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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. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims Design Data Sources Results Conclusion Reporting Method Patient or Public Contribution Trial Registration To synthesise the evidence on and to compare the diagnostic accuracy of the Nu‐DESC and CAM in detecting postoperative delirium among hospitalised patients.Systematic review and diagnostic meta‐analysis.The PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses A&I, and PsycINFO databases were systematically searched from their inception to February 10, 2023.In total, 10 (n = 1950) and seven (n = 830) reports were included for the Nu‐DESC and CAM, respectively. For Nu‐DESC and CAM, the pooled sensitivities were 0.69 and 0.65, respectively, while the summary specificities were 0.99 for Nu‐DESC and 0.92 for CAM. The pooled specificity differed significantly between the two tools (p < 0.001), despite comparable pooled sensitivities. The duration of stay in the intensive care unit significantly moderated the summary specificity of Nu‐DESC (B = −0.0003, p = 0.009). Regarding CAM, the percentage of female participants showed a positive correlation with its pooled sensitivity (B = 0.005, p = 0.02). Furthermore, studies where clinical specialists served as assessors demonstrated a higher summary sensitivity than those assessed by nurses (0.87 vs. 0.25, p = 0.01).The sensitivities of the Nu‐DESC and CAM for detecting postoperative delirium did not achieve optimal levels. Therefore, developing more accurate tools to detect postoperative delirium by integrating features from related risk factors or incorporating technology‐based algorithms to enhance the screening capability is warranted.The study has adhered to PRISMA‐DTA guideline.No patient or public contribution.The study protocol has been registered on PROSPERO (CRD42023398961) [ABSTRACT FROM AUTHOR]

Background: This study analyzed the overall incidence of delirium, comorbid conditions, injury patterns, and pharmacological risk factors for the development of delirium in an alert, geriatric trauma population. Methods: IRB-approved, prospective, consecutive cohort series at two Southeastern Level 1 trauma centers from June 11 to August 15, 2023. Delirium was assessed using the Confusion Assessment Method (CAM) score. Comorbidities and medications were detailed from electronic medical records. Inclusion criteria: age ≥55, GCS ≥14, and ICU admission for trauma. Patients on a ventilator were excluded. Data was analyzed using SPSS version 28 (Armonk, NY: IBM Corp). Results: In total, 196 patients met inclusion criteria. Incidences of delirium for Hospital 1 (n = 103) and Hospital 2 (n = 93) were 15.5% and 12.9%, respectively, with an overall incidence of 14.3% and with no statistical differences between hospitals (P =.599). CAD, CKD, dementia, stroke history, and depression were statistically significant risk factors for developing delirium during ICU admission. Inpatient SSRI/SNRIs, epinephrine/norepinephrine, and lorazepam were significant risk factors. Injury patterns, operative intervention, and use of lidocaine infusions and gabapentin were not statistically significant in delirium development. Using binary linear regression (BLR) analysis, independent risk factors for delirium were dementia, any stage CKD, home SSRI/SRNI prescription, any spine injury and cerebrovascular disease, or injury. Discussion: Comorbidities of CAD, CHF, CKD, and depression, and these medications: home lorazepam and ICU epinephrine/norepinephrine statistically are more common in patients developing delirium. Dementia, CKD, home SSRI/SRNI and stroke/cerebrovascular disease/injury, and spine injuries are independent predictors by BLR. [ABSTRACT FROM AUTHOR]

Delirium is common, especially after neurosurgery. Dexmedetomidine might reduce delirium by improving postoperative analgesia and sleep quality. We tested the primary hypothesis that dexmedetomidine administration during intracerebral tumour resection reduces the incidence of postoperative delirium. This randomised, double-blind, placebo-controlled trial was conducted in two tertiary-care hospitals in Beijing. We randomised 260 qualifying patients to either dexmedetomidine (n =130) or placebo (n =130). Subjects assigned to dexmedetomidine were given a loading dose of 0.6 μg kg−1 followed by continuous infusion at 0.4 μg kg−1 h−1 until dural closure; subjects in the placebo group were given comparable volumes of normal saline. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method twice daily during the initial 5 postoperative days. The average (standard deviation) age of participating patients was 45 (12) yr, duration of surgery was 4.2 (1.5) h, and patients assigned to dexmedetomidine were given an average of 126 (45) μg of dexmedetomidine. There was less delirium during the initial 5 postoperative days in patients assigned to dexmedetomidine (22%, 28 of 130 patients) than in those given placebo (46%, 60 of 130 patients) with a risk ratio of 0.51 (95% confidence interval: 0.36–0.74, P <0.001). Postoperative pain scores with movement, and recovery and sleep quality were improved by dexmedetomidine (P <0.001). The incidence of safety outcomes was similar in each group. Prophylactic intraoperative dexmedetomidine infusion reduced by half the incidence of delirium during the initial 5 postoperative days in patients recovering from elective brain tumour resection. NCT04674241. [ABSTRACT FROM AUTHOR]

