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Abstract Aims Many patients who are transferred to the convalescent rehabilitation ward of Kawasaki Kokoro Hospital (hereinafter, our hospital) are on psychotropics prescribed for delirium by their physicians at acute care hospitals. In this study, psychiatrists and pharmacists collaborated with rehabilitation physicians to reduce the use of psychotropics. Methods The basic information and psychotropics prescription statuses of 88 patients discharged from the convalescent rehabilitation ward of our hospital between April 1, 2021 and March 31, 2022 were derived from their medical records. Results At admission, psychotropics were prescribed to 55 patients and the number of prescribed drugs was 2 (median). At discharge, psychotropics were prescribed to 41 patients and the number of prescribed drugs was 1 (median), showing a significant decrease (p

Abstract Objective The primary aim of this study was to evaluate the influence of targeted interventions, administered through comprehensive geriatric assessments on the incidence of hospitalization‐related complications among older adults diagnosed with pulmonary diseases. Methods A retrospective analysis of medical records encompassed individuals aged 75 years and older who were admitted to a lung center during the period spanning from March to June 2023. These admissions occurred in a context where standardized geriatric management protocols were systematically implemented. This study's scope extended to assessing the prevalence of hospital‐related complications, encompassing delirium and pressure ulcers. A rigorous multivariate logistic regression analysis was conducted to discern and characterize associated factors. Results The integration of comprehensive geriatric assessment yielded a substantial reduction in in‐hospital complications among the cohort of 118 patients (mean age : 82.1 ± 5.6 years, 44.5% women). The incidence of delirium decreased from 53.3% to 21.8% [odds ratio (OR): 0.246, 95% confidence interval (CI): 0.134–0.450, p

Abstract Aim To assess the feasibility of delirium screening with the screening tool 4AT conducted by stroke unit nurses. Design Observational. Methods Patients with confirmed acute stroke admitted to the stroke unit at Bærum Hospital, Norway, from March to October 2020, were consecutively recruited. Nurses performed delirium screening using the rapid screening tool 4AT within 24 h of admission, at discharge and when delirium was suspected, and filled out a questionnaire assessing their experiences with the delirium screening. A geriatrician validated the delirium diagnosis. Results In all, 62 patients were included, mean age 73.3 years. 4AT was performed according to protocol in 49 (79.0%) and 39 (62.9%) patients at admission and discharge respectively. Lack of time (40%) was reported as the most common reason for not performing delirium screening. The nurses reported that the felt competent to carry out the 4AT screening, and did not experience it as significant extra workload. Five patients (8%) were diagnosed with delirium. Delirium screening performed by stroke unit nurses seemed feasible and the nurses experienced that 4AT was a useful tool for this purpose.

Abstract Background Postoperative delirium (POD) is an acute neurological complication in the elderly undergoing thoracic surgery and can result in serious adverse consequences. Aims This study aimed to identify the related risk factors for POD following thoracic surgery, primarily focusing on preoperative serum biomarkers, and further to establish a novel delirium index to better predict POD. Methods A total of 279 patients aged ≥60 years who underwent elective thoracic surgery from August 2021 to August 2022 were enrolled in this observational study. The platelet‐to‐white blood cell ratio (PWR) was calculated as number the of platelets divided by the number of white blood cells. POD was defined by the confusion assessment method twice daily during the postoperative first 3 days. Multivariate regression analysis was performed to identify all potential variables for POD. Moreover, a novel thoracic delirium index (TDI) was developed based on the related risk factors. The accuracy of TDI and its component factors in predicting POD was determined by the curve of receiver operating characteristic (ROC). Results In total, 25 of 279 patients developed POD (8.96%). Age, PWR, and average pain scores within the first 3 days after surgery were regarded as the independent risk factors for POD. Moreover, the ROC analysis showed the TDI, including age, PWR, and average pain scores within the first 3 days after surgery, can more accurately predict POD with the largest area under the curve of 0.790 and the optimal cutoff value of 9.072, respectively. Conclusion The TDI can scientifically and effectively predict POD to provide optimal clinical guidance for older patients after thoracic surgery.

Abstract Background and aim Delirium has been presented as the leading cause of sudden change in the mental state of patients with coronavirus disease 2019 (COVID‐19). Given that the delayed diagnosis of such a dysfunction is often associated with excess mortality, it seems essential to devote vastly more attention to this significant clinical characteristic. Materials and methods This cross‐sectional study was performed on 309 patients [viz. 259 cases hospitalized in general wards and 50 individuals admitted to the intensive care unit (ICU)]. For this purpose, a Demographic‐Clinical Information Questionnaire, the Confusion Assessment Method (CAM), the Confusion Assessment Method for the ICU (CAM‐ICU), the Richmond Agitation‐Sedation Scale (RASS) and face‐to‐face interviews were completed by a trained senior psychiatry resident. The data analysis was further done with the SPSS Statistics V22.0 software package. Results Out of 259 patients admitted to the general wards and 50 cases in the ICU due to COVID‐19, 41 (15.8%) and 11 (22%) individuals were diagnosed with delirium, respectively. As well, a significant relationship was observed between the incidence rate of delirium and age (p

Abstract Aim The aim of the study was to describe nursing teams' theoretical knowledge of delirium and their perceptions of the way in which it is handled in acute inpatient units. Design This is a descriptive cross‐sectional study using a questionnaire comprising ten questions on knowledge and seven on perception. Methods The sample consisted of 216 professionals working at a hospital complex in Madrid, Spain. Descriptive and non‐parametric bivariate analyses were performed for a p

Abstract Background Trousseau syndrome is a hypercoagulability syndrome associated with cancer. It is known that delirium occasionally occurs after the onset of Trousseau syndrome. However, there have been no detailed reports about treatment for psychiatric symptoms of delirium associated with Trousseau syndrome. Case Presentation A 61‐year‐old man with lung cancer was hospitalized due to Trousseau syndrome. Delirium occurred after hospitalization and psychiatric symptoms worsened. Although haloperidol, risperidone, and chlorpromazine were used, severe insomnia persisted. After memantine (5 mg/day) was used with perospirone, the patient's psychiatric symptoms gradually decreased; he could sleep for 4–5 h at night. Due to psychiatric improvement, he was able to return home and resume immunotherapy for lung cancer as scheduled. Conclusion We report the first case of Trousseau syndrome delirium treated by memantine used with perospirone. Although further studies are needed, memantine and perospirone might be candidates for the management of psychiatric symptoms associated with Trousseau syndrome.

