Risultati per: Il delirium

New England Journal of Medicine, Volume 387, Issue 26, Page 2464-2465, December 2022.

Objectives
Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment.

Design
Retrospective, cross-sectional, observational study.

Setting
Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020.

Participants
Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups—with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10th Revision codes or antipsychotic prescriptions.

Outcome measures
Total medical costs during hospitalisation were compared between the groups using a generalised linear model.

Results
The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p

Circulation, Volume 146, Issue Suppl_1, Page A14220-A14220, November 8, 2022. Introduction:Patients who undergo transcatheter aortic valve replacement (TAVR) often are elderly, frail and with comorbid conditions. Delirium is frequently encountered in older adults and is associated with increased morbidity and mortality.Hypothesis:The purpose of this study is to determine the clinical significance of postoperative delirium in patients with aortic stenosis undergoing TAVR.Methods:The National Inpatient Sample was queried from 2011-2019 for relevant ICD-9 and ICD-10 codes to identify patients who underwent TAVR. Baseline characteristics and in-hospital outcomes between patients with and without delirium were compared. Logistic regression was performed to adjust for pre-specified co-variates for mortality and other in-hospital outcomes. p-value was considered significant when

New England Journal of Medicine, Ahead of Print.

Introduction
Postoperative delirium (POD) is a major cause of morbidity, particularly in elderly patients. Melatonin has been suggested as a low-risk pharmacological intervention to help prevent POD. A previous systematic review found limited high-quality evidence to support the use of melatonin in the prevention of POD. Several further randomised studies have since been published. This systematic review aims to synthesise the evidence from randomised controlled trials (RCTs) examining the effect of melatonin on the prevention of POD in older adults.

Methods and analysis
A systematic search of RCTs of melatonin (any dose and formulation) in POD will be run across Embase, Medline, CINAHL and PsychInfo. RCTs published from January 1990 until the end of February 2022 and reporting outcomes for melatonin use to prevent POD in patients will be included. Screening of search results and data extraction from included articles will be performed by two independent reviewers. The primary outcome will be incidence of POD in older adults undergoing surgery. Secondary outcomes are delirium duration and length of hospital stay. The review will also describe the dosage, timing and administration regimes of melatonin therapy and as well as the scales and definitions used to describe POD. A registry review of ongoing trials will be also be performed. For the meta-analysis, data will be pooled using a random effects model to generate a forest plot and obtain an odds ratio (OR) for the incidence of POD. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Ethics and dissemination
No ethical approval is required. This review will be disseminated via peer-reviewed manuscript and conferences. The results will be used as the basis of work to optimise this intervention for future trials in surgical populations.

PROSPERO registration number
This review is registered with PROSPERO (CRD42021285019).

Objectives
This study sought to investigate nurses’ knowledge, attitudes and practices, and analyse the influencing factors for subsyndromal delirium (SSD).

Design
A descriptive cross-sectional survey.

Setting
E-questionnaires were distributed to intensive care unit (ICU) nurses from 20 tertiary-grade, A-class hospitals in Henan Province, China.

Participants
A total of 740 ICU nurses participated in the questionnaire survey.

Main outcome measures
Each dimension score is converted to a percentage scale. A score of ≤60% on each dimension of the questionnaire was considered a negative score,

Objectives
Delirium commonly occurs during hospitalisation and is associated with increased mortality, especially in elderly patients. This study aimed to determine the demographic and clinical characteristics of patients with delirium in the Japanese real-world clinical setting using a nationwide database comprising claims and discharge abstract data.

Design
This was an observational, cross-sectional, retrospective study in hospitalised patients with an incident delirium identified by a diagnosis based on International Classification of Diseases, 10th Revision codes or initiating antipsychotics recommended for delirium treatment in Japan during their hospitalisation.

Setting
Patients from the Medical Data Vision database including more than 400 acute care hospitals in Japan were evaluated from admission to discharge.

Participants
Of the 32 910 227 patients who were included in the database between April 2012 and September 2020, a total of 145 219 patients met the criteria for delirium.

Primary and secondary outcome measures
Demographic and baseline characteristics, comorbidities, clinical profiles and pharmacological treatments were evaluated in patients with delirium.