Aims: A computerized tool and interdisciplinary care were implemented to develop a novel model for older patients with delirium in the emergency department (ED). Methods: 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. Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Delirium is a common neurocognitive complication after cardiac surgery. The aim of this systematic review was to determine whether the administration of dexmedetomidine in the perioperative period decreases the incidence of postoperative delirium in adult patients undergoing cardiac surgery.Methods: Central, CINAHL, Ovid Embase, Ovid Medline, and Web of Science databases were searched for RCTs of adult patients undergoing cardiac surgery where participants received i.v. dexmedetomidine or control in the perioperative period. The methods included systematic review, meta-analysis, and trial sequential analysis. The primary outcome was the incidence of postoperative delirium. Dichotomous outcomes were presented as risk ratio (RR) using the Mantel-Haenszel method, and continuous variables were presented as mean difference with the inverse variance method.Results: Thirty trials, comprising 4090 patients, were included. With unselected inclusion of trials, dexmedetomidine vs control was associated with decreased incidence of postoperative delirium (12.4% vs 16.2%; RR=0.62; 95% confidence interval 0.44-0.86; P=0.005; I2=61%). If trials at high risk of bias were excluded, the incidence of postoperative delirium was not significantly different between groups (RR=0.71; 95% confidence interval 0.49-1.03; P=0.070; I2=58%). Postoperative delirium was not a reliably determined outcome across trials because of methodological and reporting limitations, including the heterogeneity of delirium diagnostic approach. Trial sequential analysis revealed that the optimal information size was not reached, and the Z-curve did not cross the trial sequential boundaries for benefit or futility. With respect to safety concerns, dexmedetomidine was not significantly associated with incident bradycardia or hypotension, or with the duration of mechanical ventilation.Conclusions: When trials at high risk of bias were excluded, the use of perioperative dexmedetomidine was not associated with decreased incidence of postoperative delirium.Prospero Registration Number: CRD 42021252779. [ABSTRACT FROM AUTHOR]

BackgroundMachine-generated indices based on quantitative electroencephalography (EEG), such as the patient state index (PSI™) and burst-suppression ratio (BSR), are increasingly being used to monitor intraoperative depth of anaesthesia in the endeavour to improve postoperative neurological outcomes, such as postoperative delirium (POD). However, the accuracy of the BSR compared with direct visualization of the EEG trace with regard to the prediction of POD has not been evaluated previously.MethodsForty-one consecutive patients undergoing non-cardiac, non-intracranial surgery with general anaesthesia wore a SedLine ® monitor during surgery and were assessed after surgery for the presence of delirium with the Confusion Assessment Method. The intraoperative EEG was scanned for absolute minutes of EEG suppression and correlated with the incidence of POD. The BSR and PSI™ were compared between patients with and without POD.ResultsVisual analysis of the EEG by neurologists and the SedLine ® -generated BSR provided a significantly different distribution of estimated minutes of EEG suppression ( P =0.037). The Sedline ® system markedly underestimated the amount of EEG suppression. The number of minutes of suppression assessed by visual analysis of the EEG was significantly associated with POD ( P =0.039), whereas the minutes based on the BSR generated by SedLine ® were not associated with POD ( P =0.275).ConclusionsOur findings suggest that SedLine ® (machine)-generated indices might underestimate the minutes of EEG suppression, thereby reducing the sensitivity for detecting patients at risk for POD. Thus, the monitoring of machine-generated BSR and PSI™ might benefit from the addition of a visual tracing of the EEG to achieve a more accurate and real-time guidance of anaesthesia depth monitoring and the ultimate goal, to reduce the risk of POD.

