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Delirium is a marker of acute brain insufficiency and a harbinger of poor outcomes and increased healthcare costs. Despite success preventing delirium by nonpharmacologic measures, the incidence in the postcardiac surgical ICU population remains high. Dexmedetomidine, a selective alpha-2 agonist, is a plausible preventive agent with sedative, anxiolytic, analgesic, sympatholytic and anti-inflammatory properties, and is the subject of very active study in cardiac surgery populations.Recent trials, including DEXACET (2019), DECADE (2020), LOWDEXDEL (2021), and DIRECT (2022) individually, failed to show a benefit for dexmedetomidine and highlighted associated risks. Meta-analyses have offered conflicting results, highlighting the complexity of delirium, and likely interaction of multiple etiological pathways; those that concluded benefit often were driven by trials at high risk of bias. Meta-analyses excluding biased trials currently suggest no benefit for dexmedetomidine over control in unselected cardiac surgical populations.Although using dexmedetomidine to prevent delirium in unselected cardiac surgical patients is not supported by current evidence, there remains hope that it may offer benefits in highly selected populations, and further trials are ongoing.

Current research aims at improving early detection and treatment of cognitive impairment (CI), particularly in patients at high risk for progression to dementia. It is important to treat signs and symptoms as early as possible to normalize quality of life. In older cognitively impaired patients, dentists and physicians should consider polypharmacy, uncontrolled cardiovascular risk factors, depression, metabolic or endocrine derangements, delirium due to intercurrent illness, and dementia, all of which may increase risk for CI and other negative outcomes. An interdisciplinary team approach is a necessity for a responsible and safe treatment sequence.

Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.

Delirium often occurs in elderly hospitalized patients. Multimorbidity and associated polypharmacy are known risk factors for developing delirium. Moreover, delirium itself often leads to the prescription of additional drugs. This article aims to enlighten the interrelation of delirium and polypharmacy in the context of recent evidence. It also tries to show possibilities of deprescribing. Das Delir ist ein häufiges Krankheitsbild bei älteren Menschen im Krankenhaus. Multimorbidität und dadurch bedingte Polypharmazie gelten als wichtige Risikofaktoren für die Entwicklung eines Delirs. Gleichzeitig führt ein Delir umgekehrt häufig zu einer weiteren Verordnung von Medikamenten. Dieser Artikel beleuchtet den Zusammenhang von Delir und Polypharmazie auf Basis aktueller Evidenz. Ausserdem versucht er, Möglichkeiten zur Reduktion von Medikamenten aufzuzeigen.

BackgroundDelirium is a complex neurocognitive syndrome suspected to be bidirectionally linked to dementia. Circadian rhythm disturbances likely contribute to dementia pathogenesis, but whether these disturbances are related to delirium risk and progression to all-cause dementia is unknown.MethodWe analyzed continuous actigraphy data from 53,417 middle-older-aged UK Biobank participants during a median 5 years of follow-up. Four measures were used to characterize the 24-hour daily rest-activity rhythms (RARs): normalized amplitude, acrophase representing the peak activity time, interdaily stability (IS), and intradaily variability (IV) for fragmentation of the rhythm. Cox proportional hazards models examined whether RARs predicted incident delirium (n=551) and progression to dementia (n=61).ResultsSuppressed 24-h amplitude, lowest [Q1] versus highest [Q4] quartile: hazard ratio [HR]Q1 vs. Q4: 1.94; 95% confidence interval: [1.53-2.46], pConclusion24-hour daily RAR suppression, fragmentation, and potentially delayed acrophase were associated with delirium risk. Subsequent progression to dementia was more likely in delirium cases with suppressed rhythms. The presence of RAR disturbances before delirium and prior to progression to dementia suggests that these disturbances may predict higher risk and be involved in early disease pathogenesis.

Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes.Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV).Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV- calibration-in-the-largelt;0.001, CV-slope 0.94, and CV-area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84-0.91)].A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.

Background Altered serum magnesium (Mg) levels in older persons have been hypothesized to have a role in predicting hospitalization and mortality. Hypomagnesemia and delirium are frequent problems in older patients, but no study has evaluated such an association in acute geriatric setting. Aims We investigated the impact of hypomagnesemia on the incidence of delirium in an acute geriatric setting. Methods This retrospective study was conducted on 209 older hospitalized patients. All subjects underwent a comprehensive geriatric assessment. Mg was measured in serum by routine laboratory methods. The presence of incident delirium was determined by the 4AT screening tool. A logistic regression model was used to assess the association between serum Mg and delirium controlling for multiple covariates. Results 209 patients (77.9% women) were included in the study. The mean age of the participants was 85.7 ± 6.50 years (range 65–100). 27 subjects (12.9%) developed delirium during the hospitalization, with no difference between genders. Subjects with delirium had lower serum magnesium levels than those without (1.88 ± 0.34 versus 2.04 ± 0.28; p = 0.009). Delirium risk was significantly higher in patients with lower serum magnesium levels (OR 5.80 95% CI 1.450–23.222; p = 0.013), independent of multiple covariates. Conclusion Our data show that low serum Mg level is a good predictor of incident delirium in acute geriatric settings. Present findings have relevant implications for clinical management, highlighting the need for analyzing Mg concentration carefully. Whether Mg supplementation in patients with hypomagnesemia could lead to delirium prevention and/or control needs further investigation.

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes.

