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1.  Temperature Variability during Delirium in ICU Patients: An Observational Study 
PLoS ONE  2013;8(10):e78923.
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 did not change after adjusting for confounders (βadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.63).
Conclusions
Our study suggests that temperature variability is increased during ICU delirium.
doi:10.1371/journal.pone.0078923
PMCID: PMC3806845  PMID: 24194955
2.  Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: a 2 year follow up study 
Cognitive decline is commonly stated as one of the main risk factors for delirium. The aim was to assess the importance of a delirium episode as a symptom of an underlying dementia among community dwelling healthy elderly people in a prospective 2 year follow up study. The study patients consisted of 51 people living at home and older than 65 years of age, without severe underlying disorders including diagnosed dementia, admitted consecutively as emergency cases to hospital because of an acute delirious state and followed up for 2 years. The diagnosis of delirium and dementia were based on the DSM-III-R criteria. The community dwelling patients were evaluated and tested annually by a clinical investigator, a geriatric study nurse, and a neuropsychologist. The medical records of the institutionalised patients were also evaluated. Dementia was diagnosed immediately after the assurance that delirium symptoms had subsided in 14 out of 51 subjects (27%) and the additional 14 subjects were diagnosed as being demented during the 2 year follow up, 28 out of 51 patients (55%) altogether. Alzheimer's disease or mixed dementia was diagnosed in 14 out of 51 patients (27%), vascular dementia in 10 (20%), and dementia with Lewy bodies in two (4%). One case of alcoholic dementia and one case of a non-alcoholic hepatic encephalopathia were also found. A delirium episode is often the first sign of dementia requiring attention from medical and social professionals.


doi:10.1136/jnnp.69.4.519
PMCID: PMC1737142  PMID: 10990515
3.  Predicting Delirium Duration in Elderly Hip-Surgery Patients: Does Early Symptom Profile Matter? 
Background. Features that may allow early identification of patients at risk of prolonged delirium, and therefore of poorer outcomes, are not well understood. The aim of this study was to determine if preoperative delirium risk factors and delirium symptoms (at onset and clinical symptomatology during the course of delirium) are associated with delirium duration. Methods. This study was conducted in prospectively identified cases of incident delirium. We compared patients experiencing delirium of short duration (1 or 2 days) with patients who had more prolonged delirium (≥3 days) with regard to DRS-R-98 (Delirium Rating Scale Revised-98) symptoms on the first delirious day. Delirium symptom profile was evaluated daily during the delirium course. Results. In a homogenous population of 51 elderly hip-surgery patients, we found that the severity of individual delirium symptoms on the first day of delirium was not associated with duration of delirium. Preexisting cognitive decline was associated with prolonged delirium. Longitudinal analysis using the generalised estimating equations method (GEE) identified that more severe impairment of long-term memory across the whole delirium episode was associated with longer duration of delirium. Conclusion. Preexisting cognitive decline rather than severity of individual delirium symptoms at onset is strongly associated with delirium duration.
doi:10.1155/2013/962321
PMCID: PMC3600209  PMID: 23533395
4.  Prevalence and outcomes of delirium in community and non-acute care settings in people without dementia: a report from the Canadian Study of Health and Aging 
BMC Medicine  2006;4:15.
Background
While delirium is common among older adults in acute care hospitals, its prevalence in other settings has been less well studied. We examined delirium prevalence and outcomes in a large cohort of older Canadians living outside of acute care.
Methods
In this secondary analysis of the Canadian Study of Health and Aging, the prevalence of clinically diagnosed delirium was estimated and five-year survival was compared with that of individuals with dementia of graded severity.
Results
Delirium was very uncommon (prevalence <0.5%) and was associated with reduced survival, similar to that of moderate-to-severe dementia.
