Alessandro Morandi

Delirium in Older Emergency Department Patients: Recognition, Risk Factors, and Psychomotor Subtypes

OBJECTIVES 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. METHODS 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. RESULTS 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 physician at the time of admission. Dementia, a Katz Activities of Daily Living (ADL) < or = 4, and hearing impairment were independently associated with presenting with delirium in the ED. Based on the multivariable model, a delirium risk score was constructed. Dementia, Katz ADL < or = 4, and hearing impairment were weighed equally. Patients with higher risk scores were more likely to be CAM-ICU positive (area under the receiver operating characteristic [ROC] curve = 0.82). If older ED patients with one or more delirium risk factors were screened for delirium, 165 (54.5%, 95% CI = 48.7% to 60.2%) would have required a delirium assessment at the expense of missing 1 patient with delirium, while screening 141 patients without delirium. CONCLUSIONS Delirium was a common occurrence in the ED, and the vast majority of delirium in the ED was of the hypoactive subtype. EPs missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting.

Sedation, delirium and mechanical ventilation: the 'ABCDE' approach.

Purpose of reviewDelirium and ICU-acquired weakness are frequent in critically ill mechanically ventilated patients. The number of mechanically ventilated patients is increasing, placing more patients at risk for these adverse outcomes. Sedation is given to ensure comfort and to minimize distress, but is linked to delirium and immobility. We review recent findings on the management of mechanically ventilated patients focusing on strategies that may improve neurologic and functional outcomes in critically ill patients. Recent findingsWe present the evidence-based ‘ABCDE’ bundle, an integrated and interdisciplinary approach to the management of mechanically ventilated patients. Spontaneous awakening and breathing trials have been combined into ‘awake and breathing coordination’, shortening the duration of mechanical ventilation, ICU and hospital length of stay and improving survival. The choice of α-2 agonists reduces ICU delirium and duration of mechanical ventilation. Delirium monitoring improves recognition of this disorder, but data on pharmacologic treatment are mixed. Early mobility and exercise may reduce physical dysfunction and delirium rates. SummaryOutcomes of critically ill patients can be improved by applying evidence-based therapies for the ‘liberation’ from mechanical ventilation and sedation, and the ‘animation’ through early mobilization. Clinicians should be aware of organizational approaches such as the ‘ABCDE’ bundle to improve the management of mechanically ventilated patients.

Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people

Objective: to evaluate the performance of the 4 ‘A’s Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice. Design: prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments. Setting: an acute geriatrics ward and a department of rehabilitation. Participants: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months. Measurements: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimers Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium. Results: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia. Conclusions: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.

Pathophysiology of delirium in the intensive care unit.

Delirium, or acute brain dysfunction, is a life-threatening global disturbance in cognitive functioning that frequently manifests in critically ill patients. This review examines the current status of knowledge regarding the pathophysiology of delirium in the ICU, in particular, evaluating the role of iatrogenic factors such as sedatives and analgesic administration in brain dysfunction. This hypothesis is considered along with several other plausible mechanisms of ICU delirium, including sepsis, postoperative cognitive dysfunction, and changes in biomarkers and neurotransmitters. The review concludes by highlighting potential future directions in molecular genetics for the elucidation of delirium and its long-term consequences.

The relationship between delirium duration, white matter integrity, and cognitive impairment in intensive care unit survivors as determined by diffusion tensor imaging: the VISIONS prospective cohort magnetic resonance imaging study*.