With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process. Expected final online publication date for the

Background Delirium is a severe complication in critical care patients. Accurate prediction could facilitate determination of which patients are at risk. In the past decade, several delirium prediction models have been developed. Objectives To compare the prognostic accuracy of the PRE-DELIRIC, E-PRE-DELIRIC, and Lanzhou models, and to investigate the difference in prognostic accuracy of the PRE-DELIRIC model between patients receiving and patients not receiving mechanical ventilation. Methods This retrospective study involved adult patients admitted to the intensive care unit during a 2-year period. Delirium was assessed by using the Confusion Assessment Method for the Intensive Care Unit or any administered dose of haloperidol or quetiapine. Model discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC); values were compared using the DeLong test. Results The study enrolled 1353 patients. The AUC values were calculated as 0.716 (95% CI, 0.688–0.745), 0.681 (95% CI, 0.650–0.712), and 0.660 (95% CI, 0.629–0.691) for the PRE-DELIRIC, E-PRE-DELIRIC, and Lanzhou models, respectively. The difference in model discrimination was statistically significant for comparison of the PRE-DELIRIC with the E-PRE-DELIRIC (AUC difference, 0.035; P = .02) and Lanzhou models (AUC difference, 0.056; P < .001). In the PRE-DELIRIC model, the AUC was 0.711 (95% CI, 0.680–0.743) for patients receiving mechanical ventilation and 0.664 (95% CI, 0.586–0.742) for those not receiving it (difference, 0.047; P = .27). Conclusion Statistically significant differences in prognostic accuracy were found between delirium prediction models. The PRE-DELIRIC model was the best-performing model and can be used in patients receiving or not receiving mechanical ventilation.

To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery.A systematic review, meta-analysis, and trial sequential analysis (TSA).In the operating room, postoperative anesthesia care units (PACU), and ward.Elderly patients (60 years old) undergoing surgery.The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS.Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, IThe authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.

Delirium is associated with adverse post-operative outcomes, long-term cognitive dysfunction, and prolonged hospitalization. Risk factors for its development include longer surgical duration, increased operative complexity and invasiveness, and medical comorbidities. This study aims to further evaluate the incidence of delirium and its impact on outcomes among patients undergoing both elective and emergency bowel resections.This is a retrospective cohort study using an institutional patient registry. All patients undergoing bowel resection over a 3.5-year period were included. The study measured the incidence of post-operative delirium via the nursing confusion assessment method. This incidence was then compared to patient age, emergency versus elective admission, length of stay, mortality, discharge disposition, and hospital cost.A total of 1934 patients were included with an overall delirium incidence of 8.8%. Compared to patients without delirium, patients with delirium were more likely to have undergone emergency surgery, be greater than 70 y of age, have a longer length of stay, be discharged to a skilled nursing facility, and have a more expensive hospitalization. In addition, the overall mortality was 14% in patients experiencing delirium versus 0.1% in those that did not. Importantly, when broken down between elective and emergency groups, the mortality of those experiencing delirium was similar (11 versus 13%).The development of delirium following bowel resection is an important risk factor for worsened outcomes and mortality. Although the incidence of delirium is higher in the emergency surgery population, the development of delirium in the elective population infers a similar risk of mortality.

This study sought to investigate the impact of pre-existing cognitive impairment on outcomes after transcatheter aortic valve implantation (TAVI). TAVI has been increasingly used in seniors, and evidence suggests better outcomes than surgical aortic valve replacement. Although frailty has been shown to be associated with poorer outcomes after TAVI, the effect of pre-existing cognitive impairment on patient outcomes after TAVI remains unclear. We searched the Medline, Embase, Scopus and Cochrane databases until May 14, 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was short-term (6 months to 1 year) mortality, and secondary outcomes included long-term (1 year to 3 years) mortality, in-hospital mortality, and postoperative delirium. A total of 14 studies with 32,746 patients (5,098 patients with cognitive impairment at baseline, 27,648 without) were included in our meta-analysis. Among studies that reported the raw proportion of patients with mortality of postoperative delirium, cognitive impairment significantly increased mortality (risk ratio 2.10, 95% confidence intervals [CIs] 1.43 to 3.08, p = 0.0002) and postoperative delirium (risk ratio 2.27, 95% CI 1.76 to 2.93, p0.0001). Studies which reported the hazards for mortality (pooled hazards ratio 1.97, 95% CI 1.50 to 2.60, p0.0001) and odds of postoperative delirium (pooled odds ratio 2.40, 95% CI: 1.51 to 3.80, p = 0.0002) yielded results consistent with the primary meta-analysis. In conclusion, pre-existing cognitive impairment is a significant risk factor for poorer outcomes after TAVI and should be carefully considered in this group of patients. Guidelines and future studies should take cognitive impairment into consideration for preoperative risk stratification.

Gohar Azhar,1 Shakshi Sharma,1 Onna Lau,1 Bader Alkharisi,1 Anil Anandam,1 Sakiru Isa,2 Priya Mendiratta,1 Amanda K Pangle,1 Karen Coker,1 Jeanne Wei1 1Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 2Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USACorrespondence: Gohar Azhar, Email azhargohar@uams.eduBackground: Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention.Materials and Methods: We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥ 60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2– 3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults.Results: The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p< 0.01) recognizing signs and symptoms (77% vs 94%, p< 0.05), complications (76% vs 100%, p< 0.01) and identifying the etiological factors associated with delirium.Conclusion: The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.Keywords: delirium, education, aging, healthcare

Cerebrospinal fluid (CSF) flows through the central nervous system (CNS) via the glymphatic pathway to clear the interstitium of metabolic waste. In preclinical studies, glymphatic fluid flow rate increases with low central noradrenergic tone and slow-wave activity during natural sleep and general anesthesia. By contrast, sleep deprivation reduces glymphatic clearance and leads to intracerebral accumulation of metabolic waste, suggesting an underlying mechanism linking sleep disturbances with neurodegenerative diseases. The selective α2-adrenergic agonist dexmedetomidine is a sedative drug that induces slow waves in the electroencephalogram, suppresses central noradrenergic tone, and preserves glymphatic outflow. As recently developed dexmedetomidine formulations enable self-administration, we suggest that dexmedetomidine could serve as a sedative-hypnotic drug to enhance clearance of harmful waste from the brain of those vulnerable to neurodegeneration.

Delirium is a serious acute neuropsychiatric syndrome, characterized by acute and fluctuating inattention, other cognitive deficits, and al-terations in level of consciousness, that is independently associated with several adverse outcomes. Delirium is a transdisciplinary condition since it can affect vulnerable people in all settings of care. This clinical case is the basis for a special issue on this topic in which the negative consequence of delirium and the methods to manage people affected by this condition are described across various settings of care.