Conclusion
In this cohort of older Canadians, delirium in non-demented people was associated with very low 5-year survival, at levels comparable with advanced dementia. Although it is common in hospital, delirium is uncommon among older adults in their usual place of residence, suggesting that it is a potent stimulus to seek medical care.
doi:10.1186/1741-7015-4-15
PMCID: PMC1574341  PMID: 16796755
5.  Delirium in Australian Hospitals: A Prospective Study 
Objectives. Australian data regarding delirium in older hospitalized patients are limited. Hence, this study aimed to determine the prevalence and incidence of delirium among older patients admitted to Australian hospitals and assess associated outcomes. Method. A prospective observational study (n = 493) of patients aged ≥70 years admitted to four Australian hospitals was undertaken. Trained research nurses completed comprehensive geriatric assessments using standardized instruments including the Confusion Assessment Method to assess for delirium. Nurses also visited the wards daily to assess for incident delirium and other adverse outcomes. Diagnoses of dementia and delirium were established through case reviews by independent physicians. Results. Overall, 9.7% of patients had delirium at admission and a further 7.6% developed delirium during the hospital stay. Dementia was the most important predictor of delirium at (OR = 3.18, 95% CI: 1.65–6.14) and during the admission (OR = 4.82; 95% CI: 2.19–10.62). Delirium at and during the admission predicted increased in-hospital mortality (OR = 5.19, 95% CI: 1.27–21.24; OR = 31.07, 95% CI: 9.30–103.78). Conclusion. These Australian data confirm that delirium is a common and serious condition among older hospital patients. Hospital clinicians should maintain a high index of suspicion for delirium in older patients.
doi:10.1155/2013/284780
PMCID: PMC3787633  PMID: 24151504
6.  Prevalence and detection of delirium in elderly emergency department patients 
Background
Delirium is a complex medical disorder associated with high morbidity and mortality among elderly patients. The goals of our study were to determine the prevalence of delirium in emergency department (ED) patients aged 65 years and over and to determine the sensitivity and specificity of a conventional clinical assessment by an ED physician for the detection of delirium in the same population.
Methods
All elderly patients presenting to the ED in a primary acute care, university-affiliated hospital who were triaged to the observation room on a stretcher because of the severity of their illness were screened for delirium by a research psychiatrist using the Mini-Mental State Examination and the Confusion Assessment Method. The diagnosis of "delirium" or an equivalent term by the ED physician was determined by 2 methods: completion of a mental status checklist by the ED physician and chart review. The prevalence of delirium and the sensitivity and specificity of the ED physician's clinical assessment were calculated with their 95% confidence intervals. The demographic and clinical characteristics of patients with detected delirium and those with undetected delirium were compared.
Results
A sample of 447 patients was screened. The prevalence of delirium was 9.6% (95% confidence interval 6.9%-12.4%). The sensitivity of the detection of delirium by the ED physician was 35.3% and the specificity, 98.5%. Most patients with delirium had neurologic or pulmonary diseases, and most patients with detected delirium had neurologic diseases.
Interpretation
Despite the relatively high prevalence of delirium in elderly ED patients, the sensitivity of a conventional clinical assessment for this condition is low. There is a need to improve the detection of delirium by ED physician
PMCID: PMC80546  PMID: 11068569
7.  Risk factors for delirium in acutely admitted elderly patients: a prospective cohort study 
BMC Geriatrics  2005;5:6.
Background
Delirium is a neuropsychiatric syndrome frequently observed in elderly hospitalised patients and can be found in any medical condition. Due to the severe consequences, early recognition of delirium is important in order to start treatment in time. Despite the high incidence rate, the occurrence of delirium is not always identified as such. Knowledge of potential risk factors is important. The aim of the current study is to determine factors associated with the occurrence of a prevalent delirium among elderly patients acutely admitted to an internal medicine ward.
Methods
All consecutive patients of 65 years and over acutely admitted to the Department of Internal Medicine of the Academic Medical Centre, Amsterdam, a university hospital, were asked to participate. The presence of delirium was determined within 48 hrs after admission by an experienced geriatrician.
Results
In total, 126 patients were included, 29% had a prevalent delirium after acute admission. Compared to patients without delirium, patients with delirium were older, more often were cognitively and physically impaired, more often were admitted due to water and electrolyte disturbances, and were less often admitted due to malignancy or gastrointestinal bleeding. Independent risk factors for having a prevalent delirium after acute admission were premorbid cognitive impairment, functional impairment, an elevated urea nitrogen level, and the number of leucocytes.