Abstract Objective There is not a known elevated prevalence of delirium in older adult cancer patients. However, it is unknown if the incidence of delirium varies by cancer type among older adult patients. Therefore, this study aimed to examine the association between the incidence of delirium and cancer type among older adult patients using a Japanese hospital‐based administrative claims database. Methods A total of 76,868 patients over 65 years of age or older, first diagnosed with cancer on an initial date of hospitalization between April 2008 and December 2019, were included in this retrospective longitudinal study. Delirium was defined by the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD‐10) codes or antipsychotic medication use. Cox proportional hazard models were performed to estimate the risk of delirium incidence according to 22 cancer types during the one‐year hospitalization period. Results The incidence rates of delirium were 17.1% for men and 15.3% for women. Compared to gastric cancer, the risk of delirium was significantly higher for pancreatic cancer (HR: 1.26, 95% CI: 1.11–1.42 for men; HR: 1.27, 95% CI: 1.11–1.45 for women), leukemia (HR: 1.24, 95% CI: 1.09–1.41 for men; HR: 1.20, 95% CI: 1.03–1.41 for women), and oropharyngeal cancer (HR: 1.30, 95% CI: 1.10–1.54 for men; HR: 1.32; 95% CI: 1.02–1.72 for women) after adjusting for age, initial hospitalization year, antipsychotic medications, and surgery. Conclusions As compared to gastric cancer, patients with pancreatic cancer, leukemia, oropharyngeal cancer were found to have a higher risk of developing delirium. Our study findings suggested that the risk of delirium incidence may vary by cancer type.

Objective The low recognition rate of postoperative delirium has gradually aroused clinical attention in China. The present study was to investigate the impact of consultation‐liaison psychiatry on postoperative delirium in elderly hip fracture patients. Methods From March 2012 to September 2013, 89 patients with hip fractures hospitalized in Wuhan Mental Health Center were included in this prospective study as the consultation‐liaison group. A total of 81 patients selected from August 2010 to February 2012 were defined as the conventional group. The delirium was evaluated using the confusion assessment method (CAM) recommended by the American Psychiatric Association guidelines. Results There was no difference of sex, age, trauma, surgical methods, and anesthesia between two groups (p > 0.05). The consultation rate of consultation‐liaison group was significantly higher than that of conventional group (37.07% vs 17.28%, p 0.05). In the consultation‐liaison group, three patients (9.09%) were diagnosed with anxiety and three patients (9.09%) were diagnosed with depression, while in the conventional group, three patients (21.42%) were diagnosed with communication and one patient (7.14%) was diagnosed with depression. In addition, this study showed the incidence of delirium in consultation‐liaison group was significantly higher than that of conventional group (29.21% vs 11.11%, p

Abstract Aim To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. Design Prospective cohort study. Methods Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM‐V. We performed descriptive and logistic regression analyses. Results From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho‐geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.

Abstract Aim This study aimed to determine whether family‐centred care (FCC) intervention reduces the ICU delirium prevalence. Design A systematic review and meta‐analysis. Methods The databases, including PubMed, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL Complete, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBMdisc), WANFANG Data and VIP Information, were systematically searched up to 30 November 2021. The search term includes keywords related to intensive care units, delirium and family‐centred care. Meta‐analyses were performed and presented by risk ratio (RR), mean difference (MD) and corresponding 95% confidence intervals (CIs). Results The meta‐analysis results showed that compared with the usual care, FCC intervention has positive effects on reducing ICU delirium prevalence [RR = 0.54, 95% CIs (0.36, 0.81), p

Abstract Objective The aim of this study is to find the incidence, risks, and reasons for prolonged length of hospital stay, short, long‐term mortality, and the factors contributing to mortality of postoperative delirium in proximal femoral fractures. Methods The data for the study was obtained from National Hip Fracture Database (NHFD) and internal hospital computer systems (Medway, ICE, Clinic letters) between January 2018 and December 2019. One hundred seventy‐five patients were found have developed postoperative delirium. The outcomes measured were postoperative anemia, lower respiratory tract infection, urinary tract infection, acute kidney injury, urinary retention, cardiac event and stroke, alcohol or drug withdrawal, length of hospital stay, and 30 day and 1 year mortality. Results The patients who developed delirium were 68 (38.9%) with American Society of Anesthesiologists (ASA) grade 4 and 94 (22.3%) without delirium (p

Abstract Aim Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF. Methods and results The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre‐existing dementia was identified based on International Classification of Diseases‐9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (−) of dementia and delirium. Relative to the dementia−/delirium− group, the dementia−/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia−/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium−/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group. Conclusions Delirium, independent of pre‐existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.

Objective To explore the effect of early intervention for perioperative delirium in older (> 60 years) hip fracture patients. Methods This prospective study enrolled hip fracture patients aged ≥60 years who were admitted into our hospital between July 2011 and August 2019. Hip fractures were classified according to the Arbeitsgemeinschaft für Osteo‐synthesefragen (AO) classification. This study included patients with isolated hip fracture and excluded patients with pathological or peri prosthetic fracture or patients with multiple traumatic injuries and high‐energy trauma. They were randomized to receive conventional orthopedic care group (n = 65) or comprehensive orthopedic care group including preoperative psychological counseling and preventative risperidone (n = 63). Daily assessment was based on patient interview with the CAM‐CR, and delirium was diagnosed by the Delirium Rating Scale (DRS‐R‐98). The rate, severity and duration of perioperative delirium and the length of postoperative stay were analyzed. Results Totally 200 patients were screened for eligibility. Twenty patients were excluded due to alcohol abuse and 40 were excluded because of brain lesions on head CT. In addition, 12 patients were excluded because of impaired cognition. Finally 128 patients were enrolled. Their mean age was 75.3 ± 2.2 years for the comprehensive orthopedic care group and 73.5 ± 6.1 years for the conventional orthopedic care group, and 53.9% of the patients were female. Sixty‐eight (53.1%) patients had intertrochanteric fracture, 39.8% patients had femoral head fracture, and 7.0% patients had subtrochanteric fracture. In addition, 58.6% patients underwent internal fixation and 41.4% patients received arthroplasty. In this study, 63 patients were randomized to the comprehensive orthopedic care group and 65 patients to the conventional orthopedic care group. The two groups were comparable in demographic and baseline characteristics (P > 0.05). The rate of perioperative delirium was significantly lower in the comprehensive care group vs the conventional care group (15.9% vs. 30.8%; P 60 years).

