M J; Wientjes, Rens; Schneider, Margriet M E; Kesecioglu, Jozef; Slooter, Arjen J C

    2013-03-01

    Delirium is a common disorder in intensive care unit (ICU) patients. It is unclear whether ICU environment affects delirium. We investigated the influence of ICU environment on the number of days with delirium during ICU admission. In this prospective before-after study, ICU delirium was compared between a conventional ICU with wards and a single-room ICU with, among others, improved daylight exposure. We included patients admitted for more than 24 h between March and June 2009 (ICU with wards) or between June and September 2010 (single-room ICU). Patients who remained unresponsive throughout ICU admission were excluded. The presence of delirium in the preceding 24 h was assessed daily with the confusion assessment method for the ICU (CAM-ICU) by research physicians combined with evaluation of medical and nursing charts. The number of days with delirium was investigated with Poisson regression analysis. We included 55 patients (449 observation days) in the ICU with wards and 75 patients (468 observation days) in the single-room ICU. After adjusting for confounding, the number of days with delirium decreased by 0.4 days (95 % confidence interval 0.1-0.7) in the single-room ICU (p = 0.005). The incidence of delirium during ICU stay was similar in the ICU with wards (51 %) and in the single-room ICU (45 %, p = 0.53). This study is the first to show that ICU environment may influence the course of delirium in ICU patients.

  6. Delirium detection and improved delirium management in older patients hospitalized for hip fracture.

    PubMed

    Todd, Kristine S; Barry, Jean; Hoppough, Susan; McConnell, Eleanor

    2015-11-01

    Delirium is a common and potentially devastating problem for older patients following hip fracture. Although early detection is recommended, description and evaluation of standardized approaches are scarce. The aims of this quality improvement project were to: (1) implement a clinical algorithm for improving delirium detection and management and (2) assess the impact of the clinical algorithm on length of stay, discharge disposition and patient satisfaction. The pilot study was implemented on an orthopedic unit to evaluate the effectiveness of a clinical protocol for delirium detection and management to improve outcomes. Outcomes of 33 elderly post-operative hip fracture patients were compared to historical controls from the same unit. Delirium was detected in 18% of patients. Length of stay was reduced by 22% (P < .001), discharge disposition showed a 13% improvement (P = .17) and patient satisfaction scores showed a 15% (P = .15) improvement post-intervention. Implementation of a clinical algorithm to promote early detection and treatment of delirium in post-operative hip fracture patients is feasible and associated with improved outcomes.

  7. Delirium subtype identification and the validation of the Delirium Rating Scale--Revised-98 (Dutch version) in hospitalized elderly patients.

    PubMed

    de Rooij, Sophia E; van Munster, Barbara C; Korevaar, Johanna C; Casteelen, Gerty; Schuurmans, Marieke J; van der Mast, Roos C; Levi, Marcel

    2006-09-01

    Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. The Dutch version of the Delirium Rating Scale-Revised-98 (DRS-R-98) appears to be a reliable method to classify delirium. The aim of this study was to determine the validity and reliability of the DRS-R-98 and to study clinical subtypes of delirium using the DRS-R-98. Patients received the Dutch version of the DRS-R-98, the Mini-Mental State Examination, the Confusion Assessment Method, and a clinical diagnosis of delirium according to DSM-IV criteria, and their relatives the Informant Questionnaire Cognitive Decline in the Elderly. The DRS-R-98 validation cohort (n=65) consisted of 23 patients with delirium, 22 patients with dementia, and 20 non-psychiatric comparison patients. For the delirium subtype study, a second cohort comprising 54 delirious patients was investigated. Median DRS-R-98 scores significantly distinguished delirium from dementia and no psychiatric disorder. Inter-rater reliability (intra-class correlation 0.97) and internal consistency (Crohnbach's alpha 0.94) were high. Positive scores of DRS-R-98 item 4 (affect liability) and item 7 (motor agitation) predicted the presence of non-hypoactive delirium, with a specificity of 89% and a sensitivity of 57%. The results show that the Dutch version of the DRS-R-98 is a valid and reliable measure of delirium severity and distinguishes patients with delirium from patients with dementia and comparison patients. Furthermore, the DRS-R-98 is able to exclude hypoactive delirium. Copyright (c) 2006 John Wiley & Sons, Ltd.

  8. The Johns Hopkins Delirium Consortium: One Model for Collaborating Across Disciplines and Departments for Delirium Prevention and Treatment

    PubMed Central

    Neufeld, Karin J.; Bienvenu, O. Joseph; Rosenberg, Paul B.; Mears, Simon C.; Lee, Hochang B.; Kamdar, Biren B.; Sieber, Frederick E.; Krumm, Sharon K.; Walston, Jeremy D.; Hager, David N.; Touradji, Pegah; Needham, Dale M.

    2015-01-01

    Delirium is an important syndrome affecting inpatients in various hospital settings. This article focuses on multidisciplinary and interdepartmental collaboration for advancing efforts in delirium clinical care and research. One model for such collaboration is represented by the Johns Hopkins Delirium Consortium, which includes members from the disciplines of Nursing, Medicine, Rehabilitation Therapy, Psychology, and Pharmacy within the Departments/Divisions of Anesthesiology, Geriatrics, Oncology, Orthopedic Surgery, Psychiatry, Critical Care Medicine, and Physical Medicine and Rehabilitation at both the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. This paper describes the process involved in developing functional collaboration around delirium, and highlights projects, opportunities, and challenges resulting from them. PMID:22091568

  9. How to try this: detecting delirium.

    PubMed

    Waszynski, Christine M

    2007-12-01

    For patients and their loved ones, delirium can be a frightening experience. A fluctuating mental status is important to identify because it often signals a need for additional treatment. The Confusion Assessment Method (CAM) diagnostic algorithm enables nurses to assess for delirium by identifying the four features of the disorder that distinguish it from other forms of cognitive impairment. It can be completed in five minutes and is easily incorporated into ongoing assessments of hospitalized patients. (This screening tool is included in the series Try This: Best Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York University's College of Nursing.) For a free online video demonstrating the use of this tool, go to http://links.lww.com/A209.

  10. Delirium, Caused by Suspending Treatment of Hypothyroidism

    PubMed Central

    Hernández-Sandí, Alejandro; Quirós-Baltodano, David; Oconitrillo-Chaves, Michelle

    2016-01-01

    Delirium, or acute confusional syndrome, is a set of symptoms whose care involves not only psychiatry, but also many other medical specialties. Being as how the syndrome is caused by multiple factors, it is important to recognize each risk factor affecting the patient in order to anticipate and prevent it. In case of diagnosis, identifying and treating the root cause that triggered is important, given that it has a high rate of comorbidity and an elevated cost of medical care. We describe a case where a patient with hypothyroidism began suffering from delirium due to an abrupt discontinuation of levothyroxine treatment. Previously, the patient was seemingly healthy. After the medical treatment was interrupted, sensory processing and behavior were altered, and symptoms fluctuated, for a short period of time, showing disorientation and memory and language impairment. PMID:27994835

  11. Tools to Detect Delirium Superimposed on Dementia: A Systematic Review

    PubMed Central

    Morandi, Alessandro; McCurley, Jessica; Vasilevskis, Eduard E.; Fick, Donna M.; Bellelli, Giuseppe; Lee, Patricia; Jackson, James C.; Shenkin, Susan D.; Trabucchi, Marco; Schnelle, John; Inouye, Sharon K.; Ely, Wesley E.; MacLullich, Alasdair

    2012-01-01

    Background Delirium commonly occurs in patients with dementia. Though several tools for detecting delirium exist, it is unclear which are valid in patients with delirium superimposed on dementia. Objectives Identify valid tools to diagnose delirium superimposed on dementia Design We performed a systematic review of studies of delirium tools, which explicitly included patients with dementia. Setting In-hospital patients Participants Studies were included if delirium assessment tools were validated against standard criteria, and the presence of dementia was assessed according to standard criteria that used validated instruments. Measurements PubMed, Embase, and Web of Science databases were searched for articles in English published between January 1960 and January 2012. Results Nine studies fulfilled the selection criteria. Of the total of 1569 patients, 401 had dementia, and 50 had delirium superimposed on dementia. Six delirium tools were evaluated. One studyusing the Confusion Assessment Method (CAM) with 85% patients with dementia showed a high specificity (96–100%) and moderate sensitivity (77%).Two intensive care unit studies that used the CAM for the Intensive Care Unit (CAM-ICU) ICU reported 100% sensitivity and specificity for delirium among 23 dementia patients. One study using electroencephalography reported a sensitivity of 67% and a specificity of 91% among a population with 100% prevalence of dementia. No studies examined potential effects of dementia severity or subtype upon diagnostic accuracy. Conclusions The evidence base on tools for detection of delirium superimposed on dementia is limited, although some existing tools show promise. Further studies of existing or refined tools with larger samples and more detailed characterization of dementia are now required to address the identification of delirium superimposed on dementia. PMID:23039270

  12. Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery.

    PubMed

    Rizk, Paul; Morris, William; Oladeji, Philip; Huo, Michael

    2016-06-01

    Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

  13. Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

    PubMed Central

    Morris, William; Oladeji, Philip; Huo, Michael

    2016-01-01

    Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms. PMID:27239384

  14. Does Apolipoprotein E Genotype Increase Risk of Postoperative Delirium?

    PubMed Central

    Vasunilashorn, Sarinnapha; Ngo, Long; Kosar, Cyrus M.; Fong, Tamara G.; Jones, Richard N.

    2015-01-01

    Objectives To determine whether Apolipoprotein E (ApoE) is associated with postoperative delirium incidence, severity, and duration in older patients free of dementia at baseline. Design, Setting, Participants We examined 557 non-demented patients age ≥70 undergoing major non-cardiac surgery enrolled in the Successful Aging after Elective Surgery (SAGES) Study. Measurements We considered three ApoE measures: ε2, ε4 carriers vs. non-carriers, and a three-category ApoE measure. Delirium was determined using the Confusion Assessment Method (CAM) and chart review. We used generalized linear models to estimate the association between ApoE and delirium incidence, severity (peak CAM Severity [CAM-S] score), and days. Results ApoE ε2 and ε4 was present in 15% and 19% respectively, and postoperative delirium occurred in 24%. Among patients with delirium, the mean peak CAM-S score was 8.0 (standard deviation 4), with most patients experiencing one or two delirium days (51% or 28%, respectively). After adjusting for age, sex, surgical procedure, and preoperative cognitive function, ApoE ε4 and ε2 carrier status were not associated with postoperative delirium: RR for ε4=1.0, 95% confidence interval (CI) 0.7-1.5 and RR for ε2=0.9, 95% CI 0.6-1.4. No association between ApoE and delirium severity or number of delirium days was observed. Conclusions In older surgery patients free of dementia, our findings do not support the hypothesis that the ApoE genotype does not confer either risk or protection in postoperative delirium incidence, severity, or duration. Thus, an important genetic risk factor for Alzheimer's Disease does not affect risk of delirium. PMID:26238230

  15. Cerebral oximetry as a biomarker of postoperative delirium in cardiac surgery patients.

    PubMed

    Mailhot, Tanya; Cossette, Sylvie; Lambert, Jean; Cournoyer, Alexis; Denault, André Y

    2016-08-01

    A promising monitoring strategy for delirium is the use of cerebral oximetry, but its validity during delirium is unknown. We assessed the relationship between oximetry and delirium. We hypothesized that as cerebral oximetry values increased, delirium would resorb. An observational study was conducted with 30 consecutive adults with delirium after cardiac surgery. Oximetry, delirium assessments, and clinical data were collected for 3 consecutive days after delirium onset. Oximetry was obtained using near-infrared spectroscopy. Delirium was assessed using diagnosis, occurrence (Confusion Assessment Method-ICU), and severity scales (Delirium Index). All patients presented delirium at entry. The mean oximetry value decreased from 66.4±6.7 (mean±SD) to 50.8±6.8 on the first day after delirium onset and increased in patients whose delirium resorbed over the 3 days. The relationship between oximetry, delirium diagnosis, and severity was analyzed with a marginal model and linear mixed models. Cerebral oximetry was related to delirium diagnosis (P≤.0001) and severity (P≤.0001). This study highlighted the links between increased cerebral oximetry values and delirium resorption. Oximetry values may be useful in monitoring delirium progression, thus assisting in the management of this complicated condition. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU.

    PubMed

    Simone, Shari; Edwards, Sarah; Lardieri, Allison; Walker, L Kyle; Graciano, Ana Lia; Kishk, Omayma A; Custer, Jason W

    2017-06-01

    To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases. Quality improvement project with prospective observational analysis. Nineteen-bed PICU in an urban academic medical center. All consecutive patients admitted from December 1, 2013, to September 30, 2015. A multidisciplinary team implemented an ICU bundle consisting of three clinical protocols: delirium, sedation, and early mobilization using the Plan-Do-Study-Act cycles as part of a quality improvement project. The delirium protocol implemented in December 2013 consisted of universal screening with the Cornell Assessment of Pediatric Delirium revised instrument, prevention and treatment strategies, and case conferences. The sedation protocol and early mobilization protocol were implemented in October 2014 and June 2015, respectively. One thousand eight hundred seventy-five patients were screened using the Cornell Assessment of Pediatric Delirium revised tool. One hundred forty patients (17%) had delirium (having Cornell Assessment of Pediatric Delirium revised scores ≥ 9 for 48 hr or longer). Seventy-four percent of delirium positive patients were mechanically ventilated of which 46% were younger than 12 months and 59% had baseline developmental delays. Forty-one patients had emerging delirium (having one Cornell Assessment of Pediatric Delirium revised score ≥ 9). Statistical process control was used to evaluate the impact of three ICU bundle process changes on monthly delirium rates over a 22-month period. The delirium rate decreased with the implementation of each phase of the ICU bundle. Ten months after the delirium protocol was implemented, the mean delirium rate was 19.3%; after the sedation protocol and early mobilization protocols were implemented, the mean delirium rate was 11.84%. Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and

  17. Cerebrospinal fluid markers of neuroinflammation in delirium: A role for interleukin-1β in delirium after hip fracture

    PubMed Central

    Cape, Eleanor; Hall, Roanna J; van Munster, Barbara C; de Vries, Annick; Howie, Sarah EM; Pearson, Andrew; Middleton, Scott D; Gillies, Fiona; Armstrong, Ian R; White, Tim O; Cunningham, Colm; de Rooij, Sophia E; MacLullich, Alasdair MJ

    2014-01-01

    Objective Exaggerated central nervous system (CNS) inflammatory responses to peripheral stressors may be implicated in delirium. This study hypothesised that the IL-1β family is involved in delirium, predicting increased levels of interleukin-1β (IL-1β) and decreased IL-1 receptor antagonist (IL-1ra) in the cerebrospinal fluid (CSF) of elderly patients with acute hip fracture. We also hypothesised that Glial Fibrillary Acidic Protein (GFAP) and interferon-γ (IFN-γ) would be increased, and insulin-like growth factor 1 (IGF-1) would be decreased. Methods Participants with acute hip fracture aged > 60 (N = 43) were assessed for delirium before and 3–4 days after surgery. CSF samples were taken at induction of spinal anaesthesia. Enzyme-linked immunosorbent assays (ELISA) were used for protein concentrations. Results Prevalent delirium was diagnosed in eight patients and incident delirium in 17 patients. CSF IL-1β was higher in patients with incident delirium compared to never delirium (incident delirium 1.74 pg/ml (1.02–1.74) vs. prevalent 0.84 pg/ml (0.49–1.57) vs. never 0.66 pg/ml (0–1.02), Kruskal–Wallis p = 0.03). CSF:serum IL-1β ratios were higher in delirious than non-delirious patients. CSF IL-1ra was higher in prevalent delirium compared to incident delirium (prevalent delirium 70.75 pg/ml (65.63–73.01) vs. incident 31.06 pg/ml (28.12–35.15) vs. never 33.98 pg/ml (28.71–43.28), Kruskal–Wallis p = 0.04). GFAP was not increased in delirium. IFN-γ and IGF-1 were below the detection limit in CSF. Conclusion This study provides novel evidence of CNS inflammation involving the IL-1β family in delirium and suggests a rise in CSF IL-1β early in delirium pathogenesis. Future larger CSF studies should examine the role of CNS inflammation in delirium and its sequelae. PMID:25124807

  18. Delirium in intensive care: an under-diagnosed reality

    PubMed Central

    Faria, Rita da Silva Baptista; Moreno, Rui Paulo

    2013-01-01

    Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main risk factors, clinical manifestations and preventative and therapeutic approaches (pharmacological and non-pharmacological) for this illness. PMID:23917979

  19. Sarcoid meningitis with fulminant delirium and markedly abnormal cerebrospinal fluid.

    PubMed

    Noble, James M; Anderson, Christopher Todd; Etienne, Mill; Williams, Olajide; Adams, David J

    2007-01-01

    To describe a patient with an acute fulminant delirium and eventual spinal fluid block secondary to sarcoid meningitis. Case report. Hospital and Neurology Clinic. A previously healthy, 24-year-old man. Antimicrobials, corticosteroids, lumbar puncture, myelography, and lymph node biopsy. Cerebrospinal fluid, clinical status. The patient improved after treatment with corticosteroids. Sarcoid meningitis may present with delirium and spinal block.

  20. Cognitive Reserve and Postoperative Delirium in Older Adults.

    PubMed

    Tow, Amanda; Holtzer, Roee; Wang, Cuiling; Sharan, Alok; Kim, Sun Jin; Gladstein, Aharon; Blum, Yossef; Verghese, Joe

    2016-06-01

    To examine the role of cognitive reserve in reducing delirium incidence and severity in older adults undergoing surgery. Prospective cohort study. Hospital. Older adults (mean age 71.2, 65% women) undergoing elective orthopedic surgery (N = 142). Incidence (Confusion Assessment Method) and severity (Memorial Delirium Assessment Scale) of postoperative delirium were the primary outcomes. Predictors included early- (literacy) and late-life (cognitive activities) proxies for cognitive reserve. Forty-five participants (32%) developed delirium. Greater participation in cognitive activity was associated with lower incidence (odds ratio = 0.92 corresponding to increase of 1 activity per week, 95% confidence interval (CI) = 0.86-0.98, P = .006) and severity (B = -0.06, 95% CI = -0.11 to -0.01, P = .02) of delirium after adjustment for age, sex, medical illnesses, and baseline cognition. Greater literacy was not associated with lower delirium incidence or severity. Of individual leisure activities, reading books, using electronic mail, singing, and computer games were associated with lower dementia incidence and severity. Greater late-life cognitive reserve was associated with lower delirium incidence and severity in older adults undergoing surgery. Interventions to enhance cognitive reserve by initiating or increasing participation in cognitive activities may be explored as a delirium prophylaxis strategy. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  1. Increased neutrophil-lymphocyte ratio in delirium: a pilot study.

    PubMed

    Egberts, Angelique; Mattace-Raso, Francesco Us

    2017-01-01

    Delirium is a common and severe complication among older hospitalized patients. The pathophysiology is poorly understood, but it has been suggested that inflammation and oxidative stress may play a role. The aim of this pilot study was to investigate levels of the neutrophil-lymphocyte ratio (NLR) - a marker of systemic inflammation and oxidative stress - in patients with and without delirium. This pilot study was performed within a retrospective chart review study that included acutely ill patients, 65 years and older, who were admitted to the ward of geriatrics of the Erasmus University Medical Center. All patients in whom the differential white blood cell (WBC) counts as well as the C-reactive protein (CRP) level were determined within 24 h after admission were included in the present study. Differences in NLR between patients with and without delirium were investigated using univariate analysis of variance, with adjustments for age, sex, comorbidities, CRP level, and total WBC count. Eighty-six patients were included. Thirteen patients were diagnosed with delirium. In adjusted models, higher mean NLR values were found in patients with, than in those without, delirium (9.10 vs 5.18, P=0.003). In this pilot study, we found increased NLR levels in patients with delirium. This finding might suggest that an inadequate response of the immune system and oxidative stress may play a role in the pathogenesis of delirium. Further studies are needed to confirm the association between NLR and delirium.

  2. Mental Status Change in the Elderly: Recognizing and Treating Delirium.

    ERIC Educational Resources Information Center

    Morency, Catherine Reilly

    1990-01-01

    Discusses delirium and how it differs from other types of mental status changes seen in the elderly and what interventions are most appropriate in affected individuals. Presents data from a study regarding nursing assessment of patients with delirium and outlines an educational model. (JOW)

  3. Commentary: The Diagnosis of Delirium in Pediatric Patients

    ERIC Educational Resources Information Center

    Martini, D. Richard

    2005-01-01

    Pediatric patients seem to be especially vulnerable to toxic, metabolic, or traumatic CNS insults and are at greater risk of delirium with fever regardless of the etiology. Developmental limitations, in the areas of communication and cognition, prevent a thorough evaluation of the young patient for delirium. Only the most severe cases are…

  4. Mental Status Change in the Elderly: Recognizing and Treating Delirium.

    ERIC Educational Resources Information Center

    Morency, Catherine Reilly

    1990-01-01

    Discusses delirium and how it differs from other types of mental status changes seen in the elderly and what interventions are most appropriate in affected individuals. Presents data from a study regarding nursing assessment of patients with delirium and outlines an educational model. (JOW)

  5. Commentary: The Diagnosis of Delirium in Pediatric Patients

    ERIC Educational Resources Information Center

    Martini, D. Richard

    2005-01-01

    Pediatric patients seem to be especially vulnerable to toxic, metabolic, or traumatic CNS insults and are at greater risk of delirium with fever regardless of the etiology. Developmental limitations, in the areas of communication and cognition, prevent a thorough evaluation of the young patient for delirium. Only the most severe cases are…

  6. Diagnosing delirium in very elderly intensive care patients.

    PubMed

    Heriot, Natalie R; Levinson, Michele R; Mills, Amber C; Khine, Thinn Thinn; Gellie, Anthea L; Sritharan, Gaya

    2017-02-01

    To determine the incidence of delirium in elderly intensive care patients and to compare incidence using two retrospective chart-based diagnostic methods and a hospital reporting measure (ICD-10). Retrospective study. An ICU in a large metropolitan private hospital in Melbourne, Australia. English-speaking participants (n=348) 80+ years, admitted to ICU for >24 hours. Medical files of ICU patients admitted October 2009-October 2012 were retrospectively assessed for delirium using the Inouye chart review method, DSM-IV diagnostic criteria and ICD-10 coding data. General patient characteristics, first onset of delirium symptoms, source of delirium information, administration of delirium medication, hospital and ICU length of stay, 90 day mortality were documented. Delirium was found in 11-29% of patients, the highest incidence identified by chart review. Patients diagnosed with delirium had higher 90 day mortality, and those meeting criteria for all three methods had longer hospital and ICU length of stay. ICU delirium in the elderly is often under-reported and strategies are needed to improve staff education and diagnosis. Copyright © 2016 Elsevier Ltd. All rights reserved.

  7. Neopterin: a potential biomarker for delirium in elderly patients.

    PubMed

    Egberts, Angelique; Wijnbeld, Eline H A; Fekkes, Durk; van der Ploeg, Milly A; Ziere, Gijsbertus; Hooijkaas, Herbert; van der Cammen, Tischa J M; Mattace-Raso, Francesco U S

    2015-01-01

    The diagnosis of delirium is not supported by specific biomarkers. In a previous study, high neopterin levels were found in patients with a postoperative delirium. In the present study, we investigated levels of neopterin, interleukin-6 (IL-6) and insulin-like growth factor-1 (IGF-1) in acutely ill admitted elderly patients with and without a delirium. Plasma/serum levels of neopterin, IL-6 and IGF-1 were determined in patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics. Differences in biomarker levels between patients with and without a delirium were investigated by the analysis of variance in models adjusted for age, gender, comorbidities and eGFR (when appropriate). Eighty-six patients were included; 23 of them with a delirium. In adjusted models, higher mean levels of neopterin (70.5 vs. 45.9 nmol/l, p = 0.009) and IL-6 (43.1 vs. 18.5 pg/ml, p = 0.034) and lower mean levels of IGF-1 (6.3 vs. 9.3 nmol/l, p = 0.007) were found in patients with a delirium compared to those without. The findings of this study suggest that neopterin might be a potential biomarker for delirium which, through oxidative stress and activation of the immune system, may play a role in the pathophysiology of delirium. © 2014 S. Karger AG, Basel.

  8. Systemic Corticosteroids and Transition to Delirium in Critically Ill Patients.

    PubMed

    Wolters, Annemiek E; Veldhuijzen, Dieuwke S; Zaal, Irene J; Peelen, Linda M; van Dijk, Diederik; Devlin, John W; Slooter, Arjen J C

    2015-12-01

    Corticosteroids are frequently used in critically ill patients. We investigated whether systemic corticosteroid use increases the probability of transitioning to delirium in a large population of mixed medical-surgical ICU patients. Prospective cohort study. A 32-bed medical-surgical ICU at an academic medical center. Critically ill adults (n = 1,112), admitted to the ICU for more than 24 hours without a condition that could hamper delirium assessment. None. Systemic corticosteroid exposure was measured daily and converted to prednisone equivalents (milligrams). Daily mental status was classified as coma, delirium, or an awake without delirium state. Transitions between states were analyzed using a first-order Markov multinomial logistic regression model with 11 different covariables, with the transition from an awake without delirium state to delirium as a primary interest. Among the 1,112 patients, corticosteroids were administered on 35% (3,483/9,867) of the ICU days at a median dose of 50 mg (interquartile range, 25-75 mg) prednisone equivalent. Administration of a corticosteroid, and any increase in the dose of the corticosteroid given on exposure days, was not significantly associated with the transition to delirium (adjusted odds ratio, 1.08; 95% CI, 0.89-1.32 and adjusted odds ratio, 1.00; 95% CI, 0.99-1.01, per 10 mg increase in prednisone equivalent). In a large population of mixed medical-surgical ICU patients, systemic corticosteroid use was not associated with an increased probability of transitioning to delirium.

  9. Indian research on acute organic brain syndrome: Delirium

    PubMed Central

    Pinto, Charles

    2010-01-01

    Delirium, though quite often referred to psychiatrists for management, does not find many takers for analysis, research and publications. Acute in onset, multiplicity of etiology and manifestations, high risk of mortality delirium is very rewarding in proper management and outcome. Delirium has a limited agenda on teaching programs, research protocols and therapeutic strategies. There is a dearth of Indian studies both in international and national scientific literature. This annotation is based on a Medline search for “delirium India” on Pubmed, which resulted in 54 articles. A search in Indian Journal of Psychiatry for “delirium” resulted in 38 published articles, “delirium tremens” showed up only five articles. The articles are primarily from the Indian Journal of Psychiatry with cross reference to articles on Pubmed or Google search on Indian studies and a few international studies PMID:21836671

  10. The cause of delirium in patients with hip fracture.

    PubMed

    Brauer, C; Morrison, R S; Silberzweig, S B; Siu, A L

    2000-06-26

    To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture. Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached. The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge. Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.

  11. A multicomponent intervention to prevent delirium in hospitalized older patients.

    PubMed

    Inouye, S K; Bogardus, S T; Charpentier, P A; Leo-Summers, L; Acampora, D; Holford, T R; Cooney, L M

    1999-03-04

    Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment. The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the

  12. Association between sedating medications and delirium in older inpatients.

    PubMed

    Rothberg, Michael B; Herzig, Shoshana J; Pekow, Penelope S; Avrunin, Jill; Lagu, Tara; Lindenauer, Peter K

    2013-06-01

    To examine the association between Beers criteria sedative medications and delirium in a large cohort of hospitalized elderly adults with common medical conditions. Retrospective cohort and nested case-control studies. 374 U.S. hospitals. All individuals aged 65 and older admitted to the hospital between September 2003 and June 2005 with one of six principal diagnoses (acute myocardial infarction, chronic obstructive pulmonary disease, community-acquired pneumonia, congestive heart failure, ischemic stroke, urinary tract infection). Primary outcome was presumed hospital-acquired delirium, defined as initiation of an antipsychotic medication or restraints on hospital Day 3 or later. Logistic and proportional hazards regression were used to model the associations between sedative exposure and delirium. The dataset contained 225,028 participants (median age 82; 58% female). Four percent fit the definition of hospital-acquired delirium (median onset Day 5). In all, 38,883 (17%) participants received one or more sedative medications. In the cohort study, diphenhydramine (adjusted odds ratio (AOR) = 1.22, 95% confidence interval (CI) = 1.09-1.36) and short-acting benzodiazepines (AOR = 1.18, 95% CI = 1.03-1.34) were associated with greater risk of subsequent delirium. In the nested case-control study, diphenhydramine, short- and long-acting benzodiazepines and promethazine were associated with delirium. Amitriptyline and muscle relaxants were not associated with delirium in either study. Confounding by indication could not be excluded for drugs that are sometimes used improperly to treat delirium. An association was found between several Beers criteria sedative medications and delirium in hospitalized medical patients. Given the prevalence of these medications and the morbidity associated with delirium, further investigation into the appropriateness of such prescribing is warranted. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics

  13. New horizons in the pathogenesis, assessment and management of delirium

    PubMed Central

    Maclullich, Alasdair M. J.; Anand, Atul; Davis, Daniel H. J.; Jackson, Thomas; Barugh, Amanda J.; Hall, Roanna J.; Ferguson, Karen J.; Meagher, David J.; Cunningham, Colm

    2013-01-01

    Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues

  14. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion.

    PubMed

    Barr, Juliana; Pandharipande, Pratik P

    2013-09-01

    In 2013, the American College of Critical Care Medicine published a revised version of the pain, agitation, and delirium guidelines. The guidelines included an ICU pain, agitation, and delirium care bundle designed to facilitate implementation of the pain, agitation, and delirium guidelines. Review article. Multispecialty critical care units. Adult ICU patients. This article describes: 1) the ICU pain, agitation, and delirium care bundle in more detail, linking pain, sedation/agitation, and delirium management in an integrated and interdisciplinary fashion; 2) pain, agitation, and delirium implementation strategies; and 3) the potential synergistic benefits of linking pain, agitation, and delirium management strategies to other evidence-based ICU practices, including spontaneous breathing trials, ICU early mobility programs, and ICU sleep hygiene programs, in order to improve ICU patient outcomes and to reduce costs of care. Linking the ICU pain, agitation, and delirium management strategies with spontaneous awakening trials, spontaneous breathing trials, and early mobility and sleep hygiene programs is associated with significant improvements in ICU patient outcomes and reductions in their costs of care. The 2013 ICU pain, agitation, and delirium guidelines provide critical care providers with an evidence-based, integrated, and interdisciplinary approach to managing pain, agitation/sedation, and delirium. The ICU pain, agitation, and delirium care bundle provides a framework for facilitating implementation of the pain, agitation, and delirium guidelines. Widespread implementation of the ICU pain, agitation, and delirium care bundle is likely to result in large-scale improvements in ICU patient outcomes and significant reductions in costs.

  15. Evidence-Based Treatment of Delirium in Patients With Cancer

    PubMed Central

    Breitbart, William; Alici, Yesne

    2012-01-01

    Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium. PMID:22412123

  16. Evidence-based treatment of delirium in patients with cancer.

    PubMed

    Breitbart, William; Alici, Yesne

    2012-04-10

    Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

  17. Pharmacological Risk Factors for Delirium after Cardiac Surgery: A Review

    PubMed Central

    Tse, Lurdes; Schwarz, Stephan KW; Bowering, John B; Moore, Randell L; Burns, Kyle D; Richford, Carole M; Osborn, Jill A; Barr, Alasdair M

    2012-01-01

    Purpose: The objective of this review is to evaluate the literature on medications associated with delirium after cardiac surgery and potential prophylactic agents for preventing it. Source: Articles were searched in MEDLINE, Cumulative Index to Nursing and Allied Health, and EMBASE with the MeSH headings: delirium, cardiac surgical procedures, and risk factors, and the keywords: delirium, cardiac surgery, risk factors, and drugs. Principle inclusion criteria include having patient samples receiving cardiac procedures on cardiopulmonary bypass, and using DSM-IV-TR criteria or a standardized tool for the diagnosis of delirium. Principal Findings: Fifteen studies were reviewed. Two single drugs (intraoperative fentanyl and ketamine), and two classes of drugs (preoperative antipsychotics and postoperative inotropes) were identified in the literature as being independently associated with delirium after cardiac surgery. Another seven classes of drugs (preoperative antihypertensives, anticholinergics, antidepressants, benzodiazepines, opioids, and statins, and postoperative opioids) and three single drugs (intraoperative diazepam, and postoperative dexmedetomidine and rivastigmine) have mixed findings. One drug (risperidone) has been shown to prevent delirium when taken immediately upon awakening from cardiac surgery. None of these findings was replicated in the studies reviewed. Conclusion: These studies have shown that drugs taken perioperatively by cardiac surgery patients need to be considered in delirium risk management strategies. While medications with direct neurological actions are clearly important, this review has shown that specific cardiovascular drugs may also require attention. Future studies that are methodologically consistent are required to further validate these findings and improve their utility. PMID:23449337

  18. Predictive model for postoperative delirium in cardiac surgical patients.

    PubMed

    Afonso, Anoushka; Scurlock, Corey; Reich, David; Raikhelkar, Jayashree; Hossain, Sabera; Bodian, Carol; Krol, Marina; Flynn, Brigid

    2010-09-01

    Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.

  19. Educational interventions to improve recognition of delirium: a systematic review.

    PubMed

    Yanamadala, Mamata; Wieland, Darryl; Heflin, Mitchell T

    2013-11-01

    Delirium is a common and serious condition that is underrecognized in older adults in a variety of healthcare settings. It is poorly recognized because of deficiencies in provider knowledge and its atypical presentation. Early recognition of delirium is warranted to better manage the disease and prevent the adverse outcomes associated with it. The purpose of this article is to review the literature concerning educational interventions focusing on recognition of delirium. The Medline and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases were searched for studies with specific educational focus in the recognition of delirium, and 26 studies with various designs were identified. The types of interventions used were classified according to the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, and outcomes were sorted according to Kirkpatrick's hierarchy. Educational strategies combining predisposing, enabling, and reinforcing factors achieved better results than strategies that included one or two of these components. Studies using predisposing, enabling, and reinforcing strategies together were more often effective in producing changes in staff behavior and participant outcomes. Based on this review, improvements in knowledge and skill alone seem insufficient to favorably influence recognition of delirium. Educational interventions to recognize delirium are most effective when formal teaching is interactive and is combined with strategies including engaging leadership and using clinical pathways and assessment tools. The goal of the current study was to systematically review the published literature to determine the effect of educational interventions on recognition of delirium.

  20. Knowns and Unknowns About Delirium in Stroke: A Review.

    PubMed

    Klimiec, Elzbieta; Dziedzic, Tomasz; Kowalska, Katarzyna; Slowik, Agnieszka; Klimkowicz-Mrowiec, Aleksandra

    2016-12-01

    Delirium is a transient condition characterized by sudden and fluctuating disturbances in cognitive function. The condition can be considered a sign of the brain's vulnerability and diminished resilience to insult. Among the many clinical manifestations are cognitive, psychomotor, and sleep disturbances. Delirium is associated with longer hospital stays, worse functional outcomes, and higher mortality. Although up to 48% of patients who have had a stroke develop delirium, the condition has been studied much less in these patients than in general medicine, surgical, and intensive care patients. Coexisting neurologic deficits in patients with stroke limit the use of screening tools that are widely accepted in other populations. The variability of reported assessment methods highlights the need for delirium screening guidelines in stroke. Further, risk factors that are specific to stroke may play an important role in the etiology of delirium, along with such well-known factors as older age and infections. The delirium literature lacks data on differences in clinical manifestations and course in the various types of stroke. Here we review predisposing factors, diagnostic methods, and biomarkers of delirium in stroke and discuss aspects that need further research.

  1. Melatonin and melatonin agonist for delirium in the elderly patients.

    PubMed

    Chakraborti, Dwaipayan; Tampi, Deena J; Tampi, Rajesh R

    2015-03-01

    The objective of this review is to summarize the available data on the use of melatonin and melatonin agonist for the prevention and management of delirium in the elderly patients from randomized controlled trials (RCTs). A systematic search of 5 major databases PubMed, MEDLINE, PsychINFO, Embase, and Cochrane Library was conducted. This search yielded a total of 2 RCTs for melatonin. One study compared melatonin to midazolam, clonidine, and control groups for the prevention and management of delirium in individuals who were pre- and posthip post-hip arthroplasty. The other study compared melatonin to placebo for the prevention of delirium in older adults admitted to an inpatient internal medicine service. Data from these 2 studies indicate that melatonin may have some benefit in the prevention and management of delirium in older adults. However, there is no evidence that melatonin reduces the severity of delirium or has any effect on behaviors or functions in these individuals. Melatonin was well tolerated in these 2 studies. The search for a melatonin agonist for delirium in the elderly patients yielded 1 study of ramelteon. In this study, ramelteon was found to be beneficial in preventing delirium in medically ill individuals when compared to placebo. Ramelteon was well tolerated in this study.

  2. Detection of delirium in palliative care unit patients: a prospective descriptive study of the Delirium Observation Screening Scale administered by bedside nurses.

    PubMed

    Detroyer, Elke; Clement, Paul M; Baeten, Nele; Pennemans, Michèle; Decruyenaere, Marleen; Vandenberghe, Joris; Menten, Johan; Joosten, Etienne; Milisen, Koen

    2014-01-01

    The Delirium Observation Screening Scale (DOS) is designed to detect delirium by nurses' observations and has shown good psychometric properties. Its use in palliative care unit patients has not been studied. To determine diagnostic and concurrent validity, internal consistency, and user-friendliness of the Delirium Observation Screening Scale administered by bedside nurses in palliative care unit patients. In this descriptive study, psychometric properties of the Delirium Observation Screening Scale were tested by comparing the performance on the Delirium Observation Screening Scale (bedside nurses) to the algorithm of the Confusion Assessment Method and the Delirium Index (DI) (researchers). Paired observations were collected on three time points. Afterward, the user-friendliness of the Delirium Observation Screening Scale was determined by bedside nurses using a questionnaire. In total, 48 patients were recruited from one palliative care unit (PCU) of a university hospital. Of the 14 eligible bedside nurses of the palliative care unit, 10 participated in the study. Delirium was present in 22.9% of patients. Diagnostic validity of the Delirium Observation Screening Scale was very good (area under the curve = 0.933), with 81.8% sensitivity, 96.1% specificity, 69.2% positive, and 98% negative predictive value. Concurrent validity of the Delirium Observation Screening Scale with the Delirium Index was moderate (rSpearman = 0.53, p = 0.001). The Cronbach's alpha for all Delirium Observation Screening Scale shift scores was 0.772. Generally, bedside nurses experienced the Delirium Observation Screening Scale as user-friendly. However, most Delirium Observation Screening Scale items (n = 11/13 items) need verbally active patients to perform the observations correctly. The Delirium Observation Screening Scale can be used for delirium screening in verbally active palliative care unit patients. The scale was rated as easy to use and relevant. Further validation studies in

  3. Delirium after cardiac surgery: incidence and risk factors†

    PubMed Central

    Smulter, Nina; Lingehall, Helena Claesson; Gustafson, Yngve; Olofsson, Birgitta; Engström, Karl Gunnar

    2013-01-01

    OBJECTIVES 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. METHODS 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). RESULTS 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). CONCLUSIONS 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. PMID:23887126

  4. Statin and Its Association With Delirium in the Medical ICU.

    PubMed

    Mather, Jeffrey F; Corradi, John P; Waszynski, Christine; Noyes, Adam; Duan, Yinghui; Grady, James; Dicks, Robert

    2017-09-01

    To examine the association between statin use and the risk of delirium in hospitalized patients with an admission to the medical ICU. Retrospective propensity-matched cohort analysis with accrual from September 1, 2012, to September 30, 2015. Hartford Hospital, Hartford, CT. An initial population of patients with an admission to a medical ICU totaling 10,216 visits were screened for delirium by means of the Confusion Assessment Method. After exclusions, a population of 6,664 was used to match statin users and nonstatin users. The propensity-matched cohort resulted in a sample of 1,475 patients receiving statin matched 1:1 with control patients not using statin. None. Delirium defined as a positive Confusion Assessment Method assessment was the primary end point. The prevalence of delirium was 22.3% in the unmatched cohort and 22.8% in the propensity-matched cohort. Statin use was associated with a significant decrease in the risk of delirium (odds ratio, 0.47; 95% CI, 0.38-0.56). Considering the type of statin used, atorvastatin (0.51; 0.41-0.64), pravastatin (0.40; 0.28-0.58), and simvastatin (0.33; 0.21-0.52) were all significantly associated with a reduced frequency of delirium. The use of statins was independently associated with a reduction in the risk of delirium in hospitalized patients. When considering types of statins used, this reduction was significant in patients using atorvastatin, pravastatin, and simvastatin. Randomized trials of various statin types in hospitalized patients prone to delirium should validate their use in protection from delirium.

  5. Physicians vary in approaches to the clinical management of delirium.

    PubMed

    Carnes, Molly; Howell, Timothy; Rosenberg, Marjorie; Francis, Joseph; Hildebrand, Christopher; Knuppel, Jeffrey

    2003-02-01

    To ascertain the variation in strategies for managing delirium of physicians with expertise in geriatrics. Cross-sectional mail survey. United States. A probability sample of physician members of the American Geriatrics Society. Management choices presented in a two-part case vignette of an older woman hospitalized with a hip fracture who develops mild and then severe delirium. One hundred twenty-two respondents (43%) selected the three answers constituting current "best practice," 50 (18%) selected an unnecessary diagnostic test (brain imaging, lumbar puncture, or electroencephalogram), and 47 (17%) selected unnecessary pharmacologic therapy for mild delirium. For severe delirium, 270 (96%) selected pharmacological therapy, of whom 180 chose haloperidol alone, 55 chose lorazepam alone, 23 chose lorazepam in combination with haloperidol, and 12 wrote in another drug. Thirty percent of the respondents made any selection of lorazepam, alone or in combination with haloperidol, for mild or severe delirium. Sixty-one percent of those selecting haloperidol for severe delirium chose a dose greater than that recommended for geriatric patients. Sex, date of graduation from medical school, clinical specialty, completion of a geriatric fellowship, or certification in geriatrics had no significant effect on responses. The common selection of lorazepam to treat delirium is troubling because benzodiazepines themselves are implicated in delirium. Selection of an initial dose of haloperidol higher than that recommended for geriatric patients by more than half of the respondents is also of concern. There is a paucity of sound clinical evidence to guide the choice of pharmacological agents for treating delirium in older hospitalized patients.

  6. Cognitive stimulation and occupational therapy for delirium prevention

    PubMed Central

    Tobar, Eduardo; Alvarez, Evelyn; Garrido, Maricel

    2017-01-01

    Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

  7. Delirium prevention for cognitive, sensory, and mobility impairments.

    PubMed

    Robinson, Sherry; Rich, Catherine; Weitzel, Tina; Vollmer, Charlene; Eden, Brenda

    2008-01-01

    The purpose of this study was to determine the effectiveness of a protocol designed to prevent delirium in hospitalized elders with the risk factors of dementia and/or vision, hearing, and/or mobility impairments. A group of 80 patients with risk factors hospitalized before the protocol was implemented was matched with a group of 80 patients admitted after the implementation of the protocol. Records of patients in both groups were reviewed to identify patients with delirium. A significant reduction in delirium, from 37.5% to 13.8%, occurred in the elders receiving the protocol.

  8. Rates of Delirium Diagnosis Do Not Improve with Emergency Risk Screening: Results of the Emergency Department Delirium Initiative Trial.

    PubMed

    Arendts, Glenn; Love, Jennefer; Nagree, Yusuf; Bruce, David; Hare, Malcolm; Dey, Ian

    2017-08-01

    To determine whether a bundled risk screening and warning or action card system improves formal delirium diagnosis and person-centered outcomes in hospitalized older adults. Prospective trial with sequential introduction of screening and interventional processes. Two tertiary referral hospitals in Australia. Individuals aged 65 and older presenting to the emergency department (ED) and not requiring immediate resuscitation (N = 3,905). Formal ED delirium screening algorithm and use of a risk warning card with a recommended series of actions for the prevention and management of delirium during the subsequent admission MEASUREMENTS: Delirium diagnosis at hospital discharge, proportion discharged to new assisted living arrangements, in-hospital complications (use of sedation, falls, aspiration pneumonia, death), hospital length of stay. Participants with a positive risk screen were significantly more likely (relative risk = 6.0, 95% confidence interval = 4.9-7.3) to develop delirium, and the proportion of at-risk participants with a positive screen was constant across three study phases. Delirium detection rate in participants undergoing the final intervention (Phase 3) was 12.1% (a 2% absolute and 17% relative increase from the baseline rate) but this was not statistically significant (P = .29), and a similar relative increase was seen over time in participants not receiving the intervention CONCLUSION: A risk screening and warning or action card intervention in the ED did not significantly improve rates of delirium detection or other important outcomes. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  9. Inter-professional delirium education and care: a qualitative feasibility study of implementing a delirium Smartphone application.