Introduction: Delirium is associated with an increased chance of death, prolonged hospitalisation, higher healthcare costs, and possibly long-term brain damage in survivors. Antipsychotics, both conventional and atypical, are the cornerstone of pharmacologic treatment for delirium in adults. Aim: To find out whether typical and atypical antipsychotic medication would result in a shorter duration of delirium than placebo and would improve other outcomes. Materials and Methods: This is a randomised, double-blind, placebo-controlled trial conducted on patients with delirium in Intensive Care Unit (ICU) of King George’s Medical University, Lucknow, Uttar Pradesh, India from February 2021 to February 2022. Out of 45, 15 received enteral haloperidol (maximum dose 30 mg daily), 15 received quetiapine (maximum dose 300 mg daily) and 15 were controls receiving placebo through Ryle’s tube. Delirium was detected with the use of Confusion Assessment Method for the ICU (CAM-ICU), and side-effects of the drugs were noted. Dose of a trial drug or placebo was placed halved or doubled at 12-hour intervals using these parameters. The primary end point was the number of days alive without delirium during the 14 day intervention period. Secondary end points included time to freedom from mechanical ventilation, time to ICU, hospital discharge and 30 day and 90 day survival. Results: Out of 45 patients screened, 25 were males and 20 were females with no comparable differences. The mean number of days alive without delirium or coma was 9.45 in the haloperidol group, 8.64 in the quetiapine group, and 8.57 in the placebo group (p-value=0.63) for overall effect across trial groups. The use of haloperidol or quetiapine as compared with placebo, had no significant effect on the primary end point. There were no significant between-group differences in respect to the secondary end points . Conclusion: The use of enteral haloperidol or quetiapine, as compared with placebo, did not significantly alter the duration of delirium in the critically-ill patients admitted in ICU.

Introduction: Delirium is a common neuropsychiatric condition in the general hospital population. Thus, the goal of the present study is to extend the use of diagnostic tools for delirium by developing and validating a Mandarin version of the Memorial Delirium Assessment Scale (MDAS). Methods: Participants were sampled from two general Mackay Memorial Hospital locations in Taipei and Danshui. Board‐certified psychiatrists assessed patients using the MDAS, confusion assessment method (CAM), and Mini‐Mental State Examination (MMSE). Another consultation‐liaison psychiatrist confirmed the diagnosis of delirium. We assessed the reliability and validity of the MDAS, and the receiver operating characteristic curve was used to determine the optimal cut‐off point for identifying delirium. Results: Of the 61 patients assessed, 29 were diagnosed with delirium. The mean MDAS score was 16.7 for delirium patients and 4.1 for nondelirium patients. The MDAS has good internal consistency, with a Cronbach's alpha coefficient of 0.912. Interrater reliability was 0.996 (95% confidence interval [CI]: 0.992–0.998). The diagnostic cut‐off value for the Mandarin version of the MDAS was 9, with a high sensitivity (93.1%) and specificity (96.9%). Factor analysis revealed a two‐factor structure; these factors accounted for 58.37% and 14.42% of the variance. A high correlation was found between the MDAS and the CAM scores (r = −0.849, p <.001) as well as the MMSE (r = −0.875, p <.001). Discussion: The Mandarin MDAS exhibited good reliability and validity for assessing general hospital patients. [ABSTRACT FROM AUTHOR]

Background: Delirium is underdiagnosed in clinical practice and is not routinely coded for billing. Manual chart review can be used to identify the occurrence of delirium; however, it is labor-intensive and impractical for large-scale studies. Natural language processing (NLP) has the capability to process raw text in electronic health records (EHRs) and determine the meaning of the information. We developed and validated NLP algorithms to automatically identify the occurrence of delirium from EHRs.Methods: This study used a randomly selected cohort from the population-based Mayo Clinic Biobank (N = 300, age ≥65). We adopted the standardized evidence-based framework confusion assessment method (CAM) to develop and evaluate NLP algorithms to identify the occurrence of delirium using clinical notes in EHRs. Two NLP algorithms were developed based on CAM criteria: one based on the original CAM (NLP-CAM; delirium vs no delirium) and another based on our modified CAM (NLP-mCAM; definite, possible, and no delirium). The sensitivity, specificity, and accuracy were used for concordance in delirium status between NLP algorithms and manual chart review as the gold standard. The prevalence of delirium cases was examined using International Classification of Diseases, 9th Revision (ICD-9), NLP-CAM, and NLP-mCAM.Results: NLP-CAM demonstrated a sensitivity, specificity, and accuracy of 0.919, 1.000, and 0.967, respectively. NLP-mCAM demonstrated sensitivity, specificity, and accuracy of 0.827, 0.913, and 0.827, respectively. The prevalence analysis of delirium showed that the NLP-CAM algorithm identified 12 651 (9.4%) delirium patients, the NLP-mCAM algorithm identified 20 611 (15.3%) definite delirium cases, and 10 762 (8.0%) possible cases.Conclusions: NLP algorithms based on the standardized evidence-based CAM framework demonstrated high performance in delineating delirium status in an expeditious and cost-effective manner. [ABSTRACT FROM AUTHOR]