Results
The mean (SD) patient age was 76.5 (13.8) years. More than half of the patients (n=82 159; 56.6%) were male. The most frequent comorbidities were circulatory system diseases, observed in 81 954 (56.4%) patients. Potentially inappropriate medications (PIMs) with risk of delirium including benzodiazepines and opioids were prescribed to 76 798 (52.9%) patients. Approximately three-fourths of these patients (56 949; 74.2%) were prescribed ≥4 PIMs. The most prescribed treatment for delirium was injectable haloperidol (n=82 490; 56.8%). Mean (SD) length of hospitalisation was 16.0 (12.1) days.

Conclusions
The study results provide comprehensive details of the clinical characteristics of patients with delirium and treatment patterns with antipsychotics in the Japanese acute care setting. In this patient population, the prescription rate of injectable haloperidol and PIMs was high, suggesting the need for improved understanding among healthcare providers about the appropriate management of delirium, which may benefit patients.

Introduction
Postoperative delirium (POD) is a common and distressing complication after thoracic surgery. S-ketamine has neuroprotective properties as a dissociative anaesthetic. Emerging literature has indicated that S-ketamine can reduce cognitive impairment in patients with depression. However, the role of S-ketamine in preventing POD remains unknown. Therefore, this study aims to evaluate the effect of intraoperative prophylactic S-ketamine compared with that of dexmedetomidine on the incidence of POD in elderly patients undergoing non-cardiac thoracic surgery.

Methods and analysis
This will be a randomised, double-blinded, placebo-controlled, positive-controlled, non-inferiority trial that enrolled patients aged 60–90 years undergoing thoracic surgery. The patients will be randomly allocated in a ratio of 1:1:1 to S-ketamine, dexmedetomidine or normal saline placebo groups using computer-generated randomisation with a block size of six. The primary outcome will be the incidence of POD within 4 days after surgery and this will be assessed using a 3-Minute Diagnostic Confusion Assessment Method two times per day. The severity and duration of POD, the incidence of emergence delirium, postoperative pain, quality of sleep, cognitive function, and the plasma concentrations of acetylcholine, brain-derived neurotrophic factor, tumour necrosis factor-α and incidence of adverse events will be evaluated as secondary outcomes.

Ethics and dissemination
Ethical approval has been obtained from the Institutional Review Board of the Cancer Hospital and the Institute of Guangzhou Medical University (ZN202119). At the end of the trial, we commit to making a public disclosure available, regardless of the outcome. The public disclosure will include a publication in an appropriate journal and an oral presentation at academic meetings.

Trial registration number
ChiCTR2100052750 (NCT05242692).

Introduction
Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection.

Methods and analysis
Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate.

Ethics and dissemination
Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders.

Trial registration number
ISRCTN55416525.

Objective
To internally and externally validate a delirium predictive model for adult patients admitted to intensive care units (ICUs) following surgery.

Design
A prospective, observational, multicentre study.

Setting
Three university-affiliated teaching hospitals in Thailand.

Participants
Adults aged over 18 years were enrolled if they were admitted to a surgical ICU (SICU) and had the surgery within 7 days before SICU admission.

Main outcome measures
Postoperative delirium was assessed using the Thai version of the Confusion Assessment Method for the ICU. The assessments commenced on the first day after the patient’s operation and continued for 7 days, or until either discharge from the ICU or the death of the patient. Validation was performed of the previously developed delirium predictive model: age+(5xSOFA)+(15xbenzodiazepine use)+(20xDM)+(20xmechanical ventilation)+(20xmodified IQCODE >3.42).

Results
In all, 380 SICU patients were recruited. Internal validation on 150 patients with the mean age of 75±7.5 years resulted in an area under a receiver operating characteristic curve (AUROC) of 0.76 (0.683 to 0.837). External validation on 230 patients with the mean age of 57±17.3 years resulted in an AUROC of 0.85 (0.789 to 0.906). The AUROC of all validation cohorts was 0.83 (0.785 to 0.872). The optimum cut-off value to discriminate between a high and low probability of postoperative delirium in SICU patients was 115. This cut-off offered the highest value for Youden’s index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%).

Conclusions
The model developed by the previous study was able to predict the occurrence of postoperative delirium in critically ill surgical patients admitted to SICUs.