    PubMed

    Zhang, Melvyn; Bingham, Kathleen; Kantarovich, Karin; Laidlaw, Jennifer; Urbach, David; Sockalingam, Sanjeev; Ho, Roger

    2016-04-30

    Delirium is a common medical condition with a high prevalence in hospital settings. Effective delirium management requires a multi-component intervention, including the use of Interprofessional teams and evidence-based interventions at the point of care. One vehicle for increasing access of delirium practice tools at the point of care is E-health. There has been a paucity of studies describing the implementation of delirium related clinical application. The purpose of this current study is to acquire users' perceptions of the utility, feasibility and effectiveness of a smartphone application for delirium care in a general surgery unit. In addition, the authors aimed to elucidate the potential challenges with implementing this application. This quantitative study was conducted between January 2015 and June 2015 at the University Health Network, Toronto General Hospital site. Participants met inclusion criteria if they were clinical staff on the General Surgery Unit at the Toronto General Hospital site and had experience caring for patients with delirium. At the conclusion of the 4 weeks after the implementation of the intervention, participants were invited by email to participate in a focus group to discuss their perspectives related to using the delirium application Our findings identified several themes related to the implementation and use of this smartphone application in an acute care clinical setting. These themes will provide clinicians preparing to use a smartphone application to support delirium care with an implementation framework. This study is one of the first to demonstrate the potential utility of a smartphone application for delirium inter-professional education. While this technology does appeal to healthcare professionals, it is important to note potential implementation challenges. Our findings provide insights into these potential barriers and can be used to assist healthcare professionals considering the development and use of an inter

  10. Gabapentin-induced delirium and dependence.

    PubMed

    Kruszewski, Stefan P; Paczynski, Richard P; Kahn, David A

    2009-07-01

    Gabapentin (Neurontin) is approved by the US Food and Drug Administration for treatment of epilepsy and post-herpetic neuralgia. Despite lack of strong evidence, gabapentin is also often prescribed off-label for psychiatric conditions. The case described here involved a 38-year-old male physician with substance intoxication delirium and psychoactive substance dependence due to high self-administered doses of gabapentin, which had been prescribed at lower doses in combination with buspirone and bupropion for depression and anxiety. This unusual case of gabapentin dependence and abuse involved toxic delirium, intense cravings, and a prolonged post-withdrawal confusional state reminiscent of benzodiazepine withdrawal. Gabapentin is a central nervous system inhibitory agent with likely gamma-aminobutyric acid (GABA)-ergic and non-GABAergic mechanisms of action. The similarity between benzodiazepine withdrawal and what this patient experienced with gabapentin suggests a common role for GABA-related effects. The case reported here suggests the need for heightened concern regarding the off-label prescription of this drug to vulnerable individuals with psychiatric conditions.

  11. [Cerebral vasculitis with delirium in neurosyphyllis].

    PubMed

    Sextro, F; Erceg, J; Hamann, G F

    2014-02-01

    In a 40-year-old man with delirium, right-sided facial palsy and anisocoria (right > left) were noticed. He had been suffering from headaches for four weeks prior to admission. The patient's HI-virus status was positive and he used illicit drugs regularly. Therefore, the symptoms were initially thought to be drug-induced. EXAMINATION AND DIAGNOSIS: Laboratory tests showed a pleocytosis of the cerebrospinal fluid (CSF) with 929 cells/µl. The MRI of the brain revealed several ischemic strokes in the territories of the middle cerebral artery and posterior cerebral artery in the left hemisphere. A highly positive IgG CSF/serum index confirmed the diagnosis of neurosyphilis. An antibiotic regime with penicillin was administered, during which the clinical symptoms remitted and the liquor pleocytosis nearly normalized. The intracranial stenoses persisted for three months even after therapy with nimodipine, atorvastatin, and antibiotics. Therefore they are presumed to be a result of the lues-associated vasculitis. In patients with delirium the initially suspected underlying condition needs to be challenged. Early cerebral MRI, lumbar puncture and ultrasound of the cerebral arteries are mandatory to exclude menigoencephalitis. © Georg Thieme Verlag KG Stuttgart · New York.

  12. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool.

    PubMed

    Bellelli, Giuseppe; Morandi, Alessandro; Di Santo, Simona G; Mazzone, Andrea; Cherubini, Antonio; Mossello, Enrico; Bo, Mario; Bianchetti, Angelo; Rozzini, Renzo; Zanetti, Ermellina; Musicco, Massimo; Ferrari, Alberto; Ferrara, Nicola; Trabucchi, Marco

    2016-07-18

    To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission

  13. [Delirium prevention and treatment in elderly hip fracture].

    PubMed

    Robles, María José; Formiga, Francesc; Vidán, M Teresa

    2014-04-22

    The fracture of the proximal femur or hip fracture in the elderly usually happens after a fall and carries a high morbidity and mortality. One of the most common complications during hospitalization for hip fracture is the onset of delirium or acute confusional state that in elderly patients has a negative impact on the hospital stay, and prognosis, worsening functional ability, cognitive status and mortality. Also the development of delirium during hospitalization increases health care costs. Strategies to prevent and treat delirium during hospitalization for hip fracture have been less studied. In this context, this paper aims to conduct a review of the literature on strategies that exist in the prevention and treatment of delirium in elderly patients with hip fracture. Copyright © 2013 Elsevier España, S.L. All rights reserved.

  14. Predisposing and precipitating factors for delirium in hospitalized older patients.

    PubMed

    Inouye, S K

    1999-01-01

    Delirium is a common and serious problem for older hospitalized patients. This investigation proposes a multifactorial model of delirium etiology, involving a complex interrelationship of predisposing (vulnerability) factors and precipitating factors (acute insults). An overview of risk factors for delirium identified in 14 studies published since 1980 is provided. Although these studies identify key risk factors for delirium, they do not allow the examination of the interrelationship of predisposing and precipitating factors. Thus, we present two prospective cohort studies by our group which empirically examine: (1) predisposing (vulnerability) factors, (2) precipitating factors, and (3) the interrelationship of predisposing and precipitating factors. Understanding these risk factors is the key to developing appropriate preventive strategies and to target intermediate and high risk patients for intervention efforts.

  15. Delirium in Parkinson’s Disease: A Cocktail Diagnosis

    PubMed Central

    2016-01-01

    Mental disturbances have been described in patients with Parkinson’s Disease (PD). Of these, the common conditions are delirium and psychosis. Delirium has been attributed to change of environment, especially hospital stay and infections; while psychosis is due to drugs like dopamine agonists. This is a case of a 75-year-old male, on levodopa therapy for PD, who presented with delirium and ended up with a cocktail diagnosis: Cryptococcal meningitis, Hashimoto’s Encephalopathy (HE), Urinary tract infection with acute renal failure, Uremic encephalopathy and Levodopa induced psychosis. This case report, therefore, highlights the need to look for other causes of delirium in a patient with PD who is on levodopa therapy. PMID:28208916

  16. Delirium: a cause for concern beyond the immediate postoperative period.

    PubMed

    Martin, Billie-Jean; Buth, Karen J; Arora, Rakesh C; Baskett, Roger J F

    2012-04-01

    Delirium is a common neurologic complication after cardiac surgery, and may be associated with increased morbidity and mortality. Research has focused on potential causes of delirium, with little attention to its sequelae. Perioperative data were collected prospectively on all isolated cases of coronary artery bypass grafting (CABG) performed from 1995 to 2006 at a single center. The definition of delirium used in the study was that of the Society of Thoracic Surgeons. Characteristics of patients who became delirious postoperatively were compared with those of patients who did not. The outcomes of interest were long-term all-cause mortality, hospital admission for stroke, and in-hospital mortality, examined in all three cases through multivariate analysis. Of 8,474 patients who underwent CABG within the defined period, 496 (5.8%) developed postoperative delirium and 229 (2.7%) died while in the hospital. At baseline, patients who developed delirium were more likely to be older and to have a greater burden of comorbid illness. Delirium was an independent predictor of perioperative stroke (odds ratio [OR]; 1.96; 95% confidence interval [CI], 1.22 to 3.16), but was not associated with in-hospital mortality (OR, 0.81; 95%CI, 0.49 to 1.34). Delirious patients had a median postoperative hospital stay of 12 days (interquartile range [IQR], 8 to 21 days) versus 6 days (IQR, 5 to 8 days) for those who were nondelirious. Delirium was identified as an independent predictor of all-cause mortality (hazard ratio [HR], 1.52; 95%CI, 1.29 to 1.78) and hospitalization for stroke (HR, 1.54; 95%CI, 1.10 to 2.17). There was an association between delirium and adverse outcomes after CABG that persisted beyond the immediate perioperative period. Patients with delirium after CABG appear to have an increased long-term risk of death and stroke. The advancing age and rising rates of delirium in the CABG population make it necessary to address the prevention and management of delirium in this

  17. Delirium after a traumatic brain injury: predictors and symptom patterns

    PubMed Central

    Maneewong, Jutaporn; Maneeton, Benchalak; Maneeton, Narong; Vaniyapong, Tanat; Traisathit, Patrinee; Sricharoen, Natthanidnan; Srisurapanont, Manit

    2017-01-01

    Background Delirium in traumatic brain injury (TBI) is common, may be predictable, and has a multifaceted symptom complex. This study aimed to examine: 1) the sum score of Glasgow Coma Scale (GCS) and if its component scores could predict delirium in TBI patients, and 2) the prominent symptoms and their courses over the first days after TBI. Methods TBI patients were recruited from neurosurgical ward inpatients. All participants were hospitalized within 24 hours after their TBI. Apart from the sum score of GCS, which was obtained at the emergency department (ED), the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria for delirium were applied daily. The severity of delirium symptoms was assessed daily using the Delirium Rating Scale – Revised-98 (DRS-R-98). Results The participants were 54 TBI patients with a mean GCS score of 12.7 (standard deviation [SD] =2.9). A total of 25 patients (46.3%) met the diagnosis of delirium and had a mean age of 36.7 years (SD =14.8). Compared with 29 non-delirious patients, 25 delirious patients had a significantly lower mean GCS score (P=0.04), especially a significantly lower verbal component score (P=0.03). Among 18 delirious patients, four symptoms of the DRS-R-98 cognitive domain (orientation, attention, long-term memory, and visuospatial ability) were moderate symptoms (score ≥2) at the first day of admission. After follow-up, three cognitive (orientation, attention, and visuospatial ability) and two noncognitive symptoms (lability of affect and motor agitation) rapidly resolved. Conclusion Almost half of patients with mild to moderate head injuries may develop delirium in the first 4 days after TBI. Those having a low GCS score, especially the verbal component score, at the ED were likely to have delirium in this period. Most cognitive domains of delirium described in the DRS-R-98 were prominent within the first 4 days of TBI with delirium. Three cognitive and two noncognitive

  18. Incidence and predictive factors of delirium in hospitalised neurological patients.

    PubMed

    Ruiz Bajo, B; Roche Bueno, J C; Seral Moral, M; Martín Martínez, J

    2013-01-01

    Delirium is a condition with a high prevalence in hospitalised patients (10%-30%), and it has important prognostic implications. There are few prospective studies of the incidence of delirium in Spain, and most of these were carried out in surgical wards or intensive care units. Our objective is to calculate the incidence of delirium in a neurological department and describe characteristics of affected patients. Longitudinal descriptive study including all patients admitted to the neurology department in an 8-week period. The CAM score for diagnosing delirium was recorded on the first, second and fifth day of hospitalisation and we recorded demographic data, medical history, analytical data (including inflammatory markers), use of anticholinergic treatments, cognitive and functional state at admission, reason for admission, length of stay, and other events during hospitalisation. We studied 115 patients and found an incidence of delirium of 16.52%. There was a significant correlation between delirium and age, cognitive state at admission according to the Pfeiffer test, functional situation at admission according to the Canadian Neurological Scale, kidney failure, history of stroke, anticholinergic treatment, erythrocyte sedimentation rate, and C-reactive protein. These patients were also hospitalised for longer periods of time. These results confirm a high incidence of delirium in our geographical area. Although additional studies with larger samples are needed, we would like to emphasise the importance of several risk factors which may enable early detection of patients who are at risk for developing delirium during hospitalisation. This would permit preventive action and early treatment for these patients. Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.

  19. Delirium in elderly patients: association with educational attainment.

    PubMed

    Martins, Sónia; Paiva, José Artur; Simões, Mário R; Fernandes, Lia

    2017-04-01

    Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium. The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment. The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12-0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62-0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20-9.33; p=0.020), after controlling for age and medication. Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.

  20. Agitation, Delirium, and Cognitive Outcomes in Intracerebral Hemorrhage.

    PubMed

    Rosenthal, Lisa J; Francis, Brandon A; Beaumont, Jennifer L; Cella, David; Berman, Michael D; Maas, Matthew B; Liotta, Eric M; Askew, Robert; Naidech, Andrew M

    Delirium predicts higher long-term cognitive morbidity. We previously identified a cohort of patients with spontaneous intracerebral hemorrhage and delirium and found worse outcomes in health-related quality of life (HRQoL) in the domain of cognitive function. We tested the hypothesis that agitation would have additional prognostic significance on later cognitive function HRQoL. Prospective identification of 174 patients with acute intracerebral hemorrhage, measuring stroke severity, agitation, and delirium, with a standardized protocol and measures. HRQoL was assessed using the Neuro-QOL at 28 days, 3 months, and 1 year. Functional outcomes were measured with the modified Rankin Scale. Among the 81 patients with HRQoL follow-up data available, patients who had agitation and delirium had worse cognitive function HRQoL scores at 28 days (T scores for delirium with agitation 20.9 ± 7.3, delirium without agitation 30.4 ± 16.5, agitation without delirium 36.6 ± 17.5, and neither agitated nor delirious 40.3 ± 15.9; p = 0.03) and at 1 year (p = 0.006). The effect persisted in mixed models after correction for severity of neurologic injury, age, and time of assessment (p = 0.0006) and was not associated with medication use, seizures, or infection. The presence of agitation with delirium in patients with intracerebral hemorrhage may predict higher risk of unfavorable cognitive outcomes up to 1 year later. Copyright © 2017 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

  1. Delirium in acute promyelocytic leukemia patients: two case reports

    PubMed Central

    2013-01-01

    Background Delirium is a frequently misdiagnosed and inadequately treated neuropsychiatric complication most commonly observed in terminally ill cancer patients. To our knowledge this is the first report describing delirium in two patients aged less than 60 years and enrolled in an intensive chemotherapeutic protocol for acute promyelocytic leukemia. Case presentation Two female Caucasian acute promyelocytic leukemia patients aged 46 and 56 years developed delirium during their induction treatment with all-trans retinoic acid and idarubicin. In both cases symptoms were initially attributed to all-trans retinoic acid that was therefore immediately suspended. In these two patients several situations may have contribute to the delirium: in patient 1 a previous psychiatric disorder, concomitant treatments with steroids and benzodiazepines, a severe infection and central nervous system bleeding while in patient 2 steroid treatment and isolation. In patient 1 delirium was treated with short-term low-doses of haloperidol while in patient 2 non-pharmacologic interventions had a beneficial role. When the diagnosis of delirium was clear, induction treatment was resumed and both patients completed their therapeutic program without any relapse of the psychiatric symptoms. Both patients are alive and in complete remission as far as their leukemia is concerned. Conclusions We suggest that patients with acute promyelocytic leukemia eligible to intensive chemotherapy should be carefully evaluated by a multisciplinary team including psychiatrists in order to early recognize symptoms of delirium and avoid inadequate treatments. In case of delirium, both pharmacologic and non-pharmacologic interventions may be considered. PMID:24237998

  2. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium.

    PubMed

    Flaherty, Joseph H; Little, Milta O

    2011-11-01

    Delirium is associated with several negative outcomes and is not always preventable. Current practices for the management of older hospitalized adults with delirium, such as one-on-one sitters, antipsychotic medications, and physical restraints, have limited effectiveness or potential health risks. An alternative management model, called the Delirium Room (DR), is a four-bed patient room (within an Acute Care for Elders (ACE) Unit) that provides 24-hour nursing care, emphasizes nonpharmacological approaches, and is completely free of physical restraints. This article is based on 13 years of experience at two hospitals. The authors have found that a restraint-free environment can be achieved; "tolerate, anticipate, and don't agitate" (the T-A-DA method) are the core principles of the nonpharmacological approach that go beyond the traditional strategies of management (such as reorientation); based on observational data, it appears that negative outcomes associated with delirium, such as loss of function, longer hospital stay, and greater mortality, can be decreased to levels seen in individuals without delirium; and based on limited data, it appears that the rate of falls is at least not higher in the DR than in the ACE unit overall. The limitations of the DR model include lack of randomized controlled trials and the inability to determine which component of the model provides its benefits. © 2011, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.

  3. Assessment of Delirium in Intensive Care Unit Patients: Educational Strategies.

    PubMed

    Smith, Judith M; Van Aman, M Nancy; Schneiderhahn, Mary Elizabeth; Edelman, Robin; Ercole, Patrick M

    2017-05-01

    Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. Participants (N = 34) showed a significant increase (p < .001) in confidence in their ability to assess and manage delirium following the multimodal education. No statistical change in knowledge of delirium existed following the education. A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244. Copyright 2017, SLACK Incorporated.

  4. Ethical Challenges and Solutions Regarding Delirium Studies in Palliative Care

    PubMed Central

    Sweet, Lisa; Adamis, Dimitrios; Meagher, David; Davis, Daniel; Currow, David; Bush, Shirley H.; Barnes, Christopher; Hartwick, Michael; Agar, Meera; Simon, Jessica; Breitbart, William; MacDonald, Neil; Lawlor, Peter G.

    2014-01-01

    Context Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges. Objectives Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients. Methods Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines. Results Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models. Conclusion Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC. PMID:24388124

  5. Antipsychotic-induced akathisia in delirium: A systematic review.

    PubMed

    Forcen, Fernando Espi; Matsoukas, Konstantina; Alici, Yesne

    2016-02-01

    Akathisia is a neuropsychiatric syndrome characterized by subjective and objective restlessness. It is a common side effect in patients taking antipsychotics and other psychotropics. Patients with delirium are frequently treated with antipsychotic medications that are well known to induce akathisia as a side effect. However, the prevalence, phenomenology, and management of akathisia in patients with delirium remain largely unknown. The purpose of this review was to examine the medical literature in order to establish the current state of knowledge regarding the prevalence of antipsychotic-induced akathisia in patients with delirium. A systematic review of the literature was conducted using the EMBASE, MEDLINE, PsycINFO, and CINAHL databases. Ten studies addressing the incidence of akathisia in patients taking antipsychotic medication for delirium were identified and included in our review. The included studies reported a variable prevalence of antipsychotic-induced akathisia. A higher prevalence was found in patients taking haloperidol. Among atypical antipsychotics, paliperidone and ziprasidone were associated with a higher risk of akathisia. The risk for akathisia appeared to be a dose-related phenomenon. Studies using specific scales for evaluation of akathisia in delirium are lacking. Some populations, such as patients with cancer or terminally ill patients in palliative care settings taking antipsychotics for the treatment of delirium, could be at higher risk for development of akathisia as a side effect.

  6. Antipsychotic-induced akathisia in delirium: A systematic review

    PubMed Central

    FORCEN, FERNANDO ESPI; MATSOUKAS, KONSTANTINA; ALICI, YESNE

    2017-01-01

    Objective Akathisia is a neuropsychiatric syndrome characterized by subjective and objective restlessness. It is a common side effect in patients taking antipsychotics and other psychotropics. Patients with delirium are frequently treated with antipsychotic medications that are well known to induce akathisia as a side effect. However, the prevalence, phenomenology, and management of akathisia in patients with delirium remain largely unknown. The purpose of this review was to examine the medical literature in order to establish the current state of knowledge regarding the prevalence of antipsychotic-induced akathisia in patients with delirium. Method A systematic review of the literature was conducted using the EMBASE, MEDLINE, PsycINFO, and CINAHL databases. Some 10 studies addressing the incidence of akathisia in patients taking antipsychotic medication for delirium were identified and included in our review. Results The included studies reported a variable prevalence of antipsychotic-induced akathisia. A higher prevalence was found in patients taking haloperidol. Among atypical antipsychotics, paliperidone and ziprasidone were associated with a higher risk of akathisia. The risk for akathisia appeared to be a dose-related phenomenon. Significance of results Studies using specific scales for evaluation of akathisia in delirium are lacking. Some populations, such as patients with cancer or terminally ill patients in palliative care settings taking antipsychotics for the treatment of delirium, could be at higher risk for development of akathisia as a side effect. PMID:26087817

  7. Epidemiology and risk factors for delirium across hospital settings

    PubMed Central

    Vasilevskis, Eduard E.; Han, Jin H.; Hughes, Christopher G.; Ely, E. Wesley

    2013-01-01

    Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols. PMID:23040281

  8. Emergency Department Stay Associated Delirium in Older Patients*

    PubMed Central

    Émond, Marcel; Grenier, David; Morin, Jacques; Eagles, Debra; Boucher, Valérie; Le Sage, Natalie; Mercier, Éric; Voyer, Philippe; Lee, Jacques S.

    2017-01-01

    Background Caring for older patients can be challenging in the Emergency Department (ED). A > 12 hr ED stay could lead to incident episodes of delirium in those patients. The aim of this study was to assess the incidence and impacts of ED-stay associated delirium. Methods A historical cohort of patients who presented to a Canadian ED in 2009 and 2011 was randomly constituted. Included patients were aged ≥ 65 years old, admitted to any hospital ward, non-delirious upon arrival and had at least a 12-hour ED stay. Delirium was detected using a modified chart-based Confusion Assessment Method (CAM) tool. Hospital length of stay (LOS) was log-transformed and linear regression assessed differences between groups. Adjustments were made for age and comorbidity profile. Results 200 records were reviewed, 55.5% were female, median age was 78.9 yrs (SD:7.3). 36(18%) patients experienced ED-stay associated delirium. Nearly 50% of episodes started in the ED and within 36 hours of arrival. Comorbidity profile was similar between the positive CAM group and the negative CAM group. Mean adjusted hospital LOS were 20.5 days and 11.9 days respectively (p<.03). Conclusions 1 older adult out of 5 became delirious after a 12 hr ED stay. Since delirium increases hospital LOS by more than a week, better screening and implementation of preventing measures for delirium could reduce LOS and overcrowding in the ED. PMID:28396704

  9. Brief assessment of delirium subtypes: Psychometric evaluation of the Delirium Motor Subtype Scale (DMSS)-4 in the intensive care setting.

    PubMed

    Boettger, Soenke; Nuñez, David Garcia; Meyer, Rafael; Richter, Andre; Schubert, Maria; Meagher, David; Jenewein, Josef

    2017-10-01

    The management of and prognosis for delirium are affected by its subtype: hypoactive, hyperactive, mixed, and none. The DMSS-4, an abbreviated version of the Delirium Motor Symptom Scale, is a brief instrument for the assessment of delirium subtypes. However, it has not yet been evaluated in an intensive care setting. We performed a prospective/descriptive cohort study in order to determine the internal consistency, reliability, and validity of the relevant items of the DMSS-4 versus the Delirium Rating Scale-Revised-98 (DRS-R-98) and the original DMSS in a surgical intensive care setting. A total of 289 elderly, predominantly male patients were screened for delirium, and 122 were included in our sample. The internal consistency of the DMSS-4 items was excellent (Cronbach's α = 0.92), and between the DMSS-4 and DRS-R-98 the overall concurrent validity was substantial (Cramer's V = 0.67). Within individual motor subtypes, concurrent validity remained at least substantial (Cohen's κ = 0.65-0.81) and sensitivity high (69.8 to 82.2%), in contrast to those of the no-motor subtype, with less validity and sensitivity (κ = 0.28, 22%). Similarly, total concurrent validity between the DMSS-4 and the original DMSS reached perfection (Cramer's V = 0.83), as did agreement between the subtypes (κ = 0.83-0.92), while sensitivity remained high (88.2-100%). Only in those with delirium with no-motor subtype was agreement moderate (κ = 0.56) and sensitivity lower (67%). Specificity was high across all subtypes (91.2-99.1%). The DMSS-4 yielded very sensitive ratings, particularly for hypoactive and hyperactive motor symptoms, and interrater agreement was excellent (Fleiss's κ = 0.83). We found the DMSS-4 to be a most reliable and valid brief assessment of delirium in characterizing the subtypes of delirium in an intensive care setting, with increased sensitivity to hypoactive and hyperactive motor alterations.

  10. Variability of Delirium Motor Subtype Scale-Defined Delirium Motor Subtypes in Elderly Adults with Hip Fracture: A Longitudinal Study.

    PubMed

    Scholtens, Rikie M; van Munster, Barbara C; Adamis, Dimitrios; de Jonghe, Annemarieke; Meagher, David J; de Rooij, Sophia E J A

    2017-02-01

    To examine changes in motor subtype profile in individuals with delirium. Observational, longitudinal study; substudy of a multicenter, randomized controlled trial. Departments of surgery and orthopedics, Academic Medical Center and Tergooi Hospital, the Netherlands. Elderly adults acutely admitted for hip fracture surgery who developed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for 2 days or longer (n = 76, aged 86.4 ± 6.1, 68.4% female). Delirium Motor Subtype Scale (DMSS), Delirium Rating Scale R98 (DRS-R98), comorbidity, and function. Median delirium duration was 3 days (interquartile range 2.0 days). At first assessment, the hyperactive motor subtype was most common (44.7%), followed by hypoactive motor subtype (28.9%), mixed motor subtype (19.7%), and no motor subtype (6.6%). Participants with no motor subtype had lower DRS-R98 scores than those with the other subtypes (P < .001). The DMSS-defined motor subtype of 47 (61.8%) participants changed over time. Katz Index of Activities of Daily Living, Charlson Comorbidity Index, cognitive impairment, age, sex, and delirium duration or severity were not associated with change in motor subtype. Motor subtype profile was variable in the majority of participants, although changes that occurred were often related to changes from or to no motor subtype, suggesting evolving or resolving delirium. Changes appeared not be associated with demographic or clinical characteristics, suggesting that evidence from cross-sectional studies of motor subtypes could be applied to many individuals with delirium. Further longitudinal studies should be performed to clarify the stability of motor subtypes in different clinical populations. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  11. Stop. Think. Delirium! A quality improvement initiative to explore utilising a validated cognitive assessment tool in the acute inpatient medical setting to detect delirium and prompt early intervention.

    PubMed

    Malik, Angela; Harlan, Todd; Cobb, Janice

    2016-11-01

    The paper examines the ability of nursing staff to detect delirium and apply early intervention to decrease adverse events associated with delirium. To characterise nursing practices associated with staff knowledge, delirium screening utilising the Modified Richmond Assessment Sedation Score (mRASS), and multicomponent interventions in an acute inpatient medical unit. Delirium incidence rates are up to 60% in frail elderly hospitalised patients. Under-recognition and inconsistent management of delirium is an international problem. Falls, restraints, and increased hospital length of stay are linked to delirium. A descriptive study. Exploration of relationships between cause and effect among cognitive screening, knowledge assessment and interventions. Success in identifying sufficient cases of delirium was not evident; however, multicomponent interventions were applied to patients with obvious symptoms. An increase in nursing knowledge was demonstrated after additional training. Delirium screening occurred in 49-61% of the target population monthly, with challenges in compliance and documentation of screening and interventions. Technological capabilities for trending mRASS results do not exist within the current computerised patient record system. Delirium screening increases awareness of nursing staff, prompting more emphasis on early intervention in apparent symptoms. Technological support is needed to effectively document and visualise trends in screening results. The study imparts future research on the effects of cognitive screening on delirium prevention and reduction in adverse patient outcomes. Evidence-based literature reveals negative patient outcomes associated with delirium. However, delirium is highly under-recognised indicating future research is needed to address nursing awareness and recognition of delirium. Additional education and knowledge transformation from research to nursing practice are paramount in the application of innovative strategies

  12. Review article: terminal delirium in geriatric patients with cancer at end of life.

    PubMed

    Moyer, Deborah D

    2011-02-01

    Terminal delirium is a common symptom that is frequently underdiagnosed in geriatric patients with cancer at end of life and is a major cause of distress for the patient as well as their family. This article explores the hyperactive and hypoactive delirium subtypes as well as the pathophysiology of terminal delirium and the theory of acetylcholine deficiency and dopamine excess. The causes for terminal delirium underdiagnosis as well as the causes of terminal delirium itself are identified. The use of the Confusion Assessment Method (CAM) is discussed as a means of delirium diagnosis and the Memorial Delirium Assessment scale (MDAS) is presented as a tool to measure its severity. Lastly, nonpharmacologic and pharmacologic treatment measures are reviewed and an algorithm is presented to assist the clinician in the identification and management of terminal delirium.

  13. Delirium epidemiology in critical care (DECCA): an international study

    PubMed Central

    2010-01-01

    Introduction Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU. Methods A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain. Results In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%). Conclusions In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam). PMID:21092264

  14. Delirium during acute illness in nursing home residents.

    PubMed

    Boockvar, Kenneth; Signor, Daniel; Ramaswamy, Ravishankar; Hung, William

    2013-09-01

    To ascertain the incidence of delirium during acute illness in nursing home residents, describe the timing of delirium after acute illness onset, describe risk factors for delirium, and explore the relationship between delirium and complications of acute illness. Prospective observational cohort study. Three nursing homes in metropolitan New York. Individuals who were expected to remain in the nursing home for at least 2 months, who, as part of a parent study, were receiving opioids, antidepressants, or antipsychotics on a routine basis, and who did not have an acute medical illness at the time of screening. Acute illness surveillance was performed twice weekly through communication with nursing home nursing staff and medical providers using established clinical criteria for incipient cases. We followed patients for 14 days after illness onset, and, if applicable, an additional 14 days each after hospital admission and hospital discharge. Delirium was assessed 3 times weekly using the Confusion Assessment Method (CAM). Physical function decline was calculated using change in the Minimum Data Set Activities of Daily Living Scale (MDS-ADL) and cognitive function decline using change in the Minimum Data Set Cognitive performance scale (MDS-CPS). Falls were ascertained by record review. Among 136 nursing home patients followed for a mean of 11.7 months, 78 experienced 232 acute illnesses, of which 162 (71%) were managed in the nursing home. The most common diagnoses were urinary tract infection (20%), cellulitis (15%), and lower respiratory tract infection (9%). Subjects experienced delirium during 41 (17.7%) of 232 acute illnesses. Female sex was associated with a greater risk of delirium (odds ratio 2.59; 95% confidence interval [CI] 1.04-6.43) but there were no other risk factors identified. Delirium was a risk factor for cognitive function decline (odds ratio 4.59; 95% CI 1.99-10.59; P = .0004), but not ADL function decline or falling. Delirium occurred frequently

  15. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients?

    PubMed

    Leung, Jacqueline M; Sands, Laura P; Paul, Sudeshna; Joseph, Tim; Kinjo, Sakura; Tsai, Tiffany

    2009-09-01

    BACKGROUNDPostoperative pain Is an independent predictor of postoperative delirium. Whether postoperative delirium limits patient-controlled analgesia (PCA) use has not been determined. The authors conducted a nested cohort study in older patients undergoing noncardiac surgery and used PCA for postoperative analgesia. Delirium was measured by using the Confusion Assessment Method. The authors computed a structural equation model to determine the effects of pain and opioid consumption on delirium status and the effect of delirium on opioid use. Of 335 patients, 108 (32.2%) developed delirium on postoperative day (POD) 1, and 120 (35.8%) on POD 2. Postoperative delirium did not limit the use of PCA. Patients with postoperative delirium used more PCA in a 24-h period (POD 2) compared to those without delirium (mean dose of hydromorphone +/- SE adjusted for covariates was 2.24 +/- 0.71 mg vs. 1.25 +/- 0.67 mg, P = 0.02). Despite more opioid use, patients with delirium reported higher Visual Analogue Scale scores than those without delirium (POD 1: mean visual analog scale +/- SE at rest 4.2 +/- 0.23 vs. 3.3 +/- 0.22, P = 0.0051; POD 2: 3.3 +/- 0.23 vs. 2.5 +/- 0.19, P = 0.004). Path coefficients from structural equation model revealed that pain and opioid use affect delirium status, but delirium does not affect subsequent opioid dose. Postoperative delirium did not limit PCA use. Despite more opioid use, visual analog scale scores were higher in patients with delirium. Future studies on delirium should consider the role of pain and pain management as potential etiologic factors.

  16. A Novel Computerized Test for Detecting and Monitoring Visual Attentional Deficits and Delirium in the ICU.

    PubMed

    Green, Cameron; Hendry, Kirsty; Wilson, Elizabeth S; Walsh, Timothy; Allerhand, Mike; MacLullich, Alasdair M J; Tieges, Zoë

    2017-07-01

    Delirium in the ICU is associated with poor outcomes but is under-detected. Here we evaluated performance of a novel, graded test for objectively detecting inattention in delirium, implemented on a custom-built computerized device (Edinburgh Delirium Test Box-ICU). A pilot study was conducted, followed by a prospective case-control study. Royal Infirmary of Edinburgh General ICU. A pilot study was conducted in an opportunistic sample of 20 patients. This was followed by a validation study in 30 selected patients with and without delirium (median age, 63 yr; range, 23-84) who were assessed with the Edinburgh Delirium Test Box-ICU on up to 5 separate days. Presence of delirium was assessed using the Confusion Assessment Method for the ICU. The Edinburgh Delirium Test Box-ICU involves a behavioral assessment and a computerized test of attention, requiring patients to count slowly presented lights. Thirty patients were assessed a total of 79 times (n = 31, 23, 15, 8, and 2 for subsequent assessments; 38% delirious). Edinburgh Delirium Test Box-ICU scores (range, 0-11) were lower for patients with delirium than those without at the first (median, 0 vs 9.5), second (median, 3.5 vs 9), and third (median, 0 vs 10.5) assessments (all p < 0.001). An Edinburgh Delirium Test Box-ICU score less than or equal to 5 was 100% sensitive and 92% specific to delirium across assessments. Longitudinally, participants' Edinburgh Delirium Test Box-ICU performance was associated with delirium status. These findings suggest that the Edinburgh Delirium Test Box-ICU has diagnostic utility in detecting ICU delirium in patients with Richmond Agitation and Sedation Scale Score greater than -3. The Edinburgh Delirium Test Box-ICU has potential additional value in longitudinally tracking attentional deficits because it provides a range of scores and is sensitive to change.

  17. Role of CRP, TNF-a, and IGF-1 in Delirium Pathophysiology

    PubMed Central

    ÇINAR, Mehmet Alper; BALIKÇI, Adem; SERTOĞLU, Erdim; Mehmet, AK; SERDAR, Muhittin A.; ÖZMENLER, Kamil Nahit

    2014-01-01

    Introduction Delirium is a common and life-threatening neuropsychiatric syndrome. Diagnosing delirium can be challenging, which increases mortality and mortality rates and health care costs. The biologic model of delirium is not definite yet, but evidence supports a cholinergic deficiency model. Delirium may be the result of processes and drugs that trespass a compromised blood-brain barrier. We aimed to evaluate the possible diagnostic utilization and the role of certain biomarkers, such as C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and insulin like growth factor-1 (IGF-1), in delirium etiology. Methods A total of 93 inpatients that planned to undergo cardiovascular surgery were informed; 35 of them completed the study. Medical history and current cognitive status were evaluated pre-operatively. Participants were followed using Delirium Rating Scale-Revised-98 Turkish (DRS-R98-T) for delirium symptoms, and blood samples were collected post-operatively. Results Delirium was developed more in participants who had worse pre-operative cognitive status. Also, low pre-operative IGF-1 levels were detected in the delirium group. Pre-operative CRP and TNF-α levels were not different between groups. Conclusion Low IGF-1 levels can be used to predict delirium after surgery. However, the complex nature of cytokines and delirium itself make it difficult to utilize cytokines to predict delirium instead of psychometric tools. PMID:28360657

  18. Phenomenology of delirium among patients admitted to a coronary care unit.

    PubMed

    Lahariya, Sanjay; Grover, Sandeep; Bagga, Shiv; Sharma, Akhilesh

    2016-11-01

    To study the phenomenology and motor sub-types of delirium in patients admitted in a Coronary Care Unit (CCU). Three hundred and nine consecutive patients were screened for delirium, and those found positive for the same were evaluated by a psychiatrist on DSM-IVTR criteria to confirm the diagnosis. Those with a diagnosis of delirium were evaluated on the DRS-R-98 to study the phenomenology and on the amended Delirium Motor Symptom Scale (DMSS) to study the motor sub-types. Eighty-one patients were found to have delirium. Commonly seen symptoms of delirium included: disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Very few patients had delusions. More than half of the participants were categorized as having hyperactive (n = 46; 56.8%) followed by hypoactive sub-type (n = 21; 26%) and mixed sub-type (n = 9; 11.1%) of delirium. There were minor differences in the frequency and severity of symptoms of delirium between incidence and prevalence cases of delirium and those with different motoric sub-types. Delirium in CCU set-up is characterized by the symptoms of disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Hyperactive delirium is more common than hypoactive delirium.

  19. Pilot prospective study of post-surgery sleep and EEG predictors of post-operative delirium.

    PubMed

    Evans, Joanna L; Nadler, Jacob W; Preud'homme, Xavier A; Fang, Eric; Daughtry, Rommie L; Chapman, Joseph B; Attarian, David; Wellman, Samuel; Krystal, Andrew D

    2017-08-01

    Delirium is a common post-operative complication associated with significant costs, morbidity, and mortality. We sought sleep/EEG predictors of delirium present prior to delirium symptoms to facilitate developing and targeting therapies. Continuous EEG data were obtained in 12 patients post-orthopedic surgery from the day of surgery until delirium assessment on post-operative day 2 (POD2). Diminished total sleep time (r=-0.68; p<0.05) and longer latency to sleep onset (r=0.67; p<0.05) on the first night in the hospital were associated with greater POD2 delirium severity. Patients experiencing delirium slept 2.4h less and took 2h longer to fall asleep. Greater waking EEG delta power (r=0.84; p<0.05) on POD1 and less non-REM sleep EEG delta power (r=-0.72; p<0.05) on night 2 also predicted POD2 delirium severity. Loss of sleep on night1 post-surgery is an early predictor of subsequent delirium. EEG Delta Power alterations in waking and sleep appear to be later indicators of impending delirium. Further work is needed to evaluate reproducibility/generalizability and assess whether sleep loss contributes to causing delirium. This first study to prospectively collect continuous EEG data for an extended period prior to delirium onset identified EEG-derived indices that predict subsequent delirium that could aid in developing and targeting therapies. Copyright © 2017. Published by Elsevier B.V.

  20. The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge

    PubMed Central

    Morandi, Alessandro; Davis, Daniel; Bellelli, Giuseppe; Arora, Rakesh C.; Caplan, Gideon A.; Kamholz, Barbara; Kolanowski, Ann; Fick, Donna Marie; Kreisel, Stefan; MacLullich, Alasdair; (UK), MRCP; Meagher, David; Neufeld, Karen; Pandharipande, Pratik P.; Richardson, Sarah; Slooter, Arjen J.C.; Taylor, John P.; Thomas, Christine; Tieges, Zoë; Teodorczuk, Andrew; Voyer, Philippe; Rudolph, James L.

    2017-01-01

    Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies. PMID:27650668

  1. Efficacy of Ramelteon for delirium after lung cancer surgery.

    PubMed

    Miyata, Ryo; Omasa, Mitsugu; Fujimoto, Ryo; Ishikawa, Hiroyuki; Aoki, Minoru

    2017-01-01

    The aim of the study was to evaluate the feasibility of Ramelteon for the prevention of delirium after lung cancer surgery in elderly patients. Medical records of patients over 70 years old, who underwent anatomical pulmonary resection for lung cancer at our institution from January 2013 to December 2015, were reviewed. Patients treated in 2013 and 2014 were used as a control group. Ramelteon was administered daily for 7 days after surgery. The incidence of delirium was determined based on the Intensive Care Delirium Screening Checklist (ICDSC). Scores of ≥4 and 1-3 points were used for the diagnoses of delirium and a pre-delirious state, respectively. There were 24 patients in the Ramelteon group and 58 patients in the control group. ICDSC scores of ≥4 points were found for no patients in the Ramelteon group and 5 (9%) in the control group, whereas 21 (88%) and 49 (85%) patients, in the respective groups, had ICDSC scores of 0 points. The average incidence of events, associated with delirium, showed a trend of being lower in the Ramelteon group (0.25 ± 0.74 vs 1.58 ± 4.93, P = 0.061), and all events in the Ramelteon group occurred on the day of surgery. Thus, only one day was required for complete recovery from delirium in the Ramelteon group, whereas 8 days were needed in the control group. The peak delirious state occurred after 5 days in the control group. Ramelteon is likely to reduce the incidence and intensity of delirium after surgery for lung cancer in elderly patients. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  2. The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge.

    PubMed

    Morandi, Alessandro; Davis, Daniel; Bellelli, Giuseppe; Arora, Rakesh C; Caplan, Gideon A; Kamholz, Barbara; Kolanowski, Ann; Fick, Donna Marie; Kreisel, Stefan; MacLullich, Alasdair; Meagher, David; Neufeld, Karen; Pandharipande, Pratik P; Richardson, Sarah; Slooter, Arjen J C; Taylor, John P; Thomas, Christine; Tieges, Zoë; Teodorczuk, Andrew; Voyer, Philippe; Rudolph, James L

    2017-01-01

    Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.

  3. Quality of clinical practice guidelines in delirium: a systematic appraisal

    PubMed Central

    Marchington, Katie L; Agar, Meera; Davis, Daniel H J; Sikora, Lindsey; Tsang, Tammy W Y

    2017-01-01

    Objective To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality. Design Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies. Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a ‘Rigour of Development’ domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Data sources Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search. Results 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II ‘Rigour’ scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were ‘Scope and Purpose’ (mean 80.1%, range 64–100%) and ‘Clarity and Presentation’ (mean 76.7%, range 38–97%). The lowest rating domains were ‘Applicability’ (mean 48.7%, range 8–81%) and ‘Editorial Independence’ (mean 53%, range 2–90%). The three highest rating guidelines in the ‘Applicability’ domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies. Conclusions Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more

  4. Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study.

    PubMed

    Morandi, Alessandro; Di Santo, Simona G; Cherubini, Antonio; Mossello, Enrico; Meagher, David; Mazzone, Andrea; Bianchetti, Angelo; Ferrara, Nicola; Ferrari, Alberto; Musicco, Massimo; Trabucchi, Marco; Bellelli, Giuseppe

    2017-10-01

    To date motor subtypes of delirium have been evaluated in single-center studies with a limited examination of the relationship between predisposing factors and motor profile of delirium. We sought to report the prevalence and clinical profile of subtypes of delirium in a multicenter study. This is a point prevalence study nested in the "Delirium Day 2015", which included 108 acute and 12 rehabilitation wards in Italy. Delirium was detected using the 4-AT and motor subtypes were measured with the Delirium Motor Subtype Scale (DMSS). A multinomial logistic regression was used to determine the factors associated with delirium subtypes. Of 429 patients with delirium, the DMSS was completed in 275 (64%), classifying 21.5% of the patients with hyperactive delirium, 38.5% with hypoactive, 27.3% with mixed and 12.7% with the non-motor subtype. The 4-AT score was higher in the hyperactive subtype, similar in the hypoactive, mixed subtypes, while it was lowest in the non-motor subtype. Dementia was associated with all three delirium motor subtypes (hyperactive, OR 3.3, 95% CI: 1.2-8.7; hypoactive, OR 2.8, 95% CI: 1.2-6.5; mixed OR 2.6, 95% CI: 1.1-6.2). Atypical antipsychotics were associated with hypoactive delirium (OR 0.23, 95% CI: 0.1-0.7), while intravenous lines were associated with mixed delirium (OR 2.9, 95% CI: 1.2-6.9). The study shows that hypoactive delirium is the most common subtype among hospitalized older patients. Specific clinical features were associated with different delirium subtypes. The use of standardized instruments can help to characterize the phenomenology of different motor subtypes of delirium. Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

  5. Relationship between cobalamin deficiency and delirium in elderly patients undergoing cardiac surgery.

    PubMed

    Sevuk, Utkan; Baysal, Erkan; Ay, Nurettin; Altas, Yakup; Altindag, Rojhat; Yaylak, Baris; Alp, Vahhac; Demirtas, Ertan

    2015-01-01

    Delirium is common after cardiac surgery and is independently associated with increased morbidity, mortality, prolonged hospital stays, and higher costs. Cobalamin (vitamin B12) deficiency is a common cause of neuropsychiatric symptoms and affects up to 40% of elderly people. The relationship between cobalamin deficiency and the occurrence of delirium after cardiac surgery has not been examined in previous studies. We examined the relationship between cobalamin deficiency and delirium in elderly patients undergoing coronary artery bypass grafting (CABG) surgery. A total of 100 patients with cobalamin deficiency undergoing CABG were enrolled in this retrospective study. Control group comprised 100 patients without cobalamin deficiency undergoing CABG. Patients aged 65 years or over were included. Diagnosis of delirium was made using Intensive Care Delirium Screening Checklist. Delirium severity was measured using the Delirium Rating Scale-revised-98. Patients with cobalamin deficiency had a significantly higher incidence of delirium (42% vs 26%; P=0.017) and higher delirium severity scores (16.5±2.9 vs 15.03±2.48; P=0.034) than patients without cobalamin deficiency. Cobalamin levels were significantly lower in patients with delirium than patients without delirium (P=0.004). Delirium severity score showed a moderate correlation with cobalamin levels (ρ=-0.27; P=0.024). Logistic regression analysis demonstrated that cobalamin deficiency was independently associated with postoperative delirium (OR 1.93, 95% CI 1.03-3.6, P=0.038). The results of our study suggest that cobalamin deficiency may be associated with increased risk of delirium in patients undergoing CABG. In addition, we found that preoperative cobalamin levels were associated with the severity of delirium. This report highlights the importance of investigation for cobalamin deficiency in patients undergoing cardiac surgery, especially in the elderly.