Abstract Objective Delirium in older emergency department (ED) adults is associated with poorer long‐term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration). Methods This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged ≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI). Results The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR, 0.39; 95% CI, 0.21–0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82–1.27). Conclusion In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.

Abstract Aim Psychiatric disturbances are the major adverse effects of corticosteroids. There are no consistent conclusions regarding changes in steroid dosage and the incidence of psychiatric conditions, due in part to the lack of consistent evaluation criteria. The purpose of this research was to determine the incidence and dose‐dependency of psychiatric conditions as assessed by trained psychiatrists. Methods A retrospective chart review was conducted at a university hospital in Japan. We identified inpatients receiving oral prednisolone treatment, who were referred to the consultation‐liaison psychiatry team from April 2015 to March 2018. Patients were divided into high‐dose (≥0.5 mg/kg/day) and low‐dose (

Background Delirium experienced poststroke is known to be associated with poor prognosis; however, the outcomes and functional consequences among patients with acute ischemic stroke (AIS) undergoing intravenous thrombolysis (intravenous tissue plasminogen activator) or intraarterial therapy are not well characterized. Methods Using data from 7 stroke centers with standardized delirium screening protocols, delirium was determined by a positive modified “Arousal, Attention, Abbreviated Mental‐Test, Acute Change Test” or Confusion Assessment Method for the Intensive Care Unit screen including diagnosis codes. Multivariable models were fit to estimate likelihoods of in‐hospital mortality, unfavorable discharge disposition, and longer length of stay among delirious patients with AIS, reported as adjusted odds ratios (aORs), adjusted incident rate ratios, and 95% CIs. A subset of patients with AIS with 90‐day modified Rankin scale (mRS) including those receiving intravenous tissue plasminogen activator or intraarterial therapy were analyzed for shifts in mRS scores associated with delirium, via ordinal logistic regression models. Results Between May 2016 and June 2021, AIS was the primary diagnosis in 12 409 hospitalization encounters representing 10 874 unique patients. Delirium was documented in 41.6% of AIS encounters, compared with 26.5% of age and mild cognitive impairment– or dementia‐matched non‐AIS encounters. Delirious (versus nondelirious) patients with AIS were older (median: 75 years versus 65 years), more frequently women (53.3% versus 48.7%), with a higher comorbidity burden (median Charlson Comorbidity Index: 7 versus 5). Delirious patients with AIS had higher odds of in‐hospital mortality (aOR, 2.66; [95% CI, 1.62–4.49]), unfavorable discharge disposition (aOR, 3.68; [95% CI, 3.15–4.30]), and longer length of stay (adjusted incidence rate ratio, 1.67; CI, 1.61–1.73). In the cohort of 2784 patients with treated and untreated AIS with 90‐day mRS, adjusted models indicated lower mRS (aOR, 0.54; CI, 0.46–0.63) associated with treatment, and higher mRS for delirious patients with AIS (aOR, 3.09; CI, 2.58–3.71). Among the subcohort of 948 patients with treated AIS, delirium remained significantly associated with higher mRS (aOR, 2.82; CI, 2.08–3.83). Conclusion Delirium is common among patients with AIS including those receiving intravenous tissue plasminogen activator or undergoing intraarterial therapy and prognosticates poor in‐hospital and 90‐day outcomes. Active screening and management of delirium may lead to improved stroke outcomes.

Abstract The patient was an 83‐year‐old male who, after being hospitalized for 70 days for suffocation due to aspiration, was provided with home medical care (HMC) as his physical condition did not allow him to climb stairs. Wernicke encephalopathy (WE) was suspected based on his disorientation and a continued loss of appetite. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after thiamine administration. In addition, he became able to use stairs. Patients who receive HMC should undergo active screening and receive treatment with WE in mind.