Conclusions
In this study, the most important independent risk factors for a prevalent delirium after acute admission were cognitive and physical impairment, and a high serum urea nitrogen concentration. These observations might contribute to an earlier identification and treatment of delirium in acutely admitted elderly patients.
doi:10.1186/1471-2318-5-6
PMCID: PMC1097727  PMID: 15826320
8.  Delirium Superimposed on Dementia 
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.
doi:10.3928/00989134-20110706-01
PMCID: PMC3299009  PMID: 21761816
9.  A pragmatic study exploring the prevention of delirium among hospitalized older hip fracture patients: Applying evidence to routine clinical practice using clinical decision support 
Delirium occurs in up to 65% of older hip fracture patients. Developing delirium in hospital has been associated with a variety of adverse outcomes. Trials have shown that multi-component preventive interventions can lower delirium rates. The objective of this study was to implement and evaluate the effectiveness of an evidence-based electronic care pathway, which incorporates multi-component delirium strategies, among older hip fracture patients. We conducted a pragmatic study using an interrupted time series design in order to evaluate the use and impact of the intervention. The target population was all consenting patients aged 65 years or older admitted with an acute hip fracture to the orthopedic units at two Calgary, Alberta hospitals. The primary outcome was delirium rates. Secondary outcomes included length of hospital stay, in-hospital falls, in-hospital mortality, new discharges to long-term care, and readmissions. A Durbin Watson test was conducted to test for serial correlation and, because no correlation was found, Chi-square statistics, Wilcoxon test and logistic regression analyses were conducted as appropriate. At study completion, focus groups were conducted at each hospital to explore issues around the use of the order set. During the 40-week study period, 134 patients were enrolled. The intervention had no effect on the overall delirium rate (33% pre versus 31% post; p = 0.84). However, there was a significant interaction between study phase and hospital (p = 0.03). Although one hospital did not experience a decline in delirium rate, the delirium rate at the other hospital declined from 42% to 19% (p = 0.08). This difference by hospital was mirrored in focus group feedback. The hospital that experienced a decline in delirium rates was more supportive of the intervention. Overall, post-intervention there were no significant differences in mean length of stay (12 days post versus 14 days pre; p = 0.74), falls (6% post versus 10% pre; p = 0.43) or discharges to long-term care (6% post versus 13% pre; p = 0.20). Translation of evidence-based multi-component delirium prevention strategies into everyday clinical care, using the electronic medical record, was not found to be effective at decreasing delirium rates among hip facture patients.
doi:10.1186/1748-5908-5-81
PMCID: PMC2972236  PMID: 20969770
10.  Persistent Delirium Predicts Increased Mortality 
OBJECTIVES
To examine the association between persistent delirium and one-year mortality in newly admitted delirious post-acute care (PAC) facility patients, who were followed regardless of residence.
DESIGN
Observational cohort study.
SETTING
Eight greater-Boston skilled nursing facilities specializing in PAC.
PARTICIPANTS
Four hundred and twelve PAC patients with delirium at the time of admission after an acute hospitalization.
MEASUREMENTS
Assessments were done at baseline and four follow-up times: 2-week, 4-week, 12-week and 26-week. “Confusion Assessment Method”-defined delirium was assessed, as were factors used as covariates in analyses including: age, gender, comorbidity, functional status and dementia. The outcome was one-year mortality determined by the National Death Index and corroborated by medical record, and proxy telephone interview.
RESULTS
Nearly one-third remained delirious at 6 months. The cumulative one-year mortality was 39%. Independent of age, gender, comorbidity, functional status and dementia, subjects with persistent delirium were 2.9 (95% confidence interval, 1.9, 4.4) times more likely to die during the one-year follow-up compared to subjects who resolved their delirium. This association remained strong and significant in groups with and without dementia. Additionally, when delirium resolved, the risk of death diminished thereafter.
CONCLUSION
Among patients who were delirious at the time of PAC admission and followed regardless of residence, persistent delirium was a significant independent predictor of one-year mortality.
doi:10.1111/j.1532-5415.2008.02092.x
PMCID: PMC2744464  PMID: 19170790
delirium; mortality; survival; post-acute care
11.  The Neecham Confusion Scale and the Delirium Observation Screening Scale: Capacity to discriminate and ease of use in clinical practice 
BMC Nursing  2007;6:3.
Background
Delirium is a frequent form of psychopathology in elderly hospitalized patients; it is a symptom of acute somatic illness. The consequences of delirium include high morbidity and mortality, lengthened hospital stay, and nursing home placement. Early recognition of delirium symptoms enables the underlying cause to be diagnosed and treated and can prevent negative outcomes. The aim of this study was to determine which of the two delirium observation screening scales, the NEECHAM Confusion Scale or the Delirium Observation Screening (DOS) scale, has the best discriminative capacity for diagnosing delirium and which is more practical for daily use by nurses.