  6. Risk Factors and Outcomes for Postoperative Delirium after Major Surgery in Elderly Patients

    PubMed Central

    Raats, Jelle W.; van Eijsden, Wilbert A.; Crolla, Rogier M. P. H.; Steyerberg, Ewout W.; van der Laan, Lijckle

    2015-01-01

    Background Early identification of patients at risk for delirium is important, since adequate well timed interventions could prevent occurrence of delirium and related detrimental outcomes. The aim of this study is to evaluate prognostic factors for delirium, including factors describing frailty, in elderly patients undergoing major surgery. Methods We included patients of 65 years and older, who underwent elective surgery from March 2013 to November 2014. Patients had surgery for Abdominal Aortic Aneurysm (AAA) or colorectal cancer. Delirium was scored prospectively using the Delirium Observation Screening Scale. Pre- and peri-operative predictors of delirium were analyzed using regression analysis. Outcomes after delirium included adverse events, length of hospital stay, discharge destination and mortality. Results We included 232 patients. 51 (22%) underwent surgery for AAA and 181 (78%) for colorectal cancer. Postoperative delirium occurred in 35 patients (15%). Predictors of postoperative delirium included: delirium in medical history (Odds Ratio 12 [95% Confidence Interval 2.7–50]), advancing age (Odds Ratio 2.0 [95% Confidence Interval 1.1–3.8]) per 10 years, and ASA-score ≥3 (Odds Ratio 2.6 [95% Confidence Interval 1.1–5.9]). Occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality. Conclusion Postoperative delirium is a frequent complication after major surgery in elderly patients and is related to an increase in adverse events, length of hospital stay, and mortality. A delirium in the medical history, advanced age, and ASA-score may assist in defining patients at increased risk for delirium. Further attention to prevention of delirium is essential in elderly patients undergoing major surgery. PMID:26291459

  7. Delirium in the elderly: current problems with increasing geriatric age

    PubMed Central

    Kukreja, Deepti; Günther, Ulf; Popp, Julius

    2015-01-01

    Delirium is an acute disorder of attention and cognition seen relatively commonly in people aged 65 yr or older. The prevalence is estimated to be between 11 and 42 per cent for elderly patients on medical wards. The prevalence is also high in nursing homes and long term care (LTC) facilities. The consequences of delirium could be significant such as an increase in mortality in the hospital, long-term cognitive decline, loss of autonomy and increased risk to be institutionalized. Despite being a common condition, it remains under-recognised, poorly understood and not adequately managed. Advanced age and dementia are the most important risk factors. Pain, dehydration, infections, stroke and metabolic disturbances, and surgery are the most common triggering factors. Delirium is preventable in a large proportion of cases and therefore, it is also important from a public health perspective for interventions to reduce further complications and the substantial costs associated with these. Since the aetiology is, in most cases, multfactorial, it is important to consider a multi-component approach to management, both pharmacological and non-pharmacological. Detection and treatment of triggering causes must have high priority in case of delirium. The aim of this review is to highlight the importance of delirium in the elderly population, given the increasing numbers of ageing people as well as increasing geriatric age. PMID:26831414

  8. Detecting pediatric delirium: development of a rapid observational assessment tool.

    PubMed

    Silver, Gabrielle; Traube, Chani; Kearney, Julia; Kelly, Daniel; Yoon, Margaret J; Nash Moyal, Wendy; Gangopadhyay, Maalobeeka; Shao, Huibo; Ward, Mary Jo

    2012-06-01

    Development of a novel screening tool for the detection of delirium in pediatric intensive care unit (PICU) patients of all ages by comparison with psychiatric assessment based on the reference standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. This was a prospective blinded pilot study investigating the feasibility of the Cornell Assessment of Pediatric Delirium (CAP-D) performed in a PICU at a university hospital. Fifty patients, ages 3 months to 21 years, admitted to the PICU over a 6-week period were included. No interventions were performed. After informed consent was obtained, two study teams independently assessed for delirium by completing the CAP-D and by conducting psychiatric evaluation based on the DSM-IV criteria. Concordance between the CAP-D and DSM-IV criteria was excellent, at 97%. Prevalence of delirium in this sample was 29%. The CAP-D may be a valid screen for identification of delirium in PICU patients of all ages. Further studies are required to explore its validity, inter-rater reliability, and feasibility of use as a nursing screen.

  9. Delirium in the elderly: Current problems with increasing geriatric age.

    PubMed

    Kukreja, Deepti; Günther, Ulf; Popp, Julius

    2015-12-01

    Delirium is an acute disorder of attention and cognition seen relatively commonly in people aged 65 yr or older. The prevalence is estimated to be between 11 and 42 per cent for elderly patients on medical wards. The prevalence is also high in nursing homes and long term care (LTC) facilities. The consequences of delirium could be significant such as an increase in mortality in the hospital, long-term cognitive decline, loss of autonomy and increased risk to be institutionalized. Despite being a common condition, it remains under-recognised, poorly understood and not adequately managed. Advanced age and dementia are the most important risk factors. Pain, dehydration, infections, stroke and metabolic disturbances, and surgery are the most common triggering factors. Delirium is preventable in a large proportion of cases and therefore, it is also important from a public health perspective for interventions to reduce further complications and the substantial costs associated with these. Since the aetiology is, in most cases, multifactorial, it is important to consider a multi-component approach to management, both pharmacological and non-pharmacological. Detection and treatment of triggering causes must have high priority in case of delirium. The aim of this review is to highlight the importance of delirium in the elderly population, given the increasing numbers of ageing people as well as increasing geriatric age.

  10. Recognizing encephalopathy and delirium in the cardiopulmonary rehabilitation setting.

    PubMed

    Waked, William J; Gordon, Robert M; Whiteson, Jonathan H; Baron, Erika M

    2015-05-01

    This article reviews the prevalence, underlying mechanisms, and challenges of treating encephalopathy and delirium in the postsurgical and medically compromised cardiopulmonary patient receiving services on an acute inpatient rehabilitation unit. Additionally, pertinent information is provided on conducting an evaluation to assess for neurocognitive sequelae of the above-mentioned conditions to help achieve better treatment outcomes. Review of the medical and neuropsychology literature is provided along with 2 case reports to illustrate evaluation of a persisting toxic-metabolic encephalopathy and a resolving delirium and the treatment team's effectiveness in producing a more optimal treatment outcome. The unique role of the rehabilitation psychologist, special treatment considerations, and the importance of integrated follow-up neurorehabilitation services for the cardiopulmonary patient and caregivers also are emphasized. Encephalopathy and delirium are 2 related, but somewhat different, conditions that can emerge postoperatively, any time during acute care hospitalization, and often enough, during impatient or subacute-care rehabilitation. Their association with long-term harm and poor outcome warrant early identification and immediate medical intervention. Encephalopathy and delirium can significantly affect rehabilitation outcomes and, as such, rehabilitation psychologists are encouraged to systematically screen for the presence of delirium and encephalopathy in the cardiopulmonary rehabilitation setting so to enhance treatment efficacy and quality of life in affected individuals. (c) 2015 APA, all rights reserved).

  11. Delirium in Prolonged Hospitalized Patients in the Intensive Care Unit

    PubMed Central

    Vahedian Azimi, Amir; Ebadi, Abbas; Ahmadi, Fazlollah; Saadat, Soheil

    2015-01-01

    Background: Prolonged hospitalization in the intensive care unit (ICU) can impose long-term psychological effects on patients. One of the most significant psychological effects from prolonged hospitalization is delirium. Objectives: The aim of this study was to assess the effect of prolonged hospitalization of patients and subsequent delirium in the intensive care unit. Patients and Methods: This conventional content analysis study was conducted in the General Intensive Care Unit of the Shariati Hospital of Tehran University of Medical Sciences, from the beginning of 2013 to 2014. All prolonged hospitalized patients and their families were eligible participants. From the 34 eligible patients and 63 family members, the final numbers of actual patients and family members were 9 and 16, respectively. Several semi-structured interviews were conducted face-to-face with patients and their families in a private room and data were gathered. Results: Two main themes from two different perspectives emerged, 'patients' perspectives' (experiences during ICU hospitalization) and 'family members' perspectives' (supportive-communicational experiences). The main results of this study focused on delirium, Patients' findings were described as pleasant and unpleasant, factual and delusional experiences. Conclusions: Family members are valuable components in the therapeutic process of delirium. Effective use of family members in the delirium caring process can be considered to be one of the key non-medical nursing components in the therapeutic process. PMID:26290854

  12. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.

    PubMed

    Kain, Zeev N; Caldwell-Andrews, Alison A; Maranets, Inna; McClain, Brenda; Gaal, Dorothy; Mayes, Linda C; Feng, Rui; Zhang, Heping

    2004-12-01

    Based on previous studies, we hypothesized that the clinical phenomena of preoperative anxiety, emergence delirium, and postoperative maladaptive behavioral changes were closely related. We examined this issue using data obtained by our laboratory over the past 6 years. Only children who underwent surgery and general anesthesia using sevoflurane/O(2)/N(2)O and who did not receive midazolam were recruited. Children's anxiety was assessed preoperatively with the modified Yale Preoperative Anxiety Scale (mYPAS), emergence delirium was assessed in the postanesthesia care unit, and behavioral changes were assessed with the Post Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 2, 3, 7, and 14. Regression analysis showed that the odds of having marked symptoms of emergence delirium increased by 10% for each increment of 10 points in the child's state anxiety score (mYPAS). The odds ratio of having new-onset postoperative maladaptive behavior changes was 1.43 for children with marked emergence status as compared with children with no symptoms of emergence delirium. A 10-point increase in state anxiety scores led to a 12.5% increase in the odds that the child would have a new-onset maladaptive behavioral change after the surgery. This finding is highly significant to practicing clinicians, who can now predict the development of adverse postoperative phenomena, such as emergence delirium and postoperative behavioral changes, based on levels of preoperative anxiety.

  13. Intoxication delirium following use of synthetic cathinone derivatives.

    PubMed

    Penders, Thomas M; Gestring, Richard E; Vilensky, Dmitry A

    2012-11-01

    In published reports of hallucinatory delirium following use of "bath salts" analytic laboratory testing has demonstrated the synthetic cathinone derivative methylenedioxypyrovalerone (MDPV). MDPV can cause a false-positive screening immunoassay result for phencyclidine (PCP). Patients using MDPV are prone to development of the syndrome of excited delirium (ExD), a condition also described with PCP. This review summarize reports from several series of cases of delirium associated with MDPV emphasizing the features of both intoxication and excited delirium. Literature review and clinical description of a series of patients from Eastern North Carolina. MDPV is likely the responsible agent in production of both toxic and excited delirium syndromes identified with the recreational use of "bath salts" in the United States over the past two years. Patients using MDPV are prone to the development of toxic delirum with some developing ExD. a condition associated with considerable risk for serious medical morbidity. Commonly used interventions directed at extreme agitation and paranoia may exacerbate the pathophysiology of ExD.

  14. A Flipped Classroom Approach to Improving the Quality of Delirium Care Using an Interprofessional Train-the-Trainer Program.

    PubMed

    Sockalingam, Sanjeev; James, Sandra-Li; Sinyi, Rebecca; Carroll, Aideen; Laidlaw, Jennifer; Yanofsky, Richard; Sheehan, Kathleen

    2016-01-01

    Given the prevalence and morbidity associated with delirium, there is a need for effective and efficient institutional approaches to delirium training in health care settings. Novel education methods, specifically the "flipped classroom" (FC) and "train-the-trainer" (TTT), have the potential to address these delirium training gaps. This study evaluates the effect of a TTT FC interprofessional delirium training program on participants' perceived ability to manage delirium, delirium knowledge, and clinicians' delirium assessment behaviors. FC Delirium TTT sessions were implemented in a large four-hospital network and consisted of presession online work and a 3-hour in-session component. The 156 TTT interprofessional participants who attended the sessions (ie, trainers) were expected to then deliver delirium training to their patient care units. Delirium care self-efficacy and knowledge test scores were measured before, after, and 6 months after the training session. Clinician delirium assessment rates were measured by chart audits before and 3 months after trainer's implementation of delirium training sessions. Delirium knowledge test scores (7.8 ± 1.6 versus 9.7 ± 1.2, P < .001) and delirium care self-efficacy were significantly higher immediately after the TTT session compared with those of presession and these differences remained significant at 6-month after the TTT session. Trainer sessions significantly improved clinician delirium assessment rates from 53% for pretraining to 66% for posttraining. Our data suggest that a TTT FC delirium training approach can improve participants' perceived delirium care skills and confidence, and delirium knowledge up to 6 months after the session. This approach provides a model for implementing hospitalwide delirium education that can change delirium assessment behavior while minimizing time and personnel requirements.

  15. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients.

    PubMed

    Inouye, S K

    1994-09-01

    Delirium, with occurrence rates from 14% to 56%, associated mortality rates from 10% to 65%, and excess annual health care expenditures from $1 to $2 billion, poses a common and serious problem for hospitalized elderly patients. Delirium is often unrecognized or misdiagnosed by physicians caring for elderly patients. Cognitive testing is rarely done as part of the admission evaluation of elderly hospitalized patients. Specific diagnosis has been difficult, since diagnostic criteria and instruments are still being developed. The etiology of delirium is complex and multifactorial, and both predisposing (host vulnerability) and precipitating factors must be considered. The recommended approach to the evaluation of delirium is empiric, in the absence of objective efficacy data. The cornerstone of evaluation includes a careful history, physical examination, and review of the medication list--since medications are the most common reversible cause of delirium. Research is needed to establish a cost-effective approach and to clarify the role of further testing, such as cerebrospinal fluid examination, brain imaging, and electroencephalography. This article is intended to heighten the awareness of clinicians as well as to stimulate research to address this important, neglected problem for elderly hospitalized patients.

  16. Agitation and delirium at the end of life: "We couldn't manage him".

    PubMed

    Breitbart, William; Alici, Yesne

    2008-12-24

    Delirium is the most common neuropsychiatric complication experienced by patients with advanced illness, occurring in up to 85% of patients in the last weeks of life. Using the case of Mr L, a 59-year-old man with metastatic lung cancer who developed an agitated delirium in the last week of life, we review the evaluation and management of delirium near the end of life. Although some studies have identified agitation as a central feature of delirium in 13% to 46% of patients, other studies have found up to 80% of patients near the end of life develop a hypoactive, nonagitated delirium. Both the agitated (hyperactive) and nonagitated (hypoactive) forms of delirium are harbingers of impending death and are associated with increased morbidity in patients who are terminally ill, causing distress for patients, family members, and staff. Delirium is a sign of significant physiological disturbance, usually involving multiple causes, including infection, organ failure, and medication adverse effects. Often these causes of delirium are not reversible in the dying patient, and this influences the outcomes of its management. Delirium can also significantly interfere with the recognition and control of other physical and psychological symptoms, such as pain. Unfortunately, delirium is often misdiagnosed or unrecognized and thus inappropriately treated or untreated in terminally ill patients. To manage delirium in terminally ill patients, clinicians must be able to diagnose it accurately, undertake appropriate assessment of underlying causes, and understand the benefits and risks of the available pharmacological and nonpharmacological interventions.

  17. Depressive symptoms and the risk of incident delirium in older hospitalized adults.

    PubMed

    McAvay, Gail J; Van Ness, Peter H; Bogardus, Sidney T; Zhang, Ying; Leslie, Douglas L; Leo-Summers, Linda S; Inouye, Sharon K

    2007-05-01

    To determine whether specific subsets of symptoms from the Geriatric Depression Scale (GDS), assessed at hospital admission, were associated with the incidence of delirium. Secondary analysis of a prospective cohort study of patients from the Delirium Prevention Trial. General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998. Four hundred sixteen patients aged 70 and older who were at intermediate or high risk for delirium and were not taking antidepressants at hospital admission. Depressive symptoms were assessed GDS, and daily assessments of delirium were obtained using the Confusion Assessment Method. Of the 416 patients in the analysis sample, 36 (8.6%) developed delirium within the first 5 days of hospitalization. Patients who developed delirium reported 5.7 depressive symptoms on average, whereas patients without delirium reported an average of 4.2 symptoms. Using a Cox proportional hazards model, it was found that depressive symptoms assessing dysphoric mood and hopelessness were predictive of incident delirium, controlling for measures of physical and mental health. In contrast, symptoms of withdrawal, apathy, and vigor were not significantly associated with delirium. These findings suggest that assessing symptoms of dysphoric mood and hopelessness could help identify patients at risk for incident delirium. Future studies should evaluate whether nonpharmacological treatment for these symptoms reduces the risk of delirium.

  18. Implementing Delirium Screening in the Intensive Care Unit: Secrets to Success

    PubMed Central

    Brummel, Nathan E.; Vasilevskis, Eduard E.; Han, Jin Ho; Boehm, Leanne; Pun, Brenda T.; Ely, E. Wesley

    2013-01-01

    Objective To review delirium screening tools available for use in the adult and pediatric ICU, review evidence-based delirium screening implementation and to discuss common pitfalls encountered during delirium screening in the ICU. Data Sources Review of delirium screening literature and expert opinion. Results Over the past decade, tools specifically designed for use in critically ill adults and children have been developed and validated. Delirium screening has been effectively implemented across many ICUs settings. Keys to effective implementation include addressing barriers to routine screening, multi-faceted training such as lectures, case-based scenarios, one-on-one teaching and real-time feedback of delirium screening and interdisciplinary communication through discussion of a patient’s delirium status during bedside rounds and through documentation systems. If delirium is present clinicians should search for reversible or treatable causes since it is often multifactorial. Conclusion Implementation of effective delirium screening is feasible but requires attention to implementation methods, including a change in the current ICU culture that believes delirium is inevitable or a normal part of a critical illness, to a future culture that views delirium as a dangerous syndrome which portends poor clinical outcomes and which is potentially modifiable depending on the individual patients circumstances. PMID:23896832

  19. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults.

    PubMed

    2015-01-01

    The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

  20. Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review.

    PubMed

    Carin-Levy, G; Mead, G E; Nicol, K; Rush, R; van Wijck, F

    2012-08-01

    Delirium is a common complication in acute stroke yet there is uncertainty regarding how best to screen for and diagnose delirium after stroke. We sought to establish how delirium after stroke is identified, its incidence rates and factors predicting its development. We conducted a systematic review of studies investigating delirium in acute stroke. We searched The Cochrane Collaboration, MEDLINE, EMBASE, CINHAL, PsychINFO, Web of Science, British Nursing Index, PEDro and OT Seeker in October 2010. A total of 3,127 citations were screened, full text of 60 titles and abstracts were read, of which 20 studies published between 1984 and 2010 were included in this review. The methods most commonly used to identify delirium were generic assessment tools such as the Delirium Rating Scale (n = 5) or the Confusion Assessment Method (n = 2) or both (n = 2). The incidence of delirium in acute stroke ranged from 2.3-66%, with our meta-analysis random effects approach placing the rate at 26% (95% CI 19-33%). Of the 11 studies reporting risk factors for delirium, increased age, aphasia, neglect or dysphagia, visual disturbance and elevated cortisol levels were associated with the development of delirium in at least one study. The outcomes associated with the condition are increased morbidity and mortality. Delirium is found in around 26% of stroke patients. Difference in diagnostic and screening procedures could explain the wide variation in frequency of delirium. There are a number of factors that may predict the development of the condition.

  1. A personality trait contributes to the occurrence of postoperative delirium: a prospective study.

    PubMed

    Shin, Jung Eun; Kyeong, Sunghyon; Lee, Jong-Seok; Park, Jin Young; Lee, Woo Suk; Kim, Jae-Jin; Yang, Kyu Hyun

    2016-11-03

    Although various physical risk factors for delirium have been identified, the effect of psychological aspects is currently unknown. This study aimed to examine psychological risk factors for postoperative delirium and to identify hidden subgroups of delirium in clinical and psychological feature space. Among 200 patients with hip fracture, 78 elderly patients were prospectively evaluated for clinical and psychological assessments before surgery. As delirium was assessed from the next day to the 7th day after surgery, postoperative delirium was found in 40 patients, but not in 38 patients. Univariate and multivariate logistic regression analyses were used to explore risk factors for postoperative delirium. Phenotypic subgroups of delirium were assessed using Topological Data Analysis, in which the significant risk factors were used for evaluating filter and distance metrics. Mini-Mental State Examination, neuroticism, conscientiousness, and regional anesthesia were identified as a predictive risk factor for postoperative delirium. The filter metric showed significant negative correlations with nutrition-related factors such as total protein and albumin. When filter metric and Euclidean distances were entered, delirious patients were bifurcated as a function of personality traits and anesthesia method in the patient-patient network. A personality trait of neuroticism and conscientiousness may predispose elderly patients to postoperative delirium and this influence may be amplified by regional anesthesia. This study verifies the contribution of psychological risk factors to delirium and provides new insight for complex etiologies of delirium by mapping various clinical variables in the topological space.

  2. Stability of Post-Operative Delirium Psychomotor Subtypes Among Hip Fracture Patients

    PubMed Central

    Albrecht, Jennifer S.; Marcantonio, Edward R.; Roffey, Darren M.; Orwig, Denise; Magaziner, Jay; Terrin, Michael; Carson, Jeffrey L.; Barr, Erik; Brown, Jessica P.; Gentry, Emma G.; Gruber-Baldini, Ann L.

    2015-01-01

    Objectives To determine the stability of psychomotor subtypes of delirium over time and identify characteristics associated with delirium psychomotor subtypes in patients undergoing surgical repair of hip fracture. Design Prospective cohort study. Setting The Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair Cognitive Ancillary Study was conducted at 13 participating sites from 2008-2009. Participants 139 patients who had undergone surgical repair of hip fracture Measurements Delirium was assessed up to four times post-operatively using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale. Psychomotor subtypes of delirium were categorized as hypoactive, hyperactive, mixed, and normal psychomotor activity. Results Incidence of post-operative delirium was 41% (n=57). Among CAM+ observations (n=90), 56% were hypoactive, 10% hyperactive, 21% mixed, and 14% had normal psychomotor symptoms. Among patients with more than one CAM+ assessment (n=26), 50% maintained subtype stability over time. Patients with hypoactive or normal psychomotor symptoms (n=31) were less likely to have chart documentation of delirium compared to patients with any hyperactive symptoms (n=19) (22% vs. 58%, p=0.009). Conclusion Psychomotor subtypes of delirium often fluctuate from assessment to assessment, rather than representing fixed categories of delirium. Hypoactive delirium is the most common presentation of delirium, but is the least likely to be documented by healthcare providers. PMID:25943948

  3. The neuropsychological course of acute delirium in adult hematopoietic stem cell transplantation patients.

    PubMed

    Beglinger, Leigh J; Mills, James A; Vik, Stacie M; Duff, Kevin; Denburg, Natalie L; Weckmann, Michelle T; Paulsen, Jane S; Gingrich, Roger

    2011-03-01

    Although delirium is a common medical comorbidity with altered cognition as its defining feature, few publications have addressed the neuropsychological prodrome, profile, and recovery of patients tested during delirium. We characterize neuropsychological performance in 54 hemapoietic stem cell/bone marrow transplantation (BMT) patients shortly before, during, and after delirium and in BMT patients without delirium and 10 healthy adults. Patients were assessed prospectively before and after transplantation using a brief battery. BMT patients with delirium performed more poorly than comparisons and those without delirium on cross-sectional and trend analyses. Deficits were in expected areas of attention and memory, but also in psychomotor speed and learning. The patients with delirium did not return to normative "average" on any test during observation. Most tests showed a mild decline in the visit before delirium, a sharp decline with delirium onset, and variable performance in the following days. This study adds to the few investigations of neuropsychological performance surrounding delirium and provides targets for monitoring and early detection; Trails A and B, RBANS Coding, and List Recall may be useful for delirium assessment.

  4. The Neuropsychological Course of Acute Delirium in Adult Hematopoietic Stem Cell Transplantation Patients

    PubMed Central

    Beglinger, Leigh J.; Mills, James A.; Vik, Stacie M.; Duff, Kevin; Denburg, Natalie L.; Weckmann, Michelle T.; Paulsen, Jane S.; Gingrich, Roger

    2011-01-01

    Although delirium is a common medical comorbidity with altered cognition as its defining feature, few publications have addressed the neuropsychological prodrome, profile, and recovery of patients tested during delirium. We characterize neuropsychological performance in 54 hemapoietic stem cell/bone marrow transplantation (BMT) patients shortly before, during, and after delirium and in BMT patients without delirium and 10 healthy adults. Patients were assessed prospectively before and after transplantation using a brief battery. BMT patients with delirium performed more poorly than comparisons and those without delirium on cross-sectional and trend analyses. Deficits were in expected areas of attention and memory, but also in psychomotor speed and learning. The patients with delirium did not return to normative “average” on any test during observation. Most tests showed a mild decline in the visit before delirium, a sharp decline with delirium onset, and variable performance in the following days. This study adds to the few investigations of neuropsychological performance surrounding delirium and provides targets for monitoring and early detection; Trails A and B, RBANS Coding, and List Recall may be useful for delirium assessment. PMID:21183605

  5. Experiences, understandings and support needs of family carers of older patients with delirium: a descriptive mixed methods study in a hospital delirium unit.

    PubMed

    Toye, Christine; Matthews, Anne; Hill, Andrew; Maher, Sean

    2014-09-01

    Delirium is common in older patients. Little is known of support needs of families of older hospital patients with delirium. To inform nursing practice, we sought to describe families' experiences, understanding of delirium and delirium care, and support needs. Descriptive mixed methods. Review of questionnaire items used with families of people with terminal delirium informed development of a new questionnaire to evaluate the support needs in our study population. In a tertiary hospital delirium unit, we recruited 17 family carers of older patients with (non-terminal) delirium to respond to this questionnaire. Twelve participants (11 female) also took part in interviews addressing the study's aims. Descriptive statistics were calculated and thematic analysis was undertaken. From the survey, key family issues included distress about the patient's condition, worries about future care, and a need for more information about how the patient might feel and how families could support the patient. Themes from interviews included The admission experience, Worries and concerns, Feeling supported, and The discharge experience. Limited understanding of delirium underpinned all themes. Families experienced shock and sadness at the change in the patient; they were reassured by the specialist care but needed more information about delirium, its effects and outcomes, and how they could help with care. Meeting long-term postdischarge needs was a key concern. In this study, families with a hospitalised older relative who had delirium described a distressing experience and needs for informational support. Further research is needed outside of delirium-specific units and in samples including a greater proportion of male relatives. Nurses should work within the interdisciplinary team to ensure a planned, sensitive and timely approach to informing the patient's family about delirium and its implications for their relative, recognising the family carer's role and likely distress.

  6. [Psychotic experiences in the course of alcohol withdrawal symptoms: locus of control among patients with and without delirium and analysis of subjective experiences in delirium].

    PubMed

    Kokoszka, Andrzej; Laskowska, Marta; Mikuła, Joanna

    2011-01-01

    The comparison of the locus of control in groups of patients hospitalised due to alcohol withdrawal with and without delirium and analysis of psychotic experiences of patients with delirium. 25 patients with alcohol withdrawal with delirium and 25 without delirium took part in the study. They filled-in the Internal-External (I-E) Locus of Control Scale by Rotter; Multidimensional Health Locus of Control (MHLC) scale; the group with delirium also did the Psychopathological Symptoms Inventory, by Bizoń et al. The mean score in I-E Locus of Control Scale in the group with delirium was more external than in the group without delirium (M = 13.28; SD = 2.762 versus M = 11.64; SD = 2.612; t(48) = -2.157; p = 0.036). Group with delirium had also lower mean score in the dimension of internal control in MHLC, than the group without delirium (M = 24.8; SD = 6.149 versus M = 26.8; SD = 4.648; t(48) = 1.99; p = 0.04). There were no statistically significant differences between the groups in the other subscales. The auditory and visual hallucinations were most common among patients with delirium (84%, 80% respectively, as well as delusions of taking part in not existing events (92%) and persecutory delusions (80%). Psychotic experiences influenced behaviour in nearly 50% of the cases. A more external locus of control may be one of the factors contributing to the development of alcohol delirium. The content of psychotic experiences seems to have impact on the behaviour of many patients with alcohol delirium.

  7. Development of a Clinical Competency Checklist for Care of Patients Experiencing Substance Withdrawal Delirium or Delirium: Use of a Delphi Technique and Expert Panel.

    PubMed

    Saylor, Jennifer L; Schell, Kathleen A; Mendell, Mark F; Graber, Jennifer S

    2015-06-01

    Health care providers are challenged by the presentation and management of inpatients experiencing substance withdrawal delirium (SWD) and delirium. The current Delphi study used an expert panel to develop a clinical competency checklist for nurse and physician educator use in teaching health care providers about the initial care of patients with SWD or delirium. The checklist includes categories of patient safety, history and information gathering, physical examination and assessment, treatment plan, and patient/family-centered care. Copyright 2015, SLACK Incorporated.

  8. [Effect of anaesthesia on incidence of postoperative delirium after major abdominal surgery in elderly patients].

    PubMed

    Zabolotskikh, I B; Trembach, N V

    2013-01-01

    Delirium can be caused by haemodynamics abnormalities during anaesthesia. The main role in delirium appearance is given to decreasing of cerebral perfusion pressure. Especially it can happen in patients with underlying intracranial hypertension. Anaesthetics effects on intracranial pressure are different therefore cerebral hypoperfusion can happens in these patients even without systemic hypotension. Purpose of the study was to define an effect of cerebral perfusion pressure decreasing during different technics of anaesthesia on frequency of delirium in elderly patients after major abdominal surgery. The article deals with results of study of 182 patients (medium age 69 y.o.) underwent elective major abdominal surgery. Delirium frequency was 11%, continuing of delirium was 3 days. The frequency of delirium was higher in patients who had got anaesthesia based on sevoflurane. Additionally these patients had higher frequency of cerebral perfusion pressure decreasing. Conclusions; Anaesthesia based on sevoflurane is characterized by higher frequency of postoperative delirium in elderly patients after major abdominal surgery.

  9. Use of aripiprazole for delirium in the elderly: a short review.

    PubMed

    Kirino, Eiji

    2015-03-01

    The effects and tolerability of antipsychotics in delirium treatment remain controversial. Compared to other antipsychotics, aripiprazole differs in pharmacological activity because it exerts its effect as a dopamine D2 partial agonist. The guidelines of the American Psychiatric Association rank aripiprazole highly among antipsychotics with regard to safety, and this drug is likely to be useful for delirium treatment. Here, we reviewed the efficacy and safety of aripiprazole for delirium. The results of our literature review on the efficacy and safety of delirium treatments suggest that aripiprazole is an effective treatment option for delirium in the elderly. Aripiprazole is as effective as other antipsychotics in improving delirium symptoms, and it is safer because it is less likely to cause extrapyramidal symptoms, excessive sedation, and weight gain. However, these findings are based on only a few clinical studies of elderly patients with delirium. Therefore, further investigations are necessary.

  10. [Pain, agitation and delirium in acute respiratory failure].

    PubMed

    Funk, G-C

    2016-02-01

    Avoiding pain, agitation and delirium as well as avoiding unnecessary deep sedation is a powerful yet challenging strategy in critical care medicine. A number of interactions between cerebral function and respiratory function should be regarded in patients with respiratory failure and mechanical ventilation. A cooperative sedation strategy (i.e. patient is awake and free of pain and delirium) is feasible in many patients requiring invasive mechanical ventilation. Especially patients with mild acute respiratory distress syndrome (ARDS) seem to benefit from preserved spontaneous breathing. While completely disabling spontaneous ventilation with or without neuromuscular blockade is not a standard strategy in ARDS, it might be temporarily required in patients with severe ARDS, who have substantial dyssynchrony or persistent hypoxaemia. Since pain, agitation and delirium compromise respiratory function they should also be regarded during noninvasive ventilation and during ventilator weaning. Pharmacological sedation can have favourable effects in these situations, but should not be given routinely or uncritically.

  11. [Preventive program for postoperative delirium in the elderly].

    PubMed

    Ocádiz-Carrasco, Jesús; Gutiérrez-Padilla, Ruth Alicia; Páramo-Rivas, Frida; Serrano, Alejandro Tovar; Hernández-Ortega, José Luis

    2013-01-01

    Antecedentes: el delirium es un padecimiento poco reconocido en los pacientes quirúrgicos que frecuentemente se confunde con deterioro cognitivo o demencia. Es de vital importancia conocer las medidas que pueden disminuir su incidencia y reconocerlo de manera temprana para iniciar el tratamiento específico. Objetivo: implementar un programa educativo en delirium para el equipo de salud, con el propósito de disminuir su incidencia. Material y métodos: estudio observacional, longitudinal y analítico basado en medidas no farmacológicas y con apoyo de los familiares con quienes se tuvieron sesiones educativas, material didáctico, cuestionarios y estrategias específicas para todos los pacientes mayores de 65 años. Se realizaron dos evaluaciones al personal médico y de enfermería antes y después de implementar el programa.Resultados: se observó mejoría en la capacidad para dentificar el delirium (22% inicial vs 93%; p= 0.000). Se incluyeron 200 pacientes en el grupo de ensayo a un año y se encontró un solo caso de delirium que mostró reducción importante respecto a la incidencia previa en el hospital (10 vs 0.5% p= 0.000), mientras que en el subgrupo de 98 pacientes quirúrgicos no hubo ningún caso de delirium (4.8% inicial vs 0% p= 0.01, NNT= 21). Conclusiones: la implementación de un programa preventivo para el delirium es factible. Los resultados fueron satisfactorios, por lo que puede considerarse una estrategia efectiva para reducir la incidencia de esta afección que puede causar gran morbilidad y mortalidad postoperatoria.

  12. Ethical challenges and solutions regarding delirium studies in palliative care.

    PubMed

    Sweet, Lisa; Adamis, Dimitrios; Meagher, David J; Davis, Daniel; Currow, David C; Bush, Shirley H; Barnes, Christopher; Hartwick, Michael; Agar, Meera; Simon, Jessica; Breitbart, William; MacDonald, Neil; Lawlor, Peter G

    2014-08-01

    Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges. Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients. Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines. Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models. Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  13. Opioid medications and longitudinal risk of delirium in hospitalized cancer patients.

    PubMed

    Gaudreau, Jean-David; Gagnon, Pierre; Roy, Marc-André; Harel, François; Tremblay, Annie

    2007-06-01

    Delirium is an important problem in hospitalized cancer patients. The objective of this study was to determine whether exposure to corticosteroids, benzodiazepines, or opioids predicted delirium. A prospective cohort study was conducted in an oncology/internal medicine population. Patients were assessed continuously for the presence of delirium until they were discharged by using the Nursing Delirium Screening Scale (Nu-DESC). Follow-up for outcome began after incident delirium. The primary outcome was the presence of a delirium event, which was defined as a Nu-DESC score >1. Strengths of associations of medications with delirium were expressed as odds ratios (ORs) in univariate and multivariate analyses. In total, 114 patients (1823 patient-days) met the inclusion criteria for the study. The mean follow-up from incident delirium was 16 days. The mean number of delirium events by patient was 6 (total number, 667 delirium events). Analysis by day on several occasions revealed significant associations between opioids and delirium. Corticosteroids and benzodiazepines were not associated significantly with an increased risk of delirium on any given day. Analysis by patient using generalized estimating equation (GEE) models showed an increased risk of delirium on any day of follow-up associated with opioid exposure in univariate analysis (OR of 1.70; P<.0001). The association remained significant after adjustment for corticosteroid, benzodiazepine, and antipsychotic exposure using GEE regressions (OR of 1.37; P=.0033). Truncating follow-up at 30 days did not affect the results (OR of 1.38; P<.032). Exposure to opioids during hospitalization was associated significantly with an increased longitudinal risk of delirium. (c) 2007 American Cancer Society.

  14. The Effect of Treatment of Anemia with Blood Transfusion on Delirium: A Systematic Review.

    PubMed

    van der Zanden, Vera; Beishuizen, Sara J; Swart, Lieke M; de Rooij, Sophia E; van Munster, Barbara C

    2017-04-01

    Treating the precipitating factors of delirium is the mainstay of the prevention and treatment of delirium. We aim to investigate the role of anemia and blood transfusion within the multicomponent prevention and treatment strategy of delirium. Systematic review. We included cohort studies or Randomized Controlled Trials (RCTs) that considered blood transfusion as treatment for delirium or risk factor, and had delirium as outcome. Hospitalized patients above 55 years old. We searched MEDLINE from 1946 through November 2014. Quality assessment and data extraction were performed systematically. We included 23 studies (n = 29,471). The majority of the studies (n = 22) had a limited quality and for one study quality was uncertain. Two studies evaluated the association between transfusion strategy and postoperative delirium and found no association. Twenty-one studies investigated blood transfusion as a risk factor for delirium. In four of the 21 studies it could be assumed that delirium occurred after transfusion. One of these studies stated that transfusion was a significant risk factor for subsequent delirium (odds ratio (OR) = 3.68, 95% confidence interval (CI) = 1.32-10.94). The other three studies found no association between transfusion and delirium. In the remaining 17 studies, it was not clear whether delirium occurred before or after transfusion, so no conclusion could be drawn on the role of transfusion in delirium development. The majority of the included studies was not suited to answer the research question properly as the time course of the beginning of delirium as to transfusion was lacking. Our review shows that there is no good quality evidence available for blood transfusion to be a risk factor for delirium or to be a preventive or treatment option. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  15. Cigarette smoking is an independent risk factor for post-stroke delirium.

    PubMed

    Lim, Tae Sung; Lee, Jin Soo; Yoon, Jung Han; Moon, So Young; Joo, In Soo; Huh, Kyoon; Hong, Ji Man

    2017-03-23

    Post-stroke delirium is a common problem in the care of stroke patients, and is associated with longer hospitalization, high short-term mortality, and an increased need for long-term care. Although post-stroke delirium occurs in approximately 10 ~ 30% of patients, little is known about the risk factors for post-stroke delirium in patients who experience acute stroke. A total of 576 consecutive patients who experienced ischemic stroke (mean age, 65.2 years; range, 23-93 years) were screened for delirium over a 2-year period in an acute stroke care unit of a tertiary referral hospital. We screened for delirium using the Confusion Assessment Method. Once delirium was suspected, we evaluated the symptoms using the Korean Version of the Delirium Rating Scale-Revised-98. Neurological deficits were assessed using the National Institutes of Health Stroke Scale at admission and discharge, and functional ability was assessed using the Barthel Index and modified Rankin Scale at discharge and 3 months after discharge. Thirty-eight (6.7%) patients with stroke developed delirium during admission to the acute stroke care unit. Patients with delirium were significantly older (70.6 vs. 64.9 years of age, P = .001) and smoked cigarettes more frequently (40% vs. 24%, P = .033) than patients without delirium. In terms of clinical features, the delirium group experienced a significantly higher rate of major hemispheric stroke (55% vs. 26%, P < .001), exhibited poorer functional performance at discharge and 3 months after discharge, and stayed in hospital significantly longer. Independent risk factors for delirium were older age, history of cigarette smoking, and major hemispheric stroke. Abrupt cessation of cigarette smoking may be a risk factor for post-stroke delirium in ischemic stroke patients. The development of delirium after stroke is associated with worse outcome and longer hospitalization.

  16. Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience.

    PubMed

    Morandi, Alessandro; Lucchi, Elena; Turco, Renato; Morghen, Sara; Guerini, Fabio; Santi, Rossana; Gentile, Simona; Meagher, David; Voyer, Philippe; Fick, Donna; Schmitt, Eva M; Inouye, Sharon K; Trabucchi, Marco; Bellelli, Giuseppe

    2015-10-01

    Delirium superimposed on dementia is common and is associated with adverse outcomes. Yet little is known about the patients' personal delirium experiences. We used quantitative and qualitative methods to assess the delirium superimposed on dementia experience among older patients. We conducted a prospective cohort study among patients with delirium superimposed on dementia who were admitted to a rehabilitation ward. Delirium was diagnosed using DSM-IV-TR criteria. Delirium severity and symptoms were evaluated with the Delirium-O-Meter (D-O-M). The experience of delirium was assessed after delirium resolution (T0) and one month later (T1) with a standardized questionnaire and a qualitative interview. Level of distress was measured with the Delirium Experience Questionnaire. Of the 30 patients included in the study, 50% had mild dementia; 33% and 17% had moderate and severe dementia. Half of the patients had evidence of the full range of D-O-M delirium symptoms. We evaluated 30 patients at T0 and 20 at T1. At T0, half of the patients remembered being confused as part of the delirium episode, and reported an overall moderate level of related distress. Patients reported high distress related to memories of anxiety/fear, delusions, restlessness, hypokinesia, and impaired orientation. Qualitative interviews revealed six main aspects of patient delirium experiences: Emotions; Cognitive Impairment; Psychosis; Memories; Awareness of Change; and Physical Symptoms. The study provides novel information on the delirium experience in patients with dementia. These findings are the key for health care providers to improve the everyday care of this important group of frail older patients. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. Randomized Trial of a Delirium Abatement Program for Post-acute Skilled Nursing Facilities

    PubMed Central

    Marcantonio, Edward R.; Bergmann, Margaret A.; Kiely, Dan K.; Orav, E John; Jones, Richard N.

    2010-01-01

    Objectives To determine whether a Delirium Abatement Program (DAP) can shorten the duration of delirium among new admissions to post-acute care (PAC). Design Cluster randomized controlled trial. Setting Eight skilled nursing facilities specializing in PAC within a single metropolitan region. Participants Four hundred fifty-seven participants with delirium at PAC admission. Intervention The DAP consisted of four steps: 1) assessment for delirium within 5 days of PAC admission, 2) assessment and correction of common reversible causes of delirium, 3) prevention of complications of delirium, and 4) restoration of function. Measurements Eligible patients were screened by trained researchers. Those with Confusion Assessment Method defined delirium were eligible for participation via proxy consent. Two weeks and one month after enrollment, regardless of location, participants were re-assessed for delirium by researchers blind to intervention status. Results Nurses at DAP sites detected delirium in 41% of participants vs. 12% in usual care (UC) sites (p<.001) and completed DAP documentation in most delirium-detected participants. However, the DAP intervention had no impact on delirium persistence based on two measurements at 2 weeks (DAP 68% vs. UC 66%) and 1 month (DAP 60% vs. UC 51%), adjusted p values ≥ 0.20. Adjusting for baseline differences between DAP and UC participants and restricting analysis to delirium-detected DAP participants did not alter the results. Conclusion Detection of delirium improved at the DAP sites, however, the DAP had no impact on the persistence of delirium. This effectiveness trial demonstrated that a nurse-led DAP intervention was not effective in typical PAC facilities. PMID:20487083

  18. Delirium superimposed on dementia: a quantitative and qualitative evaluation of patient experience

    PubMed Central

    Morandi, Alessandro; Lucchi, Elena; Turco, Renato; Morghen, Sara; Guerini, Fabio; Santi, Rossana; Gentile, Simona; Meagher, David; Voyer, Philippe; Fick, Donna; Schmitt, Eva M.; Inouye, Sharon K.; Trabucchi, Marco; Bellelli, Giuseppe

    2015-01-01

    Objective Delirium superimposed on dementia is common and is associated with adverse outcomes. Yet little is known about the patients’ personal delirium experiences. We used quantitative and qualitative methods to assess the delirium superimposed on dementia experience among older patients. Methods We conducted a prospective cohort study among patients with delirium superimposed on dementia who were admitted to a rehabilitation ward. Delirium was diagnosed using DSM-IV-TR criteria. Delirium severity and symptoms were evaluated with the Delirium-O-Meter (D-O-M). The experience of delirium was assessed after delirium resolution (T0) and one month later (T1) with a standardized questionnaire and a qualitative interview. Level of distress was measured with the Delirium Experience Questionnaire. Results Of the 30 patients included in the study, 50% had mild dementia; 33% and 17% had moderate and severe dementia. Half of the patients had evidence of the full range of D-O-M delirium symptoms. We evaluated 30 patients at T0 and 20 at T1. At T0, half of the patients remembered being confused as part of the delirium episode, and reported an overall moderate level of related distress. Patients reported high distress related to memories of anxiety/fear, delusions, restlessness, hypokinesia, and impaired orientation. Qualitative interviews revealed six main aspects of patients delirium experiences: Emotions; Cognitive Impairment; Psychosis; Memories; Awareness of Change; and Physical Symptoms. Conclusions The study provides novel information on the delirium experience in patients with dementia. These findings are key for health care providers to improve the everyday care of this important group of frail older patients. PMID:26282373

  19. Pain Assessment in Hospitalized Older Adults With Dementia and Delirium

    PubMed Central

    Paulson, Christina May; Monroe, Todd; Mion, Lorraine C.