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Background: Delirium is a common postoperative complication among elderly which can be easily missed and leads to poorer outcomes. The 3-Minute Diagnostic Assessment for Confusion Assessment Method (3D-CAM) is a short and structured tool to assess delirium by healthcare staff with minimal training. This study aimed to validate the translated Malay 3D-CAM (M3D-CAM) in postoperative surgical patients. Methods: In this prospective diagnostic study, 3D-CAM was translated into Malay and two assessors (1 and 2) independently interviewed surgical patients above 65 years old with M3D-CAM on postoperative day one. A psychiatrist diagnosed postoperative delirium according to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) as the reference standard. The sequence of examinations was done randomly with all results blinded to each other and the diagnostic characteristics of M3D-CAM analysed with κ coefficient used to evaluate reliability. Results: A total of 427 patients were screened, 111 recruited with a final 100 paired interviews completed. Their mean age was 72 (± 6) years old. Two-thirds of patients were proficient in Malay and English, therefore assessed in both 3D-CAM and M3D-CAM. Delirium was identified in 11% and 12% of patients by assessors 1 and 2 respectively while compared to DSM-5, M3D-CAM had 80% and 90% sensitivity with 96.7% and 97.7% specificity. M3D-CAM had excellent inter-rater reliability (85%), substantial parallel reliability (70%) and features 1 and 3 with substantial parallel agreement (p <0.001). Conclusion: This study demonstrated that M3D-CAM is reliable and valid for delirium assessment in the postoperative setting. [ABSTRACT FROM AUTHOR]

Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium. Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual−5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05. Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536). Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients. [ABSTRACT FROM AUTHOR]

Older adults' risk of developing delirium during hospitalization is well supported in the literature. The READY project added to the body of knowledge on the effect of reinforcement of delirium education using a valid screening tool, Confusion Assessment Method (CAM), on nurses' knowledge, assessment adherence, time to detection, and patient outcomes. Project results suggest education may improve delirium screening adherence and demonstrate the impact of confusion on length of stay. [ABSTRACT FROM AUTHOR]

BackgroundPostoperative delirium and cognitive dysfunction are frequent phenomena in older patients; however, few studies have examined the temporal relationship between these two conditions in the early postoperative period. Therefore, this study aimed to determine if postoperative delirium and postoperative cognitive dysfunction (POCD) coexist after major noncardiac surgery.MethodsThis was a prospective cohort study of patients who were ≥ 65 yr of age undergoing noncardiac surgery. Patients were evaluated preoperatively and for two days postoperatively for delirium and POCD. Delirium was determined using the Confusion Assessment Method, and POCD was measured by three cognitive tests addressing changes in executive function, memory, attention, and concentration. For each postoperative day, patients' neurologic status was categorized into three mutually exclusive categories: delirium, POCD, or neither condition.ResultsFour hundred sixty-one patients aged ≥ 65 yr of age were studied, and 421 patients with complete postoperative cognitive testing were reported. Eighty percent of patients experienced either delirium or POCD on the first day after surgery. Seventy percent of patients who had delirium on the first postoperative day also had delirium on the second postoperative day. Sixty-three percent of patients who had POCD on postoperative day one continued to have POCD on the next day. Sixteen percent of patients with delirium on day one were non-delirious on day two but met criteria for POCD on day two. Conversely, 15% of patients with POCD on day one became delirious on day two. Only 13% of patients did not experience delirium or POCD on either day after surgery.ConclusionsEighty percent of surgical patients experienced some form of cognitive dysfunction the day after surgery, and few recovered by the second day after surgery.

Background: Delirium occurs in as many as 82% of hospitalized patients. Use of a valid and reliable tool allows for early detection and management to mitigate adverse effects, including a decrease in patient falls. Objective: To conduct a quality improvement project to implement the confusion assessment method (CAM) tool in an intermediate care unit and measure delirium screening compliance, feasibility of the tool, and the effect on reported patient falls. Methods: Web-based training using a 14-item pre–post assessment for knowledge comprehension. The CAM tool was added to the electronic health record (EHR), and documentation compliance was measured for eight weeks. Afterwards, a nurse perception survey was distributed, and 60-day pre- and post-intervention patient falls were compared. Results: Forty-seven nurses completed the training. Post-test averages were higher than the pre-test (p =.16); five answers showed significant improvement (p <.02). Screening and documentation compliance were 79.1%. Twenty-one nurses completed the perception survey, demonstrating agreement that delirium CAM screening is a feasible intervention. Patient falls were reduced by 57%. Conclusion: Addition of the CAM tool into the EHR-enhanced screening compliance. Implications for Nursing: Early delirium detection may reduce patient falls. The CAM is a feasible instrument and delirium screening is a worthwhile intervention. [ABSTRACT FROM AUTHOR]