Trial registration number
Thai Clinical Trail Registry (TCTR20180105001).

Introduction
Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status.

Methods and analysis
This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.
Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery.

Ethics and dissemination
This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings.

Trial registration number
NCT05029050.

Introduction
Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated.

Methods and analysis
The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels.

Ethics and dissemination
This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication.

Trial registration number
NCT05010148.

Stroke, Volume 53, Issue Suppl_1, Page A92-A92, February 1, 2022. Background:Delirium in-hospital (DIH) is common among the critically ill. However, DIH incidence and outcomes are not well characterized among ischemic stroke (IS) patients, particularly those treated with intravenous tissue plasminogen activator (tPA) and / or mechanical thrombectomy (MT).Methods:Utilizing data from a healthcare system with standardized delirium screening protocols, DIH was determined by a positive 4AT / CAM-ICU screen or diagnosis codes. IS patients with tPA or MT were flagged and a subset with available 90-day modified Rankin Scale (mRS) were analyzed for shifts in mRS scores associated with DIH, via ordinal logistic regression models adjusted for age, stroke severity, tPA or MT, Charlson Comorbidity Index [CCI], prior stroke and sepsis / infections. Common odds ratios (OR) and 95% confidence intervals (CI) are reported.Results:Between May 2016 and June 2021, IS was the primary discharge diagnosis in 12,415 encounters (10,878 unique patients). DIH was documented in 41.6% of IS encounters, compared to 20.0% of non-IS encounters. Stroke-DIH patients (vs no-DIH Stroke) were older (median: 75 vs 65 years), more frequently female (53.3% vs 48.7%), with higher comorbidity burden (median CCI: 7 vs 5), longer hospital stays (median: 6 vs 3 days), higher in-hospital mortality (3.1% vs 0.5%), and fewer home discharges (36.2% vs 75.2%). Among a sub-cohort of 2,785 IS patients with 90-day mRS, fully adjusted model indicated lower mRS (OR, CI: 0.48, 0.41-0.57) for those with tPA or MT, and worse outcomes for DIH patients (OR, CI: 2.70, 2.26-3.23). Among 948 treated IS patients, DIH remained a significant risk for worse outcomes (OR, CI: 2.54, 1.89-3.43).Conclusion:Delirium was twice as common in IS patients and was a negative prognostic indicator of short and long-term outcomes among non-treated and treated IS patients. Active screening and management of DIH is critically important to improve stroke outcomes.

Stroke, Volume 53, Issue Suppl_1, Page ATMP57-ATMP57, February 1, 2022. Background:Post-stroke delirium (PSD) is associated with increased mortality and worse long-term functional outcomes. Patients who receive reperfusion therapies in the hospital are frequently kept from regular sleep-wake cycles the first 24 hrs after treatment, and this disruption could lead to an increase in PSD. In this study, we evaluate the effect of PSD on immediate and long-term outcomes in AIS patients receiving reperfusion therapies.Methods:Between September 2019 and June 2021, pts diagnosed with AIS within 48 hrs of stroke onset were prospectively evaluated for PSD using the Confusion Assessment Method (CAM)-ICU daily for the first eight days of their hospital stay. Patients with severe stroke and expected mortality within the first month at the time of admission or with severe aphasia unable to follow commands were excluded. Reperfusion therapies were defined as any IV thrombolytic, IA thrombolytic, or mechanical thrombectomy (MT). The primary outcome was considered a 90-day mRS score of 0-2.Results:Of 179 patients assessed with the CAM-ICU, 89 (49.7%) had PSD. We identified 94 patients that had undergone one or both reperfusion therapies; 52 (55.3%) had delirium. Patients who received tPa had a higher risk for delirium (42 vs 29, p = 0.04), but no difference was observed with MT (Table 1). Patients with PSD had a longer hospital length of stay and a higher median admission NIHSS. Patients with delirium who received tPA were more likely to be discharged to inpatient rehabilitation facilities than home (p-value 0.004, OR 10.1 95%CI 2.1,48). No significant difference was found in 90-day modified ranking scale (mRS) scores of 0-2 in those with or without PSD.Conclusion:AIS patients with PSD after reperfusion therapy had no significant difference in 90-day good outcomes despite having longer hospital admissions and being less likely to be discharged home. Further evaluation into how reperfusion therapies convey protection to patients is necessary.