    2015-01-01

    Pain can have negative effects leading to prolonged hospital stays. Determining the presence of uncontrolled and untreated pain in patients with cognitive impairments such as delirium, dementia, and delirium superimposed on dementia (DSD) is challenging. One tool commonly suggested for use in assessment of pain in older adults with cognitive impairment is the Pain Assessment In Advanced Dementia (PAINAD) scale. Proper use of the PAINAD scale as part of a comprehensive pain management plan can help reduce the likelihood of a patient experiencing unrecognized and untreated pain. Using an individual example, this article illustrates best practices in pain assessment and management for a woman experiencing DSD during an acute hospitalization. PMID:24800815

  20. Suspected Delirium Predicts the Thoroughness of Catatonia Evaluation.

    PubMed

    Llesuy, Joan Roig; Coffey, M Justin; Jacobson, Kristen C; Cooper, Joseph J

    2016-11-30

    Although commonly linked to psychiatric disorders, catatonia is frequently identified secondary to neurological and general medical conditions (GMCs). The present study aimed to characterize the diagnostic workup of cases of catatonia in a general hospital setting. The authors performed a retrospective chart review of 54 cases of catatonia, over 3 years. Clinical suspicion of comorbid delirium was the strongest predictor of a more thorough general medical workup. Attribution of catatonia to a psychiatric etiology was associated with significantly less diagnostic workup. Prospective studies should help clarify the relationship between catatonia and delirium and standardize the diagnostic approach to patients presenting with catatonia.

  1. Sepsis associated delirium mimicking postoperative delirium as the initial presenting symptom of urosepsis in a patient who underwent nephrolithotomy.

    PubMed

    Nag, Deb Sanjay; Chatterjee, Abhishek; Samaddar, Devi Prasad; Singh, Harprit

    2016-05-16

    We report a case of 70 years old male who underwent percutaneous nephrolithotomy for renal calculi. After an uneventful recovery from anaesthesia, the patient developed delirium which manifested as restlessness, agitation, irritability and combative behavior. All other clinical parameters including arterial blood gas, chest X-ray and core temperature were normal and the patient remained haemodynamically stable. But 45 min later the patient developed florid manifestations of septic shock. He was aggressively managed in a protocolized manner as per the Surviving Sepsis Guidelines in the Critical Care Unit and recovered completely. There are no case reports showing postoperative delirium as the only initial presentation of severe sepsis, with other clinical parameters remaining normal. Both urosepsis and sepsis associated delirium have very high mortality. High index of suspicion and a protocolized approach in the management of sepsis can save lives.

  2. Delirium as a complication of the surgical intensive care

    PubMed Central

    Horacek, Rostislav; Krnacova, Barbora; Prasko, Jan; Latalova, Klara

    2016-01-01

    Background The aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery. Patients and methods Patients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation–agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved. Results The sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48%) admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12–240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal–Wallis test: 8.022; P<0.05). The duration of delirium was significantly correlated also with blood potassium levels (Pearson’s r=0.2189, P<0.05), hypotension (hypotension 40.41±30.23 hours versus normotension 70.47±54.98 hours; Mann–Whitney U=1,512; P<0.05), administration of antipsychotics compared to other drugs (antipsychotics 72.83±40.6, benzodiazepines 42.00±20.78, others drugs, mostly piracetam 46.96±18.42 hours; Kruskal

  3. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes.

    PubMed

    Han, Jin H; Zimmerman, Eli E; Cutler, Nathan; Schnelle, John; Morandi, Alessandro; Dittus, Robert S; Storrow, Alan B; Ely, E Wesley

    2009-03-01

    Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians (EPs). Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by EPs. The authors sought to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, to identify delirium risk factors in older ED patients, and to characterize delirium by psychomotor subtypes in the ED setting. This cross-sectional study was a convenience sample of patients conducted at a tertiary care, academic ED. English-speaking patients who were 65 years and older and present in the ED for less than 12 hours at the time of enrollment were included. Patients were excluded if they refused consent, were previously enrolled, had severe dementia, were unarousable to verbal stimuli for all delirium assessments, or had incomplete data. Delirium status was determined by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants (RAs). Recognition of delirium by emergency and hospital physicians was determined from the medical record, blinded to CAM-ICU status. Multivariable logistic regression was used to identify independent delirium risk factors. The Richmond Agitation and Sedation Scale was used to classify delirium by its psychomotor subtypes. Inclusion and exclusion criteria were met in 303 patients, and 25 (8.3%) presented to the ED with delirium. The vast majority (92.0%, 95% confidence interval [CI] = 74.0% to 99.0%) of delirious patients had the hypoactive psychomotor subtype. Of the 25 patients with delirium, 19 (76.0%, 95% CI = 54.9% to 90.6%) were not recognized to be delirious by the EP. Of the 16 admitted delirious patients who were undiagnosed by the EPs, 15 (93.8%, 95% CI = 69.8% to 99.8%) remained unrecognized by the hospital

  4. An open trial of aripiprazole for the treatment of delirium in hospitalized cancer patients.

    PubMed

    Boettger, Soenke; Breitbart, William

    2011-12-01

    The purpose of this study was to examine the efficacy and safety of aripiprazole in the treatment of delirium in hospitalized cancer patients, and to examine differential responses based on delirium subtypes. We conducted an analysis of 21 hospitalized cancer patients at Memorial Sloan-Kettering Cancer Center (MSKCC) who had been evaluated and treated for delirium with aripiprazole, using an MSKCC Institutional Review Board (IRB) approved Clinical Delirium Database. Measures used were the Memorial Delirium Assessment Scale (MDAS), the Karnofsky Scale of Performance Status (KPS), and side effect rating at baseline (T1), 2-3 days (T2), and 4-7 days (T3). All measurements were integrated into the routine clinical care of patients. Doses of aripiprazole were adjusted based on clinical response. Patients treated for delirium with aripiprazole experienced significant improvement and resolution of delirium, with MDAS scores declining from a mean of 18.0 at baseline (T1) to mean of 10.8 at T2 and a mean of 8.3 at T3. KPS scores improved from 28.1 at baseline (T1) to 35.2 at T2 and 41 at T3. Delirium resolved (based on MDAS < 10) in 52.4% of cases at T2 and in 76.2% at T3. The mean dosage of aripiprazole required was 18.3 mg (range of 5-30) daily at T3. In our cohort of patients with hypoactive delirium, we observed a delirium resolution rate of 100% compared to the cohort of patients with hyperactive delirium (58.3% rate of delirium resolution). MDAS scores improved from 15.6 at T1 to 5.7 at T3 in hypoactive delirium and from 19.9 at T1 to 10.2 at T3 in hyperactive delirium. In patients with pre-morbid cognitive deficits and the hyperactive subtype of delirium, we observed a more limited treatment response to aripiprazole treatment for delirium. There were no clinically significant side effects noted. Aripiprazole is effective and safe in the treatment of delirium in hospitalized cancer patients. These preliminary finding suggest that aripiprazole may be most effective in

  5. The Frequency, Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit

    PubMed Central

    Ransing, Viraj; Yennu, Sriram; Wu, Jimin; Liu, Diane; Reddy, Akhila; Delgado-Guay, Marvin; Bruera, Eduardo

    2015-01-01

    Background. Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency, characteristics, and outcomes of delirium in patients with advanced cancer admitted to an APCU. Methods. Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients’ demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score ≥7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. Results. Of 556 patients in the APCU, 323 (58%) had a diagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admission and 94 (29%) developed delirium after admission to the APCU. Delirium reversed in 85 of 323 episodes (26%). Half of patients with delirium (n = 162) died. Patients with the diagnosis of delirium had a lower median overall survival than those without delirium. Patients who developed delirium after admission to the APCU had poorer survival (p ≤ .0001) and a lower rate of delirium reversal (p = .03) compared with those admitted with delirium. Conclusion. More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival. Implications for Practice: Delirium is the most common neuropsychiatric condition in patients with severe

  6. Preventing ICU Subsyndromal Delirium Conversion to Delirium with Low Dose IV Haloperidol: A Double-Blind, Placebo-Controlled Pilot Study

    PubMed Central

    Al-Qadheeb, Nada S.; Skrobik, Yoanna; Schumaker, Greg; Pacheco, Manuel; Roberts, Russel; Ruthazer, Robin; Devlin, John W

    2016-01-01

    Objective To compare the efficacy and safety of scheduled low-dose, haloperidol vs. placebo for the prevention of delirium [Intensive Care Delirium Screening Checklist (ICDSC) ≥ 4)] administered to critically ill adults with subsyndromal delirium (ICDSC = 1-3). Design Randomized, double-blind, placebo-controlled trial. Setting Three 10-bed ICUs (2 medical; 1 surgical) at an academic medical center in the U.S. Patients Sixty-eight mechanically ventilated patients with subsyndromal delirium without complicating neurologic conditions, cardiac surgery or requiring deep sedation. Interventions Patients were randomly assigned to receive intravenous haloperidol 1 mg or placebo every six hours until either delirium (ICDSC ≥ 4 with psychiatric confirmation), therapy ≥ 10 days or ICU discharge occurred. Measurements and Main Results Baseline characteristics were similar between the haloperidol (n=34) and placebo (n=34) groups. A similar number of patients given haloperidol [12/34 (35%)] and placebo [8/34 (23%)] patients developed delirium (p=0.29). Haloperidol use reduced the hours per study day spent agitated (SAS ≥ 5) (p=0.008), but did not influence the proportion of 12-hour ICU shifts patients’ spent alive without coma (SAS ≤ 2) or delirium (p=0.36), the time to first delirium occurrence (p=0.22) nor delirium duration (p=0.26). Days of mechanical ventilation (p=0.80), ICU mortality (p=0.55) and ICU patient disposition (p=0.22) were similar in the two groups. The proportion of patients who developed QTc-interval prolongation (p=0.16), extrapyramidal symptoms (p=0.31), excessive sedation (p=0.31) or new-onset hypotension (p=1.0) that resulted in study drug discontinuation was comparable between the two groups. Conclusions Low-dose scheduled haloperidol, initiated early in the ICU stay, does not prevent delirium and has little therapeutic advantage in mechanically ventilated, critically ill adults with subsyndromal delirium. PMID:26540397

  7. Assessing the role of hydration in delirium at the end of life.

    PubMed

    Galanakis, Chrissi; Mayo, Nancy E; Gagnon, Bruno

    2011-06-01

    Delirium is the most frequent neuropsychiatric disorder that affects the advanced cancer population who are receiving palliative care. There is limited evidence and much debate about the role of hydration in delirium management at the end of life. The purpose of this article is to review the literature on delirium management with regards to pharmacological management and hydration. Pharmacological management is the first line of treatment for delirium, whereby antipsychotics are the medication of choice. However, they have not been approved by the United States Food and Drug Administration for delirium management as there is insufficient evidence supporting their use. Hydration is a believed to be a key component of delirium reversibility; yet there are conflicting results on its efficacy as an intervention for delirium management. As there are few studies of good methodological quality on the topic and large variations in practice, the effectiveness of hydration as an alternative management option for delirium is unclear. More work is required to assess the role of hydration in delirium at the end of life. Given the lack of evidence-based research on hydration, more randomized clinical trials are needed to elucidate the effects of hydration as a delirium intervention.

  8. Atypical antipsychotics in the management of delirium: a review of the empirical literature.

    PubMed

    Boettger, Soenke; Breitbart, William

    2005-09-01

    To review the existing literature of atypical antipsychotics in the treatment of delirium and make recommendations regarding their use in the treatment of delirium. I conducted a literature search in Pubmed, Psychlit, and Embase for studies using atypical antipsychotics in the treatment of delirium. In the absence of studies, case reports were used. Overall 13 studies examined the use of risperidone, olanzapine, and quetiapine, two cases were reported about ziprasidone, and no publication was found using aripiprazole in the treatment of delirium. Among the existing studies were retrospective and prospective, open label studies in addition to one with a double blind design using risperidone. Risperidone, olanzapine, and quetiapine may be all similarly effective in the treatment of delirium, whereas there may be limited efficacy in the use of olanzapine in the hypoactive subtype of delirium in elderly populations, which may generalize to the other atypical antipsychotics. The use of atypical antipsychotics in the treatment of delirium is safe and carries a low burden of side effects. Although atypical antipsychotics are widely used in the treatment of delirium, well-designed studies do not exist. Among the existing studies, stronger data supports the use of risperidone and olanzapine, and also quetiapine may be considered in the treatment of delirium. Recommendations are made based on the existing data and literature. The need for well-designed studies to validate the use of atypical antipsychotics in the treatment of delirium continues.

  9. Effect of preadmission sunlight exposure on intensive care unit-acquired delirium: a multicenter study.

    PubMed

    Simons, Koen S; Workum, Jessica D; Slooter, Arjen J C; van den Boogaard, Mark; van der Hoeven, Johannes G; Pickkers, Peter

    2014-04-01

    It is assumed that there is a relation between light exposure and delirium incidence. The aim of our study was to determine the effect of prehospital light exposure on the incidence of intensive care unit (ICU)-acquired delirium. Data from 3 ICUs in the Netherlands were analyzed retrospectively. Delirium was assessed with the Confusion Assessment Method for the ICU. Daily light intensity data were obtained from meteorological stations in the vicinity of the 3 hospitals. The association between light intensity and delirium incidence was analyzed using logistic regression analysis adjusting for known covariates for delirium. Data of 3198 patients, aged (mean ± SD) 61.9 ± 15.3 years with Acute Physiology and Chronic Health Evaluation II score 16.4 ± 6.6 were analyzed. Delirium incidence was 31.2% and did not vary significantly throughout the year. Twenty-eight-day preadmission photoperiod was highest in spring and lowest in winter; however, no association between light exposure and delirium incidence was found (odds ratio, 1.00; 95% confidence interval, 0.99-1.00; P = 0.72). Furthermore, delirium was significantly associated with age, infection, use of sedatives, Acute Physiology and Chronic Health Evaluation II score, and diagnosis of neurological disease or trauma. The incidence of delirium does not differ per season and prior sunlight exposure does not play a role of importance in the development of ICU-acquired delirium. Copyright © 2014 Elsevier Inc. All rights reserved.

  10. Prevention of delirium in hospitalized older patients: risk factors and targeted intervention strategies.

    PubMed

    Inouye, S K

    2000-05-01

    Delirium is a common, costly, and potentially devastating condition for hospitalized older patients. Delirium is a multifactorial syndrome, involving the inter-relationship between patient vulnerability, or predisposing factors at admission, and noxious insults or precipitating factors during hospitalization. Through a series of studies, we first identified significant predisposing factors for delirium, including vision impairment, severe illness, cognitive impairment, and dehydration. Subsequently, significant precipitating factors were identified, including physical restraint use, malnutrition, adding more than three drugs, bladder catheter use, and any iatrogenic event. Through targeting preventive strategies towards six identified risk factors in a controlled clinical trial, we were successful in the primary prevention of delirium. In 852 subjects, the incidence of delirium was significantly reduced in the intervention group compared with usual care (9.9% vs 15.0%, matched odds ratio: 0.60; 95% confidence interval: 0.39-0.92). The total number of days and episodes of delirium were also significantly reduced in the intervention group. Based on this work, evidence-based recommendations for delirium prevention are proposed. While not all cases of delirium will be preventable with this approach, unifying medical and epidemiological approaches to delirium represents a key advance essential to reducing the high morbidity and mortality associated with delirium in the older population.

  11. A Family-Focused Delirium Educational Initiative With Practice and Research Implications.

    PubMed

    Paulson, Christina May; Monroe, Todd; McDougall, Graham J; Fick, Donna M

    2016-01-01

    Delirium is burdensome and psychologically distressing for formal and informal caregivers, yet family caregivers often have very little understanding or knowledge about delirium. As part of a large multisite intervention study, the Early Nurse Detection of Delirium Superimposed on Dementia (END-DSD), the authors identified a need for family educational materials. This educational initiative's purpose was to develop a delirium admission brochure for family members to aid in the prevention and earlier identification of delirium during hospitalization. A brochure was developed using an iterative approach with an expert panel. Following three iterations, a final brochure was approved. The authors found that an iterative expert consensus approach can be used to develop a brochure for families. Major content areas were helping families understand the difference between delirium and dementia, signs and symptoms of delirium, causes of delirium, and strategies family members can use to prevent delirium. A caregiver-focused educational brochure is one intervention to use in targeting older adults hospitalized with delirium.

  12. Underreporting of Delirium in Statewide Claims Data: Implications for Clinical Care and Predictive Modeling.

    PubMed

    McCoy, Thomas H; Snapper, Leslie; Stern, Theodore A; Perlis, Roy H

    2016-01-01

    Delirium is an acute neuropsychiatric syndrome that portends poor prognosis and represents a significant burden to the health care system. Although detection allows for efficacious treatment, the diagnosis is frequently overlooked. This underdiagnosis makes delirium an appealing target for translational predictive algorithmic modeling; however, such approaches require accurate identification in clinical training datasets. Using the Massachusetts All-Payers Claims Database, encompassing health claims for Massachusetts residents for 2012, we calculated the rate of delirium diagnosis in index hospitalizations by reported ICD-9 diagnosis code. We performed a review of published studies formally assessing delirium to establish an expected rate of delirium when formally assessed. Secondarily, we reported a sociodemographic comparison of cases and noncases. Rates of delirium reported in the literature vary widely, from 3.6-73% with a mean of 23.6%. The statewide claims data (Massachusetts All-Payers Claims Database) identified the rate of delirium among index hospitalizations to be only 2.1%. For Massachusetts All-Payers Claims Database hospitalizations, delirium was coded in 2.8% of patients >65 years old and for 1.2% of patients ≤65. The lower incidence of delirium in claims data may reflect a failure to diagnose, a failure to code, or a lower rate in community hospitals. The relative absence of the phenotype from large databases may limit the utility of data-driven predictive modeling to the problem of delirium recognition. Copyright © 2016. Published by Elsevier Inc.

  13. Environmental and Clinical Risk Factors for Delirium in a Neurosurgical Center: A Prospective Study.

    PubMed

    Matano, Fumihiro; Mizunari, Takayuki; Yamada, Keiko; Kobayashi, Shiro; Murai, Yasuo; Morita, Akio

    2017-07-01

    Few reports of delirium-related risk factors have focused on environmental risk factors and clinical risk factors, such as white matter signal abnormalities on magnetic resonance imaging fluid attenuated inversion recovery images. We prospectively enrolled 253 patients admitted to our neurosurgical center between December 2014 and June 2015 and analyzed 220 patients (100 male patients; mean age, 64.1 years; age range, 17-92 years). An Intensive Care Delirium Screening Checklist score ≥4 points indicated delirium. We evaluated patient factors consisting of baseline characteristics and related factors, such as white matter lesions (WMLs), as well as the surrounding environment. Delirium occurred in 29/220 cases (13.2%). Regarding baseline characteristics, there were significant statistical correlations between delirium and age (P = 0.0187), Hasegawa Dementia Scale-Revised score (P = 0.0022) on admission, and WMLs (P < 0.0001). WMLs were related to age (P < 0.0001) and atherosclerotic disease (P = 0.004). Regarding related factors, there were significant statistical correlations between delirium and stay in a neurosurgical care unit (P = 0.0245). Multivariate logistic regression analyses showed statistically significant correlations of delirium with WMLs (P < 0.0001) and surrounding patients with delirium (P = 0.026). WMLs in patients and the surrounding environment are risk factors for delirium in a neurosurgical center. To prevent delirium, clinicians must recognize risk factors, such as high-grade WMLs, and manage environmental factors. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. [Anticholinergic burden and delirium in elderly patients during acute hospital admission].

    PubMed

    Rojo-Sanchís, Aurora M; Vélez-Díaz-Pallarés, Manuel; Muñoz García, María; Delgado Silveira, Eva; Bermejo Vicedo, Teresa; Cruz Jentoft, Alfonso

    2016-01-01

    The use of anticholinergic drugs in the elderly has been associated to an increased frequency of delirium. There are different scales for estimating the anticholinergic burden, such as the Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), and Anticholinergic Cognitive Burden (ACB). The aim of the study is to establish the relationship between anticholinergic burden measured by ADS, ARS, and ACB scales and incident or prevalent delirium. An ambispective observational study was conducted for 76 days in the acute geriatric unit of a tertiary hospital. All patients over 80 years-old were included, except re-admissions or those subjected to palliative care. The data collected included sex, age, chronic medication and any recent changes, recent drugs prescribed prior to an episode of delirium, chronic kidney disease, diabetes mellitus, dementia, visual and auditory impairment, and their combination as sensory impairment, previous falls, stroke, brain tumour, and incident and prevalent delirium. A total of 72 patients were included. Incident delirium was detected in 8.1% of the patients, and prevalent delirium in 40.9%. A statistically significant association was established between anticholinergic drugs and the incident delirium measured by the ARS scale (P=.017). None of the scales was able to establish a significant association with prevalent delirium. The ARS scale was related to new episodes of delirium. All scales were insufficient when it came to establishing an association with prevalent delirium. Copyright © 2016 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.

  15. Relationship between pain and opioid analgesics on the development of delirium following hip fracture.

    PubMed

    Morrison, R Sean; Magaziner, Jay; Gilbert, Marvin; Koval, Kenneth J; McLaughlin, Mary Ann; Orosz, Gretchen; Strauss, Elton; Siu, Albert L

    2003-01-01

    Delirium and pain are common following hip fracture. Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery. This study was performed to examine the relationship among pain, analgesics, and other factors on delirium in hip fracture patients. We conducted a prospective cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium. Delirium was identified prospectively by patient interview supplemented by medical record review. Multiple logistic regression was used to identify risk factors. Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8-7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2-4.7), and heart failure (RR 2.9, 95% CI 1.6-5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4-12.3). Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3-4.5). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2). Using admission data, clinicians can identify patients at high risk for delirium following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults.

  16. Clinical associations of delirium in hospitalized adult patients and the role of on admission presentation.

    PubMed

    Lin, Robert Y; Heacock, Laura C; Bhargave, Geeta A; Fogel, Joyce F

    2010-10-01

    To describe clinical associations of delirium in hospitalized patients and relationships to on admission presentation. Retrospective analysis of an administrative hospitalization database 1998-2007. Acute care hospitalizations in the New York State (NYS). Four categories of diagnosis related group (DRG) hospitalizations were extracted from a NYS administrative database: pneumonia, congestive heart failure, urinary tract/kidney infection (UTI), and lower extremity orthopedic surgery (LEOS) DRGs. These hospitalizations were examined for clinical associations with delirium coding both on and after admission. Delirium was coded in 0.8% of the cohort, of which an on admission diagnosis was present in 59%. On admission delirium was strongly associated with dementia (adjusted odds ratio 0, 95%CI 5.8-6.3) and with adverse drug effects (ADEs) (adjusted odds ratio 4.6, 95%CI 4.3, 5.0). After admission delirium was even more highly associated with ADEs (adjusted odds ratio 22.2, 95%CI 20.7-23.7). The UTI DRG category had the greatest proportion of on admission delirium. However after admission delirium was more common in the LEOS DRG category. Over time, there was a greater increase in delirium proportions in the UTI DRG category, and an overall increase in coding for encephalopathy states (potential alternative delirium descriptors). ADEs play an important role in delirium regardless of whether or not it is present on admission. While the finding that most delirium hospitalizations presented on admission suggests that delirium impacts more as a clinical admitting determinant, in-hospital prevention strategies may still have benefit in targeted settings where after admission delirium is more frequent, such as patients with LEOS. Copyright © 2010 John Wiley & Sons, Ltd.

  17. Delirium in the Cardiovascular Intensive Care Unit: Exploring Modifiable Risk Factors

    PubMed Central

    McPherson, John A.; Wagner, Chad E.; Boehm, Leanne M.; Hall, J. David; Johnson, Daniel C.; Miller, Leanna R.; Burns, Kathleen M.; Thompson, Jennifer L.; Shintani, Ayumi K; Ely, E. Wesley; Pandharipande, Pratik P.

    2012-01-01

    Objective Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery intensive care unit (CVICU) is not well established. We sought to determine the prevalence and risk factors for delirium among CVICU patients. Design Prospective observational study. Setting 27-bed medical-surgical CVICU. Patients 200 consecutive patients with an expected CVICU length of stay >24 hours. Interventions None. Measurements Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the CVICU stay and identified daily occurring risk factors for the development of delirium on a subsequent CVICU day. Main Results Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use on admission was independently predictive of a 3-fold increased risk of delirium [Odds Ratio 3.1 (1, 9.4), p=0.04] during the CVICU stay. Of the daily occurring risk factors, patients who received benzodiazepines [2.6 (1.2, 5.7), p=0.02] or had restraints or devices that precluded mobilization [2.9 (1.3, 6.5), p<0.01] were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. Conclusions Delirium occurred in 1 in 4 patients in the CVICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of CVICUs. PMID:23263581

  18. Delirium frequency among advanced cancer patients presenting to an emergency department: A prospective, randomized, observational study.

    PubMed

    Elsayem, Ahmed F; Bruera, Eduardo; Valentine, Alan D; Warneke, Carla L; Yeung, Sai-Ching J; Page, Valda D; Wood, Geri L; Silvestre, Julio; Holmes, Holly M; Brock, Patricia A; Todd, Knox H

    2016-09-15

    The frequency of delirium among patients with cancer presenting to the emergency department (ED) is unknown. The purpose of this study was to determine delirium frequency and recognition by ED physicians among patients with advanced cancer presenting to the ED of The University of Texas MD Anderson Cancer Center. The study population was a random sample of English-speaking patients with advanced cancer who presented to the ED and met the study criteria. All patients were assessed with the Confusion Assessment Method (CAM) to screen for delirium and with the Memorial Delirium Assessment Scale (MDAS) to measure delirium severity (mild, ≤15; moderate, 16-22; and severe, ≥23). ED physicians were also asked whether their patients were delirious. Twenty-two of the 243 enrolled patients (9%) had CAM-positive delirium, and their median MDAS score was 14 (range, 9-21 [30-point scale]). The median age of the enrolled patients was 62 years (range, 19-89 years). Patients with delirium had a poorer performance status than patients without delirium (P < .001); however, the 2 groups did not differ in other characteristics. Ten of the 99 patients who were 65 years old or older (10%) had CAM-positive delirium, whereas 12 of the 144 patients younger than 65 years (8%) did (P = .6). According to the MDAS scores, delirium was mild in 18 patients (82%) and moderate in 4 patients (18%). Physicians correctly identified delirium in 13 of the CAM-positive delirious patients (59%). Delirium is relatively frequent and is underdiagnosed by physicians in patients with advanced cancer who are visiting the ED. Further research is needed to identify the optimal screening tool for delirium in ED. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2918-2924. © 2016 American Cancer Society. © 2016 American Cancer Society.

  19. Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units

    PubMed Central

    Angel, Clay; Brooks, Kristen; Fourie, Julie

    2016-01-01

    Context Delirium is common among inpatients aged 65 years and older and is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. At one hospital, baseline management of delirium on medical-surgical units varied greatly, and psychiatric consultations focused exclusively on crisis management. Objective To implement a multidisciplinary program for rapid identification and proactive management of patients with delirium on medical-surgical units. Design A pilot from September 2010 to July 2012 included 920 unique patients, of whom 470 were seen by the delirium management team. A delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role; the team provided assistance with diagnosis and recommendations for nonpharmacologic and pharmacologic management of delirium. Multidisciplinary education focused on delirium identification and management and nurses’ use of appropriate assessment tools. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. Main Outcome Measure Length of stay. Results During the study period, average LOS in the target population decreased from 8.5 days to 6.5 days (p = 0.001); average LOS for the Medical Center remained stable. Compared with patients whose delirium was diagnosed during the baseline period, patients who received a delirium diagnosis during the pilot period had a higher illness burden and were likelier to have a history of delirium and diagnosed dementia. Conclusion Program implementation was associated with reduced LOS among older inpatients with delirium. The delirium team is an effective model that can be quickly implemented with few additional resources. PMID:27644045

  20. Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units.

    PubMed

    Angel, Clay; Brooks, Kristen; Fourie, Julie

    2016-01-01

    Delirium is common among inpatients aged 65 years and older and is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. At one hospital, baseline management of delirium on medical-surgical units varied greatly, and psychiatric consultations focused exclusively on crisis management. To implement a multidisciplinary program for rapid identification and proactive management of patients with delirium on medical-surgical units. A pilot from September 2010 to July 2012 included 920 unique patients, of whom 470 were seen by the delirium management team. A delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role; the team provided assistance with diagnosis and recommendations for nonpharmacologic and pharmacologic management of delirium. Multidisciplinary education focused on delirium identification and management and nurses' use of appropriate assessment tools. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. Length of stay. During the study period, average LOS in the target population decreased from 8.5 days to 6.5 days (p = 0.001); average LOS for the Medical Center remained stable. Compared with patients whose delirium was diagnosed during the baseline period, patients who received a delirium diagnosis during the pilot period had a higher illness burden and were likelier to have a history of delirium and diagnosed dementia. Program implementation was associated with reduced LOS among older inpatients with delirium. The delirium team is an effective model that can be quickly implemented with few additional resources.

  1. Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery.

    PubMed

    Lingehall, Helena Claesson; Smulter, Nina; Engström, Karl Gunnar; Gustafson, Yngve; Olofsson, Birgitta

    2013-10-01

    Validation of the Swedish version of the Nursing Delirium Screening Scale as a screening tool for nurses to use to detect postoperative delirium in patients 70 years and older undergoing cardiac surgery. Delirium is common among old patients after cardiac surgery. Underdiagnosis and poor documentation of postoperative delirium is problematic, and nurses often misread the signs. A prospective observational study. Patients (n = 142) scheduled for cardiac surgery were assessed three times daily by the nursing staff using the Nursing Delirium Screening Scale. Nursing Delirium Screening Scale was compared with the Mini Mental State Examination and the Organic Brains Syndrome Scale, evaluated day one and day four postoperatively. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders - DSM-IV-TR criteria. A larger proportion of patients were diagnosed with delirium according to the Mini Mental State Examination and Organic Brains Syndrome Scale compared with the Nursing Delirium Screening Scale, both on day one and day four. The Nursing Delirium Screening Scale protocol identified the majority of hyperactive and mixed delirium patients, whereas several with hypoactive delirium were unrecognised. The Swedish version of the Nursing Delirium Screening Scale was easily incorporated into clinical care and showed high sensitivity in detecting hyperactive symptoms of delirium. However, in the routine use by nurses, the Nursing Delirium Screening Scale had low sensitivity in detecting hypoactive delirium, the most prevalent form of delirium after cardiac surgery. Nursing Delirium Screening Scale probably has to be combined with cognitive testing to detect hypoactive delirium. Nurses play a key role in detecting delirium. The Nursing Delirium Screening Scale was easy incorporated instrument for clinical practice and identified the majority of hyperactive and mixed delirium, but several of the patients with hypoactive delirium were unrecognised

  2. Delirium the under-recognised syndrome: survey of healthcare professionals' awareness and practice in the intensive care units.

    PubMed

    Selim, Abeer A; Wesley Ely, E

    2017-03-01

    To survey intensive care unit healthcare professionals' awareness and practice related to delirium. Despite the current evidence revealing the risks linked to delirium and advances in practice guidelines promoting delirium assessment, healthcare professionals show little sensitivity towards delirium and evident training needs. The study had a cross-sectional survey design. A sample of 168 intensive care unit healthcare professionals including nurses and physicians completed a semistructured questionnaire to survey their awareness, screening and management of delirium in intensive care units. The survey took place at 11 intensive care units from academic (university) and nonacademic (nonuniversity) governmental hospitals in Mansoura, Egypt. The mean score of delirium awareness was 64·4 ± 14·0 among intensive care unit healthcare professionals. Awareness of delirium was significantly lower when definition of delirium was not provided, among diploma nurses compared to bachelor degree nurses and physicians, among those who did not attend any workshop/lecture or read an article related to delirium and lastly, those who work in an intensive care unit when <50% of patients develop delirium. The survey found that only 26·8% of the healthcare professionals screen for delirium on a routine basis, and 14·3% reported attending workshops or lectures or reading an article related to delirium in the last year. In screening delirium, healthcare professionals did not use any tools, nor did they follow adopted protocols or guidelines to manage delirium. To manage delirium, 52·4% of the participants reported using sedatives, 36·9% used no drugs, and 10·7% reported using antipsychotics (primarily haloperidol). Intensive care unit healthcare professionals do not have adequate training or routine screening of delirium. There is an evident absence of using standardised tools or adapting protocols to monitor and manage delirium. This study has the potentials to shed some lights

  3. Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study.

    PubMed

    Tomlinson, Emily Jane; Phillips, Nicole M; Mohebbi, Mohammadreza; Hutchinson, Alison M

    2017-03-01

    To determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission. Incident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients who are most susceptible to incident delirium. Retrospective case-control study with two controls per case. An audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data were collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1 January 2012 and 31 December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation. Identified using logistic regression modelling, predisposing risk factors for incident delirium were dementia, cognitive impairment, functional impairment, previous delirium and fracture on admission. Precipitating risk factors for incident delirium were use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission. Multiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation. Nurses and other healthcare professionals should be aware of patients who have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and

  4. Effect of postoperative delirium on outcome after hip fracture.

    PubMed

    Edelstein, David M; Aharonoff, Gina B; Karp, Adam; Capla, Edward L; Zuckerman, Joseph D; Koval, Kenneth J

    2004-05-01

    Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year.

  5. [Development and validation of the Korean Nursing Delirium Scale].

    PubMed

    Kim, Kyoung-Nam; Kim, Cheol-Ho; Kim, Kwang-Il; Yoo, Hyun-Jung; Park, Si-Young; Park, Yeon-Hwan

    2012-06-01

    The aims of this study were to develop and test the validity of the Korean Nursing Delirium Scale (Nu-DESC) for older patients in hospital. The Korean Nu-DESC was developed based on the Nu-DESC (Gaudreau, 2005), and revised according to nursing records related to signs and symptoms of older patients with delirium (n=361) and the results of a pilot study (n=42) in one general hospital. To test the validity of the Korean Nu-DESC, 75 older patients whom nurses suspected of delirium from 731 older patients from 12 nursing units were assessed by bedside nurses using the Korean Nu-DESC. A Receiver Operating Characteristic Curve of the Korean Nu-DESC was constructed with an accompanying Area Under the Curve (AUC). Specific examples such as irritable, kidding, sleeping tendency, which were observed by bedside nurses in Korea, were identified in the five features of signs and symptoms of delirium in the instrument. The Korean Nu-DESC was psycho-metrically valid and had a sensitivity and specificity of .81-.76 and .97-.73, respectively. The AUC were .89, .74. Results of this study indicate that the Korean Nu-DESC is well-suited for widespread clinical use in busy inpatients settings and shows promise as a research instrument.

  6. A practical program for preventing delirium in hospitalized elderly patients.

    PubMed

    Inouye, Sharon K

    2004-11-01

    Delirium in hospitalized elderly patients is common and often unrecognized (especially the hypoactive type), and can lead to serious complications. A systematic program can improve the rate of recognition of this problem and decrease its incidence, and is cost-effective.

  7. Differential Diagnosis in Older Adults: Dementia, Depression, and Delirium.

    ERIC Educational Resources Information Center

    Gintner, Gary G.

    1995-01-01

    Examines three common disorders, dementia, depression, and delirium, which can be particularly difficult to diagnose in older adults. Presents three aspects that are helpful in making a decision: age-related differences, medical issues that need to be ruled out, and assessment methods particularly useful in the diagnostic process. (JPS)

  8. Differential Diagnosis in Older Adults: Dementia, Depression, and Delirium.

    ERIC Educational Resources Information Center

    Gintner, Gary G.

    1995-01-01

    Examines three common disorders, dementia, depression, and delirium, which can be particularly difficult to diagnose in older adults. Presents three aspects that are helpful in making a decision: age-related differences, medical issues that need to be ruled out, and assessment methods particularly useful in the diagnostic process. (JPS)

  9. Nursing care for people with delirium superimposed on dementia.

    PubMed

    Pryor, Claire; Clarke, Amanda

    2017-03-31

    Nursing and healthcare is changing in response to an ageing population. There is a renewed need for holistic nursing to provide clinically competent, appropriate and timely care for patients who may present with inextricably linked mental and physical health requirements. This article explores the dichotomy in healthcare provision for 'physical' and 'mental' health, and the unique role nurses have when caring for people with delirium superimposed on dementia (DSD). Delirium is prevalent in older people and recognised as 'acute brain failure'. As an acute change in cognition, it presents a unique challenge when occurring in a person with dementia and poses a significant risk of mortality. In this article, dementia is contrasted with delirium and subtypes of delirium presentation are discussed. Nurses can recognise DSD through history gathering, implementation of appropriate care and effective communication with families and the multidisciplinary team. A simple mnemonic called PINCH ME (Pain, INfection, Constipation, deHydration, Medication, Environment) can help identify potential underlying causes of DSD and considerations for care planning. The mnemonic can easily be adapted to different clinical settings and a fictitious scenario is presented to show its application in practice.

  10. A quick and easy delirium assessment for nonphysician research personnel.

    PubMed

    Han, Jin H; Wilson, Amanda; Graves, Amy J; Shintani, Ayumi; Schnelle, John F; Ely, E Wesley

    2016-06-01

    Delirium in the emergency department (ED) is an emerging field of research. Most ED research infrastructures utilize lay personnel to collect data, but delirium assessments that can be reliably performed by nonphysicians are lacking. We evaluated the diagnostic performance of the modified Brief Confusion Assessment Method (modified bCAM) for this purpose. This was a secondary analysis of a prospective observational study that enrolled ED patients 65years or older. The original bCAM was a brief (<2minutes) delirium assessment that assessed for inattention by asking the patient to recite the months backward from December to July. It was modified by adding the Vigilance A ("squeeze my hand when you hear the letter 'A'") to the inattention assessment. The elements of the modified bCAM were performed by a research assistant (RA) and emergency physician. The reference standard for delirium was a psychiatrist assessment performed within 3hours using Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision criteria. All assessors were blinded to each other. Sensitivities and specificities with their 95% confidence intervals (CIs) were calculated for the RA and emergency physician. Of the 406 patients enrolled, 50 (12%) were delirious. The modified bCAM was 82.0% (95% CI, 71.4%-92.6%) sensitive and 96.1% (95% CI, 94.0%-98.1%) specific when performed by the RA. The emergency physician's modified bCAM exhibited similar diagnostic performance. The modified bCAM may be a feasible and accurate method for nonphysicians to assess for delirium. Future studies are needed to confirm these findings. Copyright © 2016 Elsevier Inc. All rights reserved.

  11. Surgical intensive care unit (ICU) delirium: a "psychosomatic" problem?

    PubMed

    Reich, Michel; Rohn, Regis; Lefevre, Daniele

    2010-06-01

    Intensive Care Unit (ICU) delirium is a common complication after major surgery and related among other potential medical precipitants to either pre-existing cognitive impairment or the intensity and length of anesthesiology or the type of surgery. Nevertheless, in some rare situations, an organic etiology is not always found, which can be frustrating for the medical team. Some clinicians working in an intensive care unit have a reluctance to seek another hypothesis in the psychological field. To illustrate this, we report the case of a 59-year-old woman who developed a massive delirium during her intensive care unit stay after being operated on for a left retroperitoneal sarcoma. Interestingly, she had had no previous cognitive disorders and a somatic explanation for her psychiatric disorder could not been found. Just before the surgery, she was grieving the recent loss of a colleague of the same age, and also a close friend, and therefore had a death anxiety. With this case report, we would like to point out the importance of psychological factors that might precipitate delirium in a predominately somatic environment such as an intensive care unit. ICU delirium can sometimes be considered as a "psychosomatic" problem with either a stress response syndrome after surgery or a defense mechanism against death anxiety. Clinicians should be aware of the possibility of such psychological factors even if they always must first rule out potential somatic causes for delirium and encourage thorough investigation and treatment of these medical causes. A collaboration with the psycho-oncologist is recommended to better manage this "psychosomatic" problem.

  12. Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study

    PubMed Central

    2013-01-01

    Background Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. Methods We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. Results Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention

  13. Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies.

    PubMed

    Richardson, Sarah; Teodorczuk, Andrew; Bellelli, Giuseppe; Davis, Daniel H J; Neufeld, Karin J; Kamholz, Barbara A; Trabucchi, Marco; MacLullich, Alasdair M J; Morandi, Alessandro

    2016-05-01

    Despite advances in delirium knowledge and the publication of best practice guidelines, uncertainties exist regarding assessment of Delirium Superimposed on Dementia (DSD). An international survey of delirium specialists was undertaken to evaluate current practice. Invitations to participate in an online survey were distributed by email among members of four international delirium associations with additional publication on their websites. The survey covered the assessment and diagnosis of DSD in clinical practice and research studies. Questions were structured around current practice and attitudes. The 205 responders were mostly confident that they could detect DSD with 60% rating their confidence at 7 or above on a likert scale of 0 (none) to 10 (excellent). Seventy-six percent felt that Dementia with Lewy Bodies (DLB) was the most challenging dementia subtype in which to diagnose DSD. Several scales were used to assess for the presence of DSD including the Confusion Assessment Method (CAM) (54%), DSM-5 criteria (25%) and CAM-ICU (15%). Responders stated that attention (71%), fluctuation in cognitive status (65%), and arousability (41%) were the most clinically useful features to assess when diagnosing DSD. Motor fluctuations were also deemed important but 61% had no specific test to monitor these. The largest survey of DSD practice to date demonstrates that despite good levels of confidence in recognizing DSD, there exists a lack of consensus concerning assessment and diagnosis globally. These findings suggest the need for the development of more research leading to precise diagnostic criteria and comprehensive guidelines regarding the assessment and diagnosis of DSD.

  14. Rational Use of Second-Generation Antipsychotics for the Treatment of ICU Delirium.

    PubMed

    Mo, Yoonsun; Yam, Felix K

    2017-02-01

    Delirium, described as an acute neuropsychiatric syndrome, occurs commonly in critically ill patients and leads to many negative outcomes including increased mortality and long-term cognitive deficits. Despite the lack of clinical data supporting the use of antipsychotics for the management of intensive care unit (ICU) delirium, pharmacological interventions are often needed to control acutely agitated patients. Given that the most current guidelines do not advocate the use of haloperidol for either the prevention or treatment of ICU delirium due to a lack of evidence, second-generation antipsychotics (SGAs) have been commonly used as alternatives to haloperidol for ICU patients with delirium. Nonetheless, the evidence supporting the use of SGAs to treat ICU delirium remains limited. This review is designed to assess the available clinical evidence and highlights the different neuropharmacological and safety properties of SGAs in order to guide the rational use of SGAs for the treatment of ICU delirium.

  15. Delirium prevention in critically ill adults through an automated reorientation intervention - A pilot randomized controlled trial.

    PubMed

    Munro, Cindy L; Cairns, Paula; Ji, Ming; Calero, Karel; Anderson, W McDowell; Liang, Zhan

    Explore the effect of an automated reorientation intervention on ICU delirium in a prospective randomized controlled trial. Delirium is common in ICU patients, and negatively affects outcomes. Few prevention strategies have been tested. Thirty ICU patients were randomized to 3 groups. Ten received hourly recorded messages in a family member's voice during waking hours over 3 ICU days, 10 received the same messages in a non-family voice, and 10 (control) did not receive any automated reorientation messages. The primary outcome was delirium free days during the intervention period (evaluated by CAM-ICU). Groups were compared by Fisher's Exact Test. The family voice group had more delirium free days than the non-family voice group, and significantly more delirium free days (p = 0.0437) than the control group. Reorientation through automated, scripted messages reduced incidence of delirium. Using identical scripted messages, family voice was more effective than non-family voice. Copyright © 2017 Elsevier Inc. All rights reserved.

  16. [Emergence delirium in children - prophylaxis and treatment].