Background: Amnestic mild cognitive impairment (aMCI), a prodromal phase of Alzheimer’s disease (AD), is characterized by episodic memory dysfunction, but inhibitory deficits have also been commonly reported. Time of day (TOD) effects have been confirmed in 1) healthy aging on cognitive processes such as inhibitory control, and 2) on behavior in AD (termed the sundowning effect), but no such research has addressed aMCI. Objective: The present study examined the impact of TOD on the behavioral and electrophysiological correlates of inhibition in 54 individuals with aMCI and 52 healthy controls (HCs), all of morning chronotype. Methods: Participants were randomly assigned to complete two inhibition tasks (Go-NoGo and Flanker) during their optimal (morning) or non-optimal (evening) TOD, while electroencephalography was recorded. Results: Both tasks elicited changes in N2 and P3 event-related potential (ERP) components, which commonly index inhibitory functioning. Analyses showed that the Go-NoGo difference in P3 amplitude was reduced in individuals with aMCI relative to HCs. Compared to HCs, the Flanker difference in P3 amplitude was also reduced and coincided with more errors in the aMCI group. Notably, these behavioral and ERP differences were exaggerated in the non-optimal TOD relative to the optimal TOD. Conclusion: Findings confirm the presence of inhibition deficits in aMCI and provide novel evidence of sundowning effects on inhibitory control in aMCI. Results reinforce the need to consider the influences of TOD in clinical assessments involving individuals with aMCI.

Funder: NIHR Newcastle Biomedical Research Centre; Id: http://dx.doi.org/10.13039/501100012295, Funder: Parkinson's UK; Id: http://dx.doi.org/10.13039/501100000304, Funder: UK National Health Service (NHS), Funder: NIHR East of England Applied Research Centre, BACKGROUND: Delirium is an acute onset and fluctuating impairment of cognition, attention and arousal, often precipitated by acute illness. Lewy body disease (LBD) is an umbrella term for a range of clinical conditions, including Parkinson's disease dementia (PDD) and dementia with Lewy bodies (DLB). People living with LBD seem to be more susceptible to delirium than those with other subtypes of dementia. AIM: To describe the challenges in clinical diagnosis and management of LBD. METHODS: A systematic review of published literature on diagnosis and management of delirium in LBD. RESULTS: Delirium is particularly challenging to diagnose in LBD as many of the clinical characteristics which define delirium such as inattention, fluctuating arousal, complex visual hallucinations and delusions, are also common to LBD. Distinguishing delirium from LBD can be very difficult clinically especially in the prodromal stages. Both under and over diagnosis of delirium, and under and over treatment of the symptoms have the potential to compromise the care and safety of people with a diagnosed or undiagnosed LBD. Clinicians are currently working with an extremely limited set of evidence-based management options for those with delirium in the context of a LBD diagnosis. For patients with LBD and their families this is an area of clinical practice that needs focused research.

Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.

We conducted an updated, comprehensive, and contemporary systematic review to examine the efficacy of existing pharmacologic agents employed for management of delirium symptoms among hospitalized adults.Searches of PubMed, Scopus, Embase, and Cochrane Library databases from inception to May 2021 were performed to identify studies investigating efficacy of pharmacologic agents for management of delirium.Of 11,424 articles obtained from searches, a total of 33 articles (N = 3030 participants) of randomized or non-randomized trials, in which pharmacologic treatment was compared to active comparator, placebo, or no treatment, met all criteria and were included in this review. Medications used for management of delirium symptoms included antipsychotic medications (N = 27), alpha-2 agonists (N = 5), benzodiazepines (N = 2), antidepressants (n = 1), acetylcholinesterase inhibitors (N = 2), melatonin (N = 2), opioids (N = 1), and antiemetics (N = 2). Despite somewhat mixed findings and a relative lack of high-quality trials, it appears that antipsychotic medications (e.g., haloperidol, olanzapine, risperidone, or quetiapine) and dexmedetomidine have the potential to improve delirium outcomes.Pharmacologic agents can reduce delirium symptoms (e.g., agitation) in some hospitalized patients. Additional double-blinded, randomized, placebo-controlled clinical trials are critically needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations (e.g., post-surgical patients, patients at the end-of-life, or in intensive care units).

To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD).A single-center retrospective observational study.University teaching hospital.A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB).The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD:60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]),65 mmHg (OR = 1.72 [1.01-2.92]),70 mmHg (OR = 1.83 [1.03-3.26]), and75 mmHg (OR = 1.94 [1.02-3.69]).A longer cumulative duration of IOH with the threshold between60 and75 mmHg that occurred after CPB was independently associated with the risk of POD.

Background This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. Methods Drawing from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42,932 records for elective, urgent, and emergency cardiac surgery procedures between July 1, 2017, to December 31, 2019. Using propensity score weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes (stroke, encephalopathy, coma, and operative mortality). Results The rate of pEEG use during anesthesia use was 32.8% (n=14,086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95%CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95%CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95%CI, 0.97-1.42) or coma (OR, 1.44; 95%CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95%CI, 1.05-1.44). This association remained significant after adjusting for POD (OR: 1.21, 95%CI: 1.03-1.41), stroke (OR: 1.21, 95%CI:1.04-1.42), and encephalopathy (OR: 1.28, 95%CI: 1.07-1.52). Conclusions This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.

Post-operative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass.This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient POD. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, nonhome discharge, readmission, 30-day amputation, post-operative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival.Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (P 0.05). On multivariable analysis, independent predictors of POD were age 60-89 years old, chronic limb threatening ischemia, female sex, and nonelective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17 days vs. 9 days; P 0.001). POD was associated with increased non-home discharge (61.8% vs. 22.1%; P 0.001), 30-day major amputation (6.7% vs. 1.6%; P 0.01), 30-day postoperative myocardial infarction (11.4% vs. 4.1%; P 0.01), and 90-day mortality (7.6% vs. 2.9%; P = 0.03). Survival at 2 years was lower in those with delirium (89% vs. 75%; P 0.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR = 2.0; 95% CI = 1.15-3.38; P = 0.014) and decreased major-amputation free survival (HR = 1.9; 95% CI = 1.18-2.96; P = 0.007).POD is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, nonhome discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.