Methods
The project was conducted on four wards of a university hospital; 87 patients were included. During 3 shifts, these patients were observed for symptoms of delirium, which were rated on both scales. A DSM-IV diagnosis of delirium was made or rejected by a geriatrician. Nurses were asked to rate the practical value of both scales using a structured questionnaire.
Results
The sensitivity (0.89 – 1.00) and specificity (0.86 – 0.88) of the DOS and the NEECHAM were high for both scales. Nurses rated the practical use of the DOS scale as significantly easier than the NEECHAM.
Conclusion
Successful implementation of standardized observation depends largely on the consent of professionals and their acceptance of a scale. In our hospital, we therefore chose to involve nurses in the choice between two instruments. During the study they were able to experience both scales and give their opinion on ease of use. In the final decision on the instrument we found that both scales were very acceptable in terms of sensitivity and specificity, so the opinion of the nurses was decisive. They were positive about both instruments; however, they rated the DOS scale as significantly easier to use and relevant to their practice. Our findings were obtained from a single site study with a small sample, so a large comparative trial to study the value of both scales further is recommended. On the basis of our experience during this study and findings from the literature with regard to the implementation of delirium guidelines, we will monitor the further implementation of the DOS Scale in our hospital with intensive consultation.
doi:10.1186/1472-6955-6-3
PMCID: PMC1852304  PMID: 17394635
12.  Evidence-Based Treatment of Delirium in Patients With Cancer 
Journal of Clinical Oncology  2012;30(11):1206-1214.
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.
doi:10.1200/JCO.2011.39.8784
PMCID: PMC3646320  PMID: 22412123
13.  Delirium in the intensive care unit 
Korean Journal of Anesthesiology  2013;65(3):195-202.
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.
doi:10.4097/kjae.2013.65.3.195
PMCID: PMC3790029  PMID: 24101952
Delirium; Intensive care unit; Outcome
14.  Delirium in the Emergency Department: an Independent Predictor of Death Within Six Months 
Annals of emergency medicine  2010;56(3):244-252.e1.
Objectives
Delirium’s adverse effect on long-term mortality in older hospitalized patients is well documented, while its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients seen in the ED are also unknown. As a result, we sought to determine if delirium in the ED was independently associated with 6-month mortality in older patients and if this relationship was modified by nursing home status.
Methods
Our prospective cohort study was conducted at a tertiary care, academic ED using convenience sampling, and included English speaking patients who were 65 years and older and were in the ED for less than 12 hours at the time of enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or had incomplete data. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to determine delirium and was administered by trained research assistants. Cox proportional hazard regression was performed to determine if delirium in the ED was independently associated with 6-month mortality after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. To test whether the effect of delirium in the ED on 6-month mortality was modified by nursing home residence, an interaction term (delirium*nursing home) was incorporated into the multivariable model. Hazard ratios (HR) with their 95% confidence intervals (95% CI) were reported.
Results
Of the 628 patients enrolled, 108 (17.2%) were delirious in the ED and 58 (9.2%) were from the nursing home. For the entire cohort, the 6-month mortality rate was higher in the delirious group compared to the non-delirious group (37.0% versus 14.3%). Delirium was an independent predictor of increased 6-month mortality (HR = 1.72, 95% CI: 1.04 – 2.86) after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. The “delirium*nursing home” interaction was non-significant (p=0.86), indicating that place of residence had no effect on the relationship between delirium in the ED and 6-month mortality.
Conclusion
Delirium in older ED patients is an independent predictor of increased 6-month mortality and this relationship appears to be present regardless of nursing home status.
doi:10.1016/j.annemergmed.2010.03.003
PMCID: PMC3768121  PMID: 20363527
15.  Randomized Trial of a Delirium Abatement Program for Post-acute Skilled Nursing Facilities 
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.