    PubMed

    Wermelt, Julius Z; Ellerkmann, Richard K

    2016-07-01

    Emergence Delirium in children after general anesthesia is a common and self limitating event. Although it might be seen as being harmless it can cause other serious complications and might leave both parents and other caregivers with a negative impression behind. Although the cause may still not be clear, potential predictors can be named: preschool age, the use of fast acting volatile anesthestics, higher preoperative anxiety levels and postoperative pain.A child-focused approach to reduce preoperative anxiety focusing on distraction methods rather than pharmacological sedation may be the key as well as sufficient postoperative pain control and the use of total intravenous anesthesia. Parenteal presence during induction of anaesthesia (PPIA) may be beneficial to reduce preoperative anxiety levels, but has failed to prove a better outcome regarding ED.The use of age adopted scores/scales to diagnose ED and Pain are mandatory.In the case of an ED event it is most important to protect the child from self injury and the loss of the iv-line. Postoperative pian needs to be ruled out before treating ED. Most cases can be treated by interrupting the situation and putting the child "back to sleep". Short acting drugs as Propofol have been used successfully due to its pharmacodynamics and short acting profile. Alternatively alpha-agonists or ketamin may be preferred by other authors. If potential predictors and a positive history are present, prophylactic treatment should be considered. A TIVA or the use of alpha-2-agonists have proven to be successful in reducing the risk of an ED. Midazolam may reduce preoperative anxiety but not the incidence of ED and should therefore be used carefully and is not a good choice in PACU for the treatment of ED.Parents who witnessed ED in their children should be guided and followed up. Explaining this phenomenon to parents beforehand should be part of the pre anaesthesia clinic talk and written consent.Standard protocols should be in

  17. Post–Liver Transplant Delirium Increases Mortality and Length of Stay

    PubMed Central

    Oliver, Nathan; Bohorquez, Humberto; Anders, Stephanie; Freeman, Andrew; Fine, Kerry; Ahmed, Emily; Bruce, David S.; Carmody, Ian C.; Cohen, Ari J.; Seal, John; Reichman, Trevor W.; Loss, George E.

    2017-01-01

    Background: Incidence of delirium after liver transplantation (LT) has been reported to occur in 10%-47% of patients and is associated with increased hospital and intensive care unit lengths of stay and poor outcomes. Methods: Our primary objective was to evaluate the incidence and predisposing risk factors for developing delirium after LT. Our secondary objectives were to describe how delirium is managed in patients after LT, to examine the utilization of resources associated with delirium after LT, and to analyze the outcomes of patients who were treated for delirium after LT. Results: In a population of 181 consecutive patients who received an LT, 38 (21.0%) developed delirium. In the multivariate analysis, delirium was associated with pretransplant use of antidepressants (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.29-8.70) and pretransplant hospital admission for encephalopathy (OR 4.39, 95% CI 1.77-10.9). Patients with delirium spent more time on mechanical ventilation (2.0 vs 1.3 days, P=0.008) and had longer intensive care unit stays (4.6 vs 2.7 days, P=0.008), longer hospital stays (27.6 vs 11.2 days, P=0.003), and higher 6-month mortality (13.2% vs 1.4%, P=0.003) than patients who did not develop delirium. Conclusion: The presence of delirium is common after LT and is associated with high morbidity and mortality within the first 6 months posttransplant. Pretransplant factors independently associated with developing delirium after LT include prior use of antidepressants and pretransplant hospital admission for encephalopathy. Efforts should be made to identify patients at risk for delirium, as protocol-based management may improve outcomes in a cost-effective manner. PMID:28331444

  18. Delirium diagnosis methodology used in research: a survey-based study.

    PubMed

    Neufeld, Karin J; Nelliot, Archana; Inouye, Sharon K; Ely, E Wesley; Bienvenu, O Joseph; Lee, Hochang Benjamin; Needham, Dale M

    2014-12-01

    To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools. The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients. Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients. Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results. Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

  19. Assessment and management of delirium in the older adult with cancer.

    PubMed

    Derby, Susan

    2011-06-01

    Recognizing delirium and its impact on older patients and their caregivers is an important aspect of oncology nursing. Delirium is the most common complication of hospital admissions for older adults and is associated with a significant amount of morbidity and mortality, prolonged hospital stays, functional decline, and decreased quality of life. Oncology nurses caring for older patients with cancer have the opportunity to recognize the onset of delirium, provide ongoing patient assessment and monitoring, and implement pharmacologic and nonpharmacologic interventions.

  20. Delirium Diagnosis Methodology used in Research: A Survey-Based Study

    PubMed Central

    Neufeld, KJ; Nelliot, A; Inouye, SK; Ely, EW; Bienvenu, OJ; Lee, HB; Needham, DM

    2014-01-01

    Objectives To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools. Design A survey addressing reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information and diagnostic process. Setting Survey completed via web or telephone interview according to respondent preference. Participants Authors of 39 studies included in 3 recent systematic reviews of delirium detection instruments in hospitalized patients. Results Authors from 85% (n=33) of the 39 eligible studies responded to the survey. The median (Interquartile Range [IQR]) number of raters per study was 2.5 (2–3); 79% were physicians. The raters’ median (IQR) duration of clinical experience with delirium diagnosis was 7 (4–10) years, with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (n=21) and 45% (n=15) of studies, respectively, with 33% (n=11) using both and 27% (n=9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% (n=23) of studies used all available information for delirium diagnosis, while 15% excluded such patients. Conclusions Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results. PMID:24745562

  1. Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality.

    PubMed

    Dharmarajan, Kumar; Swami, Sunil; Gou, Ray Y; Jones, Richard N; Inouye, Sharon K

    2017-05-01

    (1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality. Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000. Large academic hospital. Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only. (1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission. Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8-6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation. Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults. © 2016, Copyright the Authors Journal compilation © 2016, The American

  2. Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of externally derived risk scores

    PubMed Central

    Pendlebury, Sarah T.; Lovett, Nicola; Smith, Sarah C.; Cornish, Emily; Mehta, Ziyah; Rothwell, Peter M.

    2016-01-01

    Background: reliable delirium risk stratification will aid recognition, anticipation and prevention and will facilitate targeting of resources in clinical practice as well as identification of at-risk patients for research. Delirium risk scores have been derived for acute medicine, but none has been prospectively validated in external cohorts. We therefore aimed to determine the reliability of externally derived risk scores in a consecutive cohort of older acute medicine patients. Methods: consecutive patients aged ≥65 over two 8-week periods (2010, 2012) were screened prospectively for delirium using the Confusion Assessment Method (CAM), and delirium was diagnosed using the DSM IV criteria. The reliability of existing delirium risk scores derived in acute medicine cohorts and simplified for use in routine clinical practice (USA, n = 2; Spain, n = 1; Indonesia, n = 1) was determined by the area under the receiver operating characteristic curve (AUC). Delirium was defined as prevalent (on admission), incident (occurring during admission) and any (prevalent + incident) delirium. Results: among 308 consecutive patients aged ≥65 (mean age/SD = 81/8 years, 164 (54%) female), existing delirium risk scores had AUCs for delirium similar to those reported in their original internal validations ranging from 0.69 to 0.76 for any delirium and 0.73 to 0.83 for incident delirium. All scores performed better than chance but no one score was clearly superior. Conclusions: externally derived delirium risk scores performed well in our independent acute medicine population with reliability unaffected by simplification and might therefore facilitate targeting of multicomponent interventions in routine clinical practice. PMID:26764396

  3. Pilot clinical trial of gabapentin to decrease postoperative delirium in older patients.

    PubMed

    Leung, J M; Sands, L P; Rico, M; Petersen, K L; Rowbotham, M C; Dahl, J B; Ames, C; Chou, D; Weinstein, P

    2006-10-10

    In this randomized pilot clinical trial, the authors tested the hypothesis that using gabapentin as an add-on agent in the treatment of postoperative pain reduces the occurrence of postoperative delirium. Postoperative delirium occurred in 5/12 patients (42%) who received placebo vs 0/9 patients who received gabapentin, p = 0.045. The reduction in delirium appears to be secondary to the opioid-sparing effect of gabapentin.

  4. Perceived Stigma and Quality of Life in Patients Following Recovery From Delirium.

    PubMed

    Kim, Seon-Young; Kim, Jae-Min; Kim, Sung-Wan; Kang, Hee-Ju; Lee, Ju-Yeon; Bae, Kyung-Yeol; Shin, Il-Seon; Yoon, Jin-Sang

    2017-07-01

    To elucidate the factors related to perceived stigma and quality of life (QoL) in patients who have recovered from delirium. This prospective cohort investigation of patients with delirium, as diagnosed according to DSM-IV-TR criteria, was conducted from July 2011 to May 2013. The perceived stigma level and QoL of each patient was assessed using the Perceived Stigma of Delirium Scale (PSDS) and European Quality of Life Visual Analog Scale (EQ-VAS), respectively, following recovery from delirium. Several clinical characteristics were assessed at baseline and after recovery from delirium, and a multivariate linear regression analysis was conducted. This study included 128 patients who completed a follow-up assessment after recovery from delirium. A multivariate analysis revealed that patients who had a history of depression (B = 3.34, P = .026), could recall their experiences with delirium (B = 1.71, P = .011), and had a longer duration from delirium detection to recovery (B = 1.39, P = .012) obtained higher PSDS scores than patients without these characteristics. The ability to recall delirium experiences (B = -7.17, P = .026) and the use of antipsychotics at follow-up assessment (B = -7.87, P = .039) were associated with lower EQ-VAS scores. Additionally, PSDS scores were negatively correlated with EQ-VAS scores (r = -0.37, P < .001). This study found that patients who experienced an episode of delirium reported varying degrees of perceived stigma and that the ability to recall their delirium experiences was associated with a higher stigma and a poorer QoL. These findings suggest that care teams should pay more attention to perceived stigma in patients with delirium.

  5. Cerebral blood flow during delirium tremens and related clinical states studied with xenon-133 inhalation tomography

    SciTech Connect

    Hemmingsen, R.; Vorstrup, S.; Clemmesen, L.; Holm, S.; Tfelt-Hansen, P.; Sorensen, A.S.; Hansen, C.; Sommer, W.; Bolwig, T.G.

    1988-11-01

    The regional cerebral blood flow of 12 patients with severe alcohol withdrawal reactions (delirium tremens or impending delirium tremens) was measured during the acute state before treatment and after recovery. Greater cerebral blood flow was significantly correlated with visual hallucinations and agitation during the acute withdrawal reaction. The results suggest that delirium tremens and related clinical states represent a type of acute brain syndrome mainly characterized by CNS hyperexcitability.

  6. New aspects of delirium in elderly patients with critical limb ischemia

    PubMed Central

    van Eijsden, Willem A; Raats, Jelle W; Mulder, Paul GH; van der Laan, Lijckle

    2015-01-01

    Objective The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality. Methods All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery. Results We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11–52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07–42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P<0.001). Conclusion Delirium is a common adverse event in patients with critical limb ischemia undergoing surgery with devastating outcome in the long term. Most patients developed delirium preoperatively, which indicates the need for early recognition and preventive strategies in the preoperative period. This study identified undernourishment and diabetes mellitus as independent risk factors for delirium. PMID:26451094

  7. Evaluation of algorithms to identify delirium in administrative claims and drug utilization database.

    PubMed

    Kim, Dae Hyun; Lee, Jung; Kim, Caroline A; Huybrechts, Krista F; Bateman, Brian T; Patorno, Elisabetta; Marcantonio, Edward R

    2017-08-01

    To evaluate the performance of delirium-identification algorithms in administrative claims and drug utilization data. We used data from a prospective study of 184 older adults who underwent aortic valve replacement at a single academic medical center to evaluate the following delirium-identification algorithms: (1) International Classification of Diseases (ICD) diagnosis codes for delirium; (2) antipsychotics use; (3) either ICD diagnosis codes or antipsychotics use; and (4) both ICD diagnosis codes and antipsychotics use. These algorithms were evaluated against a validated bedside assessment, the Confusion Assessment Method, and a validated delirium severity scale, the CAM-S. Delirium occurred in 66 patients (36%), of which 14 (21%) had hyperactive or mixed features and 15 (23%) had severe delirium. ICD diagnosis codes for delirium were present in 15 patients (8%). Antipsychotics were used in 13 patients (7%). ICD diagnosis codes alone and antipsychotics use alone had comparable sensitivity (18% vs. 18%) and specificity (98% vs. 99%). Defining delirium using either ICD diagnosis codes or antipsychotics use, sensitivity improved to 30% with little change in specificity (97%). This algorithm showed higher sensitivity for hyperactive or mixed delirium (64%) and severe delirium (73%). Requiring both ICD diagnosis codes and antipsychotics use resulted in perfect specificity but low sensitivity (6%). Delirium-identification algorithms in claims data have low sensitivity and high specificity. Defining delirium using ICD diagnosis codes or antipsychotics use performs better than considering either type of information alone. This information should inform the design and interpretation of claims-based comparative effectiveness and safety research. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

  8. Anticholinergic Medication Use and Transition to Delirium in Critically Ill Patients: A Prospective Cohort Study.

    PubMed

    Wolters, Annemiek E; Zaal, Irene J; Veldhuijzen, Dieuwke S; Cremer, Olaf L; Devlin, John W; van Dijk, Diederik; Slooter, Arjen J C

    2015-09-01

    Although cholinergic deficiency is presumed to increase delirium risk and use of medication with anticholinergic properties in the ICU is frequent, the relationship between anticholinergic medication use and delirium in this setting remains unclear. We investigated whether exposure to medication with anticholinergic properties increases the probability of transitioning to delirium in critically ill adults and whether this relationship is affected by age or the presence of acute systemic inflammation. Prospective cohort study. A 32-bed medical-surgical ICU at an academic medical center. Critically ill adults admitted to the ICU for more than 24 hours without an acute neurological disorder or another condition that would hamper delirium assessment. None. Daily anticholinergic burden was calculated for each patient based on the sum of the Anticholinergic Drug Scale score for each medication administered. Daily mental status was classified as "coma," "delirium," or an "awake without delirium" state. The primary outcome, the daily transition from an "awake without delirium" state to "delirium," was analyzed using a first-order Markov model that adjusted for eight covariables. A total of 1,112 patients were evaluated over 9,867 ICU days. The daily median summed Anticholinergic Drug Scale score was 2 (interquartile range, 1-3). The transition from being in an "awake without delirium" state to "delirium" occurred on 562 of ICU days (6%). After correcting for confounding, a one-unit increase in the Anticholinergic Drug Scale score resulted in a nonsignificant increase in the probability of delirium occurring the next day (odds ratio, 1.05; 95% CI, 0.99-1.10). Neither age nor the presence of acute systemic inflammation modified this relationship. Exposure to medication with anticholinergic properties, as defined by the Anticholinergic Drug Scale, does not increase the probability of delirium onset in patients who are awake and not delirious in the ICU.

  9. [The psychopathology of delirium. Evolution of the research from Jaspers to Kapur].

    PubMed

    D'Orazio, M; Mistretta, M; Orso, L

    2010-01-01

    Delirium represents a symptom of a thought disorder in which a belief is strongly held in spite of invalidating evidence. Many varieties of delirium have been described and this symptom is common in psychotic disorders (schizophrenia, brief psychotic disorder, chronic delusional disorders, etc.), affective disorders (major depressive disorder, psychotic depression, melancholic depression, bipolar disorder, etc.), organic illnesses and psychotropic substance abuse. Delirium has been deeply studied by psychopathology. Our work offers an overview of the most relevant psychopathological descriptions of delirium in the last century, from Jaspers to Kapur.

  10. Delirium Detection and Impact of Comorbid Health Conditions in a Post-Acute Rehabilitation Hospital Setting

    PubMed Central

    Stelmokas, Julija; Gabel, Nicolette; Flaherty, Jennifer M.; Rayson, Katherine; Tran, Kathileen; Anderson, Jason R.; Bieliauskas, Linas A.

    2016-01-01

    Misdiagnosis and under-detection of delirium may occur in many medical settings. This is important to address as delirium clearly increases risk of morbidity and mortality in such settings. This study assessed whether Veterans who screened positive on a delirium severity measure (Memorial Delirium Assessment Scale; MDAS) differed from those with and without corresponding medical documentation of delirium in terms of cognitive functioning, psychiatric/medical history, and medication use. A medical record review of 266 inpatients at a VA post-acute rehabilitation unit found that 10.9% were identified as delirious according to the MDAS and/or medical records. Of the Veterans who screened positive on the MDAS (N = 19), 68.4% went undetected by medical screening. Undetected cases had a higher number of comorbid medical conditions as measured by the Age-Adjusted Charlson Index (AACI) scores (median = 9, SD = 3.15; U = 5.5, p = .003) than medically documented cases. For Veterans with a score of 7 or greater on the AACI, the general relative risk for delirium was 4.46. Delirium is frequently under-detected in a post-acute rehabilitation unit, particularly for Veterans with high comorbid illness. The relative risk of delirium is up to 4.46 for those with high medical burden, suggesting the need for more comprehensive delirium screening in these patients. PMID:27902744

  11. Stuck Inside a Cloud: Optimizing Sedation to Reduce ICU-Associated Delirium in Geriatric Patients.

    PubMed

    Chen, Leon; Lim, Fidelindo A

    2015-01-01

    Elderly population account for more than 50% of all intensive care admissions, and during their stay, up to 87% of them suffer from delirium. There is a large body of evidence demonstrating increased mortality and worse cognitive function for elderly patients who become delirious during their intensive care unit stay. Although the cause of delirium is multifactorial, inappropriate and outdated sedation methods are preventable causes. We review the current best evidences and provide what we believe are the best sedation strategies that are in line with the Society of Critical Care Medicine's Pain, Agitation and Delirium best practice guideline to reduce the incidence of intensive care unit-associated delirium.

  12. Progression of delirium in advanced illness: a multivariate model of caregiver and clinician perspectives.

    PubMed

    Kerr, Christopher W; Donnelly, James P; Wright, Scott T; Luczkiewicz, Debra L; McKenzie, Kevin J; Hang, Pei C; Kuszczak, Sarah M

    2013-07-01

    Delirium is one of the most distressing and difficult to manage problems in advanced illness. Family caregivers have a unique view of the progression of delirium. This study examined precursors to delirium from the perspective of family caregivers. This study utilized a two-stage concept mapping design that began with semistructured interviews with caregivers of patients suffering with delirium. The interview data was sorted and rated by clinicians prior to quantitative data analysis via multidimensional scaling (MDS) and cluster analysis. The subjects were 20 family caregivers of patients with a diagnosis of delirium in a hospice inpatient unit. The main outcome of the study was a multidimensional model of precursors of delirium that included 99 specific items. The model included ten clusters within three general domains: Cognition, Distress, and Rest/Sleep. An exploratory analysis suggested that Rest and Sleep issues were evident to caregivers much earlier than other kinds of problems (mean=17.56 weeks prior to hospice admission, 95% CI=9.2-25.0 weeks). This study provides detailed insights from family caregivers about the progression of delirium. The caregiver observations were clustered by multivariate analysis to provide a map of symptom domains. The principal finding of this study is that sleep disturbance was identified by almost all family caregivers much earlier than other more commonly recognized symptoms associated with delirium. The study highlights the importance of sleep fragmentation in the temporal progression of delirium and points toward opportunities for improved measurement, prevention, and treatment.

  13. Delirium in the Older Emergency Department Patient – A Quiet Epidemic

    PubMed Central

    Han, Jin Ho; Wilson, Amanda; Ely, E. Wesley

    2013-01-01

    Synopsis Delirium is defined as an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. This form of organ dysfunction commonly occurs in older emergency department (ED) patients and is associated with a multitude of adverse patient outcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple etiologies may exist concurrently. PMID:20709246

  14. The tryptophan depletion theory in delirium: not confirmed in elderly hip fracture patients.

    PubMed

    de Jonghe, Annemarieke; van Munster, Barbara C; Fekkes, Durk; van Oosten, Hannah E; de Rooij, Sophia E

    2012-01-01

    The tryptophan depletion theory assumes that low tryptophan levels are present in delirium. These lower levels may be regarded as a biochemical marker for cellular immune activation, which may lead to increased catabolism of tryptophan into kynurenine via stimulation of the enzyme indoleamine 2,3-dioxygenase (IDO) by interferon-γ. To compare plasma tryptophan and kynurenine levels, and IDO activity in hospitalized patients with and without delirium. Repeated plasma samples were prospectively collected in hip fracture patients, aged 65 years and older. The presence of delirium was assessed daily. The associations of a delirious state and tryptophan, kynurenine, and the kynurenine/tryptophan ratio measured in samples taken 'before', 'during delirium', and 'after delirium' were analyzed with linear mixed models. A total of 469 samples from 140 patients were collected. Adjusted for the days on which they were drawn, there was no difference for all three measured factors in patients with and without delirium, except for an association between a higher kynurenine/tryptophan ratio and delirium in a subgroup analysis in preoperative samples. The results do not confirm the previously found lower tryptophan levels in delirium on which the tryptophan depletion theory is based. However, a preoperative higher kynurenine/tryptophan ratio could be indicative of delirium. Copyright © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

  15. Factors associated with onset of delirium among internal medicine inpatients in Spain.

    PubMed

    Díez-Manglano, Jesús; Palazón-Fraile, Claudia; Diez-Massó, Fabiola; Martínez-Álvarez, Rosa; Del Corral-Beamonte, Esther; Carreño-Borrego, Pilar; Pueyo-Tejedor, Pilar; Gomes-Martín, Javier

    2013-01-01

    Delirium increases mortality and length of stay among hospital inpatients. Little is known about the incidence of delirium among inpatients receiving care in internal medicine nursing units in Spain. The aim of this study was to estimate frequency of delirium onset among internal medicine inpatients and identify factors associated with delirium onset using nursing records and administrative databases. Retrospective cohort study of 744 patients hospitalized in an internal medicine department in October 2010 and January, May, and October 2011. Data concerning occurrence of delirium, age, gender, living in a nursing residence, Barthel Index of activities of daily living, Norton scale for pressure ulcer risk, intravenous fluid therapy, urinary catheterization, presence of pressure ulcers, major diagnostic category at discharge, length of stay, and mean weight in the diagnosis-related group were gathered for each patient. Backward stepwise logistic regression was used to identify factors associated with onset of delirium. Ninety-seven (13%) patients experienced delirium. Factors associated with delirium were age (OR = 1.03, 95% CI [1.01, 1.06]), Barthel Index (OR = 0.99. 95% CI [0.98, 0.99]), and urinary catheterization (OR = 2.00, 95% CI [1.19, 3.68]). Increased age and presence of a urinary catheter were associated with increased onset of delirium, whereas higher levels of independence in activities of daily living were protective.

  16. A research algorithm to improve detection of delirium in the intensive care unit

    PubMed Central

    Pisani, Margaret A; Araujo, Katy LB; Van Ness, Peter H; Zhang, Ying; Ely, E Wesley; Inouye, Sharon K

    2006-01-01

    Introduction Delirium is a serious and prevalent problem in intensive care units (ICUs). The purpose of this study was to develop a research algorithm to enhance detection of delirium in critically ill ICU patients using chart review to complement a validated clinical delirium instrument. Methods A prospective cohort study was conducted in 178 patients aged 60 years and older who were admitted to the medical ICU. The Confusion Assessment Method for the ICU (CAM-ICU) and a validated chart review method for detecting delirium were performed daily. We assessed the diagnostic accuracy of the chart-based delirium method using the CAM-ICU as the 'gold standard'. We then used an algorithm to detect delirium first using the CAM-ICU ratings and then chart review when the CAM-ICU was unavailable. Results When using both the CAM-ICU and the chart-based review, the prevalence of delirium was found to be 80% of patients (143 out of 178) or 64% of patient-days (929 out of 1,457). Of these patient-days, 292 were classified as delirium by the CAM-ICU. The remainder (637 patient-days) were classified as delirium by the validated chart review method when CAM-ICU was missing because the assessment was conducted for weekends or holidays (404 patient-days), when CAM-ICU was not performed because of stupor or coma (205 patient-days), and when the CAM-ICU was negative (28 patient-days). Sensitivity of the chart-based method was 64% and specificity was 85%. Overall agreement between chart and the CAM-ICU was 72%. Conclusion Eight out of 10 patients in this cohort study developed delirium in the ICU. Although use of a validated delirium instrument with frequent direct observations is recommended for clinical care, this approach may not always be feasible, especially in a research setting. The algorithm proposed here comprises a more comprehensive method for detecting delirium in a research setting, taking into account the fluctuation that occurs with delirium, which is a key component of

  17. Incidence and predictors of postoperative delirium after cytoreduction surgery-hyperthermic intraperitoneal chemotherapy.

    PubMed

    Plas, Matthijs; Hemmer, Patrick H J; Been, Lukas B; van Ginkel, Robert J; de Bock, Geertruida H; van Leeuwen, Barbara L

    2017-09-20

    Incidence of, and baseline characteristics associated with delirium in patients after cytoreduction surgery-hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), were subject of investigation. The study was conducted among a consecutive series of prospectively included patients who underwent CRS-HIPEC at the University Medical Center Groningen, Groningen, the Netherlands, between February 2006 and January 2015. A chart-based instrument for delirium during hospitalization was used to identify patients with symptoms of delirium who were not diagnosed by a psychiatrist during admission. Uni- and multivariate logistic regression analyses were performed. Data of 136 patients were included in the analysis. Median age was 60 years (range: 18-76) and 50 (37%) patients were male. During hospitalization, 38 (28%) patients were diagnosed with delirium. Factors that differed significantly between the patients with and without delirium by univariate analysis were included in multivariate analysis. Multivariate analysis showed that after adjustment for age and complications other than delirium, having three or more organs resected and the CRP serum levels were independent predictors for delirium (OR: 3.97; 95% 1.24-12.76; OR: 1.01; 95% 1-1.01, respectively). This report shows an incidence of 28% of delirium, occurring after CRS-HIPEC and suggests a role for systemic inflammation in the development of postoperative delirium. © 2017 Wiley Periodicals, Inc.

  18. Preoperative risk factors of postoperative delirium after transurethral prostatectomy for benign prostatic hyperplasia

    PubMed Central

    Tai, Sheng; Xu, Lingfan; Zhang, Li; Fan, Song; Liang, Chaozhao

    2015-01-01

    The aim of this observational study was to investigate the occurrence of post operation delirium in the elderly patients undergoing the transurethral prostatectomy and to identify these factors associated with the delirium. 485 patients, undergoing the transurethral prostatectomy, were selected. Demographics, medical, cognitive and functional data, IPSS and NIH-CPSI score were collected as predictors for delirium. After surgery, the patients were divided on the basis of delirium onset within one week observation period, and the delirium was diagnosed by the Confusion Assessment Method. Totally, 21.23% (103) subjects were identified as the delirium and it lasted 2.9 ± 0.8 days. Patients with post operation delirium were significantly older and single, widowed and divorced, had a previous history of prehospitalization, were with the poor International Prostate Symptom Score (IPSS) and National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score, were more impaired in the instrumental activities of daily living (IADL), and had poor clock drawing test (CDT) and geriatric depression scale (GDS) score. Age, marital status, IPSS and NIH-CPIS score, cognitive and functional status and previous history of hospitalization are the predictors of post operation delirium. Our study has implications in preventing delirium via an early and targeted evaluation. PMID:26064386

  19. High C-Reactive Protein Predicts Delirium Incidence, Duration, and Feature Severity After Major Noncardiac Surgery.

    PubMed

    Vasunilashorn, Sarinnapha M; Dillon, Simon T; Inouye, Sharon K; Ngo, Long H; Fong, Tamara G; Jones, Richard N; Travison, Thomas G; Schmitt, Eva M; Alsop, David C; Freedman, Steven D; Arnold, Steven E; Metzger, Eran D; Libermann, Towia A; Marcantonio, Edward R

    2017-08-01

    To examine associations between the inflammatory marker C-reactive protein (CRP) measured preoperatively and on postoperative day 2 (POD2) and delirium incidence, duration, and feature severity. Prospective cohort study. Two academic medical centers. Adults aged 70 and older undergoing major noncardiac surgery (N = 560). Plasma CRP was measured using enzyme-linked immunosorbent assay. Delirium was assessed from Confusion Assessment Method (CAM) interviews and chart review. Delirium duration was measured according to number of hospital days with delirium. Delirium feature severity was defined as the sum of CAM-Severity (CAM-S) scores on all postoperative hospital days. Generalized linear models were used to examine independent associations between CRP (preoperatively and POD2 separately) and delirium incidence, duration, and feature severity; prolonged hospital length of stay (LOS, >5 days); and discharge disposition. Postoperative delirium occurred in 24% of participants, 12% had 2 or more delirium days, and the mean ± standard deviation sum CAM-S was 9.3 ± 11.4. After adjusting for age, sex, surgery type, anesthesia route, medical comorbidities, and postoperative infectious complications, participants with preoperative CRP of 3 mg/L or greater had a risk of delirium that was 1.5 times as great (95% confidence interval (CI) = 1.1-2.1) as that of those with CRP less than 3 mg/L, 0.4 more delirium days (P < .001), more-severe delirium (3.6 CAM-S points higher, P < .001), and a risk of prolonged LOS that was 1.4 times as great (95% CI = 1.1-1.8). Using POD2 CRP, participants in the highest quartile (≥235.73 mg/L) were 1.5 times as likely to develop delirium (95% CI = 1.0-2.4) as those in the lowest quartile (≤127.53 mg/L), had 0.2 more delirium days (P < .05), and had more severe delirium (4.5 CAM-S points higher, P < .001). High preoperative and POD2 CRP were independently associated with delirium incidence, duration, and feature severity. CRP may be useful to

  20. Existential Absence: The Lived Experience of Family Members During Their Older Loved One's Delirium.

    PubMed

    Day, Jenny; Higgins, Isabel

    2015-12-01

    When older people develop delirium, their demeanor changes; they often behave in ways that are out of character and seem to inhabit another world. Despite this, little is known about the experiences of family members who are with their older loved one at this time. This article reports a phenomenological study that involved in-depth interviews with 14 women whose older loved one had delirium. Analysis and interpretation of the data depict the women's experiences as "Changing family portraits: Sudden existential absence during delirium," capturing the way family members lose the taken-for-granted presence of their familiar older loved one and confront a stranger during delirium.

  1. Treatment of post-electroconvulsive therapy delirium and agitation with donepezil.

    PubMed

    Logan, Christopher J; Stewart, Jonathan T

    2007-03-01

    Delirium and agitation are commonly encountered after administration of electroconvulsive therapy (ECT). Management is generally fairly straightforward, although some patients may have a severe, prolonged, or refractory course. We recently cared for a 65-year-old man who consistently developed severe and very prolonged post-ECT delirium that did not respond to typical pharmacological agents; the duration of delirium was dramatically shortened by the addition of donepezil. Cholinesterase inhibitors may have a place in mitigating severe and prolonged post-ECT delirium.

  2. Diagnosis and Management of Delirium in Critically Ill Infants: Case Report and Review.

    PubMed

    Brahmbhatt, Khyati; Whitgob, Emily

    2016-03-01

    Delirium in children is common but not widely understood by pediatric practitioners, often leading to underdiagnosis and lack of treatment. This presents a significant challenge in the young patients in the PICU who are most at risk for delirium and in whom the core features of delirium are difficult to assess and treat. However, because of the potential increased morbidity and mortality associated with untreated delirium in adults and children, it remains important to address it promptly. The literature for delirium in this age group is limited. Here we present the case of an infant with multiple underlying medical risk factors who exhibited waxing and waning motor restlessness with disrupted sleep-wake cycles contributing significantly to destabilization of vital parameters. Making a diagnosis of delirium was key to guiding further treatment. After appropriate environmental interventions are implemented and underlying medical causes are addressed, antipsychotic medications, although not Food and Drug Administration-approved in infants, are the mainstay of pharmacotherapy for delirium in older age groups. They may lengthen corrected QT interval (QTc) intervals, presenting a challenge in infants who frequently have other coexisting risks for QTc prolongation, as in our case. The risk from QTc prolongation needs to be balanced against that from untreated delirium. Low doses of risperidone were successfully used in this patient and without side effects or worsening of QTc interval. This case illustrates the importance of increased recognition of delirium in children, including infants, and the role for cautious consideration of atypical antipsychotics in the very young.

  3. Incidence and factors related to delirium in an intensive care unit.

    PubMed

    Mori, Satomi; Takeda, Juliana Rumy Tsuchihashi; Carrara, Fernanda Souza Angotti; Cohrs, Cibelli Rizzo; Zanei, Suely Sueko Viski; Whitaker, Iveth Yamaguchi

    2016-01-01

    To identify the incidence of delirium, compare the demographic and clinical characteristics of patients with and without delirium, and verify factors related to delirium in critical care patients. Prospective cohort with a sample made up of patients hospitalized in the Intensive Care Unit (ICU) of a university hospital. Demographic, clinical variables and evaluation with the Confusion Assessment Method for Intensive Care Unit to identify delirium were processed to the univariate analysis and logistic regression to identify factors related to the occurrence of delirium. Of the total 149 patients in the sample, 69 (46.3%) presented delirium during ICU stay, whose mean age, severity of illness and length of ICU stay were statistically higher. The factors related to delirium were: age, midazolam, morphine and propofol. Results showed high incidence of ICU delirium associated with older age, use of sedatives and analgesics, emphasizing the need for relevant nursing care to prevent and identify early, patients presenting these characteristics. Identificar a incidência de delirium, comparar as características demográficas e clínicas dos pacientes com e sem delirium e verificar os fatores relacionados ao delirium em pacientes internados em Unidade de Terapia Intensiva (UTI). Coorte prospectiva, cuja amostra foi constituída de pacientes internados em UTI de um hospital universitário. Variáveis demográficas, clínicas e da avaliação com o Confusion Assessment Method for Intensive Care Unit para identificação de delirium foram processadas para análise univariada, e regressão logística para identificar fatores relacionados à ocorrência do delirium. Do total de 149 pacientes da amostra, 69 (46,3%) apresentaram delirium durante a internação na UTI, observando-se que a média da idade, o índice de gravidade e o tempo de permanência nas UTI foram estatisticamente maiores. Os fatores relacionados ao delirium foram: idade, midazolam, morfina e propofol. Os

  4. Implementing the best available evidence in early delirium identification in elderly hip surgery patients.

    PubMed

    Russell-Babin, Kathleen Ann; Miley, Helen

    2013-03-01

    Delirium is a frequent complication in the surgical experience of elderly hip surgery patients. Its impact can be severe and may even include death. Implementation of a delirium predictor tool might focus attention on early recognition of delirium, thereby potentially decreasing its impact. A related aim is to evaluate best practices in implementation strategies in this project. After an exhaustive search of the literature, no consensus was found regarding delirium predictors for the elderly hip surgery patient. A local research study was implemented to determine factors that may predict delirium in this population. With evidence secured, a multidisciplinary implementation project augmented by ongoing audit was instituted. A variety of social diffusion and education tools were used. Implementation was guided by the use of the Promoting Action on Research Implementation in Health Services framework assessment tool and the Alberta Context Tool, as well as traditional performance improvement tools, such as fishbone charting. Audit identified the rate of use of the predictor tool and pre- and post-rates of delirium. This project was part of the Joanna Briggs Institute Signature Project, an implementation project consisting of six teams, each representing a different organisation. This overall project was supported by experts in the field of translation and implementation science internationally. Initial compliance to the use of the predictor tool was assessed at 54% within 3 months of implementation and increased to 56% in the ensuing months. Before the study use of the predictor tool, the delirium rate was 10.4% (12 of 115 patients). An interim analysis 4 months after implementation identified a 20% delirium rate (18 of 70 patients) and an updated analysis 8 months into the project showed a 16.3% delirium rate. Delirium predictor tool use was associated with a lower delirium rate (9/76, 11.84%) than no delirium predictor tool (13/60, 21.67%), but the difference was

  5. Sleep-wake cycle disturbances in elderly acute general medical inpatients: Longitudinal relationship to delirium and dementia.

    PubMed

    FitzGerald, James M; O'Regan, Niamh; Adamis, Dimitrios; Timmons, Suzanne; Dunne, Colum P; Trzepacz, Paula T; Meagher, David J

    2017-01-01

    Sleep disturbances in elderly medical inpatients are common, but their relationship to delirium and dementia has not been studied. Sleep and delirium status were assessed daily for a week in 145 consecutive newly admitted elderly acute general hospital patients using the Delirium Rating Scale-Revised-98 (DRS-R98), Diagnostic and Statistical Manual 5, and Richards-Campbell Sleep Quality Scale measures. The longitudinal relationship between DRS-R98 and Richards-Campbell Sleep Quality Scale sleep scores and delirium, also with dementia as a covariate, was evaluated using generalized estimating equation logistic regression. The cohort was divided into delirium only, dementia only, comorbid delirium-dementia, and no-delirium/no-dementia subgroups. Mean age of total group was 80 ± 6.3, 48% were female, and 31 (21%) had dementia, 29 had delirium at admission (20%), and 27 (18.5%) experienced incident delirium. Mild sleep disturbance (DRS-R98 sleep item score ≥1) occurred for at least 1 day in all groups, whereas moderate sleep disturbance (score ≥2) occurred in significantly more of the prevalent delirium-only (81%; n = 17) cases than incident delirium-only (46%; n = 13) cases (P < .001). There were more cases with DRS-R98 sleep item scores ≥2 (P < .001) in the delirium-only group compared with the other subgroups. Severity of sleep-wake cycle disturbance over time was significantly associated with Diagnostic and Statistical Manual 5 delirium status but not with age, sex, or dementia (P < .001). Observer-rated more severe sleep-wake cycle disturbances are highly associated with delirium irrespective of dementia status, consistent with being a core feature of delirium. Monitoring for altered sleep-wake cycle patterns may be a simple way to improve delirium detection.

  6. Occurrence of mirtazapine-induced delirium in organic brain disorder.

    PubMed

    Bailer, U; Fischer, P; Küfferle, B; Stastny, J; Kasper, S

    2000-07-01

    Mirtazapine is the first of a new class of antidepressants, the noradrenergic and specific serotonergic antidepressants. Its antidepressant effect appears to be related to its dual enhancement of both noradrenergic neurotransmission and serotonin 5-HT1 receptor-mediated serotonergic neurotransmission. Mirtazapine has demonstrated superior tolerability to the tricyclic antidepressants, primarily on account of its relative absence of anticholinergic, adrenergic and serotonin-related adverse effects. We observed mirtazapine-induced delirium in one organically depressed and two major depressed patients with subclinical brain disease. The appearance of hallucinations, psychomotoric agitation and cognitive changes after initiation of mirtazapine, and their prompt improvement after drug discontinuation, led to the impression that these were drug-induced phenomena. One possible hypothesis for the observed deliria is a central increase of norepinephrine after acute administration of mirtazapine. Subclinical brain disease might have favoured the occurrence of delirium in the three cases.

  7. Managing delirium in the acute care setting: a pilot focus group study

    PubMed Central

    Yevchak, Andrea; Steis, Melinda; Diehl, Theresa; Hill, Nikki; Kolanowski, Ann; Fick, Donna

    2012-01-01

    Background Delirium frequently occurs in hospitalised older adults leading to poor outcomes and frequent adverse events. Proper recognition and management of delirium by acute care nurses can minimise the effects of negative sequelae associated with delirium. Aim This pilot study used focus group methodology to: (i) describe acute care nurse’s experience and knowledge regarding assessment and management of delirium in hospitalised older adults; (ii) illustrate potential facilitators and barriers to non-drug management of delirium; and (iii) to explicate the use of non-drug interventions by acute care nurses to manage delirium in hospitalised older adults. Design Qualitative, pilot study. Methods A total of 16 nurse participants, working on medical, surgical and orthopaedic units from one acute care hospital participated in two focus groups. Results Main themes included the following: confusion is normal; our duty is to protect; and finding a balance. Nurses were able to identify non-pharmacological interventions for delirium and facilitators and barriers to using these in clinical practice. Conclusions Findings from this pilot study illustrate the need for regular assessment of cognitive status in hospitalised older adults and nursing staff education regarding the use of non-pharmacological management of delirium. Based on their experience, nurses have a wealth of ideas for managing delirium. Areas for future research and policy are also highlighted. Implications for practice More research is needed on how to improve delirium management by acute care nurses to increase the efficacy and use of non-pharmacological interventions in the management of delirium in hospitalised older adults. To translate these findings into practice, nursing care needs to be guided by evidence-based guidelines to implement non-pharmacological strategies in the acute care setting. PMID:22513181

  8. A New Model of Delirium Care in the Acute Geriatric Setting: Geriatric Monitoring Unit

    PubMed Central

    2011-01-01

    Background Delirium is a common and serious condition, which affects many of our older hospitalised patients. It is an indicator of severe underlying illness and requires early diagnosis and prompt treatment, associated with poor survival, functional outcomes with increased risk of institutionalisation following the delirium episode in the acute care setting. We describe a new model of delirium care in the acute care setting, titled Geriatric Monitoring Unit (GMU) where the important concepts of delirium prevention and management are integrated. We hypothesize that patients with delirium admitted to the GMU would have better clinical outcomes with less need for physical and psychotropic restraints compared to usual care. Methods/Design GMU models after the Delirium Room with adoption of core interventions from Hospital Elder Life Program and use of evening bright light therapy to consolidate circadian rhythm and improve sleep in the elderly patients. The novelty of this approach lies in the amalgamation of these interventions in a multi-faceted approach in acute delirium management. GMU development thus consists of key considerations for room design and resource planning, program specific interventions and daily core interventions. Assessments undertaken include baseline demographics, comorbidity scoring, duration and severity of delirium, cognitive, functional measures at baseline, 6 months and 12 months later. Additionally we also analysed the pre and post-GMU implementation knowledge and attitude on delirium care among staff members in the geriatric wards (nurses, doctors) and undertook satisfaction surveys for caregivers of patients treated in GMU. Discussion This study protocol describes the conceptualization and implementation of a specialized unit for delirium management. We hypothesize that such a model of care will not only result in better clinical outcomes for the elderly patient with delirium compared to usual geriatric care, but also improved staff

  9. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit

    PubMed Central

    Card, E.; Pandharipande, P.; Tomes, C.; Lee, C.; Wood, J.; Nelson, D.; Graves, A.; Shintani, A.; Ely, E. W.; Hughes, C.

    2015-01-01

    Background Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes. Methods Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure. Results Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02). Conclusions A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period. PMID:25540068

  10. EFFECT OF PREOPERATIVE PAIN AND DEPRESSIVE SYMPTOMS ON THE DEVELOPMENT OF POSTOPERATIVE DELIRIUM.

    PubMed

    Kosar, Cyrus M; Tabloski, Patricia A; Travison, Thomas G; Jones, Richard N; Schmitt, Eva M; Puelle, Margaret R; Inloes, Jennifer B; Saczynski, Jane S; Marcantonio, Edward R; Meagher, David; Reid, M Carrington; Inouye, Sharon K

    2014-11-01

    Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk. We enrolled 459 persons without dementia aged ≥70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0-10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms. Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1·6, 95% confidence interval, CI, 1·2-2·3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1·07-1·08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0·049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance. Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery. U.S. National Institute on Aging.

  11. Risk factors and clinical aspects of delirium in elderly hospitalized patients in Iran.

    PubMed

    Foroughan, Mahshid; Delbari, Ahmad; Said, Said Ebn; AkbariKamrani, Ahmad Ali; Rashedi, Vahid; Zandi, Taher

    2016-04-01

    Recognition of the risk factors of delirium has been clearly advantageous in preventing and managing it as it occurs. The main aims of this study were to investigate the occurrence of delirium and identify the associated risk factors in a sample of hospitalized elderly in Southwestern Iran. A cross-sectional, hospital-based study was performed on a total of 200 elderly patients, admitted to a general hospital for various health reasons. Data were gathered over a 3-month period of time in 2010. Abbreviated Mental Test score (AMTs) used for delirium detection in post-admission days 1, 3, and 5, followed by clinical diagnostic confirmation according to the DSM-IV-TR criteria for delirium. Information regarding physical, cognitive, emotional, and functional states of the participants was collected, too. Delirium developed in 22 % of the participants. The demographic characteristics of the patients with delirium indicated that they were typically single, older men who lived alone and had a lower level of education and poorer functional status. Among other variables, the following were significantly associated with delirium: hemoglobin ≤12 (P < 0.001); Blood urea nitrogen/creatinine ratio ≥1/20 (P < 0.005); and positive C-reactive protein (P = 0.022); depressive symptoms (P < 0.001), and previous cognitive decline (P < 0.001). Patients with more than six different categories of medications were at high risk for delirium as well. Delirium is a serious and common problem in people over 60 years of age who are admitted to hospitals. Understanding risk factors and clinical aspects of delirium in elderly hospitalized patients will provide us with a better delirium management strategy.

  12. EFFECT OF PREOPERATIVE PAIN AND DEPRESSIVE SYMPTOMS ON THE DEVELOPMENT OF POSTOPERATIVE DELIRIUM

    PubMed Central

    Kosar, Cyrus M.; Tabloski, Patricia A.; Travison, Thomas G.; Jones, Richard N.; Schmitt, Eva M.; Puelle, Margaret R.; Inloes, Jennifer B.; Saczynski, Jane S.; Marcantonio, Edward R.; Meagher, David; Reid, M. Carrington; Inouye, Sharon K.