The purpose of this study was to evaluate whether the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8 are associated with the occurrence of postoperative delirium after major urological cancer surgery.We retrospectively analyzed a total of 415 consecutive patients who underwent major urologic cancer surgery and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and July 2021. For both the G8 and the IADL-modified G8, a cut-off value of 14 was used. All patients underwent perioperative management according to the Enhanced Recovery After Surgery protocol formulated at our institution. Delirium was diagnosed using the Confusion Assessment Method. The relationship between these screening tests and clinical variables was examined. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). To determine the risk factors for the occurrence of postoperative delirium, univariate and multivariate analyses were performed.Of the 415 patients, 160 (39%) were assigned to the low G8 (score ≤ 14) group and 166 (40%) to the low IADL-modified G8 (score ≤ 14) group. The median age of the patients was 72 years. Postoperative delirium occurred in 31 patients (7%). The AUC values for predicting postoperative delirium were 0.69 for the G8 and 0.71 for the IADL-modified G8. Multivariate analysis for the G8 showed that G8 ≤ 14 (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.2-6.0; P = 0.02), preoperative use of benzodiazepine (OR = 3.8; 95% CI = 1.6-8.6; P = 0.002), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5-7.1; P = 0.003) were independent risk factors for postoperative delirium. Similarly, for the IADL-modified G8, IADL-modified G8 ≤ 14 (OR = 2.6; 95% CI = 1.1-5.8; P = 0.02), preoperative use of benzodiazepine (OR = 3.9; 95% CI = 1.7-8.8; P = 0.001), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5-7.2; P = 0.003) were independent risk factors for postoperative delirium.The G8 and the IADL-modified G8 screening may allow for better identification of patients at risk of postoperative delirium.

Evidence of symptom control outcomes in severe COVID is scant.To determine changes in symptoms among people severely ill or dying with COVID supported by palliative care, and associations with treatments and survival.Multicentre cohort study of people with COVID across England and Wales supported by palliative care services, during the pandemic in 2020 and 2021. We analysed clinical, demographic and survival data, symptom severity at baseline (referral to palliative care, first COVID assessment) and at three follow-up assessments using the Integrated Palliative care Outcome Scale - COVID version.We included 572 patients from 25 services, mostly hospital support teams; 496 (87%) were newly referred to palliative care with COVID, 75 (13%) were already supported by palliative care when they contracted COVID. At baseline, patients had a mean of 2.4 co-morbidities, mean age 77 years, a mean of five symptoms, and were often bedfast or semiconscious. The most prevalent symptoms were: breathlessness, weakness/lack of energy, drowsiness, anxiety, agitation, confusion/delirium, and pain. Median time in palliative care was 46 hours; 77% of patients died. During palliative care, breathlessness, agitation, anxiety, delirium, cough, fever, pain, sore/dry mouth and nausea improved; drowsiness became worse. Common treatments were low dose morphine and midazolam. Having moderate to severe breathlessness, agitation and multimorbidity were associated with shorter survival.Symptoms of COVID quickly improved during palliative care. Breathlessness, agitation and multimorbidity could be used as triggers for timelier referral, and symptom guidance for wider specialities should build on treatments identified in this study.

Delirium and dementia are common causes of cognitive impairment among older adults, which often coexist. Delirium is associated with poor clinical outcomes, and is more frequent and more severe in patients with dementia. Identifying delirium in the presence of dementia, also described as delirium superimposed on dementia (DSD), is particularly challenging, as symptoms of delirium such as inattention, cognitive dysfunction, and altered level of consciousness, are also features of dementia. Because DSD is associated with poorer clinical outcomes than dementia alone, detecting delirium is important for reducing morbidity and mortality in this population. We review a number of delirium screening instruments that have shown promise for use in DSD, including the 4-DSD, combined Six Item Cognitive Impairment Test (6-CIT) and 4 'A's Test (4AT), Confusion Assessment Method (CAM), and the combined UB2 and 3D-CAM (UB-CAM). Each has advantages and disadvantages. We then describe the operationalization of a CAM-based approach in a current ECT in dementia project as an example of modifying an existing instrument for patients with moderate to severe dementia. Ultimately, any instrument modified will need to be validated against a standard clinical reference, in order to fully establish its sensitivity and specificity in the moderate to severe dementia population. Future work is greatly needed to advance the challenging area of accurate identification of delirium in moderate or severe dementia.

Guidelines have recommended the use of dexmedetomidine or propofol for sedation after cardiac surgery, and propofol monotherapy for other patients. Further outcome data are required for these drugs.This systematic review and meta-analysis was prospectively registered on PROSPERO. The primary outcome was ICU length of stay. Secondary outcomes included duration of mechanical ventilation, ICU delirium, all-cause mortality, and haemodynamic effects. Intensive care patients were analysed separately as cardiac surgical, medical/noncardiac surgical, those with sepsis, and patients in neurocritical care. Subgroup analyses based on age and dosage were conducted.Forty-one trials (N=3948) were included. Dexmedetomidine did not significantly affect ICU length of stay across any ICU patient subtype when compared with propofol, but it reduced the duration of mechanical ventilation (mean difference -0.67 h; 95% confidence interval: -1.31 to -0.03 h; P=0.041; low certainty) and the risk of ICU delirium (risk ratio 0.49; 95% confidence interval: 0.29-0.87; P=0.019; high certainty) across cardiac surgical patients. Dexmedetomidine was also associated with a greater risk of bradycardia across a variety of ICU patients. Subgroup analyses revealed that age might affect the incidence of haemodynamic side-effects and mortality among cardiac surgical and medical/other surgical patients.Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.

Nonconventional clinical presentations of diseases are common in older adults. Even dramatic events, such as foreign body (FB) inhalation, can occur in a subtle and non-specific manner. Pill aspiration is a rare yet overlooked cause of airway injury. It accounts for approximately 7% of all FB aspirations. In contrast, oral dysphagia and polypharmacology, mainly administrated in solid oral dosage forms (SDOF), like tablets and pills, are common conditions in older adults. Herein, we present a case of SDOF aspiration in a 78-year-old man. FB inhalation developed with general clinical deterioration and neurological impairment (delirium) rather than overt respiratory symptoms. Bronchoscopy provided remarkable images of this unexpected finding. Caregivers and healthcare workers must be aware of the risk of SDOF aspiration and adopt proper safety measures. Early recognition and bronchoscopy for diagnostic and therapeutic purposes can be lifesaving in such cases.