Background: Physical restraint of patients in intensive care units (ICUs) has an estimated prevalence of 50%. Many medical centres do not have specific protocols for physical restraint, and the decision of whether to physically restrain a patient is up to the nursing staff. Disadvantages of physical restraint include injuries, exacerbation of agitation and an increased risk of developing post-traumatic stress disorder (PTSD)., Aim: To report prevalence and outcomes in terms of morbidity and mortality of physical restraint in general ICU patients in an 800-bed secondary medical centre., Study Design: This retrospective study included 647 patients admitted to a general ICU in an 800-bed secondary medical centre in Kfar Saba, Israel, between January and December 2020. Data included demographics, medical history, length of stay, need for mechanical ventilation, number of ventilation days, 28-day mortality, reason for admission, agitation rate assessed by Richmond Agitation and Sedation Scale (RASS) score, need for physical restraint and need for anti-psychotics., Results: Among the patients, 40% (256 of 647) required physical restraint. Older adult patients had a greater likelihood of being physically restrained along with those admitted because of sepsis or acute respiratory failure. Among the study sample, 11% (71 of 647) required anti-psychotics. Patients who were restrained had longer duration of ventilation (5.9 ± 8.2 vs. 0.36 ± 1.4 days; p < .001) and higher 28-day mortality (0.26 ± 0.45 vs. 0.07 ± 0.25, Z = 6.86, p < .001). There was no difference in medical history, except for chronic drug abuse, which was more frequent in the restraint group (18 [6.9%] vs. 11 [2.8%], respectively; p = .019), as well as the use of anti-psychotic medications (24 [9.3%] vs. 19 [4.8%], respectively; p = .034) and anti-depressants (55 [21.2%] vs. 59 [14.8%], respectively; p = .042). The restraint group had higher disease severity scores, as reflected in requirements for vasopressor support (174 [67.2%] vs. 69 [17.3%], respectively; p < .001) and need for dialysis (39 [15.1%] vs. 19 [4.8%], respectively; p < .001); higher frequency of in-hospital anti-psychotic treatment (60 [23.2%] vs. 11 [2.8%], respectively; p < .001); a greater tendency for agitation events and more severe agitation scores (episodes of RASS above zero [1.7 ± 4.0 vs. 0.04 ± 0.27, respectively; p < .001] and maximum RASS score [0.19 ± 1.6 vs. 0.01 ± 0.54, respectively; p < .001]). Overall, advanced age, number of ventilation days and need for dialysis were associated with increased 28-day mortality. In the restraint group, advanced age, chronic use of diuretics and the use of dialysis during ICU admission were associated with increased mortality risk., Conclusions: Restrained patients tended to have higher morbidity and mortality during ICU and hospital stays, as well as a greater tendency for agitation events and more severe agitation scores, with an increased need for in-hospital anti-psychotic treatment. These findings regarding patient characteristics might be used to formulate treatment plans to reduce the rate of physical restraint in the ICU., Relevance to Clinical Practice: Because restrained ICU patients tend to have higher morbidity and mortality, treatment plans should be formulated to reduce the rate of physical restraint in the ICU., Clinical Trial Registration: NCT04771793., (© 2024 The Author(s). Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs., Aim: To assess the current practices of the ABCDEF care bundle as reported by ICU nurses., Study Design: A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members., Results: A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits., Conclusions: While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation., Relevance to Clinical Practice: Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs., (© 2023 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences., Aims: The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice., Study Design: A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland., Results: The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice., Conclusions: Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland., Relevance to Clinical Practice: As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines., (© 2024 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: Dysphagia, as a geriatric syndrome, is prevalent in the intensive care unit (ICU). Malnutrition resulting from swallowing disorders is likely to correlate with adverse ICU outcomes, including delirium, thereby escalating the costs of care and hospitalization. However, malnutrition has not received the attention it deserves in ICU clinical nursing practice. As two preventable and correctable conditions-malnutrition and delirium-the advantages of early identification and intervention are substantial. Exploring the relationship between malnutrition and delirium, starting from the high-risk group of elderly patients with swallowing difficulties in the ICU, will aid us in managing patients promptly and effectively., Aim: To investigate the relationship between malnutrition and the incidence of delirium in elderly patients with dysphagia in the ICU., Sudy Design: This is a retrospective study. Data for this study were obtained from the Medical Information Mart for Intensive Care-IV. All 2273 patients included were dysphagia older patients over 65 years of age admitted to the ICU, and logistic regression was used to explore the relationship between malnutrition and delirium. We also used propensity score matching (PSM) for sensitivity analysis., Results: Among the included patients with swallowing difficulties, 13% individuals (297/2273) exhibited malnutrition, with a delirium incidence rate of 55.9% (166/297). In the non-malnutrition group (1976/2273), the delirium incidence rate is 35.6% (704/1976). After adjusting for 31 covariates, multifactorial logistic regression showed that malnutrition was significantly positively associated with the incidence of delirium in elderly dysphagic patients in the ICU (adjusted odds ratio (OR) = 1.96, 95% confidence interval (CI) = 1.47-2.62). The results remained stable after analysis by PSM., Conclusion: Malnutrition was significantly positively associated with the incidence of delirium in elderly dysphagic patients in the ICU. Malnutrition should be given adequate attention in the ICU., Relevance to Clinical Practice: ICU nurses should pay particular attention to malnutrition, especially among the high-prevalence group of patients with dysphagia. Early identification and nutritional intervention for these patients may help reduce the costs of care and health care expenditures., (© 2024 British Association of Critical Care Nurses.)

Background: Delirium is a common acute mental disorder, and its adverse outcomes often cause distress to both patients and their families. Despite its prevalence in patients treated in emergency departments, delirium is frequently overlooked., Aim: This study aims to systematically evaluated and meta-analysis the prevalence of delirium among emergency patients, providing insights into its prevalence and offering guidance for its management and prevention., Study Design: Observational studies on the prevalence of delirium in emergency departments were systematically searched in PubMed, Embase, the Cochrane Library and Medline databases. Relevant English-language studies published up to 18 September 2023 were reviewed, and meta-analysis was conducted using Stata 14.0 software. Quality assessment of included literature was performed using the methodological index for non-randomized studies (MINORS), and publication bias was assessed using Egger's test., Results: Thirteen studies encompassing a total sample size of 33 839 cases were included, with 3082 cases of delirium incidents. The findings revealed a 15% prevalence rate of delirium in emergency departments, with a 95% confidence interval (CI) of (0.10, 0.20) and an overall heterogeneity of 98.37% (p = .000). Among emergency department patients over 65 years of age, the prevalence of delirium was 12%, with a 95% CI of (0.07, 0.19) and a heterogeneity of 94.59%. For patients over 18 years of age, the prevalence was 17%, with a 95% CI of (0.10, 0.25) and a heterogeneity of 98.94%., Conclusions: This meta-analysis reveals an overall 15% prevalence rate of delirium among patients in emergency departments., Relevance to Clinical Practice: In clinical practice, emergency medical staff should strengthen the screening and management of emergency delirium patients., (© 2024 British Association of Critical Care Nurses.)