Introduction: Delirium is associated with an increased chance of death, prolonged hospitalisation, higher healthcare costs, and possibly long-term brain damage in survivors. Antipsychotics, both conventional and atypical, are the cornerstone of pharmacologic treatment for delirium in adults. Aim: To find out whether typical and atypical antipsychotic medication would result in a shorter duration of delirium than placebo and would improve other outcomes. Materials and Methods: This is a randomised, double-blind, placebo-controlled trial conducted on patients with delirium in Intensive Care Unit (ICU) of King George's Medical University, Lucknow, Uttar Pradesh, India from February 2021 to February 2022. Out of 45, 15 received enteral haloperidol (maximum dose 30 mg daily), 15 received quetiapine (maximum dose 300 mg daily) and 15 were controls receiving placebo through Ryle's tube. Delirium was detected with the use of Confusion Assessment Method for the ICU (CAM-ICU), and side effects of the drugs were noted. Dose of a trial drug or placebo was placed halved or doubled at 12-hour intervals using these parameters. The primary end point was the number of days alive without delirium during the 14 day intervention period. Secondary end points included time to freedom from mechanical ventilation, time to ICU, hospital discharge and 30 day and 90 day survival. Results: Out of 45 patients screened, 25 were males and 20 were females with no comparable differences. The mean number of days alive without delirium or coma was 9.45 in the haloperidol group, 8.64 in the quetiapine group, and 8.57 in the placebo group (p-value=0.63) for overall effect across trial groups. The use of haloperidol or quetiapine as compared with placebo, had no significant effect on the primary end point. There were no significant between-group differences in respect to the secondary end points. Conclusion: The use of enteral haloperidol or quetiapine, as compared with placebo, did not significantly alter the duration of delirium in the critically-ill patients admitted in ICU. [ABSTRACT FROM AUTHOR]

Abstract Background Delirium occurs commonly in older adults and is associated with adverse outcomes. Multicentre clinical trials evaluating interventions to prevent delirium are needed. The Confusion Assessment Method (CAM) is a validated instrument for delirium detection. We hypothesised it would be possible for a large feasibility study to train a large number of research assistants, with varying experience levels, to conduct CAM assessments reliably in multiple hospital sites. Methods A standardised training programme was followed, incorporating structured training at a central location and at study sites. CAM practice sessions on both delirious and non-delirious patients by research assistants were conducted and, thereafter, there was ongoing inter-rater reliability assessment on the CAM between research assistant pairs at study sites. The setting was eight acute care hospitals in England and Wales. Participants were research assistants working on a multicentre feasibility study of delirium prevention. The measurement used was the Confusion Assessment Method. Results Thirty-seven research assistants were trained in CAM assessment and 33 returned training logs. The logs showed there was 100% overall agreement between research assistant pairs on 295 CAM assessments, of which 263 (89.2%) were negative for delirium and 32 (10.8%) were positive. In the course of the feasibility study, research assistants successfully completed 5065 (89.7%) of the 5645 expected CAM assessments, with minimal missing data. Conclusion Using the training methods described in this study, it is possible to achieve high quality delirium assessments for large numbers of patients with little missing data across geographically dispersed sites in multicentre studies. The standardisation of multisite delirium assessments is an important contribution to research methodology, and provides a much-needed advance for the field. Trial registration ISRCT ISRCTN01187372. Registered 13 March 2014.

Abstract Background Delirium is associated with a significantly increased risk of postoperative morbidity and mortality. Furthermore, delirium has been associated with an increased risk of prolonged cognitive deficits and accelerated long-term cognitive decline. To date, experimental interventions for delirium have mainly focused on alternative pharmacologic and behavioral strategies in the postoperative period. Few studies have examined whether proactive strategies started before surgery can prevent delirium or reduce its sequelae. Neurocognitive training programs such as Lumosity have been shown to be effective in increasing cognitive performance in both elderly healthy volunteers and patients suffering from a myriad of acute and chronic medical conditions. When initiated in the preoperative period, such training programs may serve as interesting and novel patient-led interventions for the prevention of delirium and postoperative cognitive decline (POCD). We hypothesize that perioperative neurocognitive training is feasible in the older cardiac surgical population and are testing this hypothesis using a randomized controlled design. Methods The Prevention of Early Postoperative Decline (PEaPoD) study is a randomized, controlled trial with a target enrollment of 45 elderly cardiac surgical patients. Subjects will be randomized in a 1:1 ratio to undergo either at least 10 days of preoperative neurocognitive training, continued for 4 weeks postoperatively, or usual care control. The primary outcome, feasibility, will be assessed by study recruitment and adherence to protocol. Secondary outcomes will include potential differences in the incidence of postoperative in-hospital delirium and POCD up to 6 months, as determined by the Confusion Assessment Method and the Montreal Cognitive Assessment. Discussion PEaPoD will be the first trial investigating the use of perioperative cognitive training to potentially reduce delirium and POCD in the cardiac surgical population. Information gleaned from this feasibility study will prove valuable in designing future efficacy studies aimed at determining whether this low-risk, patient-led intervention can reduce serious postoperative morbidity. Trial registration ClinicalTrials.gov, NCT02908464. Registered on 21 September 2016.