A computerized tool and interdisciplinary care were implemented to develop a novel model for older patients with delirium in the emergency department (ED).We developed a computerized tool using a delirium triage screen and brief confusion assessment in the hospital information system, performed education for the healthcare providers, and developed a continuous care protocol. Comparisons for outcomes between pre- and post-intervention periods were performed.Compared with the pre-intervention period, patients in the post-intervention period had shorter hospitalization stay, lower expenditure of hospitalization, more likely to return home, lower ED revisits of ≤ 3 days, re-hospitalization of ≤ 14 days, and mortality of ≤ 1 month. All mentioned differences were not statistically significant.A novel model was successfully developed for delirium management in older patients in the ED. Outcome differences were not significant; however, the result is promising, which gives us an important reference in the future.

Background: Single-occupancy patient rooms in hospitals have become popular because of the privacy they offer. A downside, however, is the lack of social control from other patients, which might increase the risk of falls and undetected delirium. Aim: To study whether the incidence of falls in single-occupancy patient rooms differs from that in multibedded patient rooms. Secondary aims were to establish differences in the context of falls and differences in delirium incidence. Methods: An uncontrolled observational before-after study was performed during 16 months before and 16 after moving to a hospital with 100% single-occupancy patient rooms. Fall data were retrieved from the hospital incident reporting system. The Delirium Observation Screening Scale (DOSS) was retrieved from the hospital electronic patient data system. Main outcomes were the number of falls per 1,000 patient days, assessed with a Poisson regression analysis, and delirium incidence in fallers. Results: The incidence of falls was not significantly different between the before period (1.39 falls/1,000 patient days) and the after period (1.38 falls/1,000 patient days; p = .924). In the after period, falls in the bathroom were significantly more frequent than in the before period, respectively, 17.2% and 9.4% ( p = .003). In both periods, one quarter of the patients who fell had been assessed for delirium. In the before period, 57/73 (78%) of those were suspected for delirium (DOSS ≥ 3) versus 37/55 (67%) in the after period ( p = .225). Conclusions: In this study, we observed no change in incidence of falls after moving to a hospital with 100% single-occupancy bed rooms.

Dialysis central venous catheters (DCs) are used for various blood purification therapies. Accidental removal of a DC is a potentially life-threatening event. However, the risk factors associated with accidental removal have rarely been discussed in the literature.We performed a 5 year retrospective, single-center, cohort study of patients who were admitted to the ward other than intensive care units and were inserted DCs. We compared patient characteristics between patients who used DCs with and without a history of accidental removal.There were 17 cases of accidental removal (3.5%) out of 489 DC insertions during the observation period. There was no significant difference between patients with and without accidental removal in terms of age, sex, reason for DC insertion, catheter type, or insertion site. The presence of dementia was 35 and 11% (p = 0.006), and that of delirium was 88 and 13% (p 0.0001) in those with and without accidental removal, respectively. The median days from insertion to accidental removal were 5 (range 0-21) days, and removal occurred mainly at night (71%). One patient with accidental removal developed hemorrhagic shock, but there no deaths occurred due to accidental removal.The present findings suggest that to prevent accidental removal, sufficient attention should be paid to delirium that occurs after admission as well to pre-existing dementia at the time of admission. As accidental removal occurs most commonly early after insertion and at night, special attention should be paid during these periods.

A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS).A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021.Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition.Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

Objectives Cure for severe depression in elderly patients with psychotic symptoms should consider not only the results of major depression but also the nature of antidepressants and their side effects. Psychiatric disability is higher in patients who have greater deterioration in neurological function. Methods In addition to reviewing antidepressant discontinuation syndrome and depressive disorder, this study describes an elderly woman with mild depression that developed into major depression, related to high suspicion of delirium, diagnosed based on patient history, physical health examination, neurological examinations, family history, and laboratory data, with subsequent treatment plan. Results The treatment results and prognosis indicate that patients with paroxetine antidepressant deactivation may enable early use of low-dose quetiapine with less anticholinergic and extrapyramidal side effects for the treatment of depression in elderly patients with psychotic symptoms. The poor prognostic factors for patients were chronic environmental stress (poverty) and lack of a social support system. Although the patient lived with her children and grandchildren, she rarely received care. Hence, it was not possible to monitor her condition and medication intake. Conclusions The consensus is that the abrupt discontinuation of short half-life selective serotonin reuptake inhibitors (SSRIs), such as paroxetine can be associated with transient symptomatology, much of which is of a serotonergic nature. Psychotic-like symptoms have also been reported in both controlled trials and large patient databases.

Postoperative delirium incidences are increasing in older adults. A Cochrane Review found no significant difference in the incidence of postoperative delirium between total intravenous anesthesia (TIVA) and inhalational anesthesia (IA). This study evaluated the differences in postoperative delirium and morbidity between patients who underwent either TIVA or IA.A nationwide Japanese inpatient database was used to retrospectively compare differences in postoperative delirium and composite morbidity between patients older than 65 years, who underwent general anesthesia (TIVA or IA). The primary outcome was postoperative delirium. The secondary outcomes were: morbidity incidence, length of hospital stay, and mortality. A 1:3 propensity score analysis of patients who underwent all surgical procedures was conducted according to covariates, to calculate odds ratios and their 95% confidence intervals (CIs). Sensitivity analyses were conducted using an instrumental variable analysis of the proportion of TIVA by hospital scale, stabilized inverse probability of treatment weighting analyses, limiting the definitions of postoperative delirium, and subgroup analysis.Of 738,600 patients, 149,540 received TIVA and 589,060 received IA. After 1:3 propensity score matching, the adjusted odds ratios for postoperative delirium and composite morbidity were 0.93 (95% CI 0.91-0.95) and 0.94 (95% CI 0.90-0.97), respectively, for TIVA concerning IA. There were no differences in the length of the intensive care unit and hospital stay, or hospital mortality. The findings were consistent with the sensitivity analyses.This study demonstrated that TIVA was related to a slightly decreased postoperative delirium and incidence of morbidity compared to IA.