Background: Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness. Delirium causes negative outcomes in patients, and patients with delirium increase the workload of nurses. Therefore, it is important to recognize the challenges and burdens experienced by nurses caring for patients with delirium., Aim: To determine the subjective burden experienced by intensive care nurses caring for patients who have undergone open-heart surgery., Study Design: A mixed-method sequential explanatory design. A non-probability purposive sampling method was used for the quantitative stage. Using OpenEpi, we employed the method of sample calculation with an unknown universe. The sample size of the quantitive study comprised 130 nurses. Quantitative data were collected with Google survey. For gathering qualitative data, online video interviews were conducted with 10 nurses, an interpretive phenomenological approach was used and content analysis was performed., Results: In the quantitative phase, we found that the subjective burden was high. In the qualitative phase, five main themes emerged: difficulty in recognizing delirium, physical burden, emotional burden, burden in care management of patients with delirium and the effect of patients with delirium on other patients. The nurses experienced physical and emotional burden in delirium management and felt lonely while caring for patients with delirium., Conclusions: Because nurses play a key role in the care of patients with delirium, reducing the burden nurses experience when caring for patients with delirium should be considered important in ensuring that this patient population receives adequate care., Relevance to Clinical Practice: Delirium patients create a care burden for intensive care nurses. To reduce this burden of care, in-service training in patient management and bedside teaching support should be provided to nurses. Furthermore, the use of a valid scale to diagnose delirium should be integrated into health policies. Nurses should not be left alone in the management of delirium. Managing delirium patients with a team including physicians, nurses and professionals from other health disciplines will ensure that patients receive high-quality care, thereby reducing the care burden of nurses., (© 2024 The Author(s). Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Abstract In hospitalized patients the prevalence of constipation is high, especially among elderly patients. Constipation impacts significantly the quality of life of patients and is associated with increased morbidity and length of hospital stay. This retrospective observational study intended to identify the prevalence of constipation in patients hospitalized in an internal medicine ward. In a sample of 80 patients, the median age was 79 years and 53% (n = 42) were women. We identified constipation in 68% (n = 56) of the patients during hospitalization. The medical team prescribed treatment only to 70% of those patients. Constipation was responsible for delirium in 11% of patients and 5% suffered urinary retention. This study shows constipation is prevalent among patients admitted in an internal medicine ward. Systematic assessment of this problem can improve the overall care of the patients, alleviate symptoms, and prevent complications.

Abstract Improved understanding of the etiologies of delirium, a common and severe neuropsychiatric syndrome, would facilitate the disease prevention and treatment. Here, the authors invesitgate the role of circadian rhythms in the pathogenesis of delirium. They observe perturbance of circadian rhythms in mouse models of delirium and disrupted clock gene expression in patients with delirium. In turn, physiological and genetic circadian disruptions sensitize mice to delirium with aggravated cognitive impairment. Likewise, global deletion of E4bp4 (E4 promoter‐binding protein), a clock gene markedly altered in delirium conditions, results in exacerbated delirium‐associated cognitive decline. Cognitive decline in delirium models is attributed to microglial activation and impaired long‐term potentiation in the hippocampus. Single‐cell RNA‐sequencing reveals microglia as the regulatory target of E4bp4. E4bp4 restrains microglial activation via inhibiting the ERK1/2 signaling pathway. Supporting this, mice lacking in microglial E4bp4 are delirious prone, whereas mice with E4bp4 specifically deleted in hippocampal CA1 neurons have a normal phenotype. Mechanistically, E4bp4 inhibits ERK1/2 signaling by trans‐repressing Mapk1/3 (genes encoding ERK1/2) via direct binding to a D‐box element in the promoter region. These findings define a causal role of clock dysfunction in delirium development and indicate E4bp4 as a regulator of cognition at the crosstalk between circadian clock and delirium.

Abstract Background Delirium incidences during hospitalization are an important problem in elderly patients. The problem of delirium episodes in patients with obstructive disease during hospitalization was investigated. Material and Methods From a total of 37,156 subjects, the following were randomly selected: 3261 patients with asthma, 4896 with chronic obstructive pulmonary disease (COPD), and 5455 without obstructive disease. Their ages ranged from 65‐95 years, and they were hospitalized between 2006 and 2015. Delirium incidences were monitored based on the International Classification of Disease (ICD)‐10 codes and medical documentation. Results The delirium episodes during all hospitalizations were independently associated with asthma (odds ratio [OR] = 2.91, confidence interval [CI] = 1.62‐5.84), with severe type of asthma (OR = 4.24, CI = 1.94‐8.93), partim controlled asthma (OR = 3.1, CI = 1.29‐8.46), and uncontrolled asthma (OR = 4.88, CI = 2.12‐9.42). It was comparable with COPD as follows: all incidences of delirium during hospitalization (OR = 3.17, CI = 1.42‐7.23) or severe COPD (III degree OR = 5.15, CI = 2.01‐13.69). Elderly patients with asthma with uncontrolled or partially controlled asthma with a coincidence of advanced age, dementia, or smoking had a greater predisposition to delirium episodes, particularly after surgery. Additionally, delirium incidence caused death more frequently in patients with asthma than in those with COPD. Conclusion Elderly patients with asthma have a higher risk of delirium episodes during any hospitalization, and, frequently, it ends in death.

Abstract Aim To determine the relationship between the delirium of patients with mechanical ventilation during intensive care unit (ICU) stay and delusional memory after ICU discharge. Design Prospective cohort study. Methods Delirium in adult patients who received mechanical ventilation for more than 24 hr was assessed twice daily using the Confusion Assessment Method for the ICU. Delusional memories were evaluated using the ICU Memory Tool 5–10 days after ICU discharge. The associations between the presence of delirium during the ICU stay and delusional memories were evaluated. Results Of 60 enrolled patients, 62% had delirium during their ICU stay, and 68% experienced delusional memories 5–10 days after discharge. Delirium during ICU stay was an independent factor to experience delusional memories following discharge. Preventing delirium during ICU stay might reduce delusional memory. We recommend that patients with delirium during their ICU stay should be carefully followed up after discharge from the ICU.

Abstract We present a hereditary coproporphyria patient with acute psychiatric symptoms and skin lesions initially misdiagnosed with schizoaffective disorder and later developed hyperactive delirium and atrial fibrillation requiring intensive care unit admission. He recovered after administering glucose infusions and the discontinuation of porphyrinogenic medications.

Abstract Aim Delirium is a serious, acute medical condition which places a heavy burden on the patient, his or her family and healthcare professionals. There have been only a limited number of studies to explore nurses' experiences of delirium and how delirium is identified in community care. The research questions of the study are as follows: “How do community care nurses' experience delirium?” and “How is delirium identified?”. Design This study has been designed as an explorative and descriptive study. Methods A topic‐based interview guide was developed containing questions associated with the Registered Nurses' experiences of their meetings with people with delirium and their identification of delirium. Results Nurses working in the community care need to know more about delirium as they play a key role in treatment. Our results also show that the participants have difficulty in establishing whether a patient is suffering from acute confusion/delirium, depression or dementia.