    2015-01-01

    Background Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk. Methods We enrolled 459 persons without dementia aged ≥70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0–10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms. Findings Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1·6, 95% confidence interval, CI, 1·2–2·3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1·07–1·08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0·049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance. Interpretation Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery. Funding U.S. National Institute on Aging. PMID:25642413

  13. The diurnal profile of melatonin during delirium in elderly patients--preliminary results.

    PubMed

    Piotrowicz, Karolina; Klich-Rączka, Alicja; Pac, Agnieszka; Zdzienicka, Anna; Grodzicki, Tomasz

    2015-12-01

    Delirium is an acute-onset syndrome that exacerbates patients' condition and significantly increases consequential morbidity and mortality. There is no comprehensive, cellular and tissue-level, pathophysiological theory. The melatonin hormone imbalance has been shown to be linked to circadian rhythms, sleep-wake cycle disturbances, and delirium incidence. There has been relatively little research about melatonin in delirium, and there has been no such study done in the group of elderly patients of a general medicine ward yet. The aim of our study was to compare melatonin hormone concentration in relation to the presence of delirium in elderly patients hospitalized in the general medicine ward. Blood samples were collected four times a day for two days (at 12:00, 18:00, 00:00 and 6:00), on the day when delirium was diagnosed and 72 h after the delirium resolution. Delirium was diagnosed with the Confusion Assessment Method and the criteria of the Diagnostic and Statistic Manual of Mental Disorders, 4th Revision. The mean age of 30 patients (73.3% women) was 86.5 ± 5.2 years. Delirium was diagnosed most often on the second and third day of hospitalization. A lot of predisposing and precipitating factors for delirium were identified. There was a significant difference in the melatonin hormone concentration measurement at 12:00 when patients had acute delirium and after its resolution [18.5 (13.8, 27.5) vs 12.9 (9.8, 17.8), p<0.01]. Different patterns of the melatonin hormone concentration were shown in analyses in the subgroups defined according to the patients' diagnosis of dementia. We found that the delirium recovery was, in fact, associated with the alteration of the daily profile of melatonin. Copyright © 2015 Elsevier Inc. All rights reserved.

  14. Identifying Barriers to Delirium Screening and Prevention in the Pediatric ICU: Evaluation of PICU Staff Knowledge.

    PubMed

    Flaigle, Melanie Cooper; Ascenzi, Judy; Kudchadkar, Sapna R

    2016-01-01

    Delirium in the pediatric intensive care unit (PICU) setting is often unrecognized and undertreated. The importance of screening and identification of ICU delirium has been identified in both adult and pediatric literature. Delirium increases ICU morbidity, length of mechanical ventilation and length of stay. The objective of this study was to determine the current knowledge level about delirium and its risk factors among pediatric critical care nurses through a short questionnaire. We hypothesized that before a targeted educational intervention, PICU care providers do not have an adequate knowledge base for accurate screening and diagnosis of delirium in critically ill children. A 17 question online survey was given to all nurses in a tertiary 36-bed PICU to assess current knowledge about delirium in children. The response rate was 73% (105/143). When asked to identify the correct way to diagnose pediatric delirium, 11.4% of nurses surveyed (12/105) incorrectly believed that Glasgow Coma Score is the appropriate screening tool. A large proportion of respondents (40/105) believed that benzodiazepines are helpful in treatment of delirium. The results of the survey identified specific knowledge gaps about risk factors and treatment of pediatric delirium in the critically ill child. There is a critical need for education about pediatric delirium and its risk factors among PICU staff prior to unit-wide implementation of a delirium screening and prevention program, specifically with regards to screening methods and pharmacologic risk factors. These results are likely generalizable to all physicians, nurses and staff who care for critically ill children.

  15. Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes.

    PubMed

    Brown, Charles H; LaFlam, Andrew; Max, Laura; Wyrobek, Julie; Neufeld, Karin J; Kebaish, Khaled M; Cohen, David B; Walston, Jeremy D; Hogue, Charles W; Riley, Lee H

    2016-10-01

    To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery. Prospective observational study. Academic medical center. Individuals aged 70 and older undergoing spine surgery (N = 89). Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state. Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home. Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  16. Prevalence and Risk Factors for Delirium in Acute Stroke Patients. A Retrospective 5-Years Clinical Series.

    PubMed

    Alvarez-Perez, Francisco José; Paiva, Fatima

    2017-03-01

    Delirium is characterized by disturbances of attention and cognition that cause functional decline and complications. The predisposing factors of delirium are age, male gender, systemic or metabolic disorders, dementia, and stroke. This study aims to evaluate the prevalence of delirium and to identify risk factors. This is a retrospective study that includes patients admitted over 5 years with acute stroke. Patients with transient ischemic attack or venous thrombosis were excluded. Delirium was defined according the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Demographical characteristics, clinical-radiological profile, dependence on discharge (modified Rankin Scale score of ≥3 and Barthel Index < 65%), and mortality during hospitalization were compared between patients with and without delirium. A total of 1161 patients were admitted (910 ischemic and 162 hemorrhagic). During hospitalization, 118 patients presented with delirium (10.2%) and 93 died (8%). On discharge, 517 patients were dependent (44.5%). Delirium was significantly associated with age, male gender, cortical infarcts in anterior circulation, higher leukocyte count, cholesterol and fibrinogen levels, lower albumin, atrial fibrillation, previous diagnosis of Alzheimer's disease, and hemorrhagic stroke. Logistic regression results showed that only previous Alzheimer's disease was related to delirium (odds ratio 21.68 [95% confidence interval 1.190-395.026, P = .038]). Dependence on discharge was associated with delirium. Ten percent of the patients presented with delirium associated with older age, Alzheimer's disease, and cortical anterior stroke. Patients with delirium had a higher risk of functional dependence on discharge. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  17. Prevalence, determinants, and prognostic significance of delirium in patients with acute heart failure.

    PubMed

    Honda, Satoshi; Nagai, Toshiyuki; Sugano, Yasuo; Okada, Atsushi; Asaumi, Yasuhide; Aiba, Takeshi; Noguchi, Teruo; Kusano, Kengo; Ogawa, Hisao; Yasuda, Satoshi; Anzai, Toshihisa

    2016-11-01

    Delirium is a serious syndrome in critically ill patients. However, the prognostic impact of delirium and its determinants in acute heart failure (AHF) patients have not been fully elucidated. We examined 611 AHF patients who were admitted to our institution. Delirium was diagnosed based on the Intensive Care Delirium Screening Checklist (ICDSC). Delirium developed in 139 patients (23%) during hospitalization. Patients with delirium had higher incidence of non-cardiovascular death (p=0.046) and worsening heart failure (p<0.001) during hospitalization. Among patients who survived at discharge, the incidence of all-cause death, cardiovascular death and non-cardiovascular death after discharge were significantly higher in patients with delirium than those without (log-rank; p<0.001, p=0.001, p<0.001, respectively) during a median follow-up period of 335days. In multivariable model, the development of delirium was an independent determinant of worsening heart failure during hospitalization (OR: 2.44, 95% CI: 1.27-4.63) and all-cause death after discharge (HR: 2.38, 95% CI: 1.30-4.35). Furthermore, multivariate analysis indicated that history of cerebrovascular disease (OR: 2.13, 95% CI: 1.36-3.35), age (OR: 1.43, 95% CI: 1.15-1.80), log BNP (OR: 1.39, 95% CI: 1.09-1.79), serum albumin (OR: 0.84, 95% CI: 0.76-0.93) and blood glucose levels (OR: 1.03, 95% CI: 1.00-1.06) were independent determinants of delirium. In patients with AHF, the development of delirium was associated with poor clinical outcomes, suggesting the importance of early screening and careful monitoring of delirium in such patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  18. Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation.

    PubMed

    Bagienski, Maciej; Kleczynski, Pawel; Dziewierz, Artur; Rzeszutko, Lukasz; Sorysz, Danuta; Trebacz, Jaroslaw; Sobczynski, Robert; Tomala, Marek; Stapor, Maciej; Dudek, Dariusz

    2017-10-01

    There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. Delirium transitions in the medical ICU: exploring the role of sleep quality and other factors

    PubMed Central

    Colantuoni, Elizabeth; King, Lauren M.; Neufeld, Karin J.; Bienvenu, O. Joseph; Rowden, Annette M.; Collop, Nancy A.; Needham, Dale M.

    2014-01-01

    Objective Disrupted sleep is a common and potentially modifiable risk factor for delirium in the intensive care unit (ICU). As part of a quality improvement (QI) project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium. Design Secondary analysis of prospective observational study. Setting Medical ICU (MICU) over a 201-day period. Patients 223 patients with ≥1 night in the MICU in between two consecutive days of delirium assessment. Interventions None Measurements Daily perceived sleep quality ratings were measured using the Richards Campbell Sleep Questionnaire (RCSQ). Delirium was measured twice-daily using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates evaluated included: age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day’s delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Main Results Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [IQR] ratings 58 [35-76] vs. 57 [33-78], respectively p=0.71), and perceived sleep quality was unrelated to delirium transition (adjusted OR 1.00, 95% CI 0.99-1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted OR 4.02, 95% CI 2.19-7.38, p<0.001) and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted OR 0.40, 95% CI 0.20-0.80, p=0.01). Conclusions We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill

  20. One-Year Health Care Costs Associated with Delirium in the Elderly

    PubMed Central

    Leslie, Douglas L.; Marcantonio, Edward R.; Zhang, Ying; Leo-Summers, Linda; Inouye, Sharon K.

    2015-01-01

    Background While delirium has been increasingly recognized as a serious and potentially preventable source of morbidity and mortality for hospitalized older persons, its long-term implications are not well understood. The objective of this study is to determine the total 1-year health care costs associated with delirium. Methods Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed for 1 year after discharge. Total inflation-adjusted healthcare costs were computed using data from Medicare administrative files, hospital billing records, and the Connecticut Long-Term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics. Results During the index hospitalization, 109 (13%) patients developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted healthcare costs than non-delirious patients and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were over two and a half times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. Conclusions The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder. PMID:18195192

  1. The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU.

    PubMed

    Khan, Babar A; Perkins, Anthony J; Gao, Sujuan; Hui, Siu L; Campbell, Noll L; Farber, Mark O; Chlan, Linda L; Boustani, Malaz A

    2017-05-01

    Delirium severity is independently associated with longer hospital stays, nursing home placement, and death in patients outside the ICU. Delirium severity in the ICU is not routinely measured because the available instruments are difficult to complete in critically ill patients. We designed our study to assess the reliability and validity of a new ICU delirium severity tool, the Confusion Assessment Method for the ICU-7 delirium severity scale. Observational cohort study. Medical, surgical, and progressive ICUs of three academic hospitals. Five hundred eighteen adult (≥ 18 yr) patients. None. Patients received the Confusion Assessment Method for the ICU, Richmond Agitation-Sedation Scale, and Delirium Rating Scale-Revised-98 assessments. A 7-point scale (0-7) was derived from responses to the Confusion Assessment Method for the ICU and Richmond Agitation-Sedation Scale items. Confusion Assessment Method for the ICU-7 showed high internal consistency (Cronbach's α = 0.85) and good correlation with Delirium Rating Scale-Revised-98 scores (correlation coefficient = 0.64). Known-groups validity was supported by the separation of mechanically ventilated and nonventilated assessments. Median Confusion Assessment Method for the ICU-7 scores demonstrated good predictive validity with higher odds (odds ratio = 1.47; 95% CI = 1.30-1.66) of in-hospital mortality and lower odds (odds ratio = 0.8; 95% CI = 0.72-0.9) of being discharged home after adjusting for age, race, gender, severity of illness, and chronic comorbidities. Higher Confusion Assessment Method for the ICU-7 scores were also associated with increased length of ICU stay (p = 0.001). Our results suggest that Confusion Assessment Method for the ICU-7 is a valid and reliable delirium severity measure among ICU patients. Further research comparing it to other delirium severity measures, its use in delirium efficacy trials, and real-life implementation is needed to determine its role in research and clinical

  2. Prevention of Sevoflurane Delirium and Agitation With Propofol

    PubMed Central

    Messieha, Zakaria

    2013-01-01

    Emergence delirium and agitation (EAD) associated with sevoflurane general anesthesia are very commonly observed in young children. Such events pose a risk for injury as well as decreased parental satisfaction, especially in the ambulatory and office-based setting. This article reviews the different approaches described in the literature to reduce EAD. A novel approach using a Bispectral Index System (BIS)-guided anesthesia with propofol washout technique is proposed as a viable and effective approach to prevent EAD. PMID:23763562

  3. Sleep and delirium in the intensive care unit.

    PubMed

    Mistraletti, G; Carloni, E; Cigada, M; Zambrelli, E; Taverna, M; Sabbatici, G; Ombrello, M; Elia, G; Destrebecq, A L L; Iapichino, G

    2008-06-01

    Intensive Care Unit (ICU) patients almost uniformly suffer from sleep disruption. Even though the role of sleep disturbances is not still adequately understood, they may be related to metabolic, immune, neurological and respiratory dysfunction and could worsen the quality of life after discharge. A harsh ICU environment, underlying disease, mechanical ventilation, pain and drugs are the main reasons that underlie sleep disruption in the critically ill. Polysomnography is the gold standard in evaluating sleep, but it is not feasible in clinical practice; therefore, other objective (bispectral index score [BIS] and actigraphy) and subjective (nurse and patient assessment) methods have been proposed, but their adequacy in ICU patients is not clear. Frequent evaluation of neurological status with validated tools is necessary to avoid excessive or prolonged sedation in order to better titrate patient-focused therapy. Hypnotic agents like benzodiazepines can increase total sleep time, but they alter the physiological progression of sleep phases, and decrease the time spent in the most restorative phases compared to the phases normally mediated by melatonin; melatonin production is decreased in critically ill patients, and as such, exogenous melatonin supplementation may improve sleep quality. Sleep disruption and the development of delirium are frequently related, both because of sleep scarcity and inappropriate dosing with sedatives. Delirium is strongly related to increased ICU morbidity and mortality, thus the resolution of sleep disruption could significantly contribute to improved ICU outcomes. An early evaluation of delirium is strongly recommended because of the potential to resolve the underlying causes or to begin an appropriate therapy. Further studies are needed on the effects of strategies to promote sleep and on the evaluation of better sleep in clinical outcomes, particularly on the development of delirium.

  4. Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU.

    PubMed

    Ista, Erwin; Te Beest, Harma; van Rosmalen, Joost; de Hoog, Matthijs; Tibboel, Dick; van Beusekom, Babette; van Dijk, Monique

    2017-08-23

    Delirium in critically ill children is a severe neuropsychiatric disorder which has gained increased attention from clinicians. Early identification of delirium is essential for successful management. The Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale was developed to detect Paediatric Delirium (PD) at an early stage. The aim of this study was to determine the measurement properties of the PD component of the SOS-PD scale in critically ill children. A prospective, observational study was performed in patients aged 3 months or older and admitted for more than 48h. These patients were assessed with the SOS-PD scale three times a day. If the SOS-PD total score was 4 or higher in two consecutive observations, the child psychiatrist was consulted to assess the diagnosis of PD using the Diagnostic and Statistical Manual-IV criteria as the "gold standard". The child psychiatrist was blinded to outcomes of the SOS-PD. The interrater reliability of the SOS-PD between the care-giving nurse and a researcher was calculated with the intraclass correlation coefficient (ICC). A total of 2088 assessments were performed in 146 children (median age 49 months; IQR 13-140). The ICC of 16 paired nurse-researcher observations was 0.90 (95% CI 0.70-0.96). We compared 63 diagnoses of the child psychiatrist versus SOS-PD assessments in 14 patients, in 13 of whom the diagnosis of PD was confirmed. The sensitivity was 96.8% (95% CI 80.4-99.5%) and the specificity was 92.0% (95% CI 59.7-98.9%). The SOS-PD scale shows promising validity for early screening of PD. Further evidence should be obtained from an international multicentre study. Copyright © 2017 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

  5. Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.

    PubMed

    Katznelson, Rita; Djaiani, George N; Borger, Michael A; Friedman, Zeev; Abbey, Susan E; Fedorko, Ludwik; Karski, Jacek; Mitsakakis, Nicholas; Carroll, Jo; Beattie, W Scott

    2009-01-01

    Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect. Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77). Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

  6. Delirium in intensive care unit patients under noninvasive ventilation: a multinational survey

    PubMed Central

    Tanaka, Lilian Maria Sobreira; Salluh, Jorge Ibrain Figueira; Dal-Pizzol, Felipe; Barreto, Bruna Brandão; Zantieff, Ricardo; Tobar, Eduardo; Esquinas, Antonio; Quarantini, Lucas de Castro; Gusmao-Flores, Dimitri

    2015-01-01

    Objective To conduct a multinational survey of intensive care unit professionals to determine the practices on delirium assessment and management, in addition to their perceptions and attitudes toward the evaluation and impact of delirium in patients requiring noninvasive ventilation. Methods An electronic questionnaire was created to evaluate the profiles of the respondents and their related intensive care units, the systematic delirium assessment and management and the respondents' perceptions and attitudes regarding delirium in patients requiring noninvasive ventilation. The questionnaire was distributed to the cooperative network for research of the Associação de Medicina Intensiva Brasileira (AMIB-Net) mailing list and to researchers in different centers in Latin America and Europe. Results Four hundred thirty-six questionnaires were available for analysis; the majority of the questionnaires were from Brazil (61.9%), followed by Turkey (8.7%) and Italy (4.8%). Approximately 61% of the respondents reported no delirium assessment in the intensive care unit, and 31% evaluated delirium in patients under noninvasive ventilation. The Confusion Assessment Method for the intensive care unit was the most reported validated diagnostic tool (66.9%). Concerning the indication of noninvasive ventilation in patients already presenting with delirium, 16.3% of respondents never allow the use of noninvasive ventilation in this clinical context. Conclusion This survey provides data that strongly reemphasizes poor efforts toward delirium assessment and management in the intensive care unit setting, especially regarding patients requiring noninvasive ventilation. PMID:26761474

  7. Case Study: Delirium in an Adolescent Girl with Human Immunodeficiency Virus-Associated Dementia

    ERIC Educational Resources Information Center

    Scharko, Alexander M.; Baker, Eva H.; Kothari, Priti; Khattak, Hina; Lancaster, Duniya

    2006-01-01

    Delirium and human immunodeficiency virus (HIV)-associated dementia are well recognized neuropsychiatric consequences of HIV infection in adults. Almost nothing is known regarding the management of delirium in HIV-infected children and adolescents. HIV-related progressive encephalopathy is thought to represent the pediatric form of HIV-associated…

  8. Delirium in Severely Ill Young Children in the Pediatric Intensive Care Unit (PICU)

    ERIC Educational Resources Information Center

    Schieveld, Jan N. M.; Leentjens, Albert F. G.

    2005-01-01

    Delirium is a serious neuropsychiatric disorder frequently seen in severely ill adult and geriatric patients. The clinical picture in adults is well known, as are the negative prognostic implications of delirium on length of hospital stay, morbidity, and mortality (American Psychiatric Association, 1999); however, it is less appreciated that…

  9. Baseline acetylcholinesterase activity and serotonin plasma levels are not associated with delirium in critically ill patients

    PubMed Central

    Tomasi, Cristiane Damiani; Salluh, Jorge; Soares, Márcio; Vuolo, Francieli; Zanatta, Francieli; Constantino, Larissa de Souza; Zugno, Alexandra Ioppi; Ritter, Cristiane; Dal-Pizzol, Felipe

    2015-01-01

    Objective The aim of this study was to investigate whether plasma serotonin levels or acetylcholinesterase activities determined upon intensive care unit admission could predict the occurrence of acute brain dysfunction in intensive care unit patients. Methods A prospective cohort study was conducted with a sample of 77 non-consecutive patients observed between May 2009 and September 2010. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit tool, and the acetylcholinesterase and serotonin measurements were determined from blood samples collected up to a maximum of 24 h after the admission of the patient to the intensive care unit. Results In the present study, 38 (49.6%) patients developed delirium during their intensive care unit stays. Neither serum acetylcholinesterase activity nor serotonin level was independently associated with delirium. No significant correlations of acetylcholinesterase activity or serotonin level with delirium/coma-free days were observed, but in the patients who developed delirium, there was a strong negative correlation between the acetylcholinesterase level and the number of delirium/coma-free days, indicating that higher acetylcholinesterase levels are associated with fewer days alive without delirium or coma. No associations were found between the biomarkers and mortality. Conclusions Neither serum acetylcholinesterase activity nor serotonin level was associated with delirium or acute brain dysfunction in critically ill patients. Sepsis did not modify these relationships. PMID:26340158

  10. Persistent Delirium in Chronic Critical Illness as a Prodrome Syndrome before Death.

    PubMed

    DeForest, Anna; Blinderman, Craig D

    2017-05-01

    Chronic critical illness (CCI) patients have poor functional outcomes, high risk of mortality, and significant sequelae, including delirium and cognitive dysfunction. The prognostic significance of persistent delirium in patients with CCI has not been well described. We report a case of a patient with CCI following major cardiac surgery who was hemodynamically stable following a long course in the cardiothoracic intensive care unit (CTICU), but had persistent and unremitting delirium. Despite both pharmacological and nonpharmacological approaches to improve his delirium, the patient ultimately continued to have symptoms of delirium and subsequently died in the CTICU. Efforts to reconsider the goals of care, given his family's understanding of his values, were met with resistance as his cardiothoracic surgeon believed that he had a reasonable chance of recovery since his organs were not in failure. This case description raises the question of whether we should consider persistent delirium as a prodrome syndrome before death in patients with CCI. Study and analysis of a case of a patient with CCI following major cardiothoracic surgery who was hemodynamically stable with persistent delirium. Further studies of the prevalence and outcomes of prolonged or persistent agitated delirium in patients with chronic critical illness are needed to provide prognostic information that can assist patients and families in receiving care that accords with their goals and values.

  11. Risk Factors for Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation

    PubMed Central

    Weckmann, Michelle T.; Gingrich, Roger; Mills, James A.; Hook, Larry; Beglinger, Leigh J.

    2013-01-01

    Background Delirium is common following hematopoietic stem-cell transplantation (HSCT) and is associated with increased morbidity and mortality. Early recognition and treatment have been shown to improve long term outcomes. We sought to investigate the relationship between potential risk-factors and the development of delirium following HSCT. Methods Fifty-four inpatients admitted for HSCT were assessed prospectively for delirium every 2-3 days through their inpatient stay using standardized delirium and neuropsychological measures. Patient’s self-reports of medical history, medical records, and neurocognitive and psychiatric assessments were used to identify risk factors. Both pre- and post-HSCT risk factors were examined. Results Delirium incidence was 35% and occurred with highest frequency in the 2 weeks following transplant. The only pre-transplantation risk factors was lower oxygen saturation (p=0.003). Post-transplantation risk factors for delirium included higher creatinine (p<0.0001), higher blood urea nitrogen levels (p=0.005), lower creatinine clearance (p=0.0006), lower oxygen saturation (p=0.001), lower hemoglobin (p=0.04) and lower albumin (p=0.03). There was no observed association with level of cognitive performance, transplant type, disease severity, medical co-morbidity index, age or conditioning regimen. Conclusion Routine laboratory values can assist in the identification of high risk patients before delirium onset to improve early detection and treatment of delirium following HSCT. PMID:22860240

  12. [The influence of epileptic predisposition on clinical features of schizophrenia in patients after delirium tremens].

    PubMed

    Dvirskiĭ, A A

    2001-01-01

    153 patients with schizophrenia in combination with alcoholic delirium were examined. Latent epilepsy has been found in 36 patients (23.5%). The basis of the epileptic seizures during alcoholic delirium was hereditary epileptic predisposition. Frequency of the progredient course was high while that of the favourable--recurrent course of schizophrenia was low in these cases.

  13. Beyond Grand Rounds: A Comprehensive and Sequential Intervention to Improve Identification of Delirium

    ERIC Educational Resources Information Center

    Ramaswamy, Ravishankar; Dix, Edward F.; Drew, Janet E.; Diamond, James J.; Inouye, Sharon K.; Roehl, Barbara J. O.

    2011-01-01

    Purpose of the Study: Delirium is a widespread concern for hospitalized seniors, yet is often unrecognized. A comprehensive and sequential intervention (CSI) aiming to effect change in clinician behavior by improving knowledge about delirium was tested. Design and Methods: A 2-day CSI program that consisted of progressive 4-part didactic series,…

  14. Delirium in Severely Ill Young Children in the Pediatric Intensive Care Unit (PICU)

    ERIC Educational Resources Information Center

    Schieveld, Jan N. M.; Leentjens, Albert F. G.

    2005-01-01

    Delirium is a serious neuropsychiatric disorder frequently seen in severely ill adult and geriatric patients. The clinical picture in adults is well known, as are the negative prognostic implications of delirium on length of hospital stay, morbidity, and mortality (American Psychiatric Association, 1999); however, it is less appreciated that…

  15. Beyond Grand Rounds: A Comprehensive and Sequential Intervention to Improve Identification of Delirium

    ERIC Educational Resources Information Center

    Ramaswamy, Ravishankar; Dix, Edward F.; Drew, Janet E.; Diamond, James J.; Inouye, Sharon K.; Roehl, Barbara J. O.

    2011-01-01

    Purpose of the Study: Delirium is a widespread concern for hospitalized seniors, yet is often unrecognized. A comprehensive and sequential intervention (CSI) aiming to effect change in clinician behavior by improving knowledge about delirium was tested. Design and Methods: A 2-day CSI program that consisted of progressive 4-part didactic series,…

  16. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses.

    PubMed

    Öztürk Birge, Ayşegül; Tel Aydin, Hatice

    2017-08-01

    This study aims to investigate the effect of nonpharmacological intervention training on delirium recognition and the intervention strategies of intensive care (ICU) nurses. This is a quasi-experimental study conducted using a pretest-posttest design. The study sample included a total of 95 patients staying in the medical ICU of a university hospital and 19 nurses working in these units. The data were collected using the Patient and Nurse Introduction, Confusion Assessment Method for the ICU, and Delirium Risk Factors, and Non-pharmacological Interventions in Delirium Prevention Forms. Delirium was identified in 26.5% and 20.9% of the patients in the pre- and posttraining phase, respectively. Patients with delirium had a longer duration of stay in the ICU, lower mean Glasgow Coma Scale score and a higher number of medications in daily treatment (p<0.05). The risk of delirium increased 8.5-fold by physical restriction and 3.4-fold by the presence of hypo/hypernatremia. The delirium recognition rate of nurses increased from 7.7% to 33.3% in the post-training phase. Our study results show that training can increase the efficiency of ICU nurses in the management of delirium. Copyright © 2016 Elsevier Ltd. All rights reserved.

  17. Longitudinal diffusion changes following postoperative delirium in older people without dementia.

    PubMed

    Cavallari, Michele; Dai, Weiying; Guttmann, Charles R G; Meier, Dominik S; Ngo, Long H; Hshieh, Tammy T; Fong, Tamara G; Schmitt, Eva; Press, Daniel Z; Travison, Thomas G; Marcantonio, Edward R; Jones, Richard N; Inouye, Sharon K; Alsop, David C

    2017-09-05

    To investigate the effect of postoperative delirium on longitudinal brain microstructural changes, as measured by diffusion tensor imaging. We studied a subset of the larger Successful Aging after Elective Surgery (SAGES) study cohort of older adults (≥70 years) without dementia undergoing elective surgery: 113 participants who had diffusion tensor imaging before and 1 year after surgery. Postoperative delirium severity and occurrence were assessed during the hospital stay using the Confusion Assessment Method and a validated chart review method. We investigated the association of delirium severity and occurrence with longitudinal diffusion changes across 1 year, adjusting for age, sex, vascular comorbidity, and baseline cognitive performance. We also assessed the association between changes in diffusion and cognitive performance across the 1-year follow-up period, adjusting for age, sex, education, and baseline cognitive performance. Postoperative delirium occurred in 25 participants (22%). Delirium severity and occurrence were associated with longitudinal diffusion changes in the periventricular, frontal, and temporal white matter. Diffusion changes were also associated with changes in cognitive performance across 1 year, although the cognitive changes did not show significant association with delirium severity or occurrence. Our study raises the possibility that delirium has an effect on the development of brain microstructural abnormalities, which may reflect brain changes underlying cognitive trajectories. Future studies are warranted to clarify whether delirium is the driving factor of the observed changes or rather a correlate of a vulnerable brain that is at high risk for neurodegenerative processes. © 2017 American Academy of Neurology.

  18. The Comparative Risk of Delirium with Different Opioids: A Systematic Review.

    PubMed

    Swart, Lieke M; van der Zanden, Vera; Spies, Petra E; de Rooij, Sophia E; van Munster, Barbara C

    2017-06-01

    There is substantial evidence that the use of opioids increases the risk of adverse outcomes such as delirium, but whether this risk differs between the various opioids remains controversial. In this systematic review, we evaluate and discuss possible differences in the risk of delirium from the use of various types of opioids in older patients. We performed a search in MEDLINE by combining search terms on delirium and opioids. A specific search filter for use in geriatric medicine was used. Quality was scored according to the quality assessment for cohort studies of the Dutch Cochrane Institute. Six studies were included, all performed in surgical departments and all observational. No study was rated high quality, one was rated moderate quality, and five were rated low quality. Information about dose, route, and timing of administration of the opioid was frequently missing. Pain and other important risk factors of delirium were often not taken into account. Use of tramadol or meperidine was associated with an increased risk of delirium, whereas the use of morphine, fentanyl, oxycodone, and codeine were not, when compared with no opioid. Meperidine was also associated with an increased risk of delirium compared with other opioids, whereas tramadol was not. The risk of delirium appeared to be lower with hydromorphone or fentanyl, compared with other opioids. Numbers used for comparisons were small. Some data suggest that meperidine may lead to a higher perioperative risk for delirium; however, high-quality studies that compare different opioids are lacking. Further comparative research is needed.

  19. [Opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium].

    PubMed

    Verstraete, L; Joosten, E; Milisen, K

    2008-02-01

    To assess the current opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium, survey administration was conducted to 2256 nurses and 982 physicians within the University Hospitals of Leuven (Belgium). Response rate was 26% with 819 respondents (600 nurses; 219 physicians) completing the questionnaire. 72% of the respondents considered delirium as a minor problem or no problem at all. Yet over half of respondents working on a palliative care unit (87%, n=15), traumatological ward (67%, n=18), cardio-thoracic surgery ward (58%, n=20), intensive care unit (55%, n=120) and geriatric ward (55%, n=42) reported it as a serious problem. Delirium was considered as an underdiagnosed (85%) but preventable (75%) syndrome. Yet patients at risk are rarely (34%) or never (52%) screened for delirium. In case of screening (48%), only 4% used a specific validated assessment tool. 97% of all respondents were convinced that delirium requires an active and immediate intervention of nurse and physician. 82% of the physicians preferred haldol to treat delirium, in case of alcohol withdrawal 69% chose tranxene. Physical restraints were considered important in the management of delirium by a greater proportion of nurses (49%) than physicians (28%). The severity of the problem is underestimated. While opinions regarding the treatment were quite correct, prevention and early detection of delirium deserve more attention.

  20. Impact of pneumonia on hyperactive delirium in end-stage lung cancer patients.

    PubMed

    Suzuki, Hidekazu; Hirashima, Tomonori; Kobayashi, Masashi; Okamoto, Norio; Matsuura, Yuka; Tamiya, Motohiro; Morishita, Naoko; Okafuji, Kohei; Shiroyama, Takayuki; Morimura, Osamu; Morita, Satomu; Kawase, Ichiro

    2013-01-01

    Patients with incurable lung cancer often receive palliative care. Hyperactive delirium is a burden not only for the patient's family but also for caregivers. There are no reports describing the risk factors for delirium among lung cancer patients. The present study investigated the frequency of incidence and risk factors for hyperactive delirium among end-stage lung cancer patients. Patients who died of lung cancer in our institute from January 2010 to December 2010 were retrospectively investigated. Information was obtained from medical records, and patients who developed hyperactive delirium (delirium group, group D) were compared with patients who did not (control group, group C) based on clinical and laboratory data. A total of 146 patients (median age, 70 years; 80 % male) died of lung cancer. Thirty-one (21.2 %) patients developed hyperactive delirium. Sex (P = 0.0093) and pneumonia (P = 0.023) were statistically significant variables in univariate analysis. Pneumonia occurred in 27.4 % of all patients. The incidence of pneumonia was 45.2 % in group D and 22 % in group C. Only pneumonia (odds ratio, 2.89; 95 % confidence interval, 1.22-6.85; P = 0.016) was identified as a significant factor for predicting hyperactive delirium in multivariate analysis. Pneumonia was identified as a significant risk factor for the development of hyperactive delirium among end-stage lung cancer patients.

  1. Case Study: Delirium in an Adolescent Girl with Human Immunodeficiency Virus-Associated Dementia

    ERIC Educational Resources Information Center

    Scharko, Alexander M.; Baker, Eva H.; Kothari, Priti; Khattak, Hina; Lancaster, Duniya

    2006-01-01

    Delirium and human immunodeficiency virus (HIV)-associated dementia are well recognized neuropsychiatric consequences of HIV infection in adults. Almost nothing is known regarding the management of delirium in HIV-infected children and adolescents. HIV-related progressive encephalopathy is thought to represent the pediatric form of HIV-associated…

  2. Development of an abbreviated version of the delirium motor subtyping scale (DMSS-4).

    PubMed

    Meagher, D; Adamis, D; Leonard, M; Trzepacz, P; Grover, S; Jabbar, F; Meehan, K; O'Connor, M; Cronin, C; Reynolds, P; Fitzgerald, J; O'Regan, N; Timmons, S; Slor, C; de Jonghe, J; de Jonghe, A; van Munster, B C; de Rooij, S E; Maclullich, A

    2014-04-01

    Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Identification of clinical subtypes can allow for more targeted clinical and research efforts. We sought to develop a brief method for clinical subtyping in clinical and research settings. A multi-site database, including motor symptom assessments conducted in 487 patients from palliative care, adult and old age consultation-liaison psychiatry services was used to document motor activity disturbances as per the Delirium Motor Checklist (DMC). Latent class analysis (LCA) was used to identify the class structure underpinning DMC data and also items for a brief subtyping scale. The concordance of the abbreviated scale was then compared with the original Delirium Motor Subtype Scale (DMSS) in 375 patients having delirium as per the American Psychiatric Association's Diagnostic and Statistical Manual (4th edition) criteria. Latent class analysis identified four classes that corresponded closely with the four recognized motor subtypes of delirium. Further, LCA of items (n = 15) that loaded >60% to the model identified four features that reliably identified the classes/subtypes, and these were combined as a brief motor subtyping scale (DMSS-4). There was good concordance for subtype attribution between the original DMSS and the DMSS-4 (κ = 0.63). The DMSS-4 allows for rapid assessment of clinical subtypes in delirium and has high concordance with the longer and well-validated DMSS. More consistent clinical subtyping in delirium can facilitate better delirium management and more focused research effort.

  3. Excited delirium syndrome (ExDS): treatment options and considerations.

    PubMed

    Vilke, Gary M; Bozeman, William P; Dawes, Donald M; Demers, Gerard; Wilson, Michael P

    2012-04-01

    The term Excited Delirium Syndrome (ExDS) has traditionally been used in the forensic literature to describe findings in a subgroup of patients with delirium who suffered lethal consequences from their untreated severe agitation.(1-5) Excited delirium syndrome, also known as agitated delirium, is generally defined as altered mental status and combativeness or aggressiveness. Although the exact signs and symptoms are difficult to define precisely, clinical findings often include many of the following: tolerance to significant pain, rapid breathing, sweating, severe agitation, elevated temperature, delirium, non-compliance or poor awareness to direction from police or medical personnel, lack of fatiguing, unusual or superhuman strength, and inappropriate clothing for the current environment. It has become increasingly recognized that individuals displaying ExDS are at high risk for sudden death, and ExDS therefore represents a true medical emergency. Recently the American College of Emergency Physicians (ACEP) published the findings of a white paper on the topic of ExDS to better find consensus on the issues of definition, diagnosis, and treatment.(6) In so doing, ACEP joined the National Association of Medical Examiners (NAME) in recognizing ExDS as a medical condition. For both paramedics and physicians, the difficulty in diagnosing the underlying cause of ExDS in an individual patient is that the presenting clinical signs and symptoms of ExDS can be produced by a wide variety of clinical disease processes. For example, agitation, combativeness, and altered mental status can be produced by hypoglycemia, thyroid storm, certain kinds of seizures, and these conditions can be difficult to distinguish from those produced by cocaine or methamphetamine intoxication.(7) Prehospital personnel are generally not expected to differentiate between the multiple possible causes of the patient's presentation, but rather simply to recognize that the patient has a medical emergency

  4. Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery.

    PubMed

    Nazemi, Alireza K; Gowd, Anirudh K; Carmouche, Jonathan J; Kates, Stephen L; Albert, Todd J; Behrend, Caleb J

    2017-04-01

    This study is a systematic review. Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery. Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available. A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015. Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05). An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically

  5. Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes.

    PubMed

    Kosar, Cyrus M; Thomas, Kali S; Inouye, Sharon K; Mor, Vincent

    2017-07-01

    To identify the rate of delirium present during admission to postacute care (PAC) in the nursing home setting and to determine whether patients with delirium had higher risk for adverse outcomes. Retrospective cohort study. US Medicare- and Medicaid-certified nursing homes, 2011 to 2014. Individuals admitted to all US nursing homes for PAC, aged ≥65 years, and without prior history of nursing home residence (n = 5,588,702). Minimum Data Set (MDS) 3.0 admission assessments identified delirium based upon Confusion Assessment Method (CAM) items. Robust Poisson regression was used to calculate adjusted relative risks (aRRs) with 95% confidence intervals (CIs) for death following PAC admission, and for 30-day discharge outcomes including re-hospitalization from PAC, discharge home, and functional improvement. Delirium was identified in 4.3% of new postacute nursing home admissions. Mortality within 30 days of PAC admission was observed in 16.3% of patients with delirium and 5.8% of patients without delirium (aRR = 2.27, CI = 2.24-2.30). The rate of 30-day readmission from PAC was 21.3% for patients with delirium compared with 15.1% among patients without delirium (aRR = 1.42, 95% CI = 1.40, 1.43). 26.9% of patients with delirium were discharged home within 30 days of admission compared to 52.5% of patients without delirium (aRR = 0.57, 95% CI = 0.57, 0.58). 48.9% of patients with delirium showed functional improvement at discharge compared to 59.9% of patients without delirium (aRR = 0.83, 95% CI = 0.82, 0.83). Patients with delirium present upon PAC admission were at high risk for mortality and 30-day re-hospitalization and were less likely to have timely discharge to home or to improve in physical function at discharge. Early identification and care planning for individuals with delirium at PAC admission may be essential to improve outcomes. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  6. Validation of a Delirium Risk Assessment Using Electronic Medical Record Information.

    PubMed

    Rudolph, James L; Doherty, Kelly; Kelly, Brittany; Driver, Jane A; Archambault, Elizabeth

    2016-03-01

    Identifying patients at risk for delirium allows prompt application of prevention, diagnostic, and treatment strategies; but is rarely done. Once delirium develops, patients are more likely to need posthospitalization skilled care. This study developed an a priori electronic prediction rule using independent risk factors identified in a National Center of Clinical Excellence meta-analysis and validated the ability to predict delirium in 2 cohorts. Retrospective analysis followed by prospective validation. Tertiary VA Hospital in New England. A total of 27,625 medical records of hospitalized patients and 246 prospectively enrolled patients admitted to the hospital. The electronic delirium risk prediction rule was created using data obtained from the patient electronic medical record (EMR). The primary outcome, delirium, was identified 2 ways: (1) from the EMR (retrospective cohort) and (2) clinical assessment on enrollment and daily thereafter (prospective participants). We assessed discrimination of the delirium prediction rule with the C-statistic. Secondary outcomes were length of stay and discharge to rehabilitation. Retrospectively, delirium was identified in 8% of medical records (n = 2343); prospectively, delirium during hospitalization was present in 26% of participants (n = 64). In the retrospective cohort, medical record delirium was identified in 2%, 3%, 11%, and 38% of the low, intermediate, high, and very high-risk groups, respectively (C-statistic = 0.81; 95% confidence interval 0.80-0.82). Prospectively, the electronic prediction rule identified delirium in 15%, 18%, 31%, and 55% of these groups (C-statistic = 0.69; 95% confidence interval 0.61-0.77). Compared with low-risk patients, those at high- or very high delirium risk had increased length of stay (5.7 ± 5.6 vs 3.7 ± 2.7 days; P = .001) and higher rates of discharge to rehabilitation (8.9% vs 20.8%; P = .02). Automatic calculation of delirium risk using an EMR algorithm identifies patients at

  7. Delirium in a residential care facility: An exploratory study of staff knowledge.

    PubMed

    Buettel, Amy; Cleary, Michelle; Bramble, Marguerite

    2017-09-01

    To explore staff knowledge of delirium by eliciting meaning through descriptions of their experiences within a residential aged care facility (RACF). Six staff from one RACF in Australia participated in this qualitative study. Semi-structured individual interviews were conducted and analysed using Colaizzi's analytical framework. The analysis revealed four themes: (i) absence of the word delirium; (ii) care based on intuition and automated actions; (iii) reliance on teamwork; and (iv) confusing delirium, depression and dementia. Delirium was absent from clinical discourse in the RACF. Although participants concluded that delirium was common, lack of knowledge led to under-assessment. Findings emphasise the need for staff education, informed assessment and clinical guidelines to better support staff care for residents. © 2017 AJA Inc.

  8. Detection and Management of Delirium in the Neonatal Unit: A Case Series.

    PubMed

    Groves, Alan; Traube, Chani; Silver, Gabrielle

    2016-03-01

    Delirium is increasingly recognized as a common syndrome in critically ill children, but in our experience, it is rarely considered in the NICU. Delirium is independently associated with prolonged length of stay and adverse long-term outcomes in children. We report the cases of 3 infants cared for in our NICU at corrected gestational ages of 4, 11, and 17 weeks who presented with classic symptoms of delirium. All 3 children had complex medical problems and were receiving multiple analgesic and sedative medications. All 3 children exhibited agitation that was unresponsive to increasing doses of medications, and they all appeared to improve after treatment with quetiapine, allowing weaning of other medications. It is possible that with increased vigilance, delirium will be increasingly recognized in newborns, thus allowing tailored intervention. Further research is needed to investigate the prevalence and associated risk factors for developing delirium in the NICU and to explore possible treatment options. Copyright © 2016 by the American Academy of Pediatrics.

  9. Short-term cognitive effects after recovery from a delirium in a hospitalized elderly sample.

    PubMed

    Mark, Ruth E; Muselaers, Noortje; Scholten, Hetty; van Boxtel, Anton; Eerenberg, Trudy

    2014-10-01

    The aim of this study was to examine early cognitive performance after a delirium in elderly general hospital patients. Patients were divided into a delirium (n = 47) and a control (n = 25) group. One week before discharge and after delirium had cleared in the first group, all patients completed a neuropsychological test battery (The Cambridge Cognitive Examination-Revised [CAMCOG-R]). Group differences in cognitive performance were analyzed adjusting for differences in baseline sociodemographic and clinical variables. Adjusting for group differences in baseline variables, the delirium group performed significantly worse than the control group on CAMCOG-R; its subdomains language, praxis, and executive functioning; and on Mini Mental State Examination derived from CAMCOG-R. The occurrence of delirium in hospital thus detrimentally affects early cognitive performance.

  10. Under-recognition of delirium in older adults by nurses in the intensive care unit setting.

    PubMed

    Panitchote, Anupon; Tangvoraphonkchai, Kawin; Suebsoh, Naluttaporn; Eamma, Wanaporn; Chanthonglarng, Bunruam; Tiamkao, Somsak; Limpawattana, Panita

    2015-10-01

    Nurses have the key roles to detect delirium in hospitalized older patients but under-recognition of delirium among nurses is prevalent. The objectives of this study were to identify the under-recognition rate of delirium by intensive care nurses (ICU) using Confusion Assessment Method for the ICU (CAM-ICU) and factors associated with under-recognition. Participants were older patients aged ≥65 years who were admitted to the ICU of Srinagarind Medical School, Khon Kaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by a trained clinical researcher using the CAM-ICU. Demographic data were analyzed using descriptive statistics. Univariate and multiple logistic regressions were used to analyze the outcomes. Delirium occurred in 44 of 99 patients (44.4 %). Nurses could not identify delirium in 29.6 % of patients compared with researchers. Pre-existing dementia and depression were found in 47.7 % of patients. Pneumonia or other causes of respiratory failure were the most common causes of admission to ICU (47.7 %). Independent factors associated with under-recognition by nurses were identified-heart failure [adjusted odds ratio (OR), 77.8; 95 % confidence interval (CI) 2.5-2,543, p = 0.01] and pre-existing taking treatment with benzodiazepines (adjusted OR, 22.6; 95 % CI 1.8-85, p = 0.01). Under-recognition of delirium is a frequent issue. New independent factors associated with under-recognition were identified. Awareness of delirium in the patients with these factors is recommended. This study supports the finding of high under-recognition rates of delirium among hospitalized older adults in ICU. Patients with heart failure and receiving benzodiazepines were identified as barriers of recognition of delirium.