BACKGROUND: Elderly patients undergoing vascular surgery are at a risk of developing postoperative delirium, which is associated with high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS: This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery,' 'prevention,' and 'delirium' and was last run on October 21, 2021 in the electronic databases PubMed, MEDLINE, Embase, Web of Science, the Cochrane library, and Emcare. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS: Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group vs. 11% in the intervention group, P = 0.018) and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group vs. 8.2% in the intervention group, P = 0.043, Odds Ratio = 0.56). A nonsignificant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group vs. 14.6% in the intervention group, P = 0.17). The study concerning the impact of the type of anesthesia on delirium in 11 older vascular surgical patients, of which 3 developed delirium, did not differentiate between the different types of anesthesia the patients received. CONCLUSIONS: Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients. ispartof: ANNALS OF VASCULAR SURGERY vol:85 pages:433-443 ispartof: location:Netherlands status: published

BACKGROUND: Chronic limb-threatening ischemia (CLTI) has a high mortality and amputation risk even after revascularization. Owing to an aging population the incidence of peripheral arterial disease is rising. However, the current age distribution in patients with CLTI and the impact of age on outcomes remains unclear. For this reason we performed an age-dependent analysis of mortality, morbidity, and amputation-free survival after open surgical revascularization (OSR) and endovascular revascularization therapy (ERT) with identification of risk factors for mortality. Standardized mortality ratios (SMR) were calculated, comparing observed deaths in the study population to expected deaths based on age and gender specific mortality rates of the overall Dutch population. METHODS: Patients revascularized for the first episode of CLTI between 2013 and 2018 were included in this multicenter retrospective cohort study. The cohort was divided into 2 treatment groups (OSR and ERT) who were each stratified in 3 age groups: early age group < 65 years (G1), middle age group 65-74 years (G2), and elderly age group ≥ 75 years (G3). RESULTS: During the study period 274 limbs (43.9%) were treated with OSR and 350 limbs (56.1%) with ERT. The young population (G1) is only a small part of the whole CLTI population, namely for OSR 22% and ERT 18%. The risk profile of the early age group was characterized by male gender and smoking, whereas the elderly age group was characterized by poor arterial runoff, tissue loss, hypertension, hypercholesterolemia, chronic kidney disease, history of heart disease, chronic obstructive pulmonary disease, and cerebrovascular disease. One year amputation rates were similar between the age groups. However, significantly higher one-year mortality rates were observed in patients ≥ 75 years in comparison to the low mortality rates in patients < 75 years (OSR: G3 19.8% vs. G2 7.1% and G1 6.7%, P = 0.006; ERT: G3 30.7% vs. G2 12.7% and G1 7.8%, P = 0.001). The SMR in this elderly group equaled 3.72 after OSR and 4.04 after ERT. Independent risk factors for mortality after OSR were age, hazard ratio (HR) 1.03 (95% confidence interval [CI] 1.01-1.06; P = 0.006), preoperative hemoglobin level (HR 0.79; 95% CI 0.67-0.92; P = 0.003), tissue loss (HR 1.85; 95% CI 1.22-2.79; P = 0.004), cardiac history (HR 1.56; 95% CI 1.06-2.30; P = 0.024), and development of postoperative delirium (HR 2.75; 95% CI 1.61-4.71; P < 0.001). After ERT we identified age, HR 1.06 (95% CI 1.04-1.08; P < 0.001); preoperative hemoglobin level, HR 0.75 (95% CI 0.65-0.87; P < 0.001); tissue loss, HR 1.71 (95% CI 1.15-2.53; P = 0.008); history of chronic obstructive pulmonary disease, HR 1.99 (95% CI 1.43-1.79; P < 0.001); history of cerebrovascular accident (CVA), HR 1.55 (95% CI 1.09-2.21; P = 0.015); the development of postoperative pneumonia, HR 2.27 (95% CI 1.24-4.16; P = 0.008); postoperative acute kidney injury (AKI), HR 2.42 (95% CI 1.29-4.54; P = 0.006); and postoperative CVA, HR 8.17 (95% CI 1.96-34.15; P = 0.004) as risk factors. CONCLUSIONS: The current CLTI population consists mostly of elderly patients and only a small part is younger than 65 years. This shift in the population is important because increasing age is associated with considerable higher one-year mortality rates regardless of the method of revascularization in patients with CLTI. The mortality rates in the elderly group are 3 to 4 times larger than expected in the general population. In relation to the high mortality of the elderly patient, we assume that interventions to prevent postoperative delirium and correct preoperative anemia may be warranted as they appear to be independent risk factors for mortality. ispartof: ANNALS OF VASCULAR SURGERY vol:85 pages:133-145 ispartof: location:Netherlands status: published

Acute porphyrias are rarely reported in Southeast Asia. They may be underdiagnosed due to their clinical mimicry and lack of awareness among physicians. There is a common cognitive bias to gravitate towards common conditions. In this case report, a 28-year-old woman, who presented with seizures, rhabdomyolysis hyponatraemia and altered mental state, was initially diagnosed as amphetamine overdose. She had presented 3 days prior with abdominal pain, treated for acute cystitis and discharged. On readmission for seizures a day later, she was extensively worked up for altered mental state. Despite normalisation of serum sodium concentration and control of her seizures, she remained unwell. Further investigations later confirmed a diagnosis of acute porphyria. The aim of this case report is to highlight the non-specific nature of presentation of acute porphyria and the importance of considering it as a differential diagnosis in cases of abdominal pain with neuropsychiatric features.