Abstract Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life‐threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non‐pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time‐sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non‐opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric‐specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non‐pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.

Aim There are few assessments of sedatives during the acute phase under sedation protocols for patients with sepsis. We aimed to compare the influence of different sedation strategies using midazolam and propofol under light sedation on clinical outcomes of ventilated patients with sepsis. Methods This study was a post‐hoc analysis of data from the dexmedetomidine for sepsis in the ICU Randomized Evaluation (DESIRE) trial. Patients were divided into propofol and midazolam groups based on continuously used drug, and sedation control between groups compared on day three. We assessed the incidence of delirium, length of ICU stay, number of ventilator‐free days within the first 28 days, and mortality after 28 days. Results The midazolam and propofol groups consisted of 51 and 66 patients, respectively. Both groups had similar characteristics, except for age and emergency surgery. The number of well‐controlled sedation patients in the propofol group on day three was significantly higher than that in the midazolam group (odds ratio [OR] 3.9, 95% CI [1.30, 11.7]). The incidence of daily coma and delirium within the initial week was different between groups and increased with midazolam administration (P = 0.0138). The number of Confusion Assessment Method for ICU‐positive patients was significantly higher in the midazolam group than in the propofol group (OR 5.71, 95% CI [2.30, 14.2]). Conclusion In patients with sepsis required mechanical ventilation, sedation with midazolam based on a light sedation protocol may be associated with inappropriate sedation during the acute phase, with increased coma and delirium as compared to propofol.

Abstract Delirium is a challenging neuropsychiatric ailment that has a negative impact on morbidity and mortality and is difficult to treat once it has developed. The purpose of this review was to analyze the efficacy of melatonin in the prevention of delirium in hospitalized geriatric patients in the acute medically ill and perioperative wards. The databases searched included PubMed (1946 to February 12, 2020), CINAHL (1982 to February 12, 2020), EMBASE (1974 to February 12, 2020), and Web of Science (1900 to February 12, 2020) using search terms related to melatonin, delirium, and prevention. Meta‐analyses, randomized controlled trials, and observational studies were included. We excluded publications pertaining to the intensive care unit or oncology, case reports/series, and those not in English. Seven full‐text publications were included for qualitative analysis. Patient comorbidities, patient medications, melatonin dosing, dosing regimens, and duration of treatment varied between the studies, which yielded heterogeneous results. Overall, this literature review yielded four studies that showed positive results and three that showed negative results for delirium prevention. The current data for the use of melatonin in delirium is conflicting. This area requires further research of more homogeneous studies with larger sample sizes.

Abstract Background The objective of this study was to explore the underlying etiologies associated with the resolution and improvement of delirium in ill‐hospitalized cancer patients. Methods We conducted a secondary analysis of a multicenter, prospective, observational study to estimate the effectiveness of pharmacotherapy for delirium. Participants were cancer patients with delirium. We assessed the Delirium Rating Scale, Revised‐98 (DRS‐R98) severity scale score at baseline and three days after pharmacotherapy initiation. Delirium resolution was defined as a DRS‐R98 severity scale score ≤9, and improvement was defined as ≥50% reduction at Day 3. Results We enrolled 566 patients (491 patients had performance status of 3 or 4). The resolution and improvement rates in all patients were 22.6% and 19.3%, respectively. Univariate analysis determined that nonrespiratory infection (OR 2.18, 95% CI 1.38‐3.45) was significantly associated with greater resolution, while dehydration (0.40, 0.19‐0.87), organic damage to the central nervous system (CNS) (0.32, 0.43‐0.72), hypoxia (0.25, 0.12‐0.52), and hyponatremia (0.34, 0.12‐0.97) were significantly associated with no resolution. Potential causes associated with delirium improvement were nonrespiratory infection (1.93, 1.19‐3.13), organic damage to the CNS (0.40, 0.18‐1.90), and hypoxia (0.32, 0.16‐0.65). After multivariate analysis, dehydration (0.34, 0.15‐0.76), organic damage to the CNS (0.25, 0.10‐0.60), and hypoxia (0.29, 0.14‐0.61) were significantly associated with no resolution. Conclusions Delirium caused by nonrespiratory infection may be reversible, while delirium associated with dehydration, organic damage to the CNS, hypoxia, or hyponatremia seems to be irreversible in ill‐hospitalized cancer patients.

Abstract Background Anticholinergic acting drugs have been associated with delirium in older patients. Objective To examine the association between the anticholinergic burden (ACB) and the duration and severity of delirium in older hip‐surgery patients with or without haloperidol prophylaxis. Methods Older patients with a postoperative delirium following hip surgery from a randomized controlled trial investigating the effects of haloperidol prophylaxis on delirium incidence were included in this study. The ACB was quantified using two different tools, the Anticholinergic Drug Scale and an Expert Panel. Using linear regression, the association between the ACB and delirium was analyzed. Results Overall delirium duration and severity were not significantly associated with the ACB. Also, no statistically significant differences were found in delirium duration or severity between the placebo and haloperidol treatment groups for the ACB groups. The protective effect of haloperidol on delirium duration and severity however tended to be present in patients with no or a low ACB but not or to a lesser extent in patients with an intermediate to high ACB. Conclusions The ACB was not significantly associated with delirium duration or severity. Haloperidol prophylaxis tended to shorten delirium duration and decrease delirium severity in patients with no or a low ACB. To further explore the influence of anticholinergic acting drugs on delirium duration and severity and the effect of concomitant haloperidol use, additional research with a higher haloperidol dose, a larger study population, and ACB quantification taking drug exposure into account is warranted.

Background: High cognitive load in nurses is a common problem in the intensive care unit (ICU). However, it remains unclear what different types of cognitive load the ICU nurses have experienced during the implementation of delirium interventions., Aim: To describe the characteristics and explore the effect of implementing a delirium intervention on the cognitive load of nurses working in the ICU., Methods: A cluster-randomized controlled clinical trial was conducted. Six ICUs were randomized in a 1:1 ratio, and eligible nurses from these units provided either a delirium bundle intervention in addition to usual care (27 nurses) or usual care alone. An instrument was used to measure different types of cognitive load (MDT-CL), assessing intrinsic, extraneous and germane cognitive load. The repeated measures analysis of variance was used to detect between-group differences., Results: Among these nurses, significant between-group differences were identified in terms of their overall (P < 0.001), intrinsic (P < 0.001) and extraneous (P < 0.001) cognitive load. There was no significant change observed in the germane cognitive load (P = 0.489) in the delirium intervention group., Conclusion: It is important to understand how the implementation of a delirium intervention affects different types of cognitive load in nurses, in order that tailored strategies can be applied to reduce cognitive load in ICU nurses., (© 2023 John Wiley & Sons Australia, Ltd.)