Stroke, Volume 53, Issue Suppl_1, Page ATMP58-ATMP58, February 1, 2022. Background:Delirium is an acute cognitive disturbance frequently characterized by abnormal levels of motor activity and sleep-wake cycle disruption. However, the degree to which delirium affects activity patterns in the acute period after stroke is unclear. We aimed to examine these patterns in a cohort of patients with intracerebral hemorrhage (ICH).Methods:We enrolled 40 patients with supratentorial ICH and hemiparesis who had daily delirium assessments performed by expert clinicians. Continuous measurements of activity were captured using bilateral wrist actigraphs for the duration of each patient’s admission. Activity data were collected in 1-minute intervals, with “rest” intervals defined as periods with zero activity recorded. We compared differences in activity based on delirium status across multiple time intervals using linear regression models adjusted for age, ICH severity, and mechanical ventilation.Results:There were 312 total days of actigraphy monitoring, of which 233 (75%) were rated as days with delirium; 85% of patients (34/40) experienced delirium during their hospitalization. In multivariable analyses, delirium days were associated with 66.3 (95% CI 9.4-123.2) fewer total minutes of rest, including 6.1% (95% CI 2.3-9.9%) fewer minutes of rest during daytime periods (06:00-21:59) and 9.2% (95% CI 3.3-15.0%) fewer minutes of rest during nocturnal periods (22:00-5:59). In separate analyses for individual hourly intervals, delirium days were associated with significantly higher levels of activity across multiple consecutive time intervals, including 05:00-09:00 and 17:00-03:00. In subgroup analyses, hyperactive or mixed delirium was associated with fewer total daily minutes of rest compared to hypoactive delirium, along with lower proportions of time at rest during both daytime and nocturnal periods (4.3% [95% CI 0.5-8.0%] and 6.5% [95% CI 0.9-12.1%] lower, respectively).Conclusion:Post-stroke delirium is associated with less rest and higher overall levels of activity, especially during nocturnal periods and in patients with hyperactive or mixed delirium.

Stroke, Volume 53, Issue Suppl_1, Page AWP138-AWP138, February 1, 2022. Background:Delirium in-hospital (DIH) results in poor in-patient outcomes. However, it’s longer-term effects among intracerebral hemorrhage (ICH) patients are not well characterized. We sought to evaluate the association between DIH and 90-day readmission (RA) among primary ICH patients.Method:Clinical, imaging and outcomes data, from May 2016 to June 2021, were obtained from theNeurological Outcomes Registry for ICH (NEURO-RICH); an informatics pipeline across 7 comprehensive and primary stroke centers which implement protocolized delirium assessments via 4AT / CAM-ICU scales. Demographic (age, sex, race, ethnicity, marital status), Glasgow Coma Scale (GCS), systolic and diastolic blood pressure (S/DBP), sepsis, systemic inflammatory response syndrome, and comorbidity data were analyzed. Survival analysis for time-to-90-Day RA was performed with death modeled as a competing risk. Sub hazard ratios (SHR) and 95% confidence intervals (CI) are reported. Subgroup with imaging data (ICH score and cerebral small vessel disease) was analyzed.Results:Final analyses included 1,434 ICH patients (mean age: 66.0 years, 47.2% female, 24.8% non-Hispanic Black, 19.9% Hispanic, median GCS: 13.2, SBP: 163 mmHg). In the fully adjusted model, DIH was significantly associated with higher rates of 90-Day RA (SHR, CI: 2.24, 1.04 – 4.81) (Figure 1A). Anticoagulant therapy (1.36, 1.03 – 1.80), hypertension (1.95, 1.38 – 2.74), diabetes (1.13, 1.09 – 1.17), and Charlson Comorbidity Index (1.08, 1.04 – 1.13) were also independently associated with 90-Day RA (SHR, CI reported). In the imaging subgroup of 523 patients, DIH retained independent association with 90-Day RA (SHR: 3.94 [1.37 – 11.36]) (Figure 1B).Discussion:In addition to traditional predictors of poor outcomes among ICH patients, DIH demonstrated strong and independent association with 90-day RA. Screening, identification, and active management of DIH is critical to reduce long-term disease burden of ICH.