Background: Postoperative delirium (POD) is a frequent complication in older patients. Dexmedetomidine might be effective in decreasing the incidence of POD. We hypothesised that adding low-dose rate dexmedetomidine infusion to a propofol sedation regimen would have fewer side-effects and would counteract the possible delirium producing properties of propofol, resulting in a lower risk of POD than propofol with placebo.Methods: In this double-blind placebo-controlled trial, patients ≥60 yr old undergoing on-pump cardiac surgery were randomised 1:1 to the following postoperative sedative regimens: a propofol infusion and dexmedetomidine (0.4 μg kg-1 h-1) or a propofol infusion and saline 0.9% (placebo group). The study drug was started at chest closure and continued for 10 h. The primary endpoint was in-hospital POD, assessed using the Confusion Assessment Method and chart review method.Results: POD over the course of hospital stay occurred in 31/177 (18%) and 33/172 (19%) patients in the dexmedetomidine and placebo arm, respectively (P=0.687; odds ratio=0.89; 95% confidence interval, 0.52-1.54). The incidence of POD in the intensive care alone, or on the ward alone, was also not significantly different between the groups. Subjects in the dexmedetomidine group spent less median time in a delirious state (P=0.026). Median administered postoperative norepinephrine was significantly higher in the dexmedetomidine group (P<0.001). One patient in the dexmedetomidine group and 10 patients in the placebo group died in the hospital.Conclusions: Adding low-dose rate dexmedetomidine to a sedative regimen based on propofol did not result in a different risk of in-hospital delirium in older patients undergoing cardiac surgery. With a suggestion of both harm and benefit in secondary outcomes, supplementing postoperative propofol with dexmedetomidine cannot be recommended based on this study.Clinical Trial Registration: NCT03388541. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self‐evolving model of care of older hospitalized patients who had already developed delirium. DESIGN: Hypothesis testing was carried out using a pretest‐posttest design on program administrative data. SETTING: Mount Sinai Hospital, New York, NY, a tertiary‐care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non–intensive care (ICU) inpatient units over a 5.5‐year period, regardless of the suspected presence of delirium or risk status for developing delirium. INTERVENTION: A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system. MEASUREMENTS: Length of stay (LOS) for delirious and non‐delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units. RESULTS: There was a significant drop in LOS by 1.98 days (95% confidence interval =.24–3.71), a decrease in the average morphine dose equivalents administered from.38 mg to.21 mg per patient hospital day, diazepam dose equivalents from.22 mg to.15 mg per patient hospital day, and quetiapine administered from.17 mg to.14 mg per patient hospital day for delirious patients on the program pilot units. CONCLUSION: Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed. [ABSTRACT FROM AUTHOR]

Background: Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies., Objective: It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method)., Methods: The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other., Results: In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity., Conclusions: The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version., (Copyright © 2023 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Abstract Background Postoperative delirium is common in elderly cardiac surgery patients. It is multifactorial and is influenced by the patient’s baseline status and the nature of the medical and surgical interventions that the patient receives. Some of these factors are potentially modifiable, including postoperative sedation and analgesia protocols. This study has been designed to evaluate the effectiveness of postoperative intravenous acetaminophen in conjunction with either dexmedetomidine or propofol in decreasing the incidence of delirium. Methods This is a prospective, randomized, placebo-controlled, double-blinded, factorial trial that includes patients who are at least 60 years old and who are undergoing cardiac surgeries involving cardiopulmonary bypass, including coronary artery bypass graft (CABG) and combined CABG/valve surgeries. Patients are randomly assigned to receive one of four postoperative analgesic-sedation regimens: (1) acetaminophen and dexmedetomidine, (2) acetaminophen and propofol, (3) dexmedetomidine and placebo, or (4) propofol and placebo. The primary outcome, incidence of delirium, will be assessed with the Confusion Assessment Method (CAM or CAM-ICU). The secondary outcome, postoperative cognitive decline, will be assessed with the Montreal Cognitive Assessment. Additional secondary outcomes, including duration of delirium, postoperative analgesic requirement, length of stay, and incidence of adverse events, will also be reported. Data will be analyzed in 120 randomly assigned patients who received at least one dose of the study medication(s) on a modified intention-to-treat basis. Discussion This study has been approved by the institutional review board at Beth Israel Deaconess Medical Center, and the trial is currently recruiting. This study will systematically examine the implications of modification in postoperative sedative/analgesic protocols after cardiac surgery, specifically for short- and long-term cognitive outcomes. Any positive outcomes from this study could direct simple yet effective practice changes aimed to reduce morbidity. Trial registration ClinicalTrials.gov Identifier: NCT02546765, registered January 13, 2015.