  11. Melatonin treatment in the prevention of postoperative delirium in cardiac surgery patients

    PubMed Central

    Artemiou, Panagiotis; Bilecova-Rabajdova, Miroslava; Sabol, Frantisek; Torok, Pavol; Kolarcik, Peter; Kolesar, Adrian

    2015-01-01

    Introduction Post-cardiac surgery delirium is a severe complication. The circadian rhythm of melatonin secretion has been shown to be altered postoperatively. Aim of the study It was hypothesized that restoring normal sleeping patterns with a substance that is capable of resynchronizing circadian rhythm such as exogenous administration of melatonin may possibly reduce the incidence of postoperative delirium. Material and methods This paper represents a prospective clinical observational study. Two consecutive groups of 250 consecutive patients took part in the study. Group A was the control group and group B was the melatonin group. In group B, the patients received prophylactic melatonin treatment. The main objectives were to observe the incidence of delirium, to identify any predictors of delirium, and to compare the two groups based on the delirium incidence. Results The incidence of delirium was 8.4% in the melatonin group vs. 20.8% in the control group (p = 0.001). Predictors of delirium in the melatonin group were age (p = 0.001) and higher EuroSCORE II value (p = 0.001). In multivariate analysis, age and EuroSCORE II value (p = 0.014) were predictors of postoperative delirium. Comparing the groups, the main predictors of delirium were age (p = 0.001), EuroSCORE II value (p = 0.001), cardio-pulmonary bypass (CPB) time (p = 0.001), aortic cross-clamping (ACC) time (p = 0.008), sufentanil dose (p = 0.001) and mechanical ventilation (p = 0.033). Conclusions Administration of melatonin significantly decreases the incidence of postoperative delirium after cardiac surgery. Prophylactic treatment with melatonin should be considered in every patient scheduled for cardiac surgery. PMID:26336494

  12. DELirium Prediction Based on Hospital Information (Delphi) in General Surgery Patients.

    PubMed

    Kim, Min Young; Park, Ui Jun; Kim, Hyoung Tae; Cho, Won Hyun

    2016-03-01

    To develop a simple and accurate delirium prediction score that would allow identification of individuals with a high probability of postoperative delirium on the basis of preoperative and immediate postoperative data.Postoperative delirium, although transient, is associated with adverse outcomes after surgery. However, there has been no appropriate tool to predict postoperative delirium.This was a prospective observational single-center study, which consisted of the development of the DELirium Prediction based on Hospital Information (Delphi) score (n = 561) and its validation (n = 533). We collected potential risk factors for postoperative delirium, which were identified by conducting a comprehensive review of the literatures.Age, low physical activity, hearing impairment, heavy alcoholism, history of prior delirium, intensive care unit (ICU) admission, emergency surgery, open surgery, and increased preoperative C-reactive protein were identified as independent predictors of postoperative delirium. The Delphi score was generated using logistic regression coefficients. The maximum Delphi score was 15 and the optimal cut-off point identified with the Youden index was 6.5. Generated area under the (AUC) of the receiver operating characteristic (ROC) curve was 0.911 (95% CI: 0.88-0.94). In the validation study, the calculated AUC of the ROC curve based on the Delphi score was 0.938 (95% Cl: 0.91-0.97). We divided the validation cohort into the low-risk group (Delphi score 0-6) and high-risk group (7-15). Sensitivity of Delphi score was 80.8% and specificity 92.5%.Our proposed Delphi score could help health-care provider to predict the development of delirium and make possible targeted intervention to prevent delirium in high-risk surgery patients.

  13. Delirium is a risk factor for further cognitive decline in cognitively impaired hip fracture patients.

    PubMed

    Krogseth, Maria; Watne, Leiv Otto; Juliebø, Vibeke; Skovlund, Eva; Engedal, Knut; Frihagen, Frede; Wyller, Torgeir Bruun

    2016-01-01

    Delirium is a risk factor for dementia in cognitively intact patients. Whether an episode of delirium accelerates cognitive decline in patients with known dementia, is less explored. This is a prospective follow-up study of 287 hip fracture patients with pre-fracture cognitive impairment. During the hospitalization, the patients were screened daily for delirium using the Confusion Assessment Method. Pre-fracture cognitive impairment was defined as a score of 3.44 or higher on the pre-fracture Informant Questionnaire on Cognitive Decline in the Elderly Short Form (IQCODE-SF). At follow-up after 4-6 months, the caregivers rated cognitive changes emerging after the fracture using the IQCODE-SF, and the patients were tested with the Mini Mental State Examination (MMSE). A sub-group of the patients had a pre-fracture MMSE score which was used to calculate the yearly decline on the MMSE in patients with and without delirium. 201 of the 287 patients developed delirium in the acute phase. In linear regression analysis, delirium was a significant and independent predictor of a more prominent cognitive decline at follow-up measured by the IQCODE-SF questionnaire (p=0.002). Among patients having a pre-fracture MMSE score, the patients developing delirium had a median (IQR) yearly decline of 2.4 points (1.1-3.9), compared to 1.0 points (0-1.9) in the group without delirium (p=0.001, Mann-Whitney test). Hip fracture patients with pre-fracture dementia run a higher risk of developing delirium. Delirium superimposed on dementia is a significant predictor of an accelerated further cognitive decline. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  14. The development of an automated ward independent delirium risk prediction model.

    PubMed

    de Wit, Hugo A J M; Winkens, Bjorn; Mestres Gonzalvo, Carlota; Hurkens, Kim P G M; Mulder, Wubbo J; Janknegt, Rob; Verhey, Frans R; van der Kuy, Paul-Hugo M; Schols, Jos M G A

    2016-08-01

    Background A delirium is common in hospital settings resulting in increased mortality and costs. Prevention of a delirium is clearly preferred over treatment. A delirium risk prediction model can be helpful to identify patients at risk of a delirium, allowing the start of preventive treatment. Current risk prediction models rely on manual calculation of the individual patient risk. Objective The aim of this study was to develop an automated ward independent delirium riskprediction model. To show that such a model can be constructed exclusively from electronically available risk factors and thereby implemented into a clinical decision support system (CDSS) to optimally support the physician to initiate preventive treatment. Setting A Dutch teaching hospital. Methods A retrospective cohort study in which patients, 60 years or older, were selected when admitted to the hospital, with no delirium diagnosis when presenting, or during the first day of admission. We used logistic regression analysis to develop a delirium predictive model out of the electronically available predictive variables. Main outcome measure A delirium risk prediction model. Results A delirium risk prediction model was developed using predictive variables that were significant in the univariable regression analyses. The area under the receiver operating characteristics curve of the "medication model" model was 0.76 after internal validation. Conclusions CDSSs can be used to automatically predict the risk of a delirium in individual hospitalised patients' by exclusively using electronically available predictive variables. To increase the use and improve the quality of predictive models, clinical risk factors should be documented ready for automated use.

  15. Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients

    PubMed Central

    2013-01-01

    Background Aging and neurodegenerative disease predispose to delirium and are both associated with increased activity of the innate immune system resulting in an imbalance between pro- and anti-inflammatory mediators in the brain. We examined whether hip fracture patients who develop postoperative delirium have altered levels of inflammatory mediators in cerebrospinal fluid (CSF) prior to surgery. Methods Patients were 75 years and older and admitted for surgical repair of an acute hip fracture. CSF samples were collected preoperatively. In an exploratory study, we measured 42 cytokines and chemokines by multiplex analysis. We compared CSF levels between patients with and without postoperative delirium and examined the association between CSF cytokine levels and delirium severity. Delirium was diagnosed with the Confusion Assessment Method; severity of delirium was measured with the Delirium Rating Scale Revised-98. Mann–Whitney U tests or Student t-tests were used for between-group comparisons and the Spearman correlation coefficient was used for correlation analyses. Results Sixty-one patients were included, of whom 23 patients (37.7%) developed postsurgical delirium. Concentrations of Fms-like tyrosine kinase-3 (P=0.021), Interleukin-1 receptor antagonist (P=0.032) and Interleukin-6 (P=0.005) were significantly lower in patients who developed delirium postoperatively. Conclusions Our findings fit the hypothesis that delirium after surgery results from a dysfunctional neuroinflammatory response: stressing the role of reduced levels of anti-inflammatory mediators in this process. Trial registration The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient. Registration number: NCT00497978. Local ethical protocol number: NL16222.094.07. PMID:24093540

  16. Delirium Frequency and Risk Factors Among Patients With Cancer in Palliative Care Unit.

    PubMed

    Şenel, Gülcin; Uysal, Neşe; Oguz, Gonca; Kaya, Mensure; Kadioullari, Nihal; Koçak, Nesteren; Karaca, Serife

    2017-04-01

    Introductıon: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit. Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria. The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%. The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.

  17. Predisposing risk factors for delirium in living donor liver transplantation patients in intensive care units.

    PubMed

    Wang, Szu-Han; Wang, Jiun-Yi; Lin, Ping-Yi; Lin, Kuo-Hua; Ko, Chih-Jan; Hsieh, Chia-En; Lin, Hui-Chuan; Chen, Yao-Li

    2014-01-01

    Delirium is one of the main causes of increased length of intensive care unit (ICU) stay among patients who have undergone living donor liver transplantation (LDLT). We aimed to evaluate risk factors for delirium after LDLT as well as to investigate whether delirium impacts the length of ICU and hospital stay. Seventy-eight patients who underwent LDLT during the period January 2010 to December 2012 at a single medical center were enrolled. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale was used to diagnose delirium. Preoperative, postoperative, and hematologic factors were included as potential risk factors for developing delirium. During the study period, delirium was diagnosed in 37 (47.4%) patients after LDLT. The mean onset of symptoms occurred 7.0±5.5 days after surgery and the mean duration of symptoms was 5.0±2.6 days. The length of stay in the ICU for patients with delirium (39.8±28.1 days) was significantly longer than that for patients without delirium (29.3±19.0 days) (p<0.05). Risk factors associated with delirium included history of alcohol abuse [odds ratio (OR) = 6.40, 95% confidence interval (CI): 1.85-22.06], preoperative hepatic encephalopathy (OR = 4.45, 95% CI: 1.36-14.51), APACHE II score ≥16 (OR = 1.73, 95% CI: 1.71-2.56), and duration of endotracheal intubation ≥5 days (OR = 1.81, 95% CI: 1.52-2.23). History of alcohol abuse, preoperative hepatic encephalopathy, APACHE II scores ≥16 and endotracheal intubation ≥5 days were predictive of developing delirium in the ICU following liver transplantation surgery and were associated with increased length of ICU and hospital stay.

  18. Delirium in the geriatric unit: proton-pump inhibitors and other risk factors

    PubMed Central

    Otremba, Iwona; Wilczyński, Krzysztof; Szewieczek, Jan

    2016-01-01

    Background Delirium remains a major nosocomial complication of hospitalized elderly. Predictive models for delirium may be useful for identification of high-risk patients for implementation of preventive strategies. Objective Evaluate specific factors for development of delirium in a geriatric ward setting. Methods Prospective cross-sectional study comprised 675 consecutive patients aged 79.2±7.7 years (66% women and 34% men), admitted to the subacute geriatric ward of a multiprofile university hospital after exclusion of 113 patients treated with antipsychotic medication because of behavioral disorders before admission. Comprehensive geriatric assessments including a structured interview, physical examination, geriatric functional assessment, blood sampling, ECG, abdominal ultrasound, chest X-ray, Confusion Assessment Method for diagnosis of delirium, Delirium-O-Meter to assess delirium severity, Richmond Agitation-Sedation Scale to assess sedation or agitation, visual analog scale and Doloplus-2 scale to assess pain level were performed. Results Multivariate logistic regression analysis revealed five independent factors associated with development of delirium in geriatric inpatients: transfer between hospital wards (odds ratio [OR] =2.78; confidence interval [CI] =1.54–5.01; P=0.001), preexisting dementia (OR =2.29; CI =1.44–3.65; P<0.001), previous delirium incidents (OR =2.23; CI =1.47–3.38; P<0.001), previous fall incidents (OR =1.76; CI =1.17–2.64; P=0.006), and use of proton-pump inhibitors (OR =1.67; CI =1.11–2.53; P=0.014). Conclusion Transfer between hospital wards, preexisting dementia, previous delirium incidents, previous fall incidents, and use of proton-pump inhibitors are predictive of development of delirium in the geriatric inpatient setting. PMID:27103793

  19. Emerging Role of Melatonin and Melatonin Receptor Agonists in Sleep and Delirium in Intensive Care Unit Patients.

    PubMed

    Mo, Yoonsun; Scheer, Corey E; Abdallah, George T

    2016-08-01

    Delirium, an acute state of mental confusion, can lead to many adverse sequelae in intensive care unit (ICU) patients. Although the etiology of ICU delirium is often multifactorial, and at times not fully understood, sleep deprivation is considered to be a major contributing factor to its development. It has been postulated that administration of exogenous melatonin and melatonin receptor agonists such as ramelteon may prevent delirium by promoting nocturnal sleep in ICU patients. The purpose of this review is to summarize the pharmacology of melatonin and melatonin receptor agonists and investigate their potential roles in sleep promotion and delirium prevention in ICU patients. Although few studies evaluating the impact of melatonergic agents on sleep and delirium in the ICU have been completed, some data suggest their potential positive effects on sleep and delirium. However, large-scale randomized controlled trials are warranted to determine the optimal role of melatonergic agents in the prevention of ICU delirium. © The Author(s) 2015.

  20. Determining the need for team-based training in delirium management: A needs assessment of surgical healthcare professionals.

    PubMed

    Sockalingam, Sanjeev; Tehrani, Hedieh; Kacikanis, Anna; Tan, Adrienne; Hawa, Raed; Anderson, Ruthie; Okrainec, Allan; Abbey, Susan

    2015-01-01

    The high incidence of delirium in surgical units is a serious quality concern, given its impact on morbidity and mortality. While successful delirium management depends upon interdisciplinary care, training needs for surgical teams have not been studied. A needs assessment of surgical units was conducted to determine perceived comfort in managing delirium, and interprofessional training needs for team-based care. We administered a survey to 106 General Surgery healthcare professionals (69% response rate) with a focus on attitudes towards delirium and team management. Although most respondents identified delirium as important to patient outcomes, only 61% of healthcare professionals indicated that a team-based approach was always observed in practice. Less than half had a clear understanding of their role in delirium care, while just over half observed team communication of delirium care plans during handover. This is the first observation of clear gaps in perceived team performance in a General Surgery setting.

  1. ICU architectural design affects the delirium prevalence: a comparison between single-bed and multibed rooms*.

    PubMed

    Caruso, Pedro; Guardian, Lilian; Tiengo, Tatiane; Dos Santos, Lucio Souza; Junior, Pedro Medeiros

    2014-10-01

    Delirium risk factors are related to the patients' acute and chronic clinical condition, treatment, and environment. The environmental risk factors are essentially determined by the ICU architectural design. Although there are countless architectural variations among the ICUs, all can be classified as single- or multibed rooms. Our objectives were to compare the ICU delirium prevalence and characteristics (coma/delirium-free days, first day in delirium, and delirium motoric subtypes) of critically ill patients admitted in single- or multibed rooms. Retrospective. ICU of a teaching oncologic hospital with 31 beds. Twenty-three beds distributed in one multibed room with 13 beds and other with 10 beds. Eight beds distributed in single-bed rooms. All adult patients admitted from February to November 2011. None. We evaluated 1,587 patients and included 1,253 patients. Patients' characteristics at ICU admission and their outcomes along the ICU stay were not different between patients admitted in single- or multibed rooms. One hundred sixty-three patients (13.0%) had delirium, and the prevalence was significantly lower in patients admitted in single-bed rooms (6.8% × 15.1%; p < 0.01). This lower prevalence occurred in patients admitted due to a medical (11.0% × 25.6%; p < 0.01) or postoperative (5.0% × 11.4%; p < 0.01) reason. However, the coma/delirium-free days, the first day in delirium, and the delirium motoric subtypes were not different between the single- and multibed rooms. The risk factors associated with delirium were admission in multibed rooms (odds ratio, 4.03; 95% CI, 2.13-7.62), older age, ICU-acquired infection, and higher Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment score. Critically ill patients admitted in single-bed rooms have a lower prevalence of delirium than those admitted in multibed rooms. However, coma/delirium-free days, first day in delirium, and motoric subtypes were not different.

  2. Detection and management of hyperactive and hypoactive delirium in older patients during hospitalization: a retrospective cohort study evaluating daily practice.

    PubMed

    van Velthuijsen, Eveline L; Zwakhalen, Sandra M G; Mulder, Wubbo J; Verhey, Frans R J; Kempen, Gertrudis I J M

    2017-02-14

    The objectives of the study are to study daily hospital practice regarding detection and management and to study hyperactive and hypoactive delirium of older patients during their hospitalization. A retrospective cohort study evaluating care as usual for older hospitalized patients with delirium at Maastricht University Medical Center+, a university hospital in the Netherlands, was performed. Inclusion criteria were older hospitalized patients (65+ years), diagnosed with delirium between 1 January and 31 December 2014. Data were retrieved from the patients' medical files. Delirium was categorized as hyperactive or hypoactive. Primary outcome measures were prevalence and management (pharmacological, reorientation, screening for delirium and delirium consultations, and physical restraints). Secondary outcomes were short-term adverse outcomes. Prevalence of delirium was 5% (N = 401), of which 77% (n = 307) was hyperactive and 23% (n = 94) was hypoactive. Significantly, more patients with a hyperactive delirium received medication to manage the delirium than patients with a hypoactive delirium (89% vs. 77%, respectively, p = 0.004). No other significant differences between the subtypes were found. There was probably a strong under-recognition of delirium. Drugs were the main intervention of choice, especially for patients with hyperactive delirium. The two subtypes did not differ on non-pharmacological management. The retrospective nature of this study sheds light on the status quo of recognition, management, and care as usual for the different delirium subtypes in daily hospital practice, which may help in forming new guidelines and protocols for the detection and treatment of delirium for older patients in hospitals. © 2017 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd. © 2017 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd.

  3. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults”

    PubMed Central

    Fick, Donna M.; Steis, Melinda R.; Waller, Jennifer L.; Inouye, Sharon K.

    2014-01-01

    Background Current literature does not identify the significance of underlying cognitive impairment and delirium on older adults during and 30 days following acute care hospitalization. Objective Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia. Design 24-month prospective cohort study Setting community hospital Patients 139 older adults (>65 years) with dementia Methods This prospective study followed patients daily during hospitalization and one month post-hospital. Main measures included dementia (Modified Blessed Dementia Rating Score, IQ CODE), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3 and significance with an alpha level of 0.05. Logistic regression, analysis of covariance or linear regression was performed controlling for age, gender and dementia stage. Results The overall incidence of new delirium was 32% (44/140). Those with delirium had a 25% short term mortality rate, increased length of stay and poorer function at discharge. At one month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium and for every one unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium. Conclusions Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital. PMID:23955965

  4. The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial.

    PubMed

    Neerland, Bjørn Erik; Hov, Karen Roksund; Bruun Wyller, Vegard; Qvigstad, Eirik; Skovlund, Eva; MacLullich, Alasdair M J; Bruun Wyller, Torgeir

    2015-02-10

    Delirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients. The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation. LUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients. ClinicalTrials.gov NCT01956604. EudraCT Number: 2013-000815-26.

  5. [Knowledge and implementation of the S3 guideline on delirium management in Germany].

    PubMed

    Saller, T; V Dossow, V; Hofmann-Kiefer, K

    2016-10-01

    Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly. The aim of the current study was to evaluate recent German anesthetists' strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care. In an online survey German hospitals' senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014. The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of

  6. PEDIATRIC DELIRIUM AND ASSOCIATED RISK FACTORS: A SINGLE-CENTER PROSPECTIVE OBSERVATIONAL STUDY

    PubMed Central

    Gerber, Linda M.; Sun, Xuming; Kearney, Julia; Patel, Anita; Greenwald, Bruce

    2016-01-01

    Objective To describe a single-institution pilot study regarding prevalence and risk factors for delirium in critically ill children. Design A prospective observational study, with secondary analysis of data collected during the validation of a pediatric delirium screening tool, the Cornell Assessment of Pediatric Delirium (CAPD). Setting This study took place in the pediatric intensive care unit (PICU) at an urban academic medical center. Patients 99 consecutive patients, ages newborn to 21 years. Intervention Subjects underwent a psychiatric evaluation for delirium based on the DSM-IV criteria. Measurements and Main Results Prevalence of delirium in this sample was 21%. In multivariate analysis, risk factors associated with the diagnosis of delirium were presence of developmental delay, need for mechanical ventilation, and age 2-5 years. Conclusions In our institution, pediatric delirium is a prevalent problem, with identifiable risk factors. Further large-scale prospective studies are required to explore multi-institutional prevalence, modifiable risk factors, therapeutic interventions, and effect on long-term outcomes. PMID:25647240

  7. Licensed Nurse and Nursing Assistant Recognition of Delirium in Nursing Home Residents With Dementia

    PubMed Central

    Steis, Melinda R; Behrens, Liza; Colancecco, Elise M; Mogle, Jacqueline; Mulhall, Paula M; Hill, Nikki L; Fick, Donna M; Kolankowski, Ann M

    2016-01-01

    Many nursing home residents experience delirium. Nursing home personnel, especially nursing assistants, have the opportunity to become familiar with residents’ normal cognitive function and to recognize changes in a resident’s cognitive function over time. The purpose of this study was to determine the accuracy of delirium recognition by licensed nurses and nursing assistants from eight nursing homes over a 12-month period. Participants were asked to complete five case vignette assessments at three different time points (in 6-month intervals) to test their ability to identify different subtypes of delirium and delirium superimposed on dementia (DSD). A total of 760 case vignettes were completed across the different time points. Findings reveal that staff recognition of delirium was poor. The case vignette describing hyperactive DSD was correctly identified by the greatest number participants, and the case vignette describing hypoactive DSD was correctly identified by the least number of participants. Recognition of the case vignette describing hypoactive delirium improved over time. Nursing assistants performed similarly to the licensed nurses, indicating that all licensed nursing home staff require further education to correctly recognize delirium in older adults. PMID:28042285

  8. Severe, Persistent and Fatal Delirium in Psychogeriatric Patients Admitted to a Psychiatric Hospital

    PubMed Central

    Jans, Ingrid S.; Oudewortel, Letty; Brandt, Paulien M.; van Gool, Willem A.

    2015-01-01

    Background/Aims Although delirium is generally regarded as a transient syndrome, persistence of delirium in patients with cognitive impairment – even with fatal outcome – has been reported as well. This study aims to describe the clinical features and neuropathological correlates of this type of delirium. Methods Inclusion criteria for this case series were: (1) severe persistent delirium until death, (2) history of cognitive decline and (3) consent for brain autopsy. Medical records were examined in combination with collected clinical data and neuropathological findings. Result In 15 patients, all living at home before admission, episodes with delirium lasted for 4.2 months on average. No distinct medical causes of persistent delirium could be identified. Pathological diagnoses included Alzheimer's disease and dementia with Lewy bodies as well as single cases of Creutzfeldt-Jakob disease and progressive supranuclear palsy. Conclusion Severe, persistent and fatal delirium in patients with cognitive impairment can occur relatively early in the disease trajectory and is associated with diverse neuropathologies. PMID:26195981

  9. Delirium associated with concomitant use of duloxetine and bupropion in an elderly patient.

    PubMed

    Ma, Szu-Pin; Tsai, Chia-Jui; Chang, Cheng-Chen; Hsu, Wen-Yu

    2017-03-01

    Delirium is common in daily practice. Drug-induced delirium constitutes approximately one-third of all cases of delirium. In cases characterized by the limited efficacy of a single antidepressant, a combination of two antidepressants is required, which may induce a complex drug-drug interaction. We reviewed a case of duloxetine- and bupropion-related delirium in an elderly male patient in our clinical practice. The patient was diagnosed with major depressive disorder and was treated with duloxetine. However, he developed delirium 10 days after bupropion was added to his treatment regimen. Three days after the cessation of bupropion, his delirious condition gradually improved. Duloxetine and bupropion are both cytochrome P450 2D6 inhibitors that may result in a higher level of hydroxybupropion. An increased level of hydroxybupropion may cause the elevation of dopamine and a risk of subsequent delirium. We should be aware of the risk of delirium induced by drug-drug interactions. © 2016 The Authors. Psychogeriatrics © 2016 Japanese Psychogeriatric Society.

  10. [Effectiveness of IPD treatment for delirium prevention in hospitalized elderly. A controlled randomized clinical trial].

    PubMed

    Bonaventura, Marino; Zanotti, Renzo

    2007-01-01

    Delirium is a common and serious complication for hospitalized elderly people. Early detection of risk and preventive treatment may significantly reduce delirium and its consequences. In Inouye's study of elderly people with delirium (1993), an interesting predictive model was proposed ,but never applied, for hospitalized elderly. The aim of this study was to test the effectiveness of IPD, a standardized package of caring activities, in the prevention of delirium in inpatient elderly The study consisted of an experimental controlled randomized trial with standardized treatment (Prevention of Delirium Interventions - IPD) with 30 subjects in the experimental group and 30 comparable subjects in the control group. Subjects were recruited if they obtained a score of 24 or less in the Mini Mental State Examination (MMSE). All the subjects have been assessed on the first, second, fourth and seventh day of their hospital stay according to the MMSE, Barthel Index, Tinetti Balance and Gait Scale, Neecham Confusion Scale, and Delirium Rating Scale. The method of assessment was the Confusion Assessment protocol. There was a statistically and clinically significant reduction in both the risk of delirium and related events in the treatment group compared to the control. Therefore, the IPD model proved to be highly effective in comparison to traditional care for elderly inpatients.

  11. Cognitive and Brain Reserve and the Risk of Postoperative Delirium in Older Patients

    PubMed Central

    Saczynski, Jane S.; Inouye, Sharon K.; Kosar, Cyrus; Tommet, Doug; Marcantonio, Edward R.; Fong, Tamara; Hshieh, Tammy; Vasunilashorn, Sarinnapha; Metzger, Eran D.; Schmitt, Eva; Alsop, David C.; Jones, Richard N.

    2015-01-01

    Background Cognitive and brain reserve theories suggest that aspects of neural architecture or cognitive processes modify the impact of neuropathological processes on cognitive outcomes. While frequently studied in the context of dementia, reserve in delirium is relatively understudied. Methods We examined the association of three markers of brain reserve (head circumference, MRI-derived brain volume, and leisure time physical activity) and five markers of cognitive reserve (education, vocabulary, cognitive activities, cognitive demand of lifetime occupation, and interpersonal demand of lifetime occupation) and the risk of postoperative delirium in a prospective observational study of 566 older adults free of dementia undergoing scheduled surgery. Findings Twenty four percent of patients (135/566) developed delirium during the postoperative hospitalization period. Of the reserve markers examined, only the Wechsler Test of Adult Reading (WTAR) was significantly associated with the risk of delirium. A one-half standard deviation better performance on the WTAR was associated with a 38% reduction in delirium risk (P = 0·01); adjusted relative risk of 0·62, 95% confidence interval 0·45–0·85. Interpretation In this relatively large and well-designed study, most markers of reserve fail to predict delirium risk. The exception to this is the WTAR. Our findings suggest that the reserve markers that are important for delirium may be different from those considered to be important for dementia. PMID:25642414

  12. Association between frailty and delirium in older adult patients discharged from hospital

    PubMed Central

    Verloo, Henk; Goulet, Céline; Morin, Diane; von Gunten, Armin

    2016-01-01

    Background Delirium and frailty – both potentially reversible geriatric syndromes – are seldom studied together, although they often occur jointly in older patients discharged from hospitals. This study aimed to explore the relationship between delirium and frailty in older adults discharged from hospitals. Methods Of the 221 patients aged >65 years, who were invited to participate, only 114 gave their consent to participate in this study. Delirium was assessed using the confusion assessment method, in which patients were classified dichotomously as delirious or nondelirious according to its algorithm. Frailty was assessed using the Edmonton Frailty Scale, which classifies patients dichotomously as frail or nonfrail. In addition to the sociodemographic characteristics, covariates such as scores from the Mini-Mental State Examination, Instrumental Activities of Daily Living scale, and Cumulative Illness Rating Scale for Geriatrics and details regarding polymedication were collected. A multidimensional linear regression model was used for analysis. Results Almost 20% of participants had delirium (n=22), and 76.3% were classified as frail (n=87); 31.5% of the variance in the delirium score was explained by frailty (R2=0.315). Age; polymedication; scores of the Confusion Assessment Method (CAM), instrumental activities of daily living, and Cumulative Illness Rating Scale for Geriatrics; and frailty increased the predictability of the variance of delirium by 32% to 64% (R2=0.64). Conclusion Frailty is strongly related to delirium in older patients after discharge from the hospital. PMID:26848261

  13. Incidence of Delirium Among Patients Having Cancer Injected With Different Opioids for the First Time.

    PubMed

    Tanaka, Rei; Ishikawa, Hiroshi; Sato, Tetsu; Shino, Michihiro; Matsumoto, Teruaki; Mori, Keita; Omae, Katsuhiro; Osaka, Iwao

    2017-07-01

    Despite the risk of drug-induced delirium, it is difficult to avoid the use of opioids in palliative care. However, no previous study has carefully investigated how the development of delirium varies among patients injected with different opioids for the first time. To reveal the difference in the incidence of delirium between different opioids. The incidence of delirium was compared among 114 patients who had started morphine, oxycodone, or fentanyl injection at Shizuoka Cancer Center between June 2012 and September 2014. The incidence of delirium was 28.9% in the morphine group (n = 38), 19.5% in the oxycodone group (n = 41), and 8.6% in the fentanyl group (n = 35). There was a significant difference between the morphine and fentanyl groups (Fisher's exact test, P = 0.04) but not between the morphine and oxycodone groups (P = 0.43) nor between the oxycodone and fentanyl groups (P = 0.21). The incidence of delirium after the commencement of fentanyl injection was significantly lower, suggesting that fentanyl is a useful opioid injection drug from the perspective of delirium risk.

  14. Identifying pediatric emergence delirium by using the PAED Scale: a quality improvement project.

    PubMed

    Stamper, Matthew J; Hawks, Sharon J; Taicher, Brad M; Bonta, Juliet; Brandon, Debra H

    2014-04-01

    Pediatric emergence delirium is a postoperative phenomenon characterized by aberrant cognitive and psychomotor behavior, which can place the patient and health care personnel at risk for injury. A common tool for identifying emergence delirium is the Level of Consciousness-Richmond Agitation and Sedation Scale (LOC-RASS), although it has not been validated for use in the pediatric population. The Pediatric Anesthesia Emergence Delirium Scale (PAED) is a newly validated tool to measure emergence delirium in children. We chose to implement and evaluate the effectiveness and fidelity of using the PAED Scale to identify pediatric emergence delirium in one eight-bed postanesthesia care unit in comparison with the traditional LOC-RASS. The overall incidence of pediatric emergence delirium found by using the LOC-RASS with a retrospective chart review (3%) was significantly lower than the incidence found by using the LOC-RASS (7.5%) and PAED Scale (11.5%) during the implementation period. Our findings suggest that the PAED Scale may be a more sensitive measure of pediatric emergence delirium, and, in the future, we recommend that health care personnel at our facility use the PAED Scale rather than the LOC-RASS.

  15. Impact of polypharmacy on occurrence of delirium in elderly emergency patients.

    PubMed

    Hein, Christophe; Forgues, Adrien; Piau, Antoine; Sommet, Agnès; Vellas, Bruno; Nourhashémi, Fati

    2014-01-01

    To examine associations between polypharmacy and delirium diagnosed in elderly patients hospitalized in geriatric acute care unit after emergency hospital admission. Study design was an observational cohort study in the acute geriatric care unit of a university hospital. We included 410 consecutive patients admitted to the acute geriatric ward during 9 months. Within 72 hours of each patient's hospitalization, a clinically trained geriatrician collected the following data: sociodemographic details (age, sex, type of residence), predisposing factors for delirium, main cause of hospitalization, and current medications. Polypharmacy was defined as 6 or more drugs a day. Delirium was assessed by a geriatrician using the Confusion Assessment Method and was diagnosed on the basis of clinical history with an acute change in usual functional status, behavioral observation, and clinical and cognitive assessment. Nearly 25% of hospitalized patients had delirium. The Confusion Assessment Method was positive in 69% of patients receiving polypharmacy and in 30% of those not receiving polypharmacy, a relative risk of 2.33. The proportion of elderly patients receiving polypharmacy was 58.53%. In our study, polypharmacy is an independent risk factor for delirium in a population of elderly patients after emergency admission. In the geriatric population, delirium is an underestimated scourge and because of its medicosocial and economic consequences and its impact on morbidity and mortality, we need to give increased attention to the prevention and control of polypharmacy, which is a predisposing factor for delirium.

  16. A Clinical Update on Delirium: From Early Recognition to Effective Management

    PubMed Central

    Cerejeira, Joaquim; Mukaetova-Ladinska, Elizabeta B.

    2011-01-01

    Delirium is a neuropsychiatric syndrome characterized by altered consciousness and attention with cognitive, emotional and behavioural symptoms. It is particularly frequent in elderly people with medical or surgical conditions and is associated with adverse outcomes. Predisposing factors render the subject more vulnerable to a congregation of precipitating factors which potentially affect brain function and induce an imbalance in all the major neurotransmitter systems. Early diagnosis of delirium is crucial to improve the prognosis of patients requiring the identification of subtle and fluctuating signs. Increased awareness of clinical staff, particularly nurses, and routine screening of cognitive function with standardized instruments, can be decisive to increase detection rates of delirium. General measures to prevent delirium include the implementation of protocols to systematically identify and minimize all risk factors present in a particular clinical setting. As soon as delirium is recognized, prompt removal of precipitating factors is warranted together with environmental changes and early mobilization of patients. Low doses of haloperidol or olanzapine can be used for brief periods, for the behavioural control of delirium. All of these measures are a part of the multicomponent strategy for prevention and treatment of delirium, in which the nursing care plays a vital role. PMID:21994844

  17. [A relapse of multiple sclerosis manifesting as acute delirium].

    PubMed

    Castellanos-Pinedo, F; Galindo, R; Adeva-Bartolomé, M T; Zurdo, M

    2004-01-01

    Psychotic symptoms are infrequent in multiple sclerosis (MS) and their relationship to cerebral lesions has not been clearly documented. The case of a 58 year old woman with secondary progressive MS is presented. She had acute delirium with persecutory delusions associated to paresis of her left leg. Magnetic resonance imaging of the brain disclosed an active lesion in the left hippocampus. The patient was treated with risperidone and megadoses of methylprednisolone, with dramatic improvement. Clinical and radiological data in this patient suggest that psychotic disorders can be symptomatic of a relapse in MS and, therefore, susceptible to be treated with steroids.

  18. The Impact of Delirium after Cardiac Surgery on Postoperative Resource Utilization

    PubMed Central

    Brown, Charles H.; Laflam, Andrew; Max, Laura; Lymar, Daria; Neufeld, Karin J.; Tian, Jing; Shah, Ashish S.; Whitman, Glenn J.; Hogue, Charles W.

    2016-01-01

    Background Delirium is a common complication after cardiac surgery and is associated with increased morbidity and mortality. However, whether rigorously-assessed postoperative delirium is associated with increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. Methods Patients (n=66) undergoing coronary artery bypass and/or valve surgery were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record and hospital charges from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. Results Patients who developed delirium (56%) vs. no delirium (43%) had increased median LOS-ICU (75.6 hours [IQR 43.6–136.8] vs. 29.7 hours [IQR 21.7–46.0]; p=0.002), increased median LOS (9 days [IQR 6–16] vs. 7 days [IQR 5–8]; p=0.006), and increased median hospital charges ($51,805 [IQR $44,041-$80,238] vs. $41,576 [IQR $35,748-$43,660]; P=0.002). In propensity score models adjusted for patient and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated based on the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and charges in a dose-response manner. Conclusions Delirium after cardiac surgery is independently associated with both increased length of stay-ICU and higher hospital charges. Since delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement. PMID:27041454

  19. Geriatric Assessment as a Predictor of Delirium and Other Outcomes in Elderly Patients With Cancer.

    PubMed

    Korc-Grodzicki, Beatriz; Sun, Sung W; Zhou, Qin; Iasonos, Alexia; Lu, Bryan; Root, James C; Downey, Robert J; Tew, William P

    2015-06-01

    This study aimed to describe the implementation of preoperative geriatric assessment (GA) in patients undergoing major cancer surgery and to determine predictors of postoperative delirium. Geriatric surgical patients have unique vulnerabilities and are at increased risk of developing postoperative delirium. Geriatricians at Memorial Sloan Kettering Cancer Center risk-stratify surgical patients with solid tumors, ages 75 years and older, using preoperative GA, which includes basic and instrumental activities of daily living (ADLs, IADLs), cognition (Mini-Cog test), history of falls, nutritional state, and comorbidities (Charlson Comorbidity Index). The Geriatrics Service evaluates patients for postoperative delirium using the confusion assessment method. A retrospective review was performed. The associations between GA and postoperative outcomes were evaluated. Univariate logistic regression analysis was performed to determine the predictive value of GA for postoperative delirium, and a multivariate model was built. In total, 416 patients who received preoperative evaluation by the Geriatrics Service between September 1, 2010, and December 31, 2011, were included. Delirium occurred in 19% of patients. Patients with delirium had longer length of hospital stay (P < 0.001) and greater likelihood of discharge to a rehabilitation facility (P < 0.001). Charlson Comorbidity Index score, history of falls, dependent on IADL, and abnormal Mini-Cog test results predicted postoperative delirium on univariate analysis. Developed using a stepwise selection method, a multivariate model to predict delirium is presented including Charlson Comorbidity Index score (P = 0.032), dependence IADLs (P = 0.011), and falls history (P = 0.056). Preoperative GA is feasible and may achieve a better understanding of older patients' perioperative risks, including delirium.

  20. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value?

    PubMed

    Rizzo, J A; Bogardus, S T; Leo-Summers, L; Williams, C S; Acampora, D; Inouye, S K

    2001-07-01

    Delirium, or acute confusional state, is a common and serious occurrence among hospitalized older persons. Current estimates suggest that delirium complicates hospital stays for more than 2.3 million older persons each year, involving more than 17.5 million hospital days and accounting for more than $4 billion (1994 dollars) of Medicare expenditures. A 40% reduction was recently reported in the risk for delirium among hospitalized older persons receiving a multicomponent targeted risk factor intervention (MTI) strategy to prevent delirium, compared with subjects receiving usual hospital care.1 Before recommending that this preventive strategy be implemented in clinical practice, however, the cost implications must be thoroughly examined as well. The present analysis performs net cost evaluations of the MTI for the prevention of delirium among hospitalized patients. Hospital charge and cost-to-charge ratio data are linked to a database of 852 subjects, who were treated with MTI or usual care. Multivariable regression methods were used to help isolate the impact of MTI on hospital costs. These results were then combined with our earlier work on the impact of the MTI on delirium prevention to assess the cost effectiveness of this intervention. The MTI significantly reduced nonintervention costs among subjects at intermediate risk for developing delirium, but not among subjects at high risk. When MTI intervention costs were included, MTI had no significant effect on overall health care costs in the intermediate risk cohort, but raised overall costs in the high risk group. Because the MTI prevented delirium in the intermediate risk group without raising costs, the conclusion reached is that it is a cost effective treatment option for patients at intermediate risk for developing delirium. In contrast, the results suggest that the MTI is not cost effective for subjects at high risk.

  1. Delirium in postoperative nonventilated intensive care patients: risk factors and outcomes

    PubMed Central

    2012-01-01

    Background Delirium features can vary greatly depending on the postoperative population studied; however, most studies focus only on high-risk patients. Describing the impact of delirium and risk factors in mixed populations can help in the development of preventive actions. Methods The occurrence of delirium was evaluated prospectively in 465 consecutive nonventilated postoperative patients admitted to a surgical intensive care unit (SICU) using the confusion assessment method (CAM). Patients with and without delirium were compared. A multiple logistic regression was performed to identify the main risk factors for delirium in the first 24 h of admission to the SICU and the main predictors of outcomes. Results Delirium was diagnosed in 43 (9.2%) individuals and was more frequent on the second and third days of admission. The presence of delirium resulted in longer lengths of SICU and hospital stays [6 days (3–13) vs. 2 days (1–3), p < 0.001 and 26 days (12–39) vs. 6 days (3–13), p <0.001, respectively], as well as higher hospital and SICU mortality rates [16.3% vs. 4.0%, p = 0.004 and 6.5% vs. 1.7%, p = 0.042, respectively]. The risk factors for delirium were age (odds ratio (OR), 1.04 [1.02-1.07]), Acute Physiologic Score (APS; OR, 1.11 [1.04-1.2]), emergency surgery (OR, 8.05 [3.58-18.06]), the use of benzodiazepines (OR, 2.28 [1.04-5.00]), and trauma (OR, 6.16 [4.1-6.5]). Conclusions Delirium negatively impacts postoperative nonventilated patients. Risk factors can be used to detect high-risk patients in a mixed population of SICU patients. PMID:23272945

  2. Evaluating attention in delirium: A comparison of bedside tests of attention.

    PubMed

    Adamis, Dimitrios; Meagher, David; Murray, Orla; O'Neill, Donagh; O'Mahony, Edmond; Mulligan, Owen; McCarthy, Geraldine

    2016-09-01

    Impaired attention is a core diagnostic feature for delirium. The present study examined the discriminating properties for patients with delirium versus those with dementia and/or no neurocognitive disorder of four objective tests of attention: digit span, vigilance "A" test, serial 7s subtraction and months of the year backwards together with global clinical subjective rating of attention. This as a prospective study of older patients admitted consecutively in a general hospital. Participants were assessed using the Confusion Assessment Method, Delirium Rating Scale-98 Revised and Montreal Cognitive Assessment scales, and months of the year backwards. Pre-existing dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria. The sample consisted of 200 participants (mean age 81.1 ± 6.5 years; 50% women; pre-existing cognitive impairment in 126 [63%]). A total of 34 (17%) were identified with delirium (Confusion Assessment Method +). The five approaches to assessing attention had statistically significant correlations (P < 0.05). Discriminant analysis showed that clinical subjective rating of attention in conjunction with the months of the year backwards had the best discriminatory ability to identify Confusion Assessment Method-defined delirium, and to discriminate patients with delirium from those with dementia and/or normal cognition. Both of these approaches had high sensitivity, but modest specificity. Objective tests are useful for prediction of non-delirium, but lack specificity for a delirium diagnosis. Global attentional deficits were more indicative of delirium than deficits of specific domains of attention. Geriatr Gerontol Int 2016; 16: 1028-1035. © 2015 The Authors. Geriatrics & Gerontology International published by. Wiley Publishing Asia Pty Ltd on behalf of Japanese Geriatrics Society.

  3. A Systematic Review and Meta-analysis Examining the Impact of Incident Postoperative Delirium on Mortality.

    PubMed

    Hamilton, Gavin M; Wheeler, Kathleen; Di Michele, Joseph; Lalu, Manoj M; McIsaac, Daniel I

    2017-07-01

    Delirium is an acute and reversible geriatric syndrome that represents a decompensation of cerebral function. Delirium is associated with adverse postoperative outcomes, but controversy exists regarding whether delirium is an independent predictor of mortality. Thus, we assessed the association between incident postoperative delirium and mortality in adult noncardiac surgery patients. A systematic search was conducted using Cochrane, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening and data extraction were conducted by two independent reviewers. Pooled-effect estimates calculated with a random-effects model were expressed as odds ratios with 95% CIs. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Non-Randomized Studies. A total of 34 of 4,968 screened citations met inclusion criteria. Risk of bias ranged from moderate to critical. Pooled analysis of unadjusted event rates (5,545 patients) suggested that delirium was associated with a four-fold increase in the odds of death (odds ratio = 4.12 [95% CI, 3.29 to 5.17]; I = 24.9%). A formal pooled analysis of adjusted outcomes was not possible due to heterogeneity of effect measures reported. However, in studies that controlled for prespecified confounders, none found a statistically significant association between incident postoperative delirium and mortality (two studies in hip fractures; n = 729) after an average follow-up of 21 months. Overall, as study risk of bias decreased, the association between delirium and mortality decreased. Few high-quality studies are available to estimate the impact of incident postoperative delirium on mortality. Studies that controlled for prespecified confounders did not demonstrate significant independent associations of delirium with mortality.