doi:10.1111/j.1532-5415.2010.02871.x
PMCID: PMC2924954  PMID: 20487083
Delirium; Outcomes; Post-acute care; Randomized trial
16.  Computerized Decision Support for Delirium Superimposed on Dementia in Older Adults 
Delirium is common, deadly, and costly in people with dementia. The purpose of this pilot study was to test the feasibility of the computerized decision support component of an intervention strategy—Early Nurse Detection of Delirium Superimposed on Dementia—designed to improve nurse assessment and detection of delirium superimposed on dementia. This pilot study enrolled and followed 15 individuals with dementia (mean age = 83, mean admission Mini-Mental State Examination score = 14.8) and their caregivers daily for the duration of their hospitalization. Results indicated 100% adherence by nursing staff on the delirium assessment decision support screens and 75% adherence on the management screens. Despite the prevalence and severity of delirium in people with dementia, there are currently no published reports of the use of the electronic medical record in delirium detection and management. Success of this effort may encourage similar use of information technology in other settings.
doi:10.3928/00989134-20100930-01
PMCID: PMC3071445  PMID: 21053810
17.  A Clinical Update on Delirium: From Early Recognition to Effective Management 
Nursing Research and Practice  2011;2011:875196.
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.
doi:10.1155/2011/875196
PMCID: PMC3169311  PMID: 21994844
18.  Antipsychotic Use Among Nursing Home Residents Admitted with Hip Fracture 
Journal of the American Geriatrics Society  2012;61(1):10.1111/jgs.12043.
Background/Objectives
Widespread use of antipsychotic medications among skilled nursing home (NH) residents for off-label indications has become a concern of clinicians and policy makers. The objective of this study was to evaluate the association between receiving antipsychotics and the outcomes of a cohort of NH patients with and without presumed delirium after hip fracture.
Design
Population based cohort study.
Setting
11,119 nursing homes nationwide, from 01 January 2000 to 31 December 2007.
Participants
First-time NH admits with hip fracture (N=77,759).
Measurements
The Nursing Home Confusion Assessment Method was utilized to identify residents with no delirium, subsyndromal delirium, and full delirium. Propensity score reweighting was used with analyses stratified by delirium level.
Results
Among patients with no delirium symptoms, about 5 percent (n = 3,250) received antipsychotic drugs. These individuals were less likely to be discharged home (OR 0.68; P < 0.001), had a higher likelihood of death prior to nursing home discharge (OR 1.28; P = 0.03), stayed in nursing homes longer (β 2.83; P = 0.05), and had less functional improvement at discharge (β -0.47; P = 0.03). Receipt of antipsychotics among participants with mild delirium was associated with a lower likelihood of discharge home (OR 0.74; P = 0.03).
Conclusion
Among NH residents with hip fracture and no delirium symptoms, use of antipsychotics was associated with worse outcomes, with the exception of rehospitalization. No clear benefits were associated with antipsychotic use for those with presumed delirium.
doi:10.1111/jgs.12043
PMCID: PMC3854869  PMID: 23252409
Skilled Nursing Facility; Delirium; Antipsychotics
19.  Early Assessment of Delirium in Elderly Patients after Hip Surgery 
Psychiatry Investigation  2011;8(4):340-347.
Objective
This study is intended to identify predictive factors of delirium, including risk factors and prodromal symptoms.
Methods
This study included sixty-five patients aged 65 years or older who had undergone hip surgery. Baseline assessments included age; gender; admission type (acute/elective); reason for surgery (fracture/replacement); C-reactive protein (CRP); Acute Physiology, Age, Chronic Health Evaluation (APACHE III); and the Mini-Mental State Examination (MMSE). The Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98) was used to assess prodromal symptoms daily before the onset of delirium.
Results
Almost 28% (n=18) of the 65 patients developed delirium after surgery. Delirium in elderly patients after hip surgery was observed more often in older patients and those with acute admission, hip fracture, higher APACHE III score, lower MMSE score, and higher CRP levels within early days after the operation. Sleep-wake cycle disturbances, thought process abnormalities, orientation, and long-term memory in symptom items of K-DRS-98 were showed significant difference on 4 days before delirium, lability of affect on 3 days before, perceptual disturbances and hallucination, and visuo-spatial ability on 2 days before, and delusion, motor agitation, and short-term memory on the day before the occurrence of delirium. CRP levels within 24 hours and 72 hours after hospitalization were significantly higher in the delirium group.