Postoperative delirium (POD) is a common neurocognitive syndrome seen in older patients after major surgery. POD is linked to longer stays in hospital and intensive care, a greater incidence of postoperative complications, worse functional outcome, and higher mortality. Researchers have not yet fully elucidated the exact pathophysiology of POD. Several risk factors that contribute to the development of POD have been identified, such as advanced age, cardiac or hip surgery, preoperative cognitive decline or delirium, disturbances in brain levels of neurotransmitters and information processing, oxidative stress and neuro-inflammation. Identifying patients at risk for POD enables a more precise and efficient allocation of medical resources and facilitates POD prevention and management. The present review addresses how to identify patients at risk of POD and summarizes the currently available evidence and best-practice recommendations for peri-operative manage- ment and prevention of POD. ispartof: European journal of anaesthesiology and intensive care vol:2 issue:3 status: Published online

Aim: In this study, it was aimed to contribute to evidence-based nursing interventions by examining the non-pharmacological nursing approaches used in delirium management in postgraduate theses published in the field of national and international nursing. Method: The theses published between January 1, 2016 and July 11, 2021 were scanned from the national thesis center (YÖK thesis center) of the Higher Education Council in the national field, and from the Proquest (Dissertations & Theses Global‎) database in the international field. Keywords in Turkish were delirium, non-pharmacological interventions, prevention and nursing care, while they were delirium, non-pharmacological interventions, prevention and nursing care in English. The PRISMA 2020 Checklist was used to evaluate the reporting features. Keywords were found in the titles of 2801 graduate theses, 2456 in Proquest and 345 in YÖK thesis center. As a result, after the selections made according to the title, abstract and full text, 10 theses were decided. Results: 70% (n=7) of the postgraduate theses were doctoral theses and 30% (n=3) were master's theses. 85.7% (n=6) of doctoral theses belonged to international literature and 14.3% (n=1) to national literature. 66.7% (n=2) of the master's theses belonged to the national literature, and 33.3% (n=1) to the international literature. In a master's thesis, it was revealed that delirium can be prevented by environmental organisation. In an international master's thesis, there were findings that the use of a sleep hygiene checklist will reduce delirium. As a result of the training given to nurses about delirium identification tools in doctoral theses, data were obtained about the decrease in the incidence of patient delirium. Conclusion: It is predicted that national and international postgraduate theses will provide evidence-level information to non-pharmacological nursing interventions in delirium management and create a database for future research on this subject, Amaç: Bu çalışmada, ulusal ve uluslararası hemşirelik alanında yayımlanan lisansüstü tezlerde, deliryum yönetiminde kullanılan farmakolojik olmayan hemşirelik yaklaşımlarının incelenerek kanıt temelli hemşirelik girişimlerine katkı sağlaması amaçlanmıştır. Yöntem: Ulusal alandaki incelemelerde Yüksek Öğretim Kurulu (YÖK) Başkanlığı ulusal tez merkezi (YÖK tez merkezi) ve uluslararası alandakinde Proquest (Dissertations & Theses Global‎) veri tabanından 1 Ocak 2016- 11 Temmuz 2021 tarihleri arasında yayınlanan tezler taranmıştır. Taramalar Türkçe’de; deliryum, farmakolojik olmayan girişimler, önleme ve hemşirelik bakımı, İngilizce’de; delirium, non-pharmacological interventions, prevention ve nursing care kelimeleriyle gerçekleştirilmiştir. Raporlama özelliklerinin değerlendirilmesinde PRISMA 2020 Kontrol Listesi kullanılmıştır. Proquest’te 2456, YÖK tez merkezinde 345 olmak üzere toplam 2801 lisansüstü tezin başlığında anahtar kelimelerin geçtiği görülmüştür. Sonuç olarak, başlık, özet ve tam metine göre yapılan seçimlerden sonra 10 tez üzerinde karar verilmiştir. Bulgular: Lisansüstü tezlerin %70’i (n=7) doktora, %30’u (n=3) yüksek lisans tezidir. Doktora tezlerinin %85.7’si (n=6) uluslararası, %14.3’ü (n=1) ulusal literatüre aittir. Yüksek lisans tezlerinin %66.7’si (n=2) ulusal, %33.3’ü (n=1) uluslararası literatüre aittir. Bir yüksek lisans tezinde çevre düzenlemesi ile deliryumun önlenebileceği ortaya konmuştur. Uluslararası bir yüksek lisans tezinde uyku hijyeni kontrol listesinin kullanılmasının deliryumu azaltacağına yönelik bulgular mevcuttur. Doktora tezlerinde deliryum tanımlama araçları ile ilgili hemşirelere verilen eğitimler sonucunda hasta deliryum insidansında azalma yaşandığına dair verilere ulaşılmıştır. Sonuç: Ulusal ve uluslararası lisansüstü tezlerde deliryum yönetiminde farmakolojik olmayan hemşirelik girişimlerine kanıt düzeyinde bilgi sağlayacağı ve bu konudaki yapılacak ilerideki araştırmalara veri tabanı oluşturacağı öngörülmektedir.

Background and ObjectivesNeurologic complications have been associated with COVID-19, including delirium. Such complications have been reported to be frequent among intensive care unit (ICU)-admitted patients. We hypothesized that the rate of neurologic complications would be higher in COVID-19 associated acute respiratory distress syndrome (ARDS) than those who develop ARDS from a different cause.MethodsWe conducted a retrospective cohort study in the adult ICU of Lausanne University Hospital, including all consecutive patients fulfilling the Berlin criteria for ARDS hospitalized between December 2017 and June 2021, stratifying exposure between COVID-19 or not. The primary outcome was delirium onset during ICU stay, defined by the confusion assessment method (CAM-ICU). Exploratory outcomes included development of neurologic complications of the central nervous system (stroke, hemorrhage, and vasculitis), critical illness weakness, and 30- and 180-day all-cause mortality.ResultsThree hundred eleven patients were included in the study (253 with COVID-19 and 58 with other causes) and CAM-ICU could be assessed in 231 (74.3% in COVID-19 vs 74.1% in non-COVID-19). The proportion of patients developing delirium was similar in patients with COVID-19 and controls in univariate comparison (69.1% vs 60.5%,p= 0.246). Yet, patients with COVID-19 had a higher body mass index, lower ICU severity, longer mechanical ventilation, and higher sedation doses (propofol and dexmedetomidine). After adjusting for these factors in a multivariable analysis, the risk of delirium remained comparable across groups (adjusted OR [95% CI]: 0.86 [0.35–2.1]). Similarly, COVID-19–related ARDS had no effect on all-cause mortality at 30 days (adjusted OR: 0.87 [0.39–1.92]) and 180 days (adjusted OR: 0.67 [0.33–1.35]). Finally, neurologic complications affecting the CNS (adjusted OR: 1.15 [0.25–5.29]) and critical illness weakness (adjusted OR: 2.99 [0.97–9.1]) were not higher in the COVID-19 group.DiscussionCompared with other etiologies, patients with COVID-19 did not have higher incidence of delirium and other neurologic complications, after accounting for underlying disease severity in patients with ARDS. Management of COVID-19–associated ARDS needed longer invasive ventilation and higher sedation, which could explain higher rates of delirium in uncontrolled studies.

Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium.Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels.A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/212) patients received PP. Mechanical ventilation (OR 3.81 [1.16-12.52]) and PP (OR 7.38 [2.4-22.68]) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP.PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium.PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.

Objective This study evaluated the effectiveness of a multidisciplinary team deprescribing intervention to reduce polypharmacy and potentially inappropriate medications (PIMs) in elderly orthopedic inpatients. Methods In this single-center retrospective observational study, orthopedic inpatients ≥75 years old and prescribed ≥6 different medications were enrolled as participants. Interventions comprised multidisciplinary team-led polypharmacy screening and suggestions regarding deprescribing any unnecessary medications during hospital stays. The primary outcome was reduction in the mean number of regular medicines and PIMs. Secondary outcomes included falls, delirium, and other adverse events during hospitalization as well as emergency department visits or unplanned hospital admissions within six months after discharge. Results After propensity score matching, 184 patients (intervention group, n=92; control group, n=92) were included in the analysis. The mean patient age was 83 years old. The mean number of prescribed medications and PIMs at admission were similar in both groups. The mean change in the number of regular medicines was -1.4 [standard deviation (SD), 2.3] in the intervention group and +0.2 (SD, 1.8) in the control group (p0.001). The mean change in the number of PIMs was -0.5 (SD, 0.9) in the intervention group and +0.1 (SD, 0.8) in the control group (p0.001). In-hospital adverse events other than falls and delirium were significantly less common in the deprescribing intervention group than in the control group. Conclusion Deprescribing intervention by our multidisciplinary team seems to have been effective in reducing the number of prescribed medicines and PIMs in elderly orthopedic inpatients, with some accompanying reduction in certain adverse events.

Objective. This study’s objective is to establish a nurse-led pain management model for neurointensive care based on the Precede-Proceed model to provide a theoretical basis for clinical pain management in neurointensive care. Methods. ICU nurses were randomly divided into a control group (giving conventional routine pain care) and an experimental group (managed pain based on the Precede-Proceed model). The nurses from the experimental group were trained in the Precede-Proceed-based management. The nurses then treated a total of 410 critically ill patients, and the patients were randomly divided into a control and an intervention group (205 cases/nursing group), and the data were prospectively recorded. Before and after the intervention, the pain assessment ability, discomfort level, satisfaction degree, usage of the analgesic drug, and the incidence of delirium of the patients from the two groups were evaluated. Nurses from both groups also assessed their knowledge of pain, attitude, and pain nursing behaviors using indicated self-designed questionnaires. Results. Before the intervention, there was no statistical difference between the two groups of nurses in their baseline characteristics, pain knowledge, attitude, pain nursing behavior, and pain assessment ability for the patients. After the intervention, the nurses in the experimental group had better pain knowledge, attitude, pain nursing behavior, and pain assessment ability to patients than the nurses in the control group. Patients in the intervention group felt less discomfort, a higher satisfaction degree, reduced use of analgesics, and a lower incidence of delirium than patients in the control group. Conclusion. Pain management based on the Precede-Proceed model was beneficial in improving the care of neurointensive patients.

Transcatheter aortic valve implantation is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following transcatheter aortic valve implantation. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, post-operative delirium and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing transcatheter aortic valve implantation. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.

Case-control studies have associated delirium with blood-brain barrier (BBB) permeability. However, this approach cannot determine whether delirium is attributable to high pre-existing permeability or to perioperative changes. We tested whether perioperative changes in cerebrospinal fluid/plasma albumin ratio (CPAR) and plasma S100B were associated with delirium severity.Participants were recruited to two prospective cohort studies of non-intracranial surgery (NCT01980511, NCT03124303, and NCT02926417). Delirium severity was assessed using the Delirium Rating Scale-98. Delirium incidence was diagnosed with the 3D-Confusion Assessment Method (3D-CAM) or CAM-ICU (CAM for the ICU). CSF samples from 25 patients and plasma from 78 patients were analysed for albumin and S100B. We tested associations between change in CPAR (n=11) and S100B (n=61) and delirium, blood loss, CSF interleukin-6 (IL-6), and CSF lactate.The perioperative increase in CPAR and S100B correlated with delirium severity (CPAR ρ=0.78, P=0.01; S100B ρ=0.41, P0.001), delirium incidence (CPAR P=0.012; S100B P0.001) and CSF IL-6 (CPAR ρ=0.66 P=0.04; S100B ρ=0.75, P=0.025). Linear mixed-effect analysis also showed that decreased levels of S100B predicted recovery from delirium symptoms (P=0.001). Linear regression demonstrated that change in plasma S100B was independently associated with surgical risk, cardiovascular surgery, blood loss, and hypotension. Blood loss also correlated with CPAR (ρ=0.64, P=0.04), S100B (ρ=0.70, P0.001), CSF lactate (R=0.81, P=0.01), and peak delirium severity (ρ=0.36, P=0.01).Postoperative delirium is associated with a breakdown in the BBB. This increased permeability is dynamic and associated with a neuroinflammatory and lactate response. Strategies to mitigate blood loss may protect the BBB.

Systemic perturbations such as peripheral surgical trauma induce neurovascular, inflammatory, and cognitive changes. The blood-brain barrier is a key interface between the periphery and the central nervous system, and is critically involved in regulating neuroimmune interactions to maintain overall homeostasis. Mounting evidence suggests that blood-brain barrier dysfunction is a hallmark of ageing and multiple neurological conditions including Alzheimer's disease. We discuss a recent study published in the British Journal of Anaesthesia that describes blood-brain barrier changes and neuroinflammation in patients with postoperative delirium after non-intracranial surgery.