Joint models linking longitudinal biomarkers or recurrent event processes with a terminal event, for example, mortality, have been studied extensively. Motivated by studies of recurrent delirium events in patients receiving care in an intensive care unit (ICU), we devise a joint model for a recurrent event process and multiple terminal events. Being discharged alive from the ICU or experiencing mortality may be associated with a patient's hazard of delirium, violating the assumption of independent censoring. Moreover, the direction of the association between the hazards of delirium and mortality may be opposite of the direction of association between the hazards of delirium and ICU discharge. Hence treating either terminal event as independent censoring may bias inferences. We propose a competing joint model that uses a latent frailty to link a patient's recurrent and competing terminal event processes. We fit our model to data from a completed placebo-controlled clinical trial, which studied whether Haloperidol could prevent death and delirium among ICU patients. The clinical trial served as a foundation for a simulation study, in which we evaluate the properties, for example, bias and confidence interval coverage, of the competing joint model. As part of the simulation study, we demonstrate the shortcomings of using a joint model with a recurrent delirium process and a single terminal event to study delirium in the ICU. Lastly, we discuss limitations and possible extensions for the competing joint model. The competing joint model has been added to frailtypack, an R package for fitting an assortment of joint models., (© 2024 John Wiley & Sons Ltd.)

Background: The incidence of postoperative cognitive dysfunction (POCD) is notably high after cardiac surgery, ranging from 25% to 30%, and is associated with a lower quality of life, increased patient dependency, and heightened mortality. Anaesthesia during cardiothoracic surgery significantly contributes to the risk of POCD in older adults by adversely affecting the brain, including reductions in blood flow and oxygen levels., Aim: This review aimed to evaluate factors associated with anaesthesia-related postoperative cognitive dysfunction (POCD) among adults younger than 65 years who underwent cardiothoracic surgeries., Study Design: A systematic keyword search, following the scoping review framework, was performed in the PubMed and CINAHL databases. Original English-language studies that included adults younger than 65 years and addressed cognitive function after surgery along with anaesthesia management were included. Retrospective studies, animal research and in vitro and in vivo studies were excluded., Results: Twenty-three articles were included (65.2% interventional studies). All studies lacked theoretical or conceptual frameworks. Ketamine's neuroprotective potential is questionable, and intravenous lidocaine may be considered a possible early agent for preventing POCD, but long-term effectiveness is uncertain. Compared to inhalational anaesthesia, total intravenous anaesthesia (TIVA) may be related to a decreased incidence of POCD. Variation in POCD assessment impacted the lack of homogeneity in obtained data. Moreover, the shorter-term timing of POCD evaluation such as in early days after surgery could be greatly influenced by medication and delirium., Conclusion: Although strategies such as TIVA, the use of neuroprotective anaesthetics and comprehensive preoperative assessments are suggested to prevent POCD, this multifactorial phenomenon cannot be explicitly attributed solely to anaesthetics or anaesthesia-related techniques. Use of standardized, reliable and valid tools for POCD assessment is encouraged for cross-study comparison., Relevance to Clinical Practice: Nurses and certified nurse anaesthetists must be aware of risk factors for postoperative delirium and POCD so they can assess patients before and after surgery. Patients and caregivers need to be educated about cognitive changes after surgery and advised to report them to their health care provider if they occur., (© 2023 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU)., Aims: To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU., Study Design: A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method-intensive care unit (CAM-ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in-hospital mortality, 30-day and 6-month mortality, acute adverse events and length of CICU stay and hospital stay (LOS)., Results: Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p < .001) and increased in-hospital, 30-day and 6-month mortality (p < .001)., Conclusions: Delirium in ACS patients in the CICU extends hospitalization and increases in-hospital, 30-day and 6-month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high-risk population., Relevance to Clinical Practice: This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting., (© 2024 The Author(s). Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Abstract Background Violence in patients with delirium may occur suddenly and unpredictably in a fluctuating state of consciousness. Although various factors are involved, appropriate assessment and early response to factors related to violence in delirium are expected to prevent dangerous and distressing acts of violence against patients, their families and medical staff, and minimize the use of physical restraint and excessive drug sedation. Methods Subjects were 601 delirium cases referred to the department of psychiatry over the course of 5 years at a general hospital. The demographic, clinical, and pharmacological variables of patients with violence (n = 189) were compared with those of patients without violence (n = 412). Logistic regression analysis was applied to determine whether any specific individual factors were associated with violence. Results Current smoker status (p

Abstract Active surveillance and treatment of hypomagnesemia along with strict avoidance of concurrent offending agents is essential to prevent its grave clinical consequences among patients on carboplatin therapy.

Abstract Delirium is a common and deadly problem in the emergency department affecting up to 30% of older adult patients. The 2013 Geriatric Emergency Department guidelines were developed to address the unique needs of the growing older population and identified delirium as a high priority area. The emergency department (ED) environment presents unique challenges for the identification and management of delirium, including patient crowding, time pressures, competing priorities, variable patient acuity, and limitations in available patient information. Accordingly, protocols developed for inpatient units may not be appropriate for use in the ED setting. We created a Delirium Change Package and Toolkit in the Emergency Department (ED‐DEL) to provide protocols and guidance for implementing a delirium program in the ED setting. This article describes the multistep process by which the ED‐DEL program was created and the key components of the program. Our ultimate goal is to create a resource that can be disseminated widely and used to improve delirium identification, prevention, and management in older adults in the ED.