Objective: To study all aspects of delirium including occurrence, risk factors, precipitating causes and outcome in tertiary care hospital catering geriatric medicine services. Methods: A prospective observational study was done among 100 cases of delirium recruited from 520 patients admitted in geriatric block of general medicine ward during a calendar year. Patients were screened for delirium by confusion assessment method. Prevalent delirium and incident delirium was calculated. A set of predisposing risk factors were sought on admission. The cause of delirium was ascertained after full evaluation of patients by taking history, doing physical examination including neurological examination and appropriate investigations. Outcomes were measured in terms of length of hospital stay and inpatient mortality. Results: Out of 520 patients admitted in Geriatric ward during the study period, 100 patients had delirium (study prevalence 19.23%) and out of these, 7 patients developed delirium during hospitalization (study incidence 1.34%). The most common precipitating causes of delirium was infections (41%), followed by stroke (17%) and electrolyte imbalance (11%). Among infections, UTI was the most common cause. The most common predisposing risk factors for delirium were infections (52%), sensory impairment (51%), immobility/ being bedridden (40%), incontinence (32%), hypoxia (29%), electrolyte disturbances (hyponatremia- 22%), dehydration (21%), and poly pharmacy (15%). At the end of the study, mortality was 24% and 38 (38%) patients were recovered from the delirium. Conclusion: Delirium was found in 19.23% admitted geriatric patients and associated with considerable mortality (24%). The most common precipitating and predisposing causes of delirium was infection. After effective management, 38 (38%) patients recovered from delirium and were discharged in stable condition.

OBJECTIVES Although delirium is often investigated, little is known about the outcomes of patients having acute neuropsychological changes at a single time point without fulfilling the criteria of full delirium. Our aim was to determine point prevalence, predictors, and long‐term outcomes of delirium and acute neuropsychological changes in patients aged 60 years and older across different departments of a university hospital with general inpatient care. DESIGN Prospective observational study. SETTING University hospital excluding psychiatric wards. PARTICIPANTS At baseline, 669 patients were assessed, and follow‐ups occurred at months 6, 12, 18, and 36. MEASUREMENTS Measurements were obtained using the Confusion Assessment Method (CAM), comprehensive geriatric assessment, health‐related quality of life, functional state (month 6), and mortality rates (months 6, 12, 18, and 36). Subjects were classified into (1) patients with delirium according to the CAM, (2) patients with only two positive CAM items (2‐CAM state), and (3) patients without delirium. RESULTS: Delirium was present in 10.8% and the 2‐CAM state in an additional 12.7% of patients. Highest prevalence of delirium was observed in medical and surgical intensive care units and neurosurgical wards. Cognitive restrictions, restricted mobility, electrolyte imbalance, the number of medications per day, any fixations, and the presence of a urinary catheter predicted the presence of delirium and 2‐CAM‐state. The mean Karnofsky Performance Score and EuroQol‐5D were comparable between delirium and the 2‐CAM state after 6 months. The 6‐, 12‐, 18‐, and 36‐month mortality rates of patients with delirium and the 2‐CAM state were comparable. The nurses' evaluation of distinct patients showed high specificity (89%) but low sensitivity (53%) for the detection of delirium in wide‐awake patients. CONCLUSION: Patients with an acute change or fluctuation in mental status or inattention with one additional CAM symptom (ie, disorganized thinking or an altered level of consciousness) have a similar risk for a lower quality of life and death as patients with delirium. J Am Geriatr Soc 68:1469‐1475, 2020. [ABSTRACT FROM AUTHOR]