  4. Electrolyte disorders and aging: risk factors for delirium in patients undergoing orthopedic surgeries.

    PubMed

    Wang, Li-Hong; Xu, Dong-Juan; Wei, Xian-Jiao; Chang, Hao-Teng; Xu, Guo-Hong

    2016-11-23

    At present, the exact mechanism of postoperative delirium has not been elucidated. The purpose of this study was to analyze the incidence of delirium in patients undergoing orthopedic surgeries and to explore possible related factors. This is a retrospective study. We used 582 patients who had undergone orthopedic surgery between January 2011 and December 2014. The surgeries consisted of 155 cases of internal fixation for intertrochanteric fracture (IFIF), 128 cases of femoral head replacement (FHR), 169 cases of total hip arthroplasty (THA) and 130 cases of total knee arthroplasty (TKA). Among the 582 patients, 75 developed postoperative delirium (an incidence of 12.9%). The demographics of the patients, which included age, gender, operation duration and blood loss, were statistically analyzed with univariate logistic regression analysis and then multivariate logistic regression. To investigate the influences of different electrolytes disorders for postoperative delirium, the Chi-square test was used. Multivariate logistic regression analysis indicated that postoperative delirium incidence in patients aged 70-79 years and in patients aged ≥80 years was higher than that in patients aged <70 years, odds ratio (OR) values were 6.33 and 26.37, respectively. In addition, the incidence of postoperative delirium in the group of patients with electrolyte disorders was higher than that in the normal group (OR, 2.38). There were statistically significant differences between the delirium group and the non-delirium group in the incidences of the sodium and calcium disorders. Aging and postoperative electrolyte disorders (hyponatremia and hypocalcemia) are risk factors for postoperative delirium in patients undergoing orthopedic surgeries.

  5. Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening.

    PubMed

    Chester, Jennifer G; Beth Harrington, Mary; Rudolph, James L

    2012-01-01

    Because delirium is a common yet frequently unrecognized condition, this study sought to design a brief screening tool for a core feature of mental status and to validate the instrument as a serial assessment for delirium. Prospective cohort study. Tertiary VA Hospital in New England. A total of 95 veterans admitted to the medical service. A consensus panel developed a modified version of the Richmond Agitation and Sedation Scale (RASS) to capture alterations in consciousness. Upon admission, and daily thereafter, patients were screened with a modified RASS (mRASS) and independently underwent a comprehensive mental status interview by a geriatric expert, who determined whether the criteria for delirium were met. The sensitivity, specificity, and positive likelihood ratio (LR) of the mRASS for delirium are reported. As a single assessment, the mRASS had a sensitivity of 64% and a specificity of 93% for delirium (LR, 9.4). When used to detect change, serial mRASS assessments had a sensitivity of 74% and a specificity of 92% (LR, 8.9) in both prevalent and incident delirium. When prevalent cases were excluded, any change in the mRASS had a sensitivity of 85% and a specificity of 92% for incident delirium (LR, 10.2) When administered daily, the mRASS has good sensitivity and specificity for incident delirium. Given the brevity of the instrument (<30 seconds), consideration should be given to incorporating the modified RASS as a daily screening measure for consciousness and delirium. Copyright © 2012 Society of Hospital Medicine.

  6. Factors Associated With the Development of Delirium in Elderly Patients in Intensive Care Units.

    PubMed

    Lin, Wei-Li; Chen, Yi-Fan; Wang, Jeng

    2015-12-01

    High prevalence rates of delirium have been found in intensive care units (ICUs), ranging from 20% to 80%. The development of delirium may prolong length of stay, impair cognition, and result in placement in a nursing home for the patient. There is a lack of research focused on the aging population, so the purpose of this study was to establish the incidence rate of delirium among ICU elderly patients and to identify its risk factors. An observational design with repeated measures was used. Subjects older than 65 years who had been admitted to the ICU within 24 hours were recruited. The Confusion Assessment Method for the Intensive Care Unit and Richmond Agitation-Sedation Scale were used twice a day to identify subjects experiencing delirium by RA. The demographic data, history of illness, Acute Physiology and Chronic Health Evaluation II scores, and laboratory data of the participants were recorded. Ninety participants were included from a medical ICU. The incidence rate of delirium was 75.6% (n = 68). Average age was 78.28 ± 7.6 years; Acute Physiology and Chronic Health Evaluation II scores ranged from 7 to 35. Most participants were diagnosed with respiratory failure (73.3%), and 86.76% of participants developed delirium within 24 hours. The most frequently experienced type of delirium was the mixed subtype (47.05%); the second most frequently experienced was hypoactive next. The risk factors were analyzed using logistic regression. The number of anesthetic analgesics used, total number of medications prescribed, duration of dehydration, use of corticosteroids before admissions, and shock were identified and explained 31.3% of variance. Delirium is a severe problem among elderly patients in the ICU. Healthcare professionals should pay more attention to elderly patients at greater risk for experiencing delirium.

  7. Factors Associated With the Development of Delirium in Elderly Patients in Intensive Care Units.

    PubMed

    Lin, Wei-Li; Chan, Yi-Fan; Wang, Jeng

    2015-04-14

    High prevalence rates of delirium have been found in intensive care units (ICUs), ranging from 20% to 80%. The development of delirium may prolong length of stay, impair cognition, and result in placement in a nursing home for the patient. There is a lack of research focused on the aging population, so the purpose of this study was to establish the incidence rate of delirium among ICU elderly patients and to identify its risk factors. An observational design with repeated measures was used. Subjects older than 65 years who had been admitted to the ICU within 24 hours were recruited. The Confusion Assessment Method for the Intensive Care Unit and Richmond Agitation-Sedation Scale were used twice a day to identify subjects experiencing delirium by RA. The demographic data, history of illness, Acute Physiology and Chronic Health Evaluation II scores, and laboratory data of the participants were recorded. Ninety participants were included from a medical ICU. The incidence rate of delirium was 75.6% (n = 68). Average age was 78.28 ± 7.6 years; Acute Physiology and Chronic Health Evaluation II scores ranged from 7 to 35. Most participants were diagnosed with respiratory failure (73.3%), and 86.76% of participants developed delirium within 24 hours. The most frequently experienced type of delirium was the mixed subtype (47.05%); the second most frequently experienced was hypoactive next. The risk factors were analyzed using logistic regression. The numberof anesthetic analgesics used, total number of medications prescribed, duration of dehydration, use of corticosteroids before admissions, and shock were identified and explained 31.3% of variance. Delirium is a severe problem among elderly patients in the ICU. Healthcare professionals should pay more attention to elderly patients at greater risk for experiencing delirium.

  8. The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation.

    PubMed

    Turco, Renato; Bellelli, Giuseppe; Morandi, Alessandro; Gentile, Simona; Trabucchi, Marco

    2013-06-01

    Delirium is a common poststroke complication, but its prevalence and effect in rehabilitation settings is unknown. We retrospectively assessed the prevalence of delirium in elderly patients undergoing poststroke rehabilitation and its association with short-term outcomes. All patients (aged ≥65 years) admitted to the Department of Rehabilitation between November 2007 and October 2011 after a recent stroke were screened for delirium. Delirium was diagnosed using the confusion assessment method. Multiple logistic regressions were used to evaluate the association between delirium, institutionalization, and inhospital death, while multiple linear regressions were used for the association between delirium and functional recovery, defined in 3 different ways which include (1) measuring the relative functional gain of the Barthel index (BI-RFG); (2) the change in Barthel index (BI) walking subscore from admission to discharge; and (3) the change in Tinetti score from admission to discharge. In all, 58 (33%) patients of the total 176 patients were consecutively admitted to our department with delirium. After adjustment for potential confounders, poststroke delirium (PSD) was an independent predictor of institutionalization (odds ratio [OR] = 7.23; 95% confidence interval [CI] = 4.79 to 10.91; P ≤ .0003) and inhospital death (OR = 4.26; 95% CI = 1.15 to 15.81; P = .03); PSD was not a predictor of functional recovery at discharge, neither using the BI-RFG (P = .96) nor using the change from admission to discharge of both the BI walking subscore (P = .57) and the Tinetti score (P = .61) as outcome measures. In elderly patients undergoing poststroke rehabilitation, delirium is an independent predictor of institutionalization and inhospital death, but it does not affect functional recovery.

  9. Partial and No Recovery from Delirium in Older Hospitalized Adults: Frequency and Baseline Risk Factors.

    PubMed

    Cole, Martin G; Bailey, Robert; Bonnycastle, Michael; McCusker, Jane; Fung, Shek; Ciampi, Antonio; Belzile, Eric; Bai, Chun

    2015-11-01

    To determine the frequency and baseline risk factors for partial and no recovery from delirium in older hospitalized adults. Cohort study with assessment of recovery status approximately 1 and 3 months after enrollment. University-affiliated, primary, acute-care hospital. Medical or surgical inpatients aged 65 and older with delirium (N = 278). The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), and activities of daily living (ADLs) were completed at enrollment and each follow-up. Primary outcome categories were full recovery (absence of CAM core symptoms of delirium), partial recovery (presence of ≥1 CAM core symptoms but not meeting criteria for delirium), no recovery (met CAM criteria for delirium), or death. Secondary outcomes were changes in MMSE, DI, and ADL scores between the baseline and last assessment. Potential risk factors included many clinical and laboratory variables. In participants with dementia, frequencies of full, partial, and no recovery and death at first follow-up were 6.3%, 11.3%, 74.6%, and 7.7%, respectively; in participants without dementia, frequencies were 14.3%, 17%, 50.9%, and 17.9%, respectively. In participants with dementia, frequencies at the second follow-up were 7.9%, 15.1%, 57.6%, and 19.4%, respectively; in participants without dementia, frequencies were 19.2%, 20.2%, 31.7%, and 28.8%, respectively. Frequencies were similar in participants with prevalent and incident delirium and in medical and surgical participants. The DI, MMSE, and ADL scores of many participants with partial and no recovery improved. Independent baseline risk factors for delirium persistence were chart diagnosis of dementia (odds ratio (OR) = 2.51, 95% confidence interval (CI) =1.38, 4.56), presence of any malignancy (OR = 5.79, 95% CI = 1.51, 22.19), and greater severity of delirium (OR =9.39, 95% CI = 3.95, 22.35). Delirium in many older hospitalized adults appears to be much more protracted than previously

  10. Prevention of post-operative delirium in older patients with cancer undergoing surgery.

    PubMed

    Korc-Grodzicki, Beatriz; Root, James C; Alici, Yesne

    2015-01-01

    Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD. Copyright © 2014 Elsevier Inc. All rights reserved.

  11. Neural substrates of vulnerability to postsurgical delirium as revealed by presurgical diffusion MRI.

    PubMed

    Cavallari, Michele; Dai, Weiying; Guttmann, Charles R G; Meier, Dominik S; Ngo, Long H; Hshieh, Tammy T; Callahan, Amy E; Fong, Tamara G; Schmitt, Eva; Dickerson, Bradford C; Press, Daniel Z; Marcantonio, Edward R; Jones, Richard N; Inouye, Sharon K; Alsop, David C

    2016-04-01

    Despite the significant impact of postoperative delirium on surgical outcomes and the long-term prognosis of older patients, its neural basis has not yet been clarified. In this study we investigated the impact of premorbid brain microstructural integrity, as measured by diffusion tensor imaging before surgery, on postoperative delirium incidence and severity, as well as the relationship among presurgical cognitive performance, diffusion tensor imaging abnormalities and postoperative delirium. Presurgical diffusion tensor imaging scans of 136 older (≥70 years), dementia-free subjects from the prospective Successful Aging after Elective Surgery study were analysed blind to the clinical data and delirium status. Primary outcomes were postoperative delirium incidence and severity during the hospital stay, as assessed by the Confusion Assessment Method. We measured cognition before surgery using general cognitive performance, a composite score based on a battery of neuropsychological tests. We investigated the association between presurgical diffusion tensor imaging parameters of brain microstructural integrity (i.e. fractional anisotropy, axial, mean and radial diffusivity) with postoperative delirium incidence and severity. Analyses were adjusted for the following potential confounders: age, gender, vascular comorbidity status, and general cognitive performance. Postoperative delirium occurred in 29 of 136 subjects (21%) during hospitalization. Presurgical diffusion tensor imaging abnormalities of the cerebellum, cingulum, corpus callosum, internal capsule, thalamus, basal forebrain, occipital, parietal and temporal lobes, including the hippocampus, were associated with delirium incidence and severity, after controlling for age, gender and vascular comorbidities. After further controlling for general cognitive performance, diffusion tensor imaging abnormalities of the cerebellum, hippocampus, thalamus and basal forebrain still remained associated with delirium

  12. Neural substrates of vulnerability to postsurgical delirium as revealed by presurgical diffusion MRI

    PubMed Central

    Cavallari, Michele; Dai, Weiying; Guttmann, Charles R. G.; Meier, Dominik S.; Ngo, Long H.; Hshieh, Tammy T.; Callahan, Amy E.; Fong, Tamara G.; Schmitt, Eva; Dickerson, Bradford C.; Press, Daniel Z.; Marcantonio, Edward R.; Jones, Richard N.; Inouye, Sharon K.

    2016-01-01

    Despite the significant impact of postoperative delirium on surgical outcomes and the long-term prognosis of older patients, its neural basis has not yet been clarified. In this study we investigated the impact of premorbid brain microstructural integrity, as measured by diffusion tensor imaging before surgery, on postoperative delirium incidence and severity, as well as the relationship among presurgical cognitive performance, diffusion tensor imaging abnormalities and postoperative delirium. Presurgical diffusion tensor imaging scans of 136 older (≥70 years), dementia-free subjects from the prospective Successful Aging after Elective Surgery study were analysed blind to the clinical data and delirium status. Primary outcomes were postoperative delirium incidence and severity during the hospital stay, as assessed by the Confusion Assessment Method. We measured cognition before surgery using general cognitive performance, a composite score based on a battery of neuropsychological tests. We investigated the association between presurgical diffusion tensor imaging parameters of brain microstructural integrity (i.e. fractional anisotropy, axial, mean and radial diffusivity) with postoperative delirium incidence and severity. Analyses were adjusted for the following potential confounders: age, gender, vascular comorbidity status, and general cognitive performance. Postoperative delirium occurred in 29 of 136 subjects (21%) during hospitalization. Presurgical diffusion tensor imaging abnormalities of the cerebellum, cingulum, corpus callosum, internal capsule, thalamus, basal forebrain, occipital, parietal and temporal lobes, including the hippocampus, were associated with delirium incidence and severity, after controlling for age, gender and vascular comorbidities. After further controlling for general cognitive performance, diffusion tensor imaging abnormalities of the cerebellum, hippocampus, thalamus and basal forebrain still remained associated with delirium

  13. Validation of a Consensus Method for Identifying Delirium from Hospital Records

    PubMed Central

    Kuhn, Elvira; Du, Xinyi; McGrath, Keith; Coveney, Sarah; O'Regan, Niamh; Richardson, Sarah; Teodorczuk, Andrew; Allan, Louise; Wilson, Dan; Inouye, Sharon K.; MacLullich, Alasdair M. J.; Meagher, David; Brayne, Carol; Timmons, Suzanne; Davis, Daniel

    2014-01-01

    Background Delirium is increasingly considered to be an important determinant of trajectories of cognitive decline. Therefore, analyses of existing cohort studies measuring cognitive outcomes could benefit from methods to ascertain a retrospective delirium diagnosis. This study aimed to develop and validate such a method for delirium detection using routine medical records in UK and Ireland. Methods A point prevalence study of delirium provided the reference-standard ratings for delirium diagnosis. Blinded to study results, clinical vignettes were compiled from participants' medical records in a standardised manner, describing any relevant delirium symptoms recorded in the whole case record for the period leading up to case-ascertainment. An expert panel rated each vignette as unlikely, possible, or probable delirium and disagreements were resolved by consensus. Results From 95 case records, 424 vignettes were abstracted by 5 trained clinicians. There were 29 delirium cases according to the reference standard. Median age of subjects was 76.6 years (interquartile range 54.6 to 82.5). Against the original study DSM-IV diagnosis, the chart abstraction method gave a positive likelihood ratio (LR) of 7.8 (95% CI 5.7–12.0) and the negative LR of 0.45 (95% CI 0.40–0.47) for probable delirium (sensitivity 0.58 (95% CI 0.53–0.62); specificity 0.93 (95% CI 0.90–0.95); AUC 0.86 (95% CI 0.82–0.89)). The method diagnosed possible delirium with positive LR 3.5 (95% CI 2.9–4.3) and negative LR 0.15 (95% CI 0.11–0.21) (sensitivity 0.89 (95% CI 0.85–0.91); specificity 0.75 (95% CI 0.71–0.79); AUC 0.86 (95% CI 0.80–0.89)). Conclusions This chart abstraction method can retrospectively diagnose delirium in hospitalised patients with good accuracy. This has potential for retrospectively identifying delirium in cohort studies where routine medical records are available. This example of record linkage between hospitalisations and epidemiological data may lead to

  14. Emergence Delirium with Transient Associative Agnosia and Expressive Aphasia Reversed by Flumazenil in a Pediatric Patient

    PubMed Central

    Drobish, Julie K.; Kelz, Max B.; DiPuppo, Patricia M.; Cook-Sather, Scott D.

    2014-01-01

    Multiple factors may contribute to the development of emergence delirium in a child. We present the case of a healthy 12-year-old girl who received preoperative midazolam with the desired anxiolytic effect, underwent a brief general anesthetic, and then exhibited postoperative delirium, consisting of a transient associative agnosia and expressive aphasia. Administration of flumazenil led to immediate and lasting resolution of her symptoms. We hypothesize that γ-aminobutyric acid type A receptor-mediated effects, most likely related to an atypical offset of midazolam, are an important subset of emergence delirium that is amenable to pharmacologic therapy with flumazenil. PMID:26035220

  15. The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study.

    PubMed

    Taipale, Priscilla G; Ratner, Pamela A; Galdas, Paul M; Jillings, Carol; Manning, Deborah; Fernandes, Connie; Gallaher, Jaime

    2012-09-01

    Post-operative delirium after cardiac surgery is an adverse event that affects patients' recovery and complicates the delivery of nursing care. Numerous risk factors for delirium are uncontrollable; however, nurses' pro re nata drug administration of sedatives may be a controllable risk factor. This study examined the relationship between nurses' pro re nata administration of midazolam hydrochloride to cardiac surgery patients and the development of post-operative delirium. Observational study. Cardiac surgery intensive care and nursing units of a tertiary care center in Vancouver, Canada. 122 male and female patients requiring non-emergent surgery for coronary artery disease or valvular heart disease who did not have pre-existing cognitive impairment, severe hearing or visual impairment, substance misuse, alcohol intake exceeding 7 drinks per week, or renal impairment requiring hemodialysis. Patients were assessed for delirium, on three occasions, with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) during the first 72 h after surgery and through reviews of physicians' notes. Risk factor and midazolam dosage data were collected from medical records. 77.9% of the patients in this sample received midazolam hydrochloride post-operatively. The prevalence of delirium ranged from 37.7% to 44.3%. Almost all of the dosages of midazolam (85-87%) were given before the first indication of delirium; that is, most of the patients had received their entire dosage before the first signs of delirium were detected. Bivariate analysis with logistic regression models revealed that for every additional milligram of midazolam administered, the patients were 7-8% more likely to develop delirium. Multivariate logistic regression models demonstrated that the magnitude of the association between midazolam dosage and delirium was not confounded by established risk factors including age and peripheral vascular disease. Nurses play an important role in the prediction

  16. Emergence delirium with transient associative agnosia and expressive aphasia reversed by flumazenil in a pediatric patient.

    PubMed

    Drobish, Julie K; Kelz, Max B; DiPuppo, Patricia M; Cook-Sather, Scott D

    2015-06-01

    Multiple factors may contribute to the development of emergence delirium in a child. We present the case of a healthy 12-year-old girl who received preoperative midazolam with the desired anxiolytic effect, underwent a brief general anesthetic, and then exhibited postoperative delirium, consisting of a transient associative agnosia and expressive aphasia. Administration of flumazenil led to immediate and lasting resolution of her symptoms. We hypothesize that γ-aminobutyric acid type A receptor-mediated effects, most likely related to an atypical offset of midazolam, are an important subset of emergence delirium that is amenable to pharmacologic therapy with flumazenil.

  17. Revisiting the O complex: urinary incontinence, delirium and polypharmacy in elderly patients

    PubMed Central

    Hogan, D B

    1997-01-01

    Urinary incontinence, delirium and polypharmacy are common, challenging problems encountered in elderly patients. Review of the literature shows that these conditions are interrelated. For example, polypharmacy can lead to delirium, which, in turn, can lead to urinary incontinence. The drugs prescribed for urinary incontinence can precipitate delirium or contribute to polypharmacy. The underlying causes for these problems in elderly patients are frequently complex, and management in turn must often be multifactorial. The occurrence of these problems should lead to careful evaluation followed by thoughtful, responsive treatment. Brief updates are given with recommendations for management directed at primary care physicians. PMID:9347778

  18. [Not every delirium protocol in Dutch hospitals is up-to-date: evaluation of the implementation of the new delirium guideline].

    PubMed

    Kentin, Z H A; Dautzenberg, P L J; Boelens, H M; de Rooij, S E J A; van Munster, B C

    2016-01-01

    To describe the extent to which the essential changes in the new Dutch delirium guideline for adults and the elderly, published in April 2014, have been incorporated in local hospital protocols, so as to estimate the consequences this could have for patients. Quantitative study. Dutch hospital protocols were collected for two periods: before (September to December 2012) and after publication of the guideline (March to July 2015). Protocols were compared with respect to basic delirium care (screening, diagnostic approach, therapy and follow-up care) and organisation of care. Of the 80 Dutch hospitals approached, we were able to include 57 (71%) protocols in this study. 16 hospitals (28%) had adapted their protocols to the new guideline. Screening for the risk of delirium using the questions from the Dutch safety management system (Veiligheidsmanagementsysteem) was described in 29 (51%) of the protocols. Use of the Delirium Observation Screening Scale was reported in 52 (91%) protocols. A policy of moderation regarding antipsychotic therapy was described in 12 of 53 (23%) protocols, but in 21/53 (40%) the haloperidol dosages were higher than advised by the guideline. Follow-up care is described in 40 (70%) of the protocols. Organisation of delirium care, for example restriction of consultation of an expert to complex cases, was advised in 33/57 (58%) protocols. 15 months after publication, only just over a quarter of the protocols incorporated the guideline. In terms of the treatment of patients with delirium, this may have led to unnecessary treatment with antipsychotics. Furthermore, basic delirium care is apparently still not considered as the responsibility of every medical specialist in the hospital.

  19. Prevalence of delirium among patients at a cancer ward: Clinical risk factors and prediction by bedside cognitive tests.

    PubMed

    Grandahl, Mia Gall; Nielsen, Svend Erik; Koerner, Ejnar Alex; Schultz, Helga Holm; Arnfred, Sidse Marie

    2016-08-01

    Background Delirium is a frequent psychiatric complication to cancer, but rarely recognized by oncologists. Aims 1. To estimate the prevalence of delirium among inpatients admitted at an oncological cancer ward 2. To investigate whether simple clinical factors predict delirium 3. To examine the value of cognitive testing in the assessment of delirium. Methods On five different days, we interviewed and assessed patients admitted to a Danish cancer ward. The World Health Organization International Classification of Diseases Version 10, WHO ICD-10 Diagnostic System and the Confusion Assessment Method (CAM) were used for diagnostic categorization. Clinical information was gathered from medical records and all patients were tested with Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test. Results 81 cancer patients were assessed and 33% were diagnosed with delirium. All delirious participants were CAM positive. Poor performance on the cognitive tests was associated with delirium. Medical records describing CNS metastases, benzodiazepine or morphine treatment were associated with delirium. Conclusions Delirium is prevalent among cancer inpatients. The Mini Cognitive Test, The Clock Drawing Test, and the Digit Span Test can be used as screening tools for delirium among inpatients with cancer, but even in synergy, they lack specificity. Combining cognitive testing and attention to nurses' records might improve detection, yet further studies are needed to create a more detailed patient profile for the detection of delirium.

  20. Perioperative hemodynamics and risk for delirium and new onset dementia in hip fracture patients; A prospective follow-up study.

    PubMed

    Neerland, Bjørn Erik; Krogseth, Maria; Juliebø, Vibeke; Hylen Ranhoff, Anette; Engedal, Knut; Frihagen, Frede; Ræder, Johan; Bruun Wyller, Torgeir; Watne, Leiv Otto

    2017-01-01

    Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia. Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively. Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively. Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture.

  1. Perceptions, attitudes, and current practices regards delirium in China: A survey of 917 critical care nurses and physicians in China.

    PubMed

    Xing, Jinyan; Sun, Yunbo; Jie, Yaqi; Yuan, Zhiyong; Liu, Wenjuan

    2017-09-01

    The purpose of this study is to assess the knowledge, attitudes, and managements regarding delirium of intensive care nurses and physicans, and to assess the perceived barriers related to intensive care unit (ICU) delirium monitoring in China. A descriptive survey was distributed to 1156 critical care nurses and physicians from 74 tertiary and secondary hospitals across Shandong province, China. The overall response rate was 86.18% (n = 917). The majority of respondents (88%) believed that deirium was associated with prolonged mechanical ventilation, and 79.72% thought delirium was associated with prolonged length of hospitalization. Only 14.17% of respondents believed that delirium was common in the ICU setting. Only 25.62% of the respondents reported routine screening of ICU delirium, and only 15.81% utilized Confusion Assessment Method for Intensive Care Unit screening tools. "Lack of appropriate screening tools" and "time restraints" were the most common perceived barriers. 45.4% of the participants had never received any education on ICU delirium. In conclusion, most nurses and physicians consider ICU delirium to be a serious problem, but lack knowledge on delirium and monitor this condition poorly. The survey infers a disconnection between the perceived significance and current monitoring of ICU delirium. There is a critical unmet need for in-service education on ICU delirium for physicians and nurses in China.

  2. Nurse perceptions of the Nursing Delirium Screening Scale in two palliative care inpatient units: a focus group study.

    PubMed

    Hosie, Annmarie; Lobb, Elizabeth; Agar, Meera; Davidson, Patricia M; Chye, Richard; Phillips, Jane

    2015-11-01

    To explore nurse perceptions of the feasibility of integrating the Nursing Delirium Screening Scale into practice within the inpatient palliative care setting. Delirium occurs frequently in palliative care inpatient populations, yet is under-recognised. Exploring feasibility of delirium screening tools in this setting can provide insights into how recognition can be improved. This was a qualitative study using a focus group methodology. Four semi-structured focus groups were conducted with 21 nurses working in two Australian palliative care units. Focus groups were digitally recorded and transcribed verbatim. Thematic content analysis was used to analyse the data. Three major themes were identified: (1) Delirium screening using the Nursing Delirium Screening Scale is feasible, but then what? (2) Nuances, ambiguity and clinical complexity; and (3) Implementing structured processes requires firmer foundations. Themes describe how nurses perceived the Nursing Delirium Screening Scale to be an easy and brief screening tool which raised their awareness of delirium. They were largely willing to adopt it into practice, yet had uncertainty and misunderstandings of the tool specifically and delirium screening generally, application in a palliative care context, interventions for delirium and impact of screening on medical practice. The Nursing Delirium Screening Scale is feasible for use in a palliative care inpatient setting, but requires investigation of its psychometric properties before routine use in this patient population. Nurses require understanding of delirium, tailored guidance and a united approach with doctors to support their effective use of a delirium screening tool in the palliative care unit. Delirium practice change in this setting will also require nurses to become more active leaders and collaborators within their interdisciplinary teams. © 2015 John Wiley & Sons Ltd.

  3. The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people

    PubMed Central

    Siddiqi, Najma; Cheater, Francine; Collinson, Michelle; Farrin, Amanda; Forster, Anne; George, Deepa; Godfrey, Mary; Graham, Elizabeth; Harrison, Jennifer; Heaven, Anne; Heudtlass, Peter; Hulme, Claire; Meads, David; North, Chris; Sturrock, Angus; Young, John

    2016-01-01

    Background and objectives: delirium is a distressing but potentially preventable condition common in older people in long-term care. It is associated with increased morbidity, mortality, functional decline, hospitalization and significant healthcare costs. Multicomponent interventions, addressing delirium risk factors, have been shown to reduce delirium by one-third in hospitals. It is not known whether this approach is also effective in long-term care. In previous work, we designed a bespoke delirium prevention intervention, called ‘Stop Delirium!’ In preparation for a definitive trial of Stop Delirium, we sought to address key aspects of trial design for the particular circumstances of care homes. Design: a cluster randomized feasibility study with an embedded process evaluation. Setting and participants: residents of 14 care homes for older people in one metropolitan district in the UK. Intervention: Stop Delirium!: a 16-month-enhanced educational package to support care home staff to address key delirium risk factors. Control homes received usual care. Measurements: we collected data to determine the following: recruitment and attrition; delirium rates and variability between homes; feasibility of measuring delirium, resource use, quality of life, hospital admissions and falls; and intervention implementation and adherence. Results: two-thirds (215) of eligible care home residents were recruited. One-month delirium prevalence was 4.0% in intervention and 7.1% in control homes. Proposed outcome measurements were feasible, although our approach appeared to underestimate delirium. Health economic evaluation was feasible using routinely collected data. Conclusion: a definitive trial of delirium prevention in long-term care is needed but will require some further design modifications and pilot work. PMID:27207749

  4. Battery of behavioral tests in mice to study postoperative delirium

    PubMed Central

    Peng, Mian; Zhang, Ce; Dong, Yuanlin; Zhang, Yiying; Nakazawa, Harumasa; Kaneki, Masao; Zheng, Hui; Shen, Yuan; Marcantonio, Edward R.; Xie, Zhongcong

    2016-01-01

    Postoperative delirium is associated with increased morbidity, mortality and cost. However, its neuropathogenesis remains largely unknown, partially owing to lack of animal model(s). We therefore set out to employ a battery of behavior tests, including natural and learned behavior, in mice to determine the effects of laparotomy under isoflurane anesthesia (Anesthesia/Surgery) on these behaviors. The mice were tested at 24 hours before and at 6, 9 and 24 hours after the Anesthesia/Surgery. Composite Z scores were calculated. Cyclosporine A, an inhibitor of mitochondria permeability transient pore, was used to determine potential mitochondria-associated mechanisms of these behavioral changes. Anesthesia/Surgery selectively impaired behaviors, including latency to eat food in buried food test, freezing time and time spent in the center in open field test, and entries and duration in the novel arm of Y maze test, with acute onset and various timecourse. The composite Z scores quantitatively demonstrated the Anesthesia/Surgery-induced behavior impairment in mice. Cyclosporine A selectively ameliorated the Anesthesia/Surgery-induced reduction in ATP levels, the increases in latency to eat food, and the decreases in entries in the novel arm. These findings suggest that we could use a battery of behavior tests to establish a mouse model to study postoperative delirium. PMID:27435513

  5. Battery of behavioral tests in mice to study postoperative delirium.

    PubMed

    Peng, Mian; Zhang, Ce; Dong, Yuanlin; Zhang, Yiying; Nakazawa, Harumasa; Kaneki, Masao; Zheng, Hui; Shen, Yuan; Marcantonio, Edward R; Xie, Zhongcong

    2016-07-20

    Postoperative delirium is associated with increased morbidity, mortality and cost. However, its neuropathogenesis remains largely unknown, partially owing to lack of animal model(s). We therefore set out to employ a battery of behavior tests, including natural and learned behavior, in mice to determine the effects of laparotomy under isoflurane anesthesia (Anesthesia/Surgery) on these behaviors. The mice were tested at 24 hours before and at 6, 9 and 24 hours after the Anesthesia/Surgery. Composite Z scores were calculated. Cyclosporine A, an inhibitor of mitochondria permeability transient pore, was used to determine potential mitochondria-associated mechanisms of these behavioral changes. Anesthesia/Surgery selectively impaired behaviors, including latency to eat food in buried food test, freezing time and time spent in the center in open field test, and entries and duration in the novel arm of Y maze test, with acute onset and various timecourse. The composite Z scores quantitatively demonstrated the Anesthesia/Surgery-induced behavior impairment in mice. Cyclosporine A selectively ameliorated the Anesthesia/Surgery-induced reduction in ATP levels, the increases in latency to eat food, and the decreases in entries in the novel arm. These findings suggest that we could use a battery of behavior tests to establish a mouse model to study postoperative delirium.

  6. Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series.

    PubMed

    Abraha, I; Rimland, J M; Trotta, F; Pierini, V; Cruz-Jentoft, A; Soiza, R; O'Mahony, D; Cherubini, A

    2016-01-01

    The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium. To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations. A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations. The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use

  7. The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients

    PubMed Central

    Brown, Charles; Faigle, Roland; Klinker, Lauren; Bahouth, Mona; Max, Laura; LaFlam, Andrew; Neufeld, Karin J.; Mandal, Kaushik; Gottesman, Rebecca; Hogue, Charles

    2016-01-01

    Purpose Delirium is common after cardiac surgery, and it is associated with short- and long-term consequences, including cognitive decline. Identification of patients who are vulnerable to delirium might allow for early implementation of delirium-prevention strategies in older adults undergoing surgery. Brain MRI findings provide insight into structural brain changes that may identify vulnerable patients. The purpose of this study was to examine the association between brain MRI characteristics potentially associated with delirium vulnerability and the development of postoperative delirium in a nested cohort of patients undergoing cardiac surgery. Methods We identified 79 cardiac surgery patients who had brain MRI imaging after cardiac surgery, as part of an ongoing randomized trial evaluating the efficacy of blood pressure management based on cerebral autoregulation monitoring versus standard management for improving neurological outcomes. Cerebral lateral ventricular size, cortical sulcal width, and white matter hyperintensities (WMH) on brain MRI scans were graded on a validated 0 to 9 scale, and categorized into tertiles. New ischemic lesions were characterized as present or absent. Delirium was assessed using a validated chart-review. Neuropsychological testing performed before surgery was used to establish preoperative cognitive baseline. Multivariable logistic regression was used to assess the independent association between MRI characteristics and postoperative delirium. Findings Twenty-eight of 79 (35.4%) patients developed postoperative delirium. Patients with delirium had higher unadjusted ventricular size (median 4 vs. 3, p=0.003), and there was a trend towards higher sulcal sizes and WMH grades. Increasing tertiles of ventricular size (Odds Ratio [OR] 3.59; 95% Confidence Interval [CI] 1.59–8.12; p=0.002) and sulcal size (OR 2.15; 95%CI 1.13–4.12; p=0.02) were associated with postoperative delirium, with a trend for tertiles of WMH grade (OR 1

  8. Gender Differences in Factors Associated with Delirium Severity in Older Adults with Dementia

    PubMed Central

    Kolanowski, Ann M.; Hill, Nikki L.; Kurum, Esra; Fick, Donna M.; Yevchak, Andrea M.; Mulhall, Paula; Clare, Linda; Valenzuela, Michael

    2014-01-01

    The purpose of this descriptive correlational study was to explore potential gender differences in the relationship of dementia severity, age, APOE status, cognitive reserve and co-morbidity, (two potentially modifiable factors), to delirium severity in older adults. Baseline data from an ongoing clinical trial and a Poisson regression procedure were used in the analyses. Participants were 148 elderly individuals with dementia and delirium admitted to post-acute care. In women, delirium severity was related to dementia severity (p= 0.002) and co-morbidity moderated that effect (p=0.03). In men, education was marginally associated with delirium severity (p=0.06). Implications for research are discussed. PMID:24856271

  9. Validating a new clinical subtyping scheme for delirium with electronic motion analysis.

    PubMed

    Godfrey, Alan; Leonard, Maeve; Donnelly, Sinead; Conroy, Marion; Olaighin, Gearóid; Meagher, David

    2010-06-30

    The usefulness of motor subtypes of delirium is unclear due to inconsistency in sub-typing methods and a lack of validation with objective measures of activity. The activity of 40 patients was measured with 24 h accelerometry monitoring. Patients with Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) delirium (n=30) were allocated into hyperactive, hypoactive and mixed motor subtypes. Delirium subtypes differed in relation to overall amount of activity, including movement in both sagittal and transverse planes. Differences were greater in the daytime and during the early evening 'sundowning' period. Frequency of postural changes was the most discriminating measure examined. Clinical subtypes of delirium defined by observed motor behaviour on the ward differ in electronically measured activity levels.

  10. Delirium Upon Presentation to the Pediatric Emergency Department: A Case Series.

    PubMed

    Augenstein, Julie A; Klein, Eileen J; Traube, Chani

    2017-06-06

    The following cases describe children who presented to the emergency department (ED) with a constellation of symptoms consistent with delirium. In each case, there was no identified inciting cause (eg, fever, medications) other than the presence of influenza. All children had variable workups, with 2 children undergoing extensive neurologic evaluation and testing. Clinical recognition of delirium in the pediatric acute care setting can be challenging, but heightened awareness by ED and primary care physicians may lead to earlier diagnosis, prevent unwarranted investigations, and decrease hospitalization. Children with influenza may be at increased risk of developing delirium. A prospective study to assess the prevalence of delirium in pediatric patients presenting to the ED with influenza is warranted.

  11. Self-disembowelment during delirium tremens: why early diagnosis is vital.

    PubMed

    Thomasson, Rachel; Craig, Vanessa; Guthrie, Elspeth

    2016-10-24

    Delirium tremens is a serious yet treatable complication of alcohol withdrawal. Timely diagnosis is critical as there are well-established treatment regimens that provide symptomatic relief within hours to days. We report the case of a 34-year-old man with an undisclosed history of alcohol dependency. He presented with paranoid beliefs and was transferred to a psychiatric inpatient unit with suspected schizophrenia. Classic features of delirium tremens such as sympathetic overdrive and visual hallucinations were not salient features of his presentation. Within 24 hours of admission, he sustained major self-inflicted abdominal stab wounds and extracted a metre of small bowel as a result of command hallucinations. The possibility of delirium tremens was raised by the receiving trauma team and he responded rapidly to benzodiazepines. Emergency jejunal reanastomosis was successful. This case highlights the fact that delirium tremens may present atypically and that associated command hallucinations can confer grave risks.

  12. Delirium and Antipsychotics: A Systematic Review of Epidemiology and Somatic Treatment Options

    PubMed Central

    2008-01-01

    Delirium is a very common medical condition encountered throughout the world and, undoubtedly, is one of the most frequent reasons psychiatrists are consulted by primary care physicians. Recognizing delirium and treating the underlying medical cause are the first steps in the management of this potentially fatal syndrome. The selection of an appropriate medication to target the perceptual, behavioral, and cognitive abnormalities is crucial. In addition to several of the older, typical antipsychotics, which have been found to be effective for the treatment of delirium, some of the newer, atypical antipsychotic agents have been demonstrated to be efficacious. This paper will review both the typical and atypical antipsychotics with the best evidence for efficacy and safety in the treatment of delirium. Finally, environmental treatments are discussed to present the full armamentarium of therapeutic options available to the practicing clinician. PMID:19724721

  13. A New Frontier: Improving Nursing Care for People With Dementia and Delirium in Hospitals.

    PubMed

    Graham, Frederick

    2015-12-01

    Frederick Graham, a clinical nurse consultant from Princess Alexandra Hospital in Brisbane, Australia, presents this month's column focused on improving nursing care for people with dementia and delirium in hospitals.

  14. Diazepam and paraldehyde for treatment of severe delirium tremens. A controlled trial.

    PubMed

    Thompson, W L; Johnson, A D; Maddrey, W L

    1975-02-01

    Thirty-four patients with severe delirium tremens were allocated randomly to treatment with paraldehyde (10 ml rectally very 30 minutes) or diazepam (10 mg then 5 mg intravenously every 5 minutes) until they were calm but awake. Diazepam-treated patients became calm in one half the time needed to calm patients with paraldehyde. Half of the patients had delirium tremens in association with pneumonia, pancreatitis, or alcoholic hepatitis; these patients required twice as much paraldehyde or diazepam for initial calming as patients with delirium tremens alone. Maintenance of a calm state was accomplished easily with either diazepam, intramuscularly, or paraldehyde, rectally. Adverse reactions occurred in nine patients, all of whom had been treated with paraldehyde; these patients had greater degrees of fever, tachypnea, and tachycardia and required three times longer for initial calming than patients without adverse reactions. Diazepam given under this regimen is a safe and effective sedative for management of combative patients with severe delirium tremens.

  15. Delirium and depression: Inter-relationship and overlap in elderly people

    PubMed Central

    O’Sullivan, Roisin; Inouye, Sharon K.; Meagher, David

    2017-01-01

    Delirium and depression are complex neuropsychiatric syndromes that are common in the elderly and associated with a variety of poor healthcare outcomes. Accurate detection is key to providing optimal care for these conditions but is complicated by their considerable clinical overlap. This includes shared symptom profiles as well as comorbidity. Careful assessment of symptom character as well as the context and course of disturbances can allow for more accurate diagnosis. Prior depressive illness is a common finding in patients with delirium, while depressive illness is a recognised sequel of delirium. Evidence points to similar pathophysiological mechanisms involving disturbances in stress and inflammatory responses, monoaminergic and melatonergic functions, that in turn point to avenues for therapeutic intervention. Development of better tools for systematic assessment for delirium and depression in populations at high risk by virtue of age, diminished cognitive reserve and frailty is a key target to achieve improved healthcare outcomes. PMID:26360863

  16. Corticosteroids and transition to delirium in patients with acute lung injury

    PubMed Central

    Schreiber, Matthew P; Colantuoni, Elizabeth; Bienvenu, Oscar J; Neufeld, Karin J; Chen, Kuan-Fu; Shanholtz, Carl; Mendez-Tellez, Pedro A; Needham, Dale M

    2014-01-01

    Objective Delirium is common in mechanically ventilated patients in the intensive care unit (ICU) and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside of the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury (ALI). Design Prospective cohort study Setting Thirteen ICUs in 4 hospitals in Baltimore, MD Patients 520 mechanically ventilated adult patients with ALI Measurements and Main Results Delirium evaluation was performed by trained research staff using the validated CAM-ICU screening tool. A total of 330 (64%) of the 520 patients had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was non-comatose), with a total of 2286 days of observation and a median (inter-quartile range [IQR]) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior non-delirious, non-comatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio, 95% confidence interval) were independently associated with transition to delirium: older age (compared to <40 years old, 40-60 years (1.81, 1.26 to 2.62) and >=60 years (2.52, 1.65 to 3.87)) and administration of any systemic corticosteroid in the prior 24 hours (1.52, 1.05 to 2.21). Conclusions After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a non-delirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids

  17. Delirium after Cardiac Surgery: A Pilot Study from a Single Tertiary Referral Center

    PubMed Central

    Kumar, Ashok K; Jayant, Aveek; Arya, VK; Magoon, Rohan; Sharma, Ridhima

    2017-01-01

    Background: Advances in cardiac surgery has shifted paradigm of management to perioperative psychological illnesses. Delirium is a state of altered consciousness with easy distraction of thoughts. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The goal of the present study was to prospectively identify the incidence, motoric subtypes, and risk factors associated with development of delirium in cardiac surgical patients admitted to postoperative cardiac intensive care, using a validated delirium monitoring instrument. Materials and Methods: This is a prospective, observational study. This study included 120 patients of age 18–80 years, admitted to undergo cardiac surgery after applying inclusion and exclusion criteria. Specific preoperative, intraoperative, and postoperative data for possible risk factors were obtained. Once in a day, assessment of delirium was done. Continuous variables were measured as mean ± standard deviation, whereas categorical variables were described as proportions. Differences between groups were analyzed using Student's t-test, Mann–Whitney U-test, or Chi-square test. Variables with a P < 0.1 were then used to develop a predictive model using stepwise logistic regression with bootstrapping. Results: Delirium was seen in 17.5% patients. The majority of cases were of hypoactive delirium type (85.72%). Multiple risk factors were found to be associated with delirium, and when logistic regression with bootstrapping applied to these risk factors, five independent variables were detected. History of hypertension (relative risk [RR] =6.7857, P = 0.0003), carotid artery disease (RR = 4.5000, P < 0.0001) in the form of stroke or hemorrhage, noninvasive ventilation (NIV) use (RR = 5.0446, P < 0.0001), Intensive Care Unit (ICU) stay more than 10 days (RR = 3.1630, P = 0.0021), and poor postoperative pain control (RR = 2.4958, P = 0.0063) was associated

  18. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability.

    PubMed

    Inouye, S K; Charpentier, P A

    1996-03-20

    To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability. Two prospective cohort studies, in tandem. General medical wards, university teaching hospital. For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients. New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria. Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant. A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating

  19. Methodology of development of a Delirium clinical application and initial feasibility results.

    PubMed

    Zhang, Melvyn W B; Ho, Roger C M; Sockalingam, Sanjeev

    2015-01-01

    Delirium is a highly prevalent condition in the hospital settings, with prevalence rates ranging from 6% to 56%, based on previous studies. A recent review provides evidence for the need of practice tools at the point of care to increase impact and to improve patient outcomes related to delirium care. The major challenge is to help maintain the skill-sets required by clinicians and allied healthcare workers over time. There have been massive advancements in smartphone technologies, as well as several papers being published recently about how clinicians could be application developers. The following study will serve to illustrate how the authors made use of the lates