Abstract Although there have been recent reports of nonalcoholic thiamine deficiency (TD), no association has been reported between the exacerbation of the psychiatric symptoms of Alzheimer's disease patient and TD. An 89‐year‐old woman with dementia visited our hospital because of acute deterioration in behavioral and psychological symptoms of dementia (BPSD). Her medical history revealed a decrease in oral food intake lasting more than 2 weeks, so that TD was suspected and abnormal behavior improved significantly after thiamine administration. Thiamine deficiency should be suspected in patients with dementia who demonstrate acute deterioration in BPSD possibly related to poor oral food intake.

Thrombotic Thrombocytopenic Purpura (TTP) is a poorly understood entity involving multiple organs and having grave prognosis if not treated promptly. Acute pancreatitis (AP) is a rare cause of TTP and TTP is also a rare complication of acute pancreatitis. TTP is induced in AP by poorly understood mechanism, which involves multiple pathways apart from only ADAMTS13 deficiency. Here, we report a case of a 32‐year‐old male who developed acute pancreatitis due to chronic alcoholism. He developed signs of TTP from Day 4 of his onset of pain. High clinical suspicion and prompt initiation of plasmapheresis was associated with good outcome. In this case report, we have discussed details of our case and the different mechanisms involved in pathogenesis of TTP in AP and their outcome with prompt management.

Aim Pediatric delirium has been well investigated and its prevalence is reported to be from 20% to 44%. For pediatric intensive care settings, several validated assessment tools for diagnosing delirium, including the Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM‐ICU), are available in English. However, validated assessment tools for identifying pediatric delirium are unavailable in Japanese. Therefore, the aim of this study is to verify the Japanese translation of the psCAM‐ICU. Methods We enrolled patients at the Pediatric ICU at University of Tsukuba Hospital (Tsukuba, Japan) from May 2017 to February 2019. Enrollment criteria included patients aged 6 months to 5 years, and we excluded coma patients scoring under −4 on the Richmond Agitation–Sedation Scale or suffering from stroke. Pediatric patient delirium was simultaneously evaluated by three medical workers (pediatric intensivist and researchers). Psychiatrists then verified these findings against criteria of the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition. We evaluated criterion validity (sensitivity and specificity) and reliability using Cohen's κ coefficient. Results We made a total of 56 independent assessments of 19 patients (42% female) with an average age of 18 (±15) weeks. Mechanical ventilation was used at least once in 73% of patients and the positive rate of delirium was 54% in total observation. Overall, the psCAM‐ICU showed high sensitivity, specificity (sensitivity, 0.90 [95% confidence interval [CI], 0.80–0.94]; specificity, 0.93 [95% CI, 0.83–0.97]), and high reliability within the researcher assessments (κ = 0.92; 95% CI, 0.82–1.0). Conclusion We verified the psCAM‐ICU and it shows high validity and reliability.

Aim There are no definitive data to determine whether age influences the effects of dexmedetomidine (DEX) treatment. Thus, we investigated whether older age was associated with more favorable sedative action by DEX in sepsis patients who required mechanical ventilation. Methods This study involved a post‐hoc analysis of data from the Dexmedetomidine for Sepsis in the ICU Randomized Evaluation (DESIRE) trial. The patients were categorized based on median age into elderly and younger groups. The two groups were then compared during the first 7 days after ventilation based on proportion of patients with well‐controlled sedation (Richmond Agitation–Sedation Scale score between −3 and +1), days free from delirium (based on the Confusion Assessment Method for ICU), and days free from coma (Richmond Agitation–Sedation Scale score between −4 and −5). Results One hundred and one patients were assigned to the elderly group and 100 patients were assigned to the younger group. In the elderly group, 50 patients received DEX treatment and 51 patients received non‐DEX treatment, with the DEX arm having significantly better‐controlled sedation (range, 14–52% versus 16–27%; P = 0.01). In the younger group, 50 patients received DEX treatment and 50 patients received non‐DEX treatment, with no significant difference in the proportions of well‐controlled sedation (range, 20–64% versus 24–60%; P = 0.73). There were no significant differences in the numbers of days free from delirium or coma between the groups. Conclusion In elderly sepsis patients who require ventilation, dexmedetomidine could be more effective than other sedative agents for achieving proper sedation.

Abstract Introduction The interaction between delirium and dementia is complex. We examined if Alzheimer's disease (AD) biomarkers in patients without clinical dementia are associated with increased risk of postoperative delirium, and whether AD biomarkers demonstrate a graded association with delirium severity. Methods Participants (n = 59) were free of clinical dementia, age ≥70 years, and scheduled for elective total knee or hip arthroplasties. Cerebrospinal fluid (CSF) was collected at the time of induction for spinal anesthesia. CSF AD biomarkers were measured by enzyme‐linked immunosorbent assay (ELISA) (ADX/Euroimmun); cut points for amyloid, tau, and neurodegeneration (ATN) biomarker status were A = amyloid beta (Aβ)42 80 pg/mL; and N = t‐tau >700 pg/mL. Confusion Assessment Method (CAM) and CAM‐Severity (CAM‐S) were rated daily post‐operatively for delirium and delirium severity, respectively. Results Aβ42, tau, and p‐tau mean pg/mL (SD) were 361.5 (326.1), 618.3 (237.1), and 97.1 (66.1), respectively, for those with delirium, and 550.4 (291.6), 518.3 (213.5), and 54.6 (34.5), respectively, for those without delirium. Thirteen participants (22%) were ATN positive. Delirium severity by peak CAM‐S [mean difference (95% confidence interval)] was 1.48 points higher (0.29‐2.67), P = 0.02 among the ATN positive. Delirium in the ATN‐positive group trended toward but did not reach statistical significance (23% vs. 7%, p = 0.10). Peak CAM‐S [mean (SD)] in the delirium group was 7 (2.8) compared to no delirium group 2.5 (1.3), but when groups were further classified by ATN status, an incremental effect on delirium severity was observed, such that patients who were both ATN and delirium negative had the lowest mean (SD) peak CAM‐S scores of 2.5 (1.3) points, whereas those who were ATN and delirium positive had CAM‐S scores of 8.7 (2.3) points; other groups (either ATN or delirium positive) had intermediate CAM‐S scores. Discussion The presence of AD biomarkers adds important information in predicting delirium severity. Future studies are needed to confirm this relationship and to better understand the role of AD biomarkers, even in pre‐clinical phase, in delirium.