Aim: The lack of standardized tools limits the diagnosis ?f postoperative delirium (POD) in the Greek population. Our aim was the translation and the cultural adaptation of the confusion assessment method (CAM) diagnostic algorithm and the nursing delirium screening scale (nu-DESC) in the Greek surgical population, and the determination of their interrater reliability. Methods: After Ethical approval and registration as a clinical trial (NCT04154176), a prospective cohort study was conducted in the Department of Anesthesiology, University Hospital of Larissa, Greece. Patients at least 60 years old, undergoing elective non-cardiac surgery, under general anesthesia were included. Results: Data from 60 patients, 180 records in total, were analyzed. There was an "almost perfect agreement" between the raters with the use of CAM (Cohen's Kappa estimate: 0.960; 95% CI: 0.905-1.000) and nu-DESC (Cohen's Kappa estimate: 0.981; 95% CI: 0.944-1.000). The agreement on each specific question of CAM and nu-DESC ranged from "substantial" to "almost perfect agreement". Based on the CAM, the sensitivity and specificity of nu-DESC were 0.97 (95% CI: 0.82-1.00) and 0.99 (95% CI: 0.96-1.00), respectively. The Greek versions of CAM and nu-DESC showed a high inter-rater agreement. Conclusion: With the translation, the cultural adaptation, and the determination of their inter-rater agreement, the CAM diagnostic algorithm and the nu-DESC may serve as reliable instruments for the detection of POD in the Greek population. [ABSTRACT FROM AUTHOR]

Background: Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology. Aims: The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery. Methods: We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium. Results: Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium. Conclusion: Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium. [ABSTRACT FROM AUTHOR]

Previous studies showed that the Confusion Assessment Method based delirium severity evaluation tool (CAM-S) had good reliability and validity. However, there is no Chinese version of the CAM-S. Therefore, we set out to perform a prospective investigation in older Chinese patients who had total joint replacement surgery under general anesthesia in Tenth People's Hospital in Shanghai, P.R. China. A total of 576 participants, aged 60 years or older, were screened, 179 participants were enrolled, and 125 of them were included for the final analysis. Pre-operative evaluations were conducted one day before the surgery. Postoperative evaluations were conducted twice daily from postoperative day 1 to day 3. The incidence of postoperative delirium was 24.8%. The Chinese version of CAM-S [including a Short Form (CAM-S Short Form) and a Long Form (CAM-S Long Form)] had an optimal reliability reflected by internal consistency (Cronbach's α= 0.748 and 0.839 for CAM-S Short Form and CAM-S Long Form respectively), split-halves reliability (Pearson correlation coefficient = 0.372 and 0.384 for CAM-S Short Form and CAM-S Long Form respectively), and inter-rater reliability (intra-class correlation coefficients = 0.629 and 0.945 for CAM-S Short Form and CAM-S Long Form respectively). Additionally, the Chinese version of CAM-S also showed a good discriminate validity. The domain scores of CAM-S were inversely correlated with corresponding domain scores of the MMSE. Finally, a receiver operating characteristic (ROC) analysis obtained an optimal cutoff point of 2.5 for CAM-S Short Form and 3.5 for CAM-S Long Form in recognizing delirium diagnosed by CAM. The areas under the ROC were 0.989 (95% CI 0.972 - 1.000, p < 0.001) and 0.964 (95% CI 0.946 - 0.982, p < 0.001), respectively. These data suggest that the Chinese version of CAM-S has good reliability and validity in evaluating postoperative delirium in geriatric Chinese patients and may be a useful tool to assess the severity of delirium. [ABSTRACT FROM AUTHOR]

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Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P =.01) and Nu-DESC 0.99 vs 0.90, P =.003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings. • The 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) are commonly used for delirium detection. • The 4AT, Nu-DESC, and CAM had comparable pooled sensitivity in screening delirium (0.76, 0.78, and 0.80, respectively). • The CAM had the optimal ability to exclude patients without delirium. • Nu-DESC is suitable for screening delirium among older adults through daily nursing practice in few minutes. [ABSTRACT FROM AUTHOR]

Iwona Otremba, Krzysztof Wilczyński, Jan SzewieczekDepartment of Geriatrics, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, PolandBackground: Delirium remains a major nosocomial complication of hospitalized elderly. Predictive models for delirium may be useful for identification of high-risk patients for implementation of preventive strategies.Objective: Evaluate specific factors for development of delirium in a geriatric ward setting.Methods: Prospective cross-sectional study comprised 675 consecutive patients aged 79.2±7.7 years (66% women and 34% men), admitted to the subacute geriatric ward of a multiprofile university hospital after exclusion of 113 patients treated with antipsychotic medication because of behavioral disorders before admission. Comprehensive geriatric assessments including a structured interview, physical examination, geriatric functional assessment, blood sampling, ECG, abdominal ultrasound, chest X-ray, Confusion Assessment Method for diagnosis of delirium, Delirium-O-Meter to assess delirium severity, Richmond Agitation-Sedation Scale to assess sedation or agitation, visual analog scale and Doloplus-2 scale to assess pain level were performed.Results: Multivariate logistic regression analysis revealed five independent factors associated with development of delirium in geriatric inpatients: transfer between hospital wards (odds ratio [OR] =2.78; confidence interval [CI] =1.54–5.01; P=0.001), preexisting dementia (OR =2.29; CI =1.44–3.65; P