Objective:Evidence is emerging that delirium duration is a predictor of long-term cognitive impairment in intensive care unit survivors. Relationships between 1) delirium duration and brain white matter integrity, and 2) white matter integrity and long-term cognitive impairment are poorly understood and could be explored using magnetic resonance imaging. Design, Setting, Patients:A two-center, prospective cohort study incorporating delirium monitoring, neuroimaging, and cognitive testing in intensive care unit survivors. Measurements:Delirium was evaluated with the Confusion Assessment Method for the Intensive Care Unit and cognitive outcomes were tested at 3 and 12-month follow-up. Following the intensive care unit stay, fractional anisotropy, a measure of white matter integrity, was calculated quantitatively using diffusion tensor imaging with a 3-T magnetic resonance imaging scanner at hospital discharge and 3-month follow-up. We examined associations between 1) delirium duration and fractional anisotropy and 2) fractional anisotropy and cognitive outcomes using linear regression adjusted for age and sepsis. Results:A total of 47 patients with a median age of 50 yrs completed the diffusion tensor imaging-magnetic resonance imaging protocol. Greater duration of delirium (3 vs. 0 days) was associated with lower fractional anisotropy (i.e., reduced fractional anisotropy = white matter disruption) in the genu (−0.02; p = .04) and splenium (−0.01; p = .02) of the corpus callosum and anterior limb of the internal capsule (−0.02; p =.01) at hospital discharge. These associations persisted at 3 months for the genu (−0.02; p =.02) and splenium (−0.01; p = .004). Lower fractional anisotropy in the anterior limb of internal capsule at discharge and in genu of corpus callosum at three months was associated with worse cognitive scores at 3 and 12 months. Conclusions:In this pilot investigation, delirium duration in the intensive care unit was associated with white matter disruption at both discharge and 3 months. Similarly, white matter disruption was associated with worse cognitive scores up to 12 months later. This hypothesis-generating investigation may help design future studies to explore these complex relationships in greater depth.

The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*.

Objective:Delirium duration is predictive of long-term cognitive impairment in intensive care unit survivors. Hypothesizing that a neuroanatomical basis may exist for the relationship between delirium and long-term cognitive impairment, we conducted this exploratory investigation of the associations between delirium duration, brain volumes, and long-term cognitive impairment. Design, Setting, and Patients:A prospective cohort of medical and surgical intensive care unit survivors with respiratory failure or shock. Measurements:Quantitative high resolution 3-Tesla brain magnetic resonance imaging was used to calculate brain volumes at discharge and 3-month follow-up. Delirium was evaluated using the confusion assessment method for the intensive care unit; cognitive outcomes were tested at 3- and 12-month follow-up. Linear regression was used to examine associations between delirium duration and brain volumes, and between brain volumes and cognitive outcomes. Results:A total of 47 patients completed the magnetic resonance imaging protocol. Patients with longer duration of delirium displayed greater brain atrophy as measured by a larger ventricle-to-brain ratio at hospital discharge (0.76, 95% confidence intervals [0.10, 1.41]; p = .03) and at 3-month follow-up (0.62 [0.02, 1.21], p = .05). Longer duration of delirium was associated with smaller superior frontal lobe (−2.11 cm3 [−3.89, −0.32]; p = .03) and hippocampal volumes at discharge (−0.58 cm3 [−0.85, −0.31], p < .001)—regions responsible for executive functioning and memory, respectively. Greater brain atrophy (higher ventricle-to-brain ratio) at 3 months was associated with worse cognitive performances at 12 months (lower Repeatable Battery for the Assessment of Neuropsychological Status score −11.17 [−21.12, −1.22], p = .04). Smaller superior frontal lobes, thalamus, and cerebellar volumes at 3 months were associated with worse executive functioning and visual attention at 12 months. Conclusions:These preliminary data show that longer duration of delirium is associated with smaller brain volumes up to 3 months after discharge, and that smaller brain volumes are associated with long-term cognitive impairment up to 12 months. We cannot, however, rule out that smaller preexisting brain volumes explain these findings.

Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study

Background Critical illness is associated with cognitive impairment, but mental health and functional disabilities in general intensive care unit (ICU) survivors are inadequately characterized and there are a paucity of data regarding the relationship between age and delirium and these outcomes.BACKGROUND Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations of age and duration of delirium with mental health and functional disabilities in this group. METHODS In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795. FINDINGS We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes. INTERPRETATION Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care. FUNDING National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.

Tools to Detect Delirium Superimposed on Dementia: A Systematic Review

To identify valid tools to diagnose delirium superimposed on dementia.

Duration of Postoperative Delirium Is an Independent Predictor of 6‐Month Mortality in Older Adults After Hip Fracture

To evaluate the association between number of days with delirium and 6‐month mortality in elderly adults after hip fracture surgery.

Delirium Superimposed on Dementia Strongly Predicts Worse Outcomes in Older Rehabilitation Inpatients

Objective Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation. Design Prospective cohort study. Setting Hospital rehabilitation unit. Participants A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006. Measurements Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations. Results The median age was 77 years (interquartile range: 71–83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6–42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8–8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1–2.8; P = .01). Conclusions DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.