Delirium and Clusters of Older Patients Affected by Multimorbidity in Acute Hospitals

ObjectivesDelirium is commonly seen in older adults with multimorbidity, during a hospitalization, resulting from the interplay between predisposing factors such as advanced age, frailty, and dementia, and a series of precipitating factors. The association between delirium and specific multimorbidity is largely unexplored so far although of potential key relevance for targeted interventions. The aim of the study was to check for a potential association of multimorbidity with delirium in a large cohort of older patients hospitalized for an acute medical or surgical condition.DesignThis is a cross-sectional study nested in the 2017 Delirium Day project.Setting and ParticipantsThe study includes 1829 hospitalized patients (age: 81.8, SD: 5.5). Of them, 419 (22.9%) had delirium.MethodsSociodemographic and medical history were collected. The 4AT was used to assess the presence of delirium. The Charlson Comorbidity index was used to assess multimorbidity.ResultsThe results identified neurosensorial multimorbidity as the most prevalent, including patients with dementia, cerebrovascular diseases, and sensory impairments. In light of the highest co-occurrence of 3 neurosensorial chronic conditions, we could hypothesize that a baseline altered brain functional and neural connectivity might determine the vulnerability signature for incipient overall system disruption in presence of acute insults.Conclusions and ImplicationsEventually, our findings moved a step forward in supporting the key importance of routine screening for sensory impairments and cognitive status of older patients for the highest risk of in-hospital delirium. In fact, preventive interventions could be particularly relevant and effective in preventing delirium in such vulnerable populations and might help refining this early diagnosis.     

Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients

Background

Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale-Thai version (MDAS-T) in PC patients.

Materials and Methods

The MDAS was translated into Thai. Content validity, inter-rater reliability, and internal consistency were explored. The construct validity of the MDAS-T was analyzed using exploratory factor analysis. Instrument testing of the MDAS-T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU-T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded.

Results

The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one-factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93–0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS-T were 0.92 (0.85–0.96) and 0.90 (0.82–0.94), respectively, with a cutoff score of 9, whereas the CAM-ICU-T yielded 0.58 (0.48–0.67) and 0.98 (0.93–0.99), respectively. The median MDAS-T assessment time was 5 minutes.

Conclusion

This study established and validated the MDAS-T as a good and feasible tool for delirium screening and severity rating in PC settings.

Implications for Practice

Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS-T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population.

     

The training needs of Korean intensive care unit nurses regarding delirium

ObjectivesThe aim of this study was to investigate high-priority training needs by analysing the perceived importance and self-reported performance of nurses’ delirium care competency.DesignA cross-sectional survey with a convenience sample of 255 Korean intensive care units nurses.SettingIntensive care units in the Republic of Korea.Main outcome measuresIntensive care unit nurses’ delirium care competency.ResultsExploratory factor analysis of the Nurse Delirium Care Competency Scale showed a six-factor structure, which accounted for 67.51% of the variance in nurses’ delirium care competency: management algorithm, prevention, communication, nursing management, assessment, and collaboration. The self-reported performance scores of all six factors were significantly lower than their perceived importance scores. The delirium assessment factor was identified as a high training priority on the importance-performance matrix for new graduate nurses.ConclusionTraining programmes should be developed considering the six delirium care competency factors identified in this study. Further, nurse educators must adopt active educational modalities such as case-based small group learning and simulation-based learning to improve nurse competency in recognising and managing delirium.     

Combination of lithium and electroconvulsive therapy (ECT) is associated with higher odds of delirium and cognitive problems in a large national sample across the United States

BackgroundLithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue.ObjectiveIn this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder?MethodsA national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses.ResultsThe prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania.ConclusionThese results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.     

首次无抽搐电休克治疗后迟发性谵妄1例

无抽搐电休克治疗(MECT)是在传统电休克治疗基础上配合麻醉技术,是一种快速、安全、高效的治疗方法。MECT虽减少了因抽搐而产生的不良反应,但仍存在头痛、肌肉疼痛、认知功能损害等副作用。本文报告了1例MECT治疗后谵妄(PECTD)的案例,并对PECTD发生的可能机制进行探讨,考虑发作时间过长、双侧电极片放置是本例发生PECTD的可能原因。提示临床工作者加强对PECTD的预防、识别。     

Investigating how electroencephalogram measures associate with delirium: A systematic review

Delirium is a common neurocognitive disorder in hospital settings, characterised by fluctuating impairments in attention and arousal following an acute precipitant. Electroencephalography (EEG) is a useful method to understand delirium pathophysiology. We performed a systematic review to investigate associations between delirium and EEG measures recorded prior, during, and after delirium. A total of 1,655 articles were identified using PsycINFO, Embase and MEDLINE, 31 of which satisfied inclusion criteria. Methodological quality assessment was undertaken, resulting in a mean quality score of 4 out of a maximum of 5. Qualitative synthesis revealed EEG slowing and reduced functional connectivity discriminated between those with and without delirium (i.e. EEG during delirium); the opposite pattern was apparent in children, with cortical hyperexcitability. EEG appears to have utility in differentiating those with and without delirium, but delirium vulnerability and the long-term effects on brain function require further investigation. Findings provide empirical support for the theory that delirium is a disorder of reduced functional brain integration.     

重症医学监护室亚综合征谵妄发生的相关因素分析

目的探讨重症医学监护室(I C U)发生亚综合征谵妄的相关因素。方法选择2018年6月—2019年6月黄石爱康医院I C U出现亚综合征谵妄的79例患者作为研究组,选择同期I C U未出现亚综合征谵妄的238例患者作为对照组,比较两组基线资料、基础疾病、一般状况、主要实验室检查结果和入住I C U方式。结果两组年龄、文化程度、A P A C H EⅡ评分、简易精神状态检查表评分,以及使用机械通气、使用约束带、低蛋白血症和低钠血症的比例差异均有统计学意义(P<0.05)。多因素Logistic回归分析显示,低简易精神状态检查表评分、使用约束带和低蛋白血症与亚综合征谵妄的发生密切相关(P<0.05)。结论对于ICU患者,简易精神状态检查表评分低、存在低蛋白血症及使用约束带的情况下易出现亚综合征谵妄。