Conclusion
Medical professionals must pay attention to behavioral, cognitive changes and risk factors in elderly patients undergoing hip surgery and to the prodromal phase of delirium. K-DRS-98 may help in identifying the prodromal symptoms of delirium in elderly patients after hip surgery.
doi:10.4306/pi.2011.8.4.340
PMCID: PMC3246142  PMID: 22216044
Delirium; Elderly; Hip surgery; Prodromal; K-DRS-98
20.  Recognizing Delirium Superimposed on Dementia 
Delirium is a serious and prevalent problem that occurs in many hospitalized older adults. Delirium superimposed on dementia (DSD) occurs when a delirium occurs concurrently with a pre-existing dementia. DSD is typically under-recognized by medical and nursing staff. The current study measured nursing identification of DSD using standardized case vignettes, and the Mary Starke Harper Aging Knowledge Exam (MSHAKE). Results revealed that the nurses in this study had a high level of general geropsychiatric nursing knowledge as measured by the MSHAKE, yet had difficulty recognizing DSD compared to dementia alone and delirium alone. Only 21% were able to correctly identify the hypoactive form of DSD, and 41% correctly identified hypoactive delirium alone in the case vignettes. Interventions and educational programs designed to increase nursing awareness of DSD symptoms could help to decrease this gap in nursing knowledge.
PMCID: PMC2247368  PMID: 17310662
21.  Days of Delirium Are Associated with 1-Year Mortality in an Older Intensive Care Unit Population 
Rationale: Delirium is a frequent occurrence in older intensive care unit (ICU) patients, but the importance of the duration of delirium in contributing to adverse long-term outcomes is unclear.
Objectives: To examine the association of the number of days of ICU delirium with mortality in an older patient population.
Methods: We performed a prospective cohort study in a 14-bed ICU in an urban acute care hospital. The patient population comprised 304 consecutive admissions 60 years of age and older.
Measurements and Main Results: The main outcome was 1-year mortality after ICU admission. Patients were assessed daily for delirium with the Confusion Assessment Method for the ICU and a validated chart review method. The median duration of ICU delirium was 3 days (range, 1–46 d). During the follow-up period, 153 (50%) patients died. After adjusting for relevant covariates, including age, severity of illness, comorbid conditions, psychoactive medication use, and baseline cognitive and functional status, the number of days of ICU delirium was significantly associated with time to death within 1 year post-ICU admission (hazard ratio, 1.10; 95% confidence interval, 1.02–1.18).
Conclusions: Number of days of ICU delirium was associated with higher 1-year mortality after adjustment for relevant covariates in an older ICU population. Investigations should be undertaken to reduce the number of days of ICU delirium and to study the impact of this reduction on important health outcomes, including mortality and functional and cognitive status.
doi:10.1164/rccm.200904-0537OC
PMCID: PMC2784414  PMID: 19745202
delirium; aging; mortality; intensive care
22.  Factors Associated with Recovery from Early Postoperative Delirium 
Background
Delirium has been shown to occur in 14-56% of postoperative, hospitalized elderly persons, making it one of the most common postoperative complications for the older patient.
Objective
The aim of this study was to determine factors associated with recovery of delirium from postoperative day one (POD 1) to postoperative day two (POD 2). The hypothesis was that those with less pain are more likely to recover from delirium by POD 2.
Methods
Patients aged 65 or older who were scheduled for noncardiac surgery, spoke English, and who developed delirium on POD 1 as detected by the Confusion Assessment Method (CAM) were included. Total sample size was 176 patients. Postoperative delirium on day two was also measured with the CAM. Postoperative pain was assessed on POD 1 and 2 using the Numeric Rating Scale (NRS). Postoperative pain medications were abstracted from patient medical records.
Results
One hundred seventy six patients developed delirium on POD 1 with 66 (38%) recovering from delirium by POD 2. The mean age of those patients who recovered from delirium was 72.5 ± 5.7 (N=66) while the mean age of those patients who did not recover from delirium was 75.9 ± 6.5 (N=110). Multivariate logistic regression revealed that patients less than age 75 were more likely to recover from delirium (OR=2.31; 95% CI=1.18-4.53; p=0.015) as were patients who had pain scores of less than 5 on day two (OR=2.59; 95% CI=1.26-5.35; p=0.0098).
Conclusion
Patients with lower pain levels (NRS 4 or less) were more likely to recover from delirium on POD 2. The type of postoperative pain therapy (the use or non-use of patient controlled analgesia) was not related to the recovery of delirium. The results suggest that aggressive pain management in the first 48 hours postoperatively may be important in promoting recovery from postoperative delirium.
doi:10.1016/j.jopan.2011.03.001
PMCID: PMC3148485  PMID: 21803271
Postoperative delirium; pain management; geriatrics; research
23.  A research algorithm to improve detection of delirium in the intensive care unit 
Critical Care  2006;10(4):R121.
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 accurate determination of delirium status. Improving detection of delirium is of paramount importance both to advance delirium research and to enhance clinical care and patient safety.
doi:10.1186/cc5027
PMCID: PMC1750978  PMID: 16919169
24.  Incidence and Risk Factors of Acute Postoperative Delirium in Geriatric Neurosurgical Patients 
Objective
Postoperative delirium (POD) is characterized by an acute change in cognitive function and can result in longer hospital stays, higher morbidity rates, and more frequent discharges to long-term care facilities. In this study, we investigated the incidence and risk factors of POD in 224 patients older than 70 years of age, who had undergone a neurosurgical operation in the last two years.
Methods
Data related to preoperative factors (male gender, >70 years, previous dementia or delirium, alcohol abuse, serum levels of sodium, potassium and glucose, and co morbidities), perioperative factors (type of surgery and anesthesia, and duration of surgery) and postoperative data (length of stay in recovery room, severity of pain and use of opioid analgesics) were retrospectively collected and statistically analyzed.
Results
POD appeared in 48 patients (21.4%) by postoperative day 3. When we excluded 26 patients with previous dementia or delirium, 17 spontaneously recovered by postoperative day 14, while 5 patients recovered by postoperative 2 months with medication, among 22 patients with newly developed POD. The univariate risk factors for POD included previously dementic or delirious patients, abnormal preoperative serum glucose level, pre-existent diabetes, the use of local anesthesia for the operation, longer operation time (>3.2 hr) or recovery room stay (>90 min), and severe pain (VAS>6.8) requiring opioid treatment (p<0.05). Backward regression analysis revealed that previously dementic patients with diabetes, the operation being performed under local anesthesia, and severe postoperative pain treated with opioids were independent risk factors for POD.
Conclusion
Our study shows that control of blood glucose levels and management of pain during local anesthesia and in the immediate postoperative period can reduce unexpected POD and help preventing unexpected medicolegal problems and economic burdens.
doi:10.3340/jkns.2008.43.3.143
PMCID: PMC2588241  PMID: 19096622
Anesthesia; Diabetes; Geriatric; Pain; Postoperative delirium (POD)
25.  The effect of a complementary e-learning course on implementation of a quality improvement project regarding care for elderly patients: a stepped wedge trial 
Background
Delirium occurs frequently in elderly hospitalised patients and is associated with higher mortality, increased length of hospital stay, functional decline, and admission to long-term care. Healthcare professionals frequently do not recognise delirium, indicating that education can play an important role in improving delirium care for hospitalised elderly. Previous studies have indicated that e-learning can provide an effective way of educating healthcare professionals and improving quality of care, though results are inconsistent.
Methods and design
This stepped wedge cluster randomised trial will assess the effects of a complementary delirium e-learning course on the implementation of quality improvement initiative, which aims to enhance the recognition and management of delirium in elderly patients. The trial will be conducted in 18 Dutch hospitals and last 11 months. Measurements will be taken in all participating wards using monthly record reviews, in order to monitor delivered care. These measurements will include the percentage of elderly patients who were screened for the risk of developing delirium, use of the Delirium Observation Screening scale, use of nursing or medical interventions, and the percentage of elderly patients who were diagnosed with delirium. Data regarding the e-learning course will be gathered as well. These data will include user characteristics, information regarding use of the course, delirium knowledge before and after using the course, and the attitude and intentions of nurses concerning delirium care.
Setting
The study will be conducted in internal medicine and surgical wards of eighteen hospitals that are at the beginning stages of implementing the Frail Elderly Project in the Netherlands.
Discussion
Better recognition of elderly patients at risk for delirium and subsequent care is expected from the introduction of an e-learning course for nurses that is complementary to an existing quality improvement project. This trial has the potential to demonstrate that e-learning can be a vital part of the implementation process, especially for quality improvement projects aimed at complex health issues such as delirium. The study will contribute to a growing body of knowledge concerning e-learning and the effects it can have on knowledge as well as delivered care.
Trial registration
Netherlands Trial Register (NTR): NTR2885
doi:10.1186/1748-5908-7-13
PMCID: PMC3310782  PMID: